The 3-Year Cost-Effectiveness of a Nurse-Based Case Management versus Usual Care for Elderly Patients with Myocardial Infarction: Results from the KORINNA Follow-Up Study

Effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity: a scoping review

BACKGROUND

Chronic ultimorbidity is the most frequent and serious health problem in older adults. Home visiting programmes could be a strategy with potential benefits. However, there are no scoping reviews to date that examine the effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity.

OBJECTIVE

To examine the effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity.

METHODS

A scoping review was carried out following PRISMA-ScR reporting guidelines. The search was conducted in six databases (PubMed/Medline, Cochrane, CINAHL, Web of Science, Scopus and EMBASE) between October 2021 and April 2022.

RESULTS

Four RCTs with 560 patients were included. The visits were carried out by nurses, nursing students, volunteers, and other healthcare professionals. The interventions varied in the number of visits, frequency, duration of follow-up, and whether or not they were combined with other strategies such as telephone calls. Discrepancies were found in the effects of the interventions on quality of life, self-efficacy, self-rated health, and use and cost of health and social services.

CONCLUSION

This review shows that home visiting programmes could have potential benefits for older adults with chronic multimorbidity. However, its results have been inconclusive. There is a need for high quality studies involving a larger number of patients, in which home visits are the main intervention.

Effectiveness of Workplace Interventions to Improve Health and Well-Being of Health and Social Service Workers: A Narrative Review of Randomised Controlled Trials

Health and social service workers face high levels of workload and job stressors, which can affect their health and well-being. Therefore, it is important to evaluate the effectiveness of workplace interventions that aim to improve their mental and physical health outcomes. This review summarizes the findings of randomized controlled trials (RCTs) that examined the impact of different types of workplace interventions on various health indicators among health and social service workers. The review searched the PubMed database from its inception to December 2022 and included RCTs that reported on the effectiveness of organizational-level interventions and qualitative studies that explored barriers and facilitators to participation in such interventions. A total of 108 RCTs were included in the review, covering job burnout (N = 56 RCTs), happiness or job satisfaction (N = 35), sickness absence (N = 18), psychosocial work stressors (N = 14), well-being (N = 13), work ability (N = 12), job performance or work engagement (N = 12), perceived general health (N = 9), and occupational injuries (N = 3). The review found that several workplace interventions were effective in improving work ability, well-being, perceived general health, work performance, and job satisfaction and in reducing psychosocial stressors, burnout, and sickness absence among healthcare workers. However, the effects were generally modest and short-lived. Some of the common barriers to participation in workplace interventions among healthcare workers were inadequate staff, high workload, time pressures, work constraints, lack of manager support, scheduling health programs outside work hours, and lack of motivation. This review suggests that workplace interventions have small short-term positive effects on health and well-being of healthcare workers. Workplace interventions should be implemented as routine programs with free work hours to encourage participation or integrate intervention activities into daily work routines.

[Cost-Effectiveness of Case and Care Management in Older Populations in Germany: a Systematic Literature Review]

BACKGROUND

Despite trends toward longer-lasting health, the complexity of older people's health problems is increasing, raising the need for interprofessional care in all settings. A lack of coordination among providers risks fragmented care, leading to a repetition or gaps in services, conflicting treatment recommendations, medication errors and higher costs. Accordingly, new integrated models of care are needed that are based on patient needs. Case and Care Management (CCM) is currently being tested in Germany in a variety of settings to improve care.

AIM OF THE STUDY

The aim of the present study was to analyze the results of health economic evaluations of CCM interventions in Germany in populations over 60 years of age compared to standard care.

MATERIAL AND METHODS

The study is based on a systematic literature review conducted via Pubmed and Livivo and supplemented by a comprehensive hand search. The primary studies included for analysis were assessed using the CHEERS statement and narratively synthesized.

RESULTS

A total of five cost-effectiveness studies were included, predominantly based on randomized controlled trials. Results regarding cost effectiveness were mixed. Individual studies found significant differences on effectiveness and cost endpoints.

CONCLUSIONS

The mixed, small number of studies does not currently provide a clear picture of whether CCM interventions have health economic advantages over standard care. Further research is indicated. Innovation fund projects on the topic area are expected to generate new evidence in the future.

Community-Based Advanced Case Management for Patients with Complex Multimorbidity and High Medical Dependence: A Longitudinal Study

This longitudinal study aimed to evaluate a community-based and nurse-led advanced case management model centered on disease management. Participants were chronically ill patients aged 20 years and older who were highly dependent on medical care. The case management group (CMG) received nurse-led advanced case management, and the comparison group (CG) was selected by matching estimated propensity scores with the CMG. We compared the changes in medico-economic indicators between the two groups and analyzed the physical and psychological indicators of the CMG over time. The CMG comprised 51 participants, of which eight dropped out by 12 months after registration. After 1:1 propensity score matching, there were 40 participants in the CMG and CG, respectively. At 12 months after the registration, there was no significant difference between the two groups and no change in the CMG. At 24 months after the registration, the CMG’s medical and long-term care costs decreased significantly, while the CG’s costs increased. Moreover, there was a significant reduction in the number of hospital days and hospital admissions in the CMG. Our findings revealed that nurse-led advanced case management could be useful for patients with complex needs to avoid hospitalization due to exacerbations.

Roles of Nursing in the Management of Geriatric Cardiovascular Diseases

The nursing field occupies the largest secion of the cardiovascular healthcare services. Despite this, the roles of nursing within the cardiovascular healthcare system has not been well displayed. The authors searched PubMed and Embase (between January 1, 1950, and June 17, 2021) and created a narrative review of recent publications regarding the role of nursing in the management of geriatric cardiovascular disease (CVD). Patients with geriatric CVD, which includes mainly myocardial ischemia and heart failure, were enrolled. Nursing can improve the outcomes of myocardial ischemia and heart failure. It plays a pivotal role in the recovery, rehabilitation, and outcomes of geriatric CVD, especially for chronic heart diseases. Taken together, this paper compiled is focused on the current status of cardiovascular nursing and may facilitate future treatment and rehabilitation in geriatric CVD.

Costs and where to find them: identifying unit costs for health economic evaluations of diabetes in France, Germany and Italy

BACKGROUND

Health economic evaluations require cost data as key inputs. Many countries do not have standardized reference costs so costs used often vary between studies, thereby reducing transparency and transferability. The present review provided a comprehensive overview of cost sources and suggested unit costs for France, Germany and Italy, to support health economic evaluations in these countries, particularly in the field of diabetes.

METHODS

A literature review was conducted across multiple databases to identify published unit costs and cost data sources for resource items commonly used in health economic evaluations of antidiabetic therapies. The quality of unit cost reporting was assessed with regard to comprehensiveness of cost reporting and referencing as well as accessibility of cost sources from published cost-effectiveness analyses (CEA) of antidiabetic medications.

RESULTS

An overview of cost sources, including tariff and fee schedules as well as published estimates, was developed for France, Germany and Italy, covering primary and specialist outpatient care, emergency care, hospital treatment, pharmacy costs and lost productivity. Based on these sources, unit cost datasets were suggested for each country. The assessment of unit cost reporting showed that only 60% and 40% of CEAs reported unit costs and referenced them for all pharmacy items, respectively. Less than 20% of CEAs obtained all pharmacy costs from publicly available sources.

CONCLUSIONS

This review provides a comprehensive account of available costs and cost sources in France, Germany and Italy to support health economists and increase transparency in health economic evaluations in diabetes.

Cost-utility analysis of home-based cardiac rehabilitation as compared to usual post-discharge care: systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Determining cost-utility differences between home-based cardiac rehabilitation (HBCR) on the one hand, and usual post-discharge care (UC) on the other, can improve resource-allocation in healthcare settings.

AREAS COVERED

In June 2019, PubMed, Web of Science, Scopus, and Cochrane library were searched for randomized controlled HBCR trials. Standardized mean differences (SMDs) of cost and quality-adjusted life years (QALYs) between HBCRs and UCs were calculated using random effect models. Heterogeneity was assessed by inconsistency index (I2) and publication bias by funnel plot and Egger's regression test. Thirteen articles, representing 2,992 participants, were deemed representative for final analysis. In the meta-analysis, a significant difference with respect to QALYs favored HBCR, while no significant cost difference was observed between HBCR and UC. However, subgroup-analysis of trials with different follow-up durations revealed somewhat different results, and HBCR was found to be significantly better with regard to both cost and QALYs for patients with heart failure. Cost-utility analysis categorizing interventions as 'dominant', 'effective', 'doubtful', and 'dominated', found HBCRs dominant.

EXPERT OPINION

Although HBCR tended to be superior compared to UC in this review, larger and more robust trials addressing specific patients groups are needed for definitive results.

A Review of the Development and Application of Generic Preference-Based Instruments with the Older Population

Older people (aged 65 years and over) are the fastest growing age cohort in the majority of developed countries, and the proportion of individuals defined as the oldest old (aged 80 years and over) living with physical frailty and cognitive impairment is rising. These population changes put increasing pressure on health and aged care services, thus it is important to assess the cost effectiveness of interventions targeted for older people across health and aged care sectors to identify interventions with the strongest capacity to enhance older peoples' quality of life and provide value for money. Cost-utility analysis (CUA) is a form of economic evaluation that typically uses preference-based instruments to measure and value health-related quality of life for the calculation of quality-adjusted life-years (QALYS) to enable comparisons of the cost effectiveness of different interventions. A variety of generic preference-based instruments have been used to measure older people's quality of life, including the Adult Social Care Outcomes Toolkit (ASCOT); Health Utility Index Mark 2 (HUI2); Health Utility Index Mark 3 (HUI3); Short-Form-6 Dimensions (SF-6D); Assessment of Quality of Life-6 dimensions (AQoL-6D); Assessment of Quality of Life-8 dimensions (AQoL-8D); Quality of Wellbeing Scale-Self-Administered (QWB-SA); 15 Dimensions (15D); EuroQol-5 dimensions (EQ-5D); and an older person specific preference-based instrument-the Investigating Choice Experiments Capability Measure for older people (ICECAP-O). This article reviews the development and application of these instruments within the older population and discusses the issues surrounding their use with this population. Areas for further research relating to the development and application of generic preference-based instruments with populations of older people are also highlighted.

Multivariable and Structural Uncertainty Analyses for Cost-Effectiveness Estimates: Back to the Future

BACKGROUND

In this commentary, celebrating the 20th anniversary of the journal Value in Health, I present a brief overview and illustration of the evolution over the past 20 years of the methodological literature providing guidelines for multivariable and structural uncertainty analysis for cost-effectiveness estimates.

METHODS

To illustrate the impact of the guidelines for uncertainty analyses, I show how the inclusion of multivariable and structural uncertainty analyses in cost-effectiveness analyses published in Value in Health changed over the past 20 years using publications from 1999/2000, 2007 and 2017.

RESULTS

The commentary is organized in three sections: past, focusing on the development and use of methods for multivariable uncertainty analysis; present, focusing on the growing awareness of the need for structural uncertainty analysis, suggested frameworks for structural uncertainty analysis and how it is currently implemented; and future, considering different methods for combining multivariable and structural uncertainty analyses over the next decades.

CONCLUSIONS

I conclude by suggesting how the continued evolution of uncertainty analyses in published studies and health technology assessment submissions can best take into account an important goal of cost-effectiveness analyses: to provide useful information to decision makers.

Cost-effectiveness analysis of case management for optimized antithrombotic treatment in German general practices compared to usual care - results from the PICANT trial

BACKGROUND

By performing case management, general practitioners and health care assistants can provide additional benefits to their chronically ill patients. However, the economic effects of such case management interventions often remain unclear although how to manage the burden of chronic disease is a key question for policy-makers. This analysis aimed to compare the cost-effectiveness of 24 months of primary care case management for patients with a long-term indication for oral anticoagulation therapy with usual care.

METHODS

This analysis is part of the cluster-randomized controlled Primary Care Management for Optimized Antithrombotic Treatment (PICANT) trial. A sample of 680 patients with German statutory health insurance was initially considered for the cost analysis (92% of all participants at baseline). Costs included all disease-related direct health care costs from the payer's perspective (German statutory health insurers) plus case management costs for the intervention group. A-Quality Adjusted Life Year (QALY) measurement (EQ-5D-3 L instrument) was used to evaluate utility, and incremental cost-effectiveness ratio (ICER) to assess cost-effectiveness. Mean differences were calculated and displayed with 95%-confidence intervals (CI) from non-parametric bootstrapping (1000 replicates).

RESULTS

N = 505 patients (505/680, 74%) were included in the cost analysis (complete case analysis with a follow-up after 12 and 24 months as well as information on cost and QALY). After two years, the mean difference of direct health care costs per patient (€115, 95% CI [- 201; 406]) and QALYs (0.03, 95% CI [- 0.04; 0.11]) in the two groups was small and not significant. The costs of case management in the intervention group caused mean total costs per patient in this group to rise significantly (mean difference €503, 95% CI [188; 794]). The ICER was €16,767 per QALY. Regardless of the willingness of insurers to pay per QALY, the probability of the intervention being cost-effective never rose above 70%.

CONCLUSIONS

A primary care case management for patients with a long-term indication for oral anticoagulation therapy improved QALYs compared to usual care, but was more costly. However, the results may help professionals and policy-makers allocate scarce health care resources in such a way that the overall quality of care is improved at moderate costs, particularly for chronically ill patients.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41847489 .

Determinants of adherence and effects on health-related quality of life after myocardial infarction: a prospective cohort study

BACKGROUND

Adherence to recommendations and medication is deemed to be important for effectiveness of case management interventions. Thus, reasons for non-adherence and effects on health-related quality of life (HRQoL) should be fully understood. The objective of this research was to identify determinants of non-adherence to medication and recommendations, and to test whether increased adherence improved HRQoL in patients after myocardial infarction (MI) in a case management intervention.

METHODS

Data were obtained from the intervention group of the KORINNA study, a randomized controlled trail of a nurse-led case management intervention with targeted recommendations in the elderly after MI in Germany. Reasons for non-adherence were described. Logistic mixed effects models and OLS (ordinary least squares) were used to analyze the effect of recommendations on the probability of adherence and the association between adherence and HRQoL.

RESULTS

One hundred and twenty-seven patients with 965 contacts were included. Frequent reasons for non-adherence to medication and recommendations were "forgotten" (22%; 11%), "reluctant" (18%; 18%), "side effects" (38%; 7%), "the problem disappeared" (6%; 13%), and "barriers" (0%; 13%). The probability of adherence was lowest for disease and self-management (38%) and highest for visits to the doctor (61%). Only if patients diverging from prescribed medication because of side effects were also considered as adherent, 3-year medication adherence was associated with a significant gain of 0.34 quality-adjusted life years (QALYs).

CONCLUSIONS

Most important determinants of non-adherence to medication were side effects, and to recommendations reluctance. Recommended improvements in disease and self-management were least likely adhered. Medication adherence was associated with HRQoL.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN02893746 , retrospectively registered, date assigned 27/03/2009.