A cost effectiveness analysis within a randomised controlled trial of post-acute care of older people in a community hospital

Cost Utility Analysis of Multidisciplinary Postacute Care for Stroke: A Prospective Six-Hospital Cohort Study

Background

Few studies have compared the optimal duration and intensity of organized multidisciplinary neurological/rehabilitative care delivered in a regional/district hospital with the standard rehabilitative care delivered in the general neurology/rehabilitation ward of a medical center. This study measured functional outcomes and conducted cost-utility analysis of an organized multidisciplinary postacute care (PAC) project in secondary care compared with standard rehabilitative care delivered in tertiary care.

Methods

This prospective cohort study enrolled 1,476 patients who had a stroke between March 2014 and March 2018 and had a modified Rankin scale score of 2–4. After exact matching for age ± 1 year, sex, year of stroke diagnosis, nasogastric tube, and Foley catheter and propensity score matching for the other covariates, we obtained 120 patients receiving PAC (the PAC group) from four regional/district hospitals and 120 patients not receiving PAC (the non-PAC group) from two medical centers.

Results

At baseline, the non-PAC group showed significantly better functional outcomes than the PAC group, including EuroQol-5 dimensions (EQ-5D), Mini-Mental State Examination (MMSE) and Barthel index (BI). During weeks 7–12 of rehabilitation, improvements in all functional outcomes were significantly larger in the PAC group (P < 0.001) except for Functional Oral Intake Scale (FOIS). Cost-utility analysis revealed that the PAC group had a significantly lower mean (± standard deviation) of direct medical costs (US$3,480 ± $1,758 vs. US$3,785 ± $3,840, P < 0.001) and a significantly higher average gain of quality-adjusted life years (0.1993 vs. 0.1233, P < 0.001). The PAC project was an economically “dominant” strategy.

Conclusions

The PAC project saved costs and significantly improved the functional outcomes of patients with stroke with slight to moderately severe disabilities. Randomized control trials are required to corroborate these results.

Post-Acute Care as a Key Component in a Healthcare System for Older Adults

Older adults often experience functional decline following acute medical care. This functional decline may lead to permanent disability, which will increase the burden on the medical and long-term care systems, families, and society as a whole. Post-acute care aims to promote the functional recovery of older adults, prevent unnecessary hospital readmission, and avoid premature admission to a long-term care facility. Research has shown that post-acute care is a cost-effective service model, with both the hospital-at-home and community hospital post-acute care models being highly effective. This paper describes the post-acute care models of the United States and the United Kingdom and uses the example of Taiwan’s highly effective post-acute care system to explain the benefits and importance of post-acute care. In the face of rapid demographic aging and smaller household size, a post-acute care system can lower medical costs and improve the health of older adults after hospitalization.

Improvements in Quality-Adjusted Life Years and Cost-Utility After Pharmacotherapy for Premenstrual Dysphoric Disorder: A Retrospective Study

BACKGROUND AND OBJECTIVE

To investigate the cost-effectiveness of pharmacotherapy for premenstrual dysphoric disorder (PMDD), a relatively new classification of depressive disorder that is characterized by recurrent depression during the premenstrual phase of the menstrual cycle.

METHODS

We performed a retrospective analysis of data from 49 previously untreated PMDD patients who visited our psychiatric department between October 2013 and February 2016 and received pharmacotherapy for 3 or 6 subsequent menstrual cycles. Quality-adjusted life years (QALYs) were estimated across individual menstrual cycles using mean EuroQoL-5D values. Direct costs per patient were estimated in order to conduct a preliminary cost-effectiveness analysis.

RESULTS

Pharmacotherapy produced a 0.190-point increase in mean EuroQoL-5D score per menstrual cycle after 6 menstrual cycles and an improvement of approximately 0.2 QALYs. Based on direct costs of 156,000 yen per patient, the cost-effectiveness of pharmacotherapy was calculated to be 823,000 yen per QALY. A cost-effectiveness acceptability curve analysis indicated that escitalopram tended to be superior to sertraline when willingness to pay per QALY was over 4,000,000 yen, whereas sertraline was superior when willingness to pay was below 2,000,000 yen.

CONCLUSIONS

Pharmacotherapy is cost effective for the treatment of PMDD. Moreover, escitalopram is a more cost-effective option than sertraline when willingness to pay is sufficiently high.

Comprehensive geriatric assessment for older adults admitted to hospital

BACKGROUND

Comprehensive geriatric assessment (CGA) is a multi-dimensional, multi-disciplinary diagnostic and therapeutic process conducted to determine the medical, mental, and functional problems of older people with frailty so that a co-ordinated and integrated plan for treatment and follow-up can be developed. This is an update of a previously published Cochrane review.

OBJECTIVES

We sought to critically appraise and summarise current evidence on the effectiveness and resource use of CGA for older adults admitted to hospital, and to use these data to estimate its cost-effectiveness.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers on 5 October 2016; we also checked reference lists and contacted study authors.

SELECTION CRITERIA

We included randomised trials that compared inpatient CGA (delivered on geriatric wards or by mobile teams) versus usual care on a general medical ward or on a ward for older people, usually admitted to hospital for acute care or for inpatient rehabilitation after an acute admission.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures expected by Cochrane and Effective Practice and Organisation of Care (EPOC). We used the GRADE approach to assess the certainty of evidence for the most important outcomes. For this update, we requested individual patient data (IPD) from trialists, and we conducted a survey of trialists to obtain details of delivery of CGA. We calculated risk ratios (RRs), mean differences (MDs), or standardised mean differences (SMDs), and combined data using fixed-effect meta-analysis. We estimated cost-effectiveness by comparing inpatient CGA versus hospital admission without CGA in terms of cost per quality-adjusted life year (QALY) gained, cost per life year (LY) gained, and cost per life year living at home (LYLAH) gained.

MAIN RESULTS

We included 29 trials recruiting 13,766 participants across nine, mostly high-income countries. CGA increases the likelihood that patients will be alive and in their own homes at 3 to 12 months' follow-up (risk ratio (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10; 16 trials, 6799 participants; high-certainty evidence), results in little or no difference in mortality at 3 to 12 months' follow-up (RR 1.00, 95% CI 0.93 to 1.07; 21 trials, 10,023 participants; high-certainty evidence), decreases the likelihood that patients will be admitted to a nursing home at 3 to 12 months follow-up (RR 0.80, 95% CI 0.72 to 0.89; 14 trials, 6285 participants; high-certainty evidence) and results in little or no difference in dependence (RR 0.97, 95% CI 0.89 to 1.04; 14 trials, 6551 participants; high-certainty evidence). CGA may make little or no difference to cognitive function (SMD ranged from -0.22 to 0.35 (5 trials, 3534 participants; low-certainty evidence)). Mean length of stay ranged from 1.63 days to 40.7 days in the intervention group, and ranged from 1.8 days to 42.8 days in the comparison group. Healthcare costs per participant in the CGA group were on average GBP 234 (95% CI GBP -144 to GBP 605) higher than in the usual care group (17 trials, 5303 participants; low-certainty evidence). CGA may lead to a slight increase in QALYs of 0.012 (95% CI -0.024 to 0.048) at GBP 19,802 per QALY gained (3 trials; low-certainty evidence), a slight increase in LYs of 0.037 (95% CI 0.001 to 0.073), at GBP 6305 per LY gained (4 trials; low-certainty evidence), and a slight increase in LYLAH of 0.019 (95% CI -0.019 to 0.155) at GBP 12,568 per LYLAH gained (2 trials; low-certainty evidence). The probability that CGA would be cost-effective at a GBP 20,000 ceiling ratio for QALY, LY, and LYLAH was 0.50, 0.89, and 0.47, respectively (17 trials, 5303 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Older patients are more likely to be alive and in their own homes at follow-up if they received CGA on admission to hospital. We are uncertain whether data show a difference in effect between wards and teams, as this analysis was underpowered. CGA may lead to a small increase in costs, and evidence for cost-effectiveness is of low-certainty due to imprecision and inconsistency among studies. Further research that reports cost estimates that are setting-specific across different sectors of care are required.

Community hospitals and their services in the NHS: identifying transferable learning from international developments – scoping review, systematic review, country reports and case studies

Background

The notion of a community hospital in England is evolving from the traditional model of a local hospital staffed by general practitioners and nurses and serving mainly rural populations. Along with the diversification of models, there is a renewed policy interest in community hospitals and their potential to deliver integrated care. However, there is a need to better understand the role of different models of community hospitals within the wider health economy and an opportunity to learn from experiences of other countries to inform this potential.

Objectives

This study sought to (1) define the nature and scope of service provision models that fit under the umbrella term ‘community hospital’ in the UK and other high-income countries, (2) analyse evidence of their effectiveness and efficiency, (3) explore the wider role and impact of community engagement in community hospitals, (4) understand how models in other countries operate and asses their role within the wider health-care system, and (5) identify the potential for community hospitals to perform an integrative role in the delivery of health and social care.

Methods

A multimethod study including a scoping review of community hospital models, a linked systematic review of their effectiveness and efficiency, an analysis of experiences in Australia, Finland, Italy, Norway and Scotland, and case studies of four community hospitals in Finland, Italy and Scotland.

Results

The evidence reviews found that community hospitals provide a diverse range of services, spanning primary, secondary and long-term care in geographical and health system contexts. They can offer an effective and efficient alternative to acute hospitals. Patient experience was frequently reported to be better at community hospitals, and the cost-effectiveness of some models was found to be similar to that of general hospitals, although evidence was limited. Evidence from other countries showed that community hospitals provide a wide spectrum of health services that lie on a continuum between serving a ‘geographic purpose’ and having a specific population focus, mainly older people. Structures continue to evolve as countries embark on major reforms to integrate health and social care. Case studies highlighted that it is important to consider local and national contexts when looking at how to transfer models across settings, how to overcome barriers to integration beyond location and how the community should be best represented.

Limitations

The use of a restricted definition may have excluded some relevant community hospital models, and the small number of countries and case studies included for comparison may limit the transferability of findings for England. Although this research provides detailed insights into community hospitals in five countries, it was not in its scope to include the perspective of patients in any depth.

Conclusions

At a time when emphasis is being placed on integrated and community-based care, community hospitals have the potential to assume a more strategic role in health-care delivery locally, providing care closer to people’s homes. There is a need for more research into the effectiveness and cost-effectiveness of community hospitals, the role of the community and optimal staff profile(s).

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A single-item self-rated health measure correlates with objective health status in the elderly: a survey in suburban beijing

INTRODUCTION

The measurement of health status of the elderly remains one important topic. Self-rated health status (SRH) is considered to be a simple indicator to measure the health status of the old population. But some researchers still take a skeptical view about its reliability. This study aims to investigate the association between SRH indicator and health status of the elderly and discuss its subsequent public health implications.

METHODS

In a total 1096 people who were 60 years of age or older from 1784 households from a suburban area of Beijing were interviewed using multistage stratified cluster sampling. SRH was measured by a single question "please choose one point in this 0-100 scale, which can best represent your health today." The disease status and physical functional status were also obtained. A multiple linear regression was conducted to test the associate between SRH and individual's disease/functional status.

RESULTS

The average of SRH scores of the elderly was 72.49 ± 15.64 (on a 1-100 scale). The SRH scores declined not only with the severity of self-reported mental/disease status, but also with the decrease of physical functional status. Multiple linear regression showed that after adjustment for other variables, 2-week sickness, chronic diseases, hospitalization, and ability of self-care (washing and dressing) were able to explain 35% of the variation in SRH among the elderly. Among them, disease status and self-care ability were the most powerful predictor of SRH. After adjusting other variables, physical functional status could explain only 5% of the variation in SRH.

CONCLUSION

Self-rated health reflects the disease/functional health status of the elderly. It is an easy-to-implement variable and it can reduce both recall bias and investigator bias, thus being widely used in health surveys. It is a cost-effective means of measuring the health status. However, the comparability of SRH in different populations should be studied in future.

Mapping utility scores from the Barthel index

PURPOSE

It is not always possible to collect utility-based outcome data, like EQ-5D, needed for conducting economic evaluations in populations of older people. Sometimes, information on other non-utility outcome measures may have been collected. This paper examines the possibility of mapping the EQ-5D from a non-utility-based outcome, the Barthel index.

METHODS

Data for 1,189 UK intermediate care patients were used. Ordinary least squares (OLS), censored least absolute deviations (CLAD) estimator and multinomial logistic (ML) models were used. The mean absolute error (MAE) and root-mean-squared error (RMSE) were used to estimate the predictive accuracy of eight regression models. Validation of primary models was carried out on random samples of data collected at admission and discharge.

RESULTS

Models where the EQ-5D was entered as a continuous dependent variable and Barthel dimensions used as explanatory variables performed better. CLAD performed best on MAE and OLS on the RMSE, while the ML performed the worst on both measures. The CLAD predicted EQ-5D scores that matched the observed values more closely than the OLS.

CONCLUSIONS

It is possible to reasonably predict that the EQ-5D from the Barthel using regression methods and the CLAD model (4) is recommended.

Socio-demographic and Clinical Profile of Admissions to Community Hospitals in Singapore from 1996 to 2005: A Descriptive Study

Introduction: Little data is available on community hospital admissions. We examined the differences between community hospitals and the annual trends in sociodemographic characteristics of all patient admissions in Singaporean community hospitals over a 10-year period from 1996 to 2005. Materials and Methods: Data were manually extracted from medical records of 4 community hospitals existent in Singapore from 1996 to 2005. Nineteen thousand and three hundred and sixty patient records were examined. Chi-square test was used for univariate analysis of categorical variables by type of community hospitals. For annual trends, test for linear by linear association was used. ANOVA was used to generate beta coefficients for continuous variables. Results: Mean age of all patient admissions has increased from 72.8 years in 1996 to 74.8 years in 2005. The majority was Chinese (88.4%), and female (58.1%) and admissions were mainly for rehabilitation (88.0%). Almost one third had foreign domestic workers as primary caregivers and most (73.5%) were discharged to their own home. There were significant differences in socio-demographic profile of admissions between hospitals with one hospital having more patients with poor social support. Over the 10-year period, the geometric mean length of stay decreased from 29.7 days (95% CI, 6.4 to 138.0) to 26.7 days (95% CI, 7.5 to 94.2), and both mean admission and discharge Barthel Index scores increased from 41.0 (SD = 24.9) and 51.8 (SD = 30.0), respectively in 1996 to 48.4 (SD = 24.5) and 64.2 (SD = 27.3) respectively in 2005. Conclusion: There are significant differences in socio-demographic characteristics and clinical profile of admissions between various community hospitals and across time. Understanding these differences and trends in admission profiles may help in projecting future healthcare service needs. Key words: Annual trends, Barthel Index scores, Caregivers, Length of stay, Rehabilitation

Comprehensive geriatric assessment for older adults admitted to hospital

BACKGROUND

Comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological and functional capabilities of a frail elderly person in order to develop a co-ordinated and integrated plan for treatment and long-term follow up.

OBJECTIVES

We sought to evaluate the effectiveness of CGA in hospital for older adults admitted as an emergency.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), the Database of Abstracts of Reviews of Effects (DARE), MEDLINE, EMBASE, CINAHL and AARP Ageline, and handsearched high-yield journals.

SELECTION CRITERIA

We searched for randomised controlled trials comparing CGA (whether by mobile teams or in designated wards) to usual care.

DATA COLLECTION AND ANALYSIS

Two review authors initially assessed eligibility and trial quality and extracted published data.

MAIN RESULTS

Twenty-two trials evaluating 10,315 participants in six countries were identified. Patients in receipt of CGA were more likely to be alive and in their own homes at up to six months (OR 1.25, 95% CI 1.11 to 1.42, P = 0.0002) and at the end of scheduled follow up (median 12 months) (OR 1.16, 95% CI 1.05 to 1.28, P = 0.003) when compared to general medical care. In addition, patients were less likely to be institutionalised (OR 0.79, 95% CI 0.69 to 0.88, P < 0.0001). They were less likely to suffer death or deterioration (OR 0.76, 95% CI 0.64 to 0.90, P = 0.001), and were more likely to experience improved cognition in the CGA group (OR 1.11, 95% CI 0.20 to 2.01, P = 0.02). Subgroup interaction in the primary outcomes suggests that the effects of CGA are primarily the result of CGA wards.

AUTHORS' CONCLUSIONS

Comprehensive geriatric assessment increases a patient's likelihood of being alive and in their own home at up to 12 months.

The hospital-based, post-acute geriatric evaluation and management unit: the experience of the acute geriatric unit in Trieste

In 2005, the Azienda Ospedaliero-Universitaria of Trieste (AOUT) activated the hospital-based post-acute geriatric evaluation and management unit (PAGEMU). The purpose of the study is to illustrate the activities of the PAGEMU, and to evaluate the effects of personalized and multidisciplinary care on geriatric inpatients. The evaluation for admission in PAGEMU included general admitting criteria, co-morbidity, autonomy, and assessment of the patient's pre-morbid functional status. During the stay, inpatients completed their treatment plan, comprehensive geriatric assessment was carried out, and rehabilitation and nutritional interventions were implemented. If necessary, a new diagnostic-therapeutic plan was provided. A number of 826 patients were evaluated for admission in PAGEMU (612 patients from surgical departments and 214 from medical wards). The mean length of stay was 19.55 days. Re-evaluation of patients at discharge showed a statistically significant improvement in co-morbidity and in self-sufficiency, not in cognitive or mood status. PAGEMU is a valid model both for patient-oriented and for management-oriented objectives, shortening the length of stay in acute care settings and increasing hospital turnover.

Structured re-assessment system at 6 months after a disabling stroke: a randomised controlled trial with resource use and cost study

BACKGROUND

national policy recommends routine re-assessment of disabled patients and their carers at 6 months after stroke onset. The clinical and resource outcomes of this policy were investigated.

DESIGN

prospective, single-blind, randomised controlled trial in two centres.

PARTICIPANTS

a total of 265 patients with a disabling stroke and their carers.

INTERVENTIONS

a structured re-assessment system for patients and their carers at 6 months post-stroke or existing care.

OUTCOME MEASURES

primary: patient independence (Frenchay activities index) and carer stress (general health questionnaire 28). Secondary: activities of daily living, mood state, satisfaction with services, carer strain index, health and social service resource use and costs.

RESULTS

independence at 12 months post-stroke was similar in both groups (Frenchay activities index, adjusted mean difference 0.64; 95% confidence interval -0.74-2.02). Emotional distress in carers was similar in both groups (general health questionnaire 28, mean difference 0.02; 95% confidence interval -0.95-1.00). Results for the secondary outcome measures and total mean costs were similar for both groups. The intervention group patients used 301 fewer hospital bed days and 1,631 fewer care home bed days.

CONCLUSIONS

the structured, systematic re-assessment for patients and their carers was not associated with any clinically significant evidence of benefit at 12 months. Health and social care resource use and mean cost per patient were broadly similar in both groups.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Register; number: ISRCTN55412871.

Post-acute care for older people in community hospitals--a cost-effectiveness analysis within a multi-centre randomised controlled trial

OBJECTIVES

to compare the cost effectiveness of post-acute care for older people provided in community hospitals with general hospital care.

DESIGN

cost-effectiveness study embedded within a randomised controlled trial.

SETTING

seven community hospitals and five general hospitals at five centres in the midlands and north of England.

PARTICIPANTS

490 patients needing rehabilitation following hospital admission with an acute illness.

INTERVENTION

multidisciplinary team care for older people in community hospitals.

MEASUREMENTS

EuroQol EQ-5D scores transformed into quality-adjusted life years; health and social service costs during the 6-month period following randomisation.

RESULTS

there was a non-significant difference between the community hospital and general hospital groups for changes in quality-adjusted life-year values from baseline to 6 months (mean difference 0.048; 95% confidence interval -0.028 to 0.123; P = 0.214). Resource use was similar for both groups. The mean (standard deviation) costs per patient for health and social services resources used were comparable for both groups: community hospital group 8,946 pounds ( 6,514 pounds); general hospital group 8,226 pounds ( 7,453 pounds). These findings were robust to sensitivity analyses. The incremental cost-effectiveness ratio estimate was 16,324 pounds per quality-adjusted life year. A cost effectiveness acceptability curve suggests that if decision makers' willingness to pay per quality-adjusted life year was 10,000 pounds, then community hospital care was effective in 47% of cases, and this increased to only 50% if the threshold willingness to pay was raised to 30,000 pounds.

CONCLUSIONS

the cost effectiveness of post-acute rehabilitation for older people was similar in community hospitals and general hospitals.