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Desmet L, Seuntjens L, van Bogaert P. Task redistribution from general practitioners to nurses in acute infection care: A prospective cohort study. J Adv Nurs 2024; 80:3179-3189. [PMID: 38297442 DOI: 10.1111/jan.16075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/19/2023] [Accepted: 01/10/2024] [Indexed: 02/02/2024]
Abstract
AIM To examine the impact of implementing nurse-led consultations compared to physician-led consultations on the frequency of follow-up contacts within 14 days following an acute infectious consultation. DESIGN Monocentric, prospective cohort study. METHODS The study was conducted in a multidisciplinary, capitation-based general practice in Belgium. Through analysis of patient files, the number of follow-up contacts within 14 days after an infection consultation was investigated to determine any difference between physician-led or nurse-led consultations. Secondary outcomes included pharmacological interventions and the prescribing behaviour of medical leave certificates. RESULTS A total of 352 consultations were analysed, of which 174 conducted by physicians and 178 by nurses. No significant difference was found in the number of follow-up contacts. However, the probability of a pharmacological intervention by a physician was revealed to be significantly higher. The presence or absence of such pharmacological intervention did not significantly influence the number of follow-up contacts. CONCLUSION This study demonstrates that nurses can be safely and efficiently utilized in acute infection care within a general practice setting. Although these results are promising, more extensive research is needed which incorporates the experiences of patients and healthcare providers. Furthermore, it is advisable to consider the experience and education of the nurses and incorporate them into the analyses. IMPACT This study addressed the high workload on general practitioners by researching a task shift in the acute infectious, primary health care. The results demonstrate the feasibility of this task shift, which may have an impact on primary health care professionals (whose workload may be reorganized), as well as on patients for whom primary care may become more accessible. PATIENT OR PUBLIC CONTRIBUTION This study includes direct patient data from people who presented themselves with acute infectious complaints in a primary healthcare practice.
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Affiliation(s)
- Laurent Desmet
- Geneeskunde voor het Volk, Deurne, Belgium
- University of Antwerp, Wilrijk, Belgium
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Goetz K, Warkentin N, Weiss L, Kasprick L. "We are the patients' advocates": Care and case managers' reasons to participate in a geriatric health care project - A qualitative study. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2021; 161:28-32. [PMID: 33454231 DOI: 10.1016/j.zefq.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/11/2020] [Accepted: 12/12/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Healthcare provision for the multimorbid elderly is complex. Care and Case Managers (CCMs) can help to coordinate and structure outpatient care for these patient groups. This approach will be realized in the project RubiN ("Continuous Care in Regional Networks"), which is funded by the Federal Joint Committee. The aim of the present qualitative study was to explore the motivation to work as a CCM. METHODS As part of the qualitative study framework, semi-structured interviews with CCMs were conducted as part of a joint kick-off event. The interviews were focused on the reasons and motivation for participating in the RubiN project. The transcribed interviews were analyzed using qualitative content analysis. RESULTS Eight of 20 CCMs agreed to take part in the interviews. One of the main motivations for taking part in RubiN was to shift away from working conditions that were perceived as stressful and towards an activity that was experienced as appreciative. The CCMs felt that their professional expertise was recognized by other service providers, and that appreciation of their role increased through their active involvement in the care of geriatric patients. CONCLUSIONS Care and Case Management as a practical application with extensive coordination services for geriatric patients may contribute to an increase in appreciation and recognition through establishing a separate area of responsibility and scope as well as working in an interdisciplinary team.
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Affiliation(s)
- Katja Goetz
- Institut für Allgemeinmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
| | - Nicole Warkentin
- Institut für Allgemeinmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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Roberts SLE, Healey A, Sevdalis N. Use of health economic evaluation in the implementation and improvement science fields-a systematic literature review. Implement Sci 2019; 14:72. [PMID: 31307489 PMCID: PMC6631608 DOI: 10.1186/s13012-019-0901-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 04/29/2019] [Indexed: 01/09/2023] Open
Abstract
Background Economic evaluation can inform whether strategies designed to improve the quality of health care delivery and the uptake of evidence-based practices represent a cost-effective use of limited resources. We report a systematic review and critical appraisal of the application of health economic methods in improvement/implementation research. Method A systematic literature search identified 1668 papers across the Agris, Embase, Global Health, HMIC, PsycINFO, Social Policy and Practice, MEDLINE and EconLit databases between 2004 and 2016. Abstracts were screened in Rayyan database, and key data extracted into Microsoft Excel. Evidence was critically appraised using the Quality of Health Economic Studies (QHES) framework. Results Thirty studies were included—all health economic studies that included implementation or improvement as a part of the evaluation. Studies were conducted mostly in Europe (62%) or North America (23%) and were largely hospital-based (70%). The field was split between improvement (N = 16) and implementation (N = 14) studies. The most common intervention evaluated (43%) was staffing reconfiguration, specifically changing from physician-led to nurse-led care delivery. Most studies (N = 19) were ex-post economic evaluations carried out empirically—of those, 17 were cost effectiveness analyses. We found four cost utility analyses that used economic modelling rather than empirical methods. Two cost-consequence analyses were also found. Specific implementation costs considered included costs associated with staff training in new care delivery pathways, the impacts of new processes on patient and carer costs and the costs of developing new care processes/pathways. Over half (55%) of the included studies were rated ‘good’ on QHES. Study quality was boosted through inclusion of appropriate comparators and reporting of incremental analysis (where relevant); and diminished through use of post-hoc subgroup analysis, limited reporting of the handling of uncertainty and justification for choice of discount rates. Conclusions The quantity of published economic evaluations applied to the field of improvement and implementation research remains modest; however, quality is overall good. Implementation and improvement scientists should work closely with health economists to consider costs associated with improvement interventions and their associated implementation strategies. We offer a set of concrete recommendations to facilitate this endeavour.
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Affiliation(s)
- Sarah Louise Elin Roberts
- King's Health Economics, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, David Goldberg Centre, De Crespigny Park, London, SE5 8AF, UK.
| | - Andy Healey
- King's Health Economics, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, David Goldberg Centre, De Crespigny Park, London, SE5 8AF, UK.,Centre for Implementation Science, King's College London, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, King's College London, London, UK
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Lee YH, Lu CW, Huang CT, Chang HH, Yang KC, Kuo CS, Chang YK, Hsu CC, Huang KC. Impact of a home health care program for disabled patients in Taiwan: A nationwide population-based cohort study. Medicine (Baltimore) 2019; 98:e14502. [PMID: 30762778 PMCID: PMC6408017 DOI: 10.1097/md.0000000000014502] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to evaluate the impact of home health care (HHC) for disabled patients.We conducted a nationwide population-based retrospective cohort study. A total of 5838 disabled patients with HHC were identified to match by propensity score with 15,829 disabled patients without HHC receiving tube or catheter care (tracheostomy tube, nasogastric tube, urinary catheter, cystostomy tube, nephrostomy tube) or stage 3 or 4 pressure sore care from the Taiwanese National Health Insurance Research Database between 2005 and 2009. After 1:1 matching, 2901 subjects in the HHC group and 2901 subjects in the non-HHC group were selected and analyzed. Generalized estimating equations (GEEs) were used to compare the risk of health outcomes (rate of hospitalization and emergency services use) and the healthcare expenditure between the 2 groups.Compared to those in the non-HHC group, the patients in the HHC group had significantly higher risk for hospitalization (odds ratio [OR] = 18.43, 95% confidence interval [CI]: 15.62-21.75, P < .001) and emergency services use (OR = 3.72, 95% CI: 3.32-4.17, P < .001) 1 year before the index date. However, 1 year after the index date, the risk for hospitalization (OR = 1.6, 95% CI: 1.41-1.83, P < .001) and emergency services use (OR = 1.16, 95% CI: 1.04-1.30, P < .05) attenuated significantly. Regarding the comparison of total healthcare expenditure 1 year before and after the index date, our study showed an insignificant decrease of US$1.5 per person per day and a significant increase of US$5.2 per person per day (P < .001) in the HHC and non-HHC groups, respectively.The HHC for disabled patients has a potential role to reduce hospitalization and emergency services use. Besides, the improvement of healthcare quality through HHC was not accompanied by increased healthcare expenditure. The clinical impact of HHC emphasizes the importance for public health officials to promote HHC model to meet the needs of disabled patients.
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Affiliation(s)
- Yi-Hsuan Lee
- Department of Family Medicine
- Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch
- Department of Family Medicine, National Taiwan University Hospital
| | - Chia-Wen Lu
- Department of Family Medicine, National Taiwan University Hospital
- Department of Family Medicine, College of Medicine, National Taiwan University, Taipei
| | - Chi-Ting Huang
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli
| | - Hao-Hsiang Chang
- Department of Family Medicine, National Taiwan University Hospital
| | - Kuen-Cheh Yang
- Department of Family Medicine
- Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch
- Department of Family Medicine, National Taiwan University Hospital
- Department of Family Medicine, College of Medicine, National Taiwan University, Taipei
| | - Chia-Sheng Kuo
- Department of Family Medicine
- Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch
- Department of Family Medicine, National Taiwan University Hospital
- Department of Family Medicine, College of Medicine, National Taiwan University, Taipei
| | - Yu-Kang Chang
- Department of Medical Research, Tung's Taichung Metro Harbor Hospital
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli
- Department of Health Services Administration, China Medical University, Taichung
- Department of Family Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Kuo-Chin Huang
- Department of Family Medicine
- Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch
- Department of Family Medicine, National Taiwan University Hospital
- Department of Family Medicine, College of Medicine, National Taiwan University, Taipei
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli
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Nuckols TK, Keeler E, Morton S, Anderson L, Doyle BJ, Pevnick J, Booth M, Shanman R, Arifkhanova A, Shekelle P. Economic Evaluation of Quality Improvement Interventions Designed to Prevent Hospital Readmission: A Systematic Review and Meta-analysis. JAMA Intern Med 2017; 177:975-985. [PMID: 28558095 PMCID: PMC5710454 DOI: 10.1001/jamainternmed.2017.1136] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 02/02/2017] [Indexed: 01/11/2023]
Abstract
Importance Quality improvement (QI) interventions can reduce hospital readmission, but little is known about their economic value. Objective To systematically review economic evaluations of QI interventions designed to reduce readmissions. Data Sources Databases searched included PubMed, Econlit, the Centre for Reviews & Dissemination Economic Evaluations, New York Academy of Medicine's Grey Literature Report, and Worldcat (January 2004 to July 2016). Study Selection Dual reviewers selected English-language studies from high-income countries that evaluated organizational or structural changes to reduce hospital readmission, and that reported program and readmission-related costs. Data Extraction and Synthesis Dual reviewers extracted intervention characteristics, study design, clinical effectiveness, study quality, economic perspective, and costs. We calculated the risk difference and net costs to the health system in 2015 US dollars. Weighted least-squares regression analyses tested predictors of the risk difference and net costs. Main Outcomes and Measures Main outcomes measures included the risk difference in readmission rates and incremental net cost. This systematic review and data analysis is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Results Of 5205 articles, 50 unique studies were eligible, including 25 studies in populations limited to heart failure (HF) that included 5768 patients, 21 in general populations that included 10 445 patients, and 4 in unique populations. Fifteen studies lasted up to 30 days while most others lasted 6 to 24 months. Based on regression analyses, readmissions declined by an average of 12.1% among patients with HF (95% CI, 8.3%-15.9%; P < .001; based on 22 studies with complete data) and by 6.3% among general populations (95% CI, 4.0%-8.7%; P < .001; 18 studies). The mean net savings to the health system per patient was $972 among patients with HF (95% CI, -$642 to $2586; P = .23; 24 studies), and the mean net loss was $169 among general populations (95% CI, -$2610 to $2949; P = .90; 21 studies), reflecting nonsignificant differences. Among general populations, interventions that engaged patients and caregivers were associated with greater net savings ($1714 vs -$6568; P = .006). Conclusions and Relevance Multicomponent QI interventions can be effective at reducing readmissions relative to the status quo, but net costs vary. Interventions that engage general populations of patients and their caregivers may offer greater value to the health system, but the implications for patients and caregivers are unknown.
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Affiliation(s)
- Teryl K. Nuckols
- Cedars-Sinai Medical Center, Los Angeles, California
- RAND Corporation, Santa Monica, California
| | | | - Sally Morton
- College of Science, Virginia Polytechnic Institute and State University, Blacksburg
| | - Laura Anderson
- Cedars-Sinai Medical Center, Los Angeles, California
- Jonathan and Karin Fielding School of Public Health, University of California–Los Angeles, Los Angeles
| | - Brian J. Doyle
- Jonathan and Karin Fielding School of Public Health, University of California–Los Angeles, Los Angeles
- VA Greater Los Angeles Healthcare System, Los Angeles, California
| | | | | | | | | | - Paul Shekelle
- RAND Corporation, Santa Monica, California
- VA Greater Los Angeles Healthcare System, Los Angeles, California
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Suijker JJ, MacNeil-Vroomen JL, van Rijn M, Buurman BM, de Rooij SE, Moll van Charante EP, Bosmans JE. Cost-effectiveness of nurse-led multifactorial care to prevent or postpone new disabilities in community-living older people: Results of a cluster randomized trial. PLoS One 2017; 12:e0175272. [PMID: 28414806 PMCID: PMC5393862 DOI: 10.1371/journal.pone.0175272] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 03/23/2017] [Indexed: 01/06/2023] Open
Abstract
Objective To evaluate the cost-effectiveness of nurse-led multifactorial care to prevent or postpone new disabilities in community-living older people in comparison with usual care. Methods We conducted cost-effectiveness and cost-utility analyses alongside a cluster randomized trial with one-year follow-up. Participants were aged ≥ 70 years and at increased risk of functional decline. Participants in the intervention group (n = 1209) received a comprehensive geriatric assessment and individually tailored multifactorial interventions coordinated by a community-care registered nurse with multiple follow-up visits. The control group (n = 1074) received usual care. Costs were assessed from a healthcare perspective. Outcome measures included disability (modified Katz-Activities of Daily Living (ADL) index score), and quality-adjusted life-years (QALYs). Statistical uncertainty surrounding Incremental Cost-Effectiveness Ratios (ICERs) was estimated using bootstrapped bivariate regression models while adjusting for confounders. Results There were no statistically significant differences in Katz-ADL index score and QALYs between the two groups. Total mean costs were significantly higher in the intervention group (EUR 6518 (SE 472) compared with usual care (EUR 5214 (SE 338); adjusted mean difference €1457 (95% CI: 572; 2537). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective was 0.14 at a willingness to pay (WTP) of EUR 50,000 per one point improvement on the Katz-ADL index score and 0.04 at a WTP of EUR 50,000 per QALY gained. Conclusion The current intervention was not cost-effective compared to usual care to prevent or postpone new disabilities over a one-year period. Based on these findings, implementation of the evaluated multifactorial nurse-led care model is not to be recommended.
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Affiliation(s)
- Jacqueline J. Suijker
- Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands
- * E-mail:
| | - Janet L. MacNeil-Vroomen
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Marjon van Rijn
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Bianca M. Buurman
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Sophia E. de Rooij
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, Amsterdam, The Netherlands
- University Center for Geriatric Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Judith E. Bosmans
- Department of Health Sciences and EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Joo JY, Liu MF. Case management effectiveness in reducing hospital use: a systematic review. Int Nurs Rev 2016; 64:296-308. [PMID: 27861853 DOI: 10.1111/inr.12335] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIM This systematic review synthesizes recent evidence of the effectiveness of case management in reducing hospital use by individuals with chronic illnesses. BACKGROUND Hospital use by individuals with chronic illnesses accounts for 66% of healthcare costs in the United States. its has been cited as care coordination that can reduce healthcare costs; however, its effectiveness in improving hospital use outcomes is contradictory, and no review has yet synthesized recent studies of case management with respect to hospital use outcomes. METHODS This systematic review followed the Cochrane processes and was guided by use of PRISMA statements. Five electronic databases were searched to obtain randomized controlled trials published within the last 10 years that evaluated case management hospital use as a primary outcome by individuals with chronic illnesses. RESULTS Ten studies published between 2007 and 2015 were retrieved and assessed for risk of methodological bias. All studies used case management as an intervention, focused on transitional care services and reported hospital use, including readmissions and emergency department and hospital visits, as a primary outcome. Analysis of the studies showed that case management greatly reduced hospital readmissions and emergency department visits. LIMITATIONS Only studies published in English were searched, and retrieved studies tended to report positive results. CONCLUSIONS There was strong evidence of significant reductions in hospital use with case management as an intervention. However, other results about the efffectiveness of case management remain mixed; more rigorously designed studies with case management interventions are needed. IMPLICATIONS FOR NURSING AND HEALTH POLICY The complexity and cost of chronic illnesses means that case management should be considered as a tool to improve quality of care and lower healthcare costs.
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Affiliation(s)
- J Y Joo
- College of Nursing, Gachon University, Incheon, Korea
| | - M F Liu
- School of Gerontology Health Management, College of Nursing, Taipei Medical University, Taipei, Taiwan
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Hudon C, Chouinard MC, Diadiou F, Lambert M, Bouliane D. Case Management in Primary Care for Frequent Users of Health Care Services With Chronic Diseases: A Qualitative Study of Patient and Family Experience. Ann Fam Med 2015; 13:523-8. [PMID: 26553891 PMCID: PMC4639377 DOI: 10.1370/afm.1867] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Although case management (CM) is increasingly being implemented to address the complex needs of vulnerable clienteles, few studies have examined the patient experience of CM. This study aimed to examine the experience of patients and their family members with care integration as part of a primary care CM intervention. Patients in the study were frequent users of health care services who had chronic diseases. METHODS A descriptive, qualitative approach was conducted involving 25 patients and 8 of their family members. Data were collected through in-depth interviews of the patients and 2 focus groups of family members and were analyzed thematically. RESULTS While some participants did not fully understand the CM intervention and a few believed that it involved too many appointments, the CM nurses were patients' preferred contact with primary care. The nurses actively involved the patients in developing and carrying out their individualized services plans (ISPs) with other health care partners. Patients felt that their needs were taken into consideration, especially regarding access to the health care system. The case manager facilitated access to information as well as communication and coordination among health care and community partners. This improved communication comforted the patients and nurtured a relationship of trust. Participants were actively involved in decision-making. Their ISPs helped them know where they were going and improved transitions between services. CONCLUSIONS The experience of patients and family members was overall very positive regarding care integration. They reported improved access, communication, coordination, and involvement in decision-making as well as better health care transitions.
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Affiliation(s)
- Catherine Hudon
- Département de médecine de famille et médecine d'urgence, Université de Sherbrooke, Québec, Canada Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Québec, Canada
| | - Maud-Christine Chouinard
- Centre de santé et de services sociaux de Chicoutimi, Québec, Canada Département des sciences de la santé, Université du Québec à Chicoutimi, Québec, Canada
| | - Fatoumata Diadiou
- Centre de santé et de services sociaux de Chicoutimi, Québec, Canada
| | - Mireille Lambert
- Centre de santé et de services sociaux de Chicoutimi, Québec, Canada
| | - Danielle Bouliane
- Centre de santé et de services sociaux de Chicoutimi, Québec, Canada
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Sandberg M, Kristensson J, Midlöv P, Jakobsson U. Effects on healthcare utilization of case management for frail older people: A randomized controlled trial (RCT). Arch Gerontol Geriatr 2015; 60:71-81. [DOI: 10.1016/j.archger.2014.10.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 08/20/2014] [Accepted: 10/11/2014] [Indexed: 10/24/2022]
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The Impact of Outliers on Net-Benefit Regression Model in Cost-Effectiveness Analysis. PLoS One 2013; 8:e65930. [PMID: 23840378 PMCID: PMC3686836 DOI: 10.1371/journal.pone.0065930] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 05/01/2013] [Indexed: 11/22/2022] Open
Abstract
Ordinary least square (OLS) in regression has been widely used to analyze patient-level data in cost-effectiveness analysis (CEA). However, the estimates, inference and decision making in the economic evaluation based on OLS estimation may be biased by the presence of outliers. Instead, robust estimation can remain unaffected and provide result which is resistant to outliers. The objective of this study is to explore the impact of outliers on net-benefit regression (NBR) in CEA using OLS and to propose a potential solution by using robust estimations, i.e. Huber M-estimation, Hampel M-estimation, Tukey's bisquare M-estimation, MM-estimation and least trimming square estimation. Simulations under different outlier-generating scenarios and an empirical example were used to obtain the regression estimates of NBR by OLS and five robust estimations. Empirical size and empirical power of both OLS and robust estimations were then compared in the context of hypothesis testing. Simulations showed that the five robust approaches compared with OLS estimation led to lower empirical sizes and achieved higher empirical powers in testing cost-effectiveness. Using real example of antiplatelet therapy, the estimated incremental net-benefit by OLS estimation was lower than those by robust approaches because of outliers in cost data. Robust estimations demonstrated higher probability of cost-effectiveness compared to OLS estimation. The presence of outliers can bias the results of NBR and its interpretations. It is recommended that the use of robust estimation in NBR can be an appropriate method to avoid such biased decision making.
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Graves N, Courtney M, Edwards H, Chang A, Parker A, Finlayson K. Cost-effectiveness of an intervention to reduce emergency re-admissions to hospital among older patients. PLoS One 2009; 4:e7455. [PMID: 19829702 PMCID: PMC2759083 DOI: 10.1371/journal.pone.0007455] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Accepted: 09/22/2009] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The objective is to estimate the cost-effectiveness of an intervention that reduces hospital re-admission among older people at high risk. A cost-effectiveness model to estimate the costs and health benefits of the intervention was implemented. METHODOLOGY/PRINCIPAL FINDINGS The model used data from a randomised controlled trial conducted in an Australian tertiary metropolitan hospital. Participants were acute medical admissions aged >65 years with at least one risk factor for re-admission: multiple comorbidities, impaired functionality, aged >75 years, recent multiple admissions, poor social support, history of depression. The intervention was a comprehensive nursing and physiotherapy assessment and an individually tailored program of exercise strategies and nurse home visits with telephone follow-up; commencing in hospital and continuing following discharge for 24 weeks. The change to cost outcomes, including the costs of implementing the intervention and all subsequent use of health care services, and, the change to health benefits, represented by quality adjusted life years, were estimated for the intervention as compared to existing practice. The mean change to total costs and quality adjusted life years for an average individual over 24 weeks participating in the intervention were: cost savings of $333 (95% Bayesian credible interval $ -1,932:1,282) and 0.118 extra quality adjusted life years (95% Bayesian credible interval 0.1:0.136). The mean net-monetary-benefit per individual for the intervention group compared to the usual care condition was $7,907 (95% Bayesian credible interval $5,959:$9,995) for the 24 week period. CONCLUSIONS/SIGNIFICANCE The estimation model that describes this intervention predicts cost savings and improved health outcomes. A decision to remain with existing practices causes unnecessary costs and reduced health. Decision makers should consider adopting this program for elderly hospitalised patients.
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Affiliation(s)
- Nicholas Graves
- School of Public Health, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia.
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Kathol RG, Kunkel EJS, Weiner JS, McCarron RM, Worley LLM, Yates WR, Summergrad P, Huyse FJ. Psychiatrists for medically complex patients: bringing value at the physical health and mental health/substance-use disorder interface. PSYCHOSOMATICS 2009; 50:93-107. [PMID: 19377017 DOI: 10.1176/appi.psy.50.2.93] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND In their current configuration, traditional reactive consultation-liaison services see a small percentage of the general-hospital patients who could benefit from their care. These services are poorly reimbursed and bring limited value in terms of clinical improvement and reduction in health-service use. METHOD The authors examine models of cross-disciplinary, integrated health services that have been shown to promote health and lower cost in medically-complex patients, those with complicated admixtures of physical, mental, social, and health-system difficulties. CONCLUSION Psychiatrists who specialize in the treatment of medically-complex patients must now consider a transition from traditional consultation to proactive, value-added programs and bill for services from medical, rather than behavioral, insurance dollars, since the majority of health-enhancement and cost-savings from these programs occur in the medical sector. The authors provide the clinical and financial arguments for such program-creation and the steps that can be taken as psychiatrists for medically-complex patients move to the next generation of interdisciplinary service.
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Affiliation(s)
- Roger G Kathol
- Dept. of Internal Medicine and Psychiatry, Univ. of Minnesota, USA.
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