Methods for analyzing cost effectiveness data from cluster randomized trials

Cost effectiveness of a GP delivered medication review to reduce polypharmacy and potentially inappropriate prescribing in older patients with multimorbidity in Irish primary care: the SPPiRE cluster randomised controlled trial

BACKGROUND

Evidence on the cost effectiveness of deprescribing in multimorbidity is limited.

OBJECTIVE

To investigate the cost effectiveness of a general practitioner (GP) delivered, individualised medication review to reduce polypharmacy and potentially inappropriate prescribing in older patients with multimorbidity in Irish primary care.

METHODS

Within trial economic evaluation, from a healthcare perspective and based on a cluster randomised controlled trial with a 6 month follow up and 403 patients (208 Intervention and 195 Control) recruited between April 2017 and December 2019. Intervention GPs used the SPPiRE website which contained educational materials and a template to support a web-based individualised medication review. Control GPs delivered usual care. Incremental costs, quality adjusted life years (QALYs) generated using the EQ-5D-5L instrument, and expected cost effectiveness were estimated using multilevel modelling and multiple imputation techniques. Uncertainty was explored using parametric, deterministic and probabilistic methods.

RESULTS

On average, the SPPiRE intervention was dominant over usual care, with non-statistically significant mean cost savings of €410 (95% confidence interval (CI): - 2211, 1409) and mean health gains of 0.014 QALYs (95% CI - 0.011, 0.039). At cost effectiveness threshold values of €20,000 and €45,000 per QALY, the probability of SPPiRE being cost effective was 0.993 and 0.988. Results were sensitive to missing data and data collection period.

CONCLUSIONS

The study observed a pattern towards dominance for the SPPiRE intervention, with high expected cost effectiveness. Notably, observed differences in costs and outcomes were consistent with chance, and missing data and related uncertainty was non trivial. The cost effectiveness evidence may be considered promising but equivocal.

TRIAL REGISTRATION

ISRCTN: 12752680, 20th October 2016.

A scoping review of statistical methods for trial-based economic evaluations: The current state of play

The statistical quality of trial-based economic evaluations is often suboptimal, while a comprehensive overview of available statistical methods is lacking. Therefore, this review summarized and critically appraised available statistical methods for trial-based economic evaluations. A literature search was performed to identify studies on statistical methods for dealing with baseline imbalances, skewed costs and/or effects, correlated costs and effects, clustered data, longitudinal data, missing data and censoring in trial-based economic evaluations. Data was extracted on the statistical methods described, their advantages, disadvantages, relative performance and recommendations of the study. Sixty-eight studies were included. Of them, 27 (40%) assessed methods for baseline imbalances, 39 (57%) assessed methods for skewed costs and/or effects, 27 (40%) assessed methods for correlated costs and effects, 18 (26%) assessed methods for clustered data, 7 (10%) assessed methods for longitudinal data, 26 (38%) assessed methods for missing data and 10 (15%) assessed methods for censoring. All identified methods were narratively described. This review provides a comprehensive overview of available statistical methods for dealing with the most common statistical complexities in trial-based economic evaluations. Herewith, it can provide valuable input for researchers when deciding which statistical methods to use in a trial-based economic evaluation.

Health Economic Evaluation Alongside Stepped Wedge Trials: A Methodological Systematic Review

BACKGROUND

Recently, there has been an increase in use of the stepped wedge trial (SWT) design in the context of health services research, due to its pragmatic and methodological advantages over the parallel group design.

OBJECTIVE

Our objective was to summarise the statistical methods used when conducting economic evaluations alongside SWTs.

METHODS

A systematic literature search extending to February 2020 was conducted in the PubMed, Scopus, Cochrane and National Health Service Economic Evaluation Database (NHS-EED) databases to find and evaluate studies where there was an intention to conduct an economic evaluation alongside an SWT. Studies were assessed for their eligibility, findings, reporting of statistical methods and quality of reporting.

RESULTS

Of the 586 studies retrieved from the literature search, 69 studies were identified and included in this systematic review. A total of 54 studies were published protocols, with eight economic evaluations and seven studies reporting full trial results. Included studies varied in terms of their reporting of statistical methods, in both detail and methodology. There were 34 studies that did not report any statistical methods for the economic evaluation, and only 16 studies reported appropriate methods, mainly using some form of mixed/multilevel model, and two used seemingly unrelated regression. Twelve studies reported the use of generic bootstrap methods and other modelling techniques, whilst the remaining studies failed to appropriately account for clustering, correlation or adjustment for time.

CONCLUSIONS

The use of appropriate statistical methods that account for time, clustering and correlation between costs and outcomes is an important part of SWT health economics analysis, one that will benefit from an effort to communicate the methods available and their performance.

Taking the Analysis of Trial-Based Economic Evaluations to the Next Level: The Importance of Accounting for Clustering

OBJECTIVES

The aim of this study was to assess the performance and impact of multilevel modelling (MLM) compared with ordinary least squares (OLS) regression in trial-based economic evaluations with clustered data.

METHODS

Three thousand datasets with balanced and unbalanced clusters were simulated with correlation coefficients between costs and effects of - 0.5, 0, and 0.5, and intraclass correlation coefficients (ICCs) varying between 0.05 and 0.30. Each scenario was analyzed using both MLM and OLS. Statistical uncertainty around MLM and OLS estimates was estimated using bootstrapping. Performance measures were estimated and compared between approaches, including bias, root mean squared error (RMSE) and coverage probability. Cost and effect differences, and their corresponding confidence intervals and standard errors, incremental cost-effectiveness ratios, incremental net-monetary benefits and cost-effectiveness acceptability curves were compared.

RESULTS

Cost-effectiveness outcomes were similar between OLS and MLM. MLM produced larger statistical uncertainty and coverage probabilities closer to nominal levels than OLS. The higher the ICC, the larger the effect on statistical uncertainty between MLM and OLS. Significant cost-effectiveness outcomes as estimated by OLS became non-significant when estimated by MLM. At all ICCs, MLM resulted in lower probabilities of cost effectiveness than OLS, and this difference became larger with increasing ICCs. Performance measures and cost-effectiveness outcomes were similar across scenarios with varying correlation coefficients between costs and effects.

CONCLUSIONS

Although OLS produced similar cost-effectiveness outcomes, it substantially underestimated the amount of variation in the data compared with MLM. To prevent suboptimal conclusions and a possible waste of scarce resources, it is important to use MLM in trial-based economic evaluations when data are clustered.

What do national pharmacoeconomic guidelines recommend regarding the statistical analysis of trial-based economic evaluations?

Introduction: The statistical quality of many trial-based economic evaluations is poor. When conducting trial-based economic evaluations, researchers often turn to national pharmacoeconomic guidelines for guidance. Therefore, this study reviewed which recommendations are currently given by national pharmacoeconomic guidelines on the statistical analysis of trial-based economic evaluations.Areas covered: 40 national pharmacoeconomic guidelines were identified. Data were extracted on the guidelines' recommendations on how to deal with baseline imbalances, skewed costs, correlated costs and effects, clustering of data, longitudinal data, and missing data in trial-based economic evaluations. Four guidelines (10%) were found to include recommendations on how to deal with baseline imbalances, five (13%) on how to deal with skewed costs, and seven (18%) on how to deal with missing data. Recommendations were very general in nature and recommendations on dealing with correlated costs and effects, clustering of data, and longitudinal data were lacking.Expert opinion: Current national pharmacoeconomic guidelines provide little to no guidance on how to deal with the statistical challenges to trial-based economic evaluations. Since the use of suboptimal statistical methods may lead to biased results, and, therefore, possibly to a waste of scarce resources, national agencies are advised to include more statistical guidance in their pharmacoeconomic guidelines.

Economic evaluation of a childhood obesity prevention programme for children: Results from the WAVES cluster randomised controlled trial conducted in schools

Background

Childhood obesity is a serious public health challenge and schools have been identified as an ideal place to implement prevention interventions. The aim of this study was to measure the cost-effectiveness of a multi-faceted school-based obesity prevention intervention targeting children aged 6–7 years when compared to ‘usual activities’.

Methods

A cluster randomised controlled trial in 54 schools across the West Midlands (UK) was conducted. The 12-month intervention aimed to increase physical activity by 30 minutes per day and encourage healthy eating. Costs were captured from a public sector perspective and utility-based health related outcomes measured using the CHU-9D. Multiple imputation using chained equations was used to address missing data. The cost effectiveness was measured at 30 months from baseline using a hierarchical net-benefit regression framework, that controlled for clustering and prespecified covariates. Any uncertainty in the results was characterised using cost-effectiveness acceptability curves.

Results

At 30 months, the total adjusted incremental mean cost of the intervention was £155 (95% confidence interval [CI]: £139, £171), and the incremental mean QALYs gained was 0.006 (95% CI: -0.024, 0.036), per child. The incremental cost-effectiveness at 30 months was £26,815 per QALY and using a standard willingness to pay threshold of £30,000 per QALY, there was a 52% chance that the intervention was cost-effective.

Conclusions

The cost-effectiveness of the school-based WAVES intervention was subject to substantial uncertainty. We therefore recommend more research to explore obesity prevention within schools as part of a wider systems approach to obesity prevention.

Trial registration

This paper uses data collected by the WAVES trial: Controlled trials ISRCTN97000586 (registered May 2010).

Cost-Utility Analysis of Routine Anxiety and Depression Screening in Patients Consulting for Osteoarthritis: Results From a Clinical, Randomized Controlled Trial

OBJECTIVE

To investigate the cost-effectiveness (cost-utility) of introducing general practitioner screening for anxiety and depression in patients consulting for osteoarthritis (OA).

METHODS

A cluster-randomized trial-based economic evaluation to assess general practitioners screening for anxiety and depression symptoms in patients consulting for OA compared to usual care (screening for pain intensity) was undertaken over a 12-month period from a UK National Health Service and societal perspective. Patient-level mean costs and mean quality-adjusted life years (QALYs) were estimated, and cost-effectiveness acceptability curves controlling for cluster-level data were constructed. The base-case analysis used the net benefit regressions approach. The 2-stage nonparametric sampling technique was explored in a sensitivity analysis.

RESULTS

The base-case analysis demonstrated that the intervention was as costly as, and less effective than, the control (QALY differential -0.029 [95% confidence interval -0.062, 0.003]). In the base-case analyses, general practitioner screening for anxiety and depression was unlikely to be a cost-effective option (probability <5% at £20,000/QALY). Similar results were observed in all sensitivity analyses.

CONCLUSION

Prompting general practitioners to routinely screen and manage comorbid anxiety and depression in patients presenting with OA is unlikely to be cost-effective. Further research is needed to explore clinically effective and cost-effective models of managing anxiety and depression in patients presenting with clinical OA.

Optimising pain management in children with acute otitis media through a primary care-based multifaceted educational intervention: study protocol for a cluster randomised controlled trial

Background

Whilst current guidelines highlight the importance of pain management for children with acute otitis media (AOM), there is evidence to suggest that this is not implemented in everyday practice. We have developed a primary care-based multifaceted educational intervention to optimise pain management in children with AOM, and we trial its clinical and cost effectiveness.

Methods

This cluster randomised controlled trial aims to recruit 250 children aged 6 months to 10 years presenting with AOM to general practitioners (GPs) in 30 primary care centres (PCCs) across the Netherlands. GPs in the PCCs allocated to the intervention group receive a blended GP educational programme (online and face-to-face training). The intervention asks GPs to proactively discuss pain management with parents using an information leaflet, and to prescribe paracetamol and ibuprofen according to current guidelines. GPs in both groups complete an online module illustrating various otoscopic images to standardise AOM diagnosis. GPs in the PCCs allocated to the control group do not receive any further training and provide ‘care as usual’.

During the 4-week follow-up, parents complete a symptom diary. The primary outcome is the difference in parent-reported mean earache scores over the first 3 days. Secondary outcomes include both number of days with earache and fever, GP re-consultations for AOM, antibiotic prescriptions, and costs. Analysis will be by intention-to-treat.

Discussion

The optimal use of analgesics through the multifaceted intervention may provide symptom relief and thereby reduce re-consultations and antibiotic prescriptions in children with AOM.

Trial registration

Netherlands Trial Register, NTR4920. Registered on 19 December 2014.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2880-4) contains supplementary material, which is available to authorized users.

Tailored Versus Generic Knowledge Brokering to Integrate Mood Management Into Smoking Cessation Interventions in Primary Care Settings: Protocol for a Cluster Randomized Controlled Trial

Background

Both tobacco smoking and depression are major public health problems associated with high morbidity and mortality. In addition, individuals with depression are almost twice as likely to smoke and less likely to achieve smoking cessation. In the Smoking Treatment for Ontario Patients program, an established smoking cessation program in Ontario, Canada, 38% of smokers in primary care settings have current or past depression with 6-month quit rates that are significantly lower than those without depression (33% versus 40%, P<.001). Integrating self-help mood management (eg, relaxation exercises and mood monitoring) with smoking cessation treatment increases long-term quit rates by 12%-20%. However, integration in real-world settings has not been reported. It is unclear which knowledge translation strategy would be more effective for motivating clinicians to provide resources on mood management to eligible patients.

Objective

The objectives of this study are to investigate the following comparisons among depressed smokers enrolled in a smoking cessation program: 1) the effectiveness of generalized, exclusively email-based prompts versus a personalized knowledge broker in implementing mood management interventions; 2) the effectiveness of the two knowledge translation strategies on smoking quit rates; and 3) the incremental costs of the two knowledge translation strategies on the implementation of mood management interventions.

Methods

The study design is a cluster randomized controlled trial of Family Health Teams participating in the Smoking Treatment for Ontario Patients program. Family Health Teams will be randomly allocated 1:1 to receive either generalized messages (related to depression and smoking) exclusively via email (group A) or be assigned a knowledge broker who provides personalized support through phone- and email-based check-ins (group B). The primary outcome, measured at the site level, is the proportion of eligible baseline visits that result in the provision of the mood management intervention to eligible patients.

Results

Recruitment for the primary outcome of this study will be completed in 2018/2019. Results will be reported in 2019/2020.

Conclusions

This study will address the knowledge gap in the implementation strategies (ie, email-based prompts versus a knowledge broker) of mood management interventions for smokers with depression in primary care settings.

Trial Registration

ClinicalTrials.gov NCT03130998; https://clinicaltrials.gov/ct2/show/NCT03130998 (Archived on WebCite at www.webcitation.org/6ylyS6RTe)

Is an enhanced behaviour change intervention cost-effective compared with physiotherapy for patients with chronic low back pain? Results from a multicentre trial in Israel

OBJECTIVE

To assess the cost-effectiveness of an enhanced transtheoretical model of behaviour change in conjunction with physiotherapy compared with standard care (physiotherapy) in patients with chronic lower back pain (CLBP).

DESIGN

Cost-utility and cost-effectiveness analyses alongside a multicentre controlled trial from a healthcare perspective with a 1-year time horizon.

SETTING

The trial was conducted in eight centres within the Sharon district in Israel.

PARTICIPANTS

220 participants aged between 25 and 55 years who suffered from CLBP for a minimum of 3 months were recruited.

INTERVENTIONS

The intervention used a model of behaviour change that sought to increase the adherence and implementation of physical activity in conjunction with physiotherapy. The control arm received standard care in the form of physiotherapy.

PRIMARY AND SECONDARY MEASURES

The primary outcome was the incremental cost per quality-adjusted life year (QALY) of the intervention arm compared with standard care. The secondary outcome was the incremental cost per Roland-Morris Disability Questionnaire point.

RESULTS

The cost per QALY point estimate was 10 645 New Israeli shekels (NIS) (£1737.11). There was an 88% chance the intervention was cost-effective at NIS50 000 per QALY threshold. Excluding training costs, the intervention dominated the control arm, resulting in fewer physiotherapy and physician visits while improving outcomes.

CONCLUSIONS

The enhanced transtheoretical model intervention appears to be a very cost-effective intervention leading to improved outcomes for low cost. Given limitations within this study, there is justification for examining the intervention within a larger, long-term randomised controlled trial.

TRIAL REGISTRATION NUMBER

NCT01631344; Pre-results.

A cluster randomised controlled trial and evaluation and cost-effectiveness analysis of the Roots of Empathy schools-based programme for improving social and emotional well-being outcomes among 8- to 9-year-olds in Northern Ireland

Background

There is growing consensus regarding the importance of attending to children’s social and emotional well-being. There is now a substantial evidence base demonstrating the links between a child’s early social and emotional development and a range of key longer-term education, social and health outcomes. Universal school-based interventions provide a significant opportunity for early intervention in this area and yet the existing evidence base, particularly in relation to their long-term effects, is limited.

Objectives and main outcomes

To determine the effectiveness and cost-effectiveness of Roots of Empathy (ROE), a universal school-based programme that, through attempting to enhance children’s empathy, seeks to achieve the following two main outcomes: improvement in prosocial behaviour and reduction in difficult behaviour.

Design

A cluster randomised controlled trial and an economic evaluation. A total of 74 primary schools were randomly assigned to deliver ROE or to join a waiting list control group. Seven schools withdrew post randomisation and a further two withdrew before the immediate post-test time point. Children (n = 1278) were measured pre test and immediately post test, and then for 3 years following the end of the programme. Data were also collected from teachers and parents.

Setting and participants

The intervention schools delivered ROE to their Year 5 children (aged 8–9 years) as a whole class.

Intervention

ROE is delivered on a whole-class basis for one academic year (October–June). It consists of 27 lessons based around the monthly visit from a baby and parent who are usually recruited from the local community. Children learn about the baby’s growth and development and are encouraged to generalise from this to develop empathy towards others.

Results

Although it was developed in Canada, the programme was very well received by schools, parents and children, and it was delivered effectively with high fidelity. ROE was also found to be effective in achieving small improvements in children’s prosocial behaviour (Hedges’ g = 0.20; p = 0.045) and reductions in their difficult behaviour (Hedges’ g = –0.16; p = 0.060) immediately post test. Although the gains in prosocial behaviour were not sustained after the immediately post-test time point, there was some tentative evidence that the effects associated with reductions in difficult behaviour may have remained up to 36 months from the end of the programme. These positive effects of ROE on children’s behaviour were not found to be associated with improvements in empathy or other social and emotional skills (such as emotional recognition and emotional regulation), on which the trial found no evidence of ROE having an effect. The study also found that ROE was likely to be cost-effective in line with national guidelines.

Conclusions

These findings are consistent with those of other evaluations of ROE and suggest that it is an effective and cost-effective programme that can be delivered appropriately and effectively in regions such as Northern Ireland. A number of issues for further consideration are raised regarding opportunities to enhance the role of parents; how a time-limited programme such as ROE can form part of a wider and progressive curriculum in schools to build on and sustain children’s social and emotional development; and the need to develop a better theory of change for how ROE works.

Trial registration

Current Controlled Trials ISRCTN07540423.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 6, No. 4. See the NIHR Journals Library website for further project information.

Cost-benefit and extended cost-effectiveness analysis of a comprehensive adolescent pregnancy prevention program in Zambia: study protocol for a cluster randomized controlled trial

Background

Early marriages, pregnancies and births are the major cause of school drop-out among adolescent girls in sub-Saharan Africa. Birth complications are also one of the leading causes of death among adolescent girls. This paper outlines a protocol for a cost-benefit analysis (CBA) and an extended cost-effectiveness analysis (ECEA) of a comprehensive adolescent pregnancy prevention program in Zambia. It aims to estimate the expected costs, monetary and non-monetary benefits associated with health-related and non-health outcomes, as well as their distribution across populations with different standards of living.

Methods

The study will be conducted alongside a cluster-randomized controlled trial, which is testing the hypothesis that economic support with or without community dialogue is an effective strategy for reducing adolescent childbearing rates. The CBA will estimate net benefits by comparing total costs with monetary benefits of health-related and non-health outcomes for each intervention package. The ECEA will estimate the costs of the intervention packages per unit health and non-health gain stratified by the standards of living. Cost data include program implementation costs, healthcare costs (i.e. costs associated with adolescent pregnancy and birth complications such as low birth weight, pre-term birth, eclampsia, medical abortion procedures and post-abortion complications) and costs of education and participation in community and youth club meetings. Monetary benefits are returns to education and averted healthcare costs. For the ECEA, health gains include reduced rate of adolescent childbirths and non-health gains include averted out-of-pocket expenditure and financial risk protection. The economic evaluations will be conducted from program and societal perspectives.

Discussion

While the planned intervention is both comprehensive and expensive, it has the potential to produce substantial short-term and long-term health and non-health benefits. These benefits should be considered seriously when evaluating whether such a program can justify the required investments in a setting with scarce resources. The economic evaluations outlined in this paper will generate valuable information that can be used to guide large-scale implementation of programs to address the problem of the high prevalence of adolescent childbirth and school drop-outs in similar settings.

Trial registration

ClinicalTrials.gov, NCT02709967. Registered on 2 March 2016. ISRCTN, ISRCTN12727868. Registered on 4 March 2016.

Subgroup analysis of telehealthcare for patients with chronic obstructive pulmonary disease: the cluster-randomized Danish Telecare North Trial

PURPOSE

Results from the Danish cluster-randomized trial of telehealthcare to 1,225 patients with chronic obstructive pulmonary disease (COPD), the Danish Telecare North Trial, concluded that the telehealthcare solution was unlikely to be cost-effective, by applying international willingness-to-pay threshold values. The purpose of this article was to assess potential sources of variation across subgroups, which could explain overall cost-effectiveness results or be utilized in future economic studies in telehealthcare research.

METHODS

First, the cost-structures and cost-effectiveness across COPD severities were analyzed. Second, five additional subgroup analyses were conducted, focusing on differences in cost-effectiveness across a set of comorbidities, age-groups, genders, resource patterns (resource use in the social care sector prior to randomization), and delivery sites. All subgroups were investigated post hoc. In analyzing cost-effectiveness, two separate linear mixed-effects models with treatment-by-covariate interactions were applied: one for quality-adjusted life-year (QALY) gain and one for total healthcare and social sector costs. Probabilistic sensitivity analysis was used for each subgroup result in order to quantify the uncertainty around the cost-effectiveness results.

RESULTS

The study concludes that, across the COPD severities, patients with severe COPD (GOLD 3 classification) are likely to be the most cost-effective group. This is primarily due to lower hospital-admission and primary-care costs. Telehealthcare for patients younger than 60 years is also more likely to be cost-effective than for older COPD patients. Overall, results indicate that existing resource patterns of patients and variations in delivery-site practices might have a strong influence on cost-effectiveness, possibly stronger than the included health or sociodemographic sources of heterogeneity.

CONCLUSION

Future research should focus more on sources of heterogeneity found in the implementation context and the way telehealthcare is adopted (eg, by integrating formative evaluation into cost-effectiveness analyses).

TRIAL REGISTRATION

Clinicaltrials.gov, NCT01984840.

Cost-effectiveness of telehealthcare to patients with chronic obstructive pulmonary disease: results from the Danish 'TeleCare North' cluster-randomised trial

OBJECTIVES

To investigate the cost-effectiveness of a telehealthcare solution in addition to usual care compared with usual care.

DESIGN

A 12-month cost-utility analysis conducted alongside a cluster-randomised trial.

SETTING

Community-based setting in the geographical area of North Denmark Region in Denmark.

PARTICIPANTS

26 municipality districts define randomisation clusters with 13 districts in each arm. 1225 patients with chronic obstructive pulmonary disease were enrolled, of which 578 patients were randomised to telehealthcare and 647 to usual care.

INTERVENTIONS

In addition to usual care, patients in the intervention group received a set of telehealthcare equipment and were monitored by a municipality-based healthcare team. Patients in the control group received usual care.

MAIN OUTCOME MEASURE

Incremental costs per quality-adjusted life-years gained from baseline up to 12 months follow-up.

RESULTS

From a healthcare and social sector perspective, the adjusted mean difference in total costs between telehealthcare and usual care was €728 (95% CI -754 to 2211) and the adjusted mean difference in quality-adjusted life-years gained was 0.0132 (95% CI -0.0083 to 0.0346). The incremental cost-effectiveness ratio was €55 327 per quality-adjusted life-year gained. Decision-makers should be willing to pay more than €55 000 to achieve a probability of cost-effectiveness >50%. This conclusion is robust to changes in the definition of hospital contacts and reduced intervention costs. Only in the most optimistic scenario combining the effects of all sensitivity analyses, does the incremental cost-effectiveness ratio fall below the UK thresholds values (€21 068 per quality-adjusted life-year).

CONCLUSIONS

Telehealthcare is unlikely to be a cost-effective addition to usual care, if it is offered to all patients with chronic obstructive pulmonary disease and if the willingness-to-pay threshold values from the National Institute for Health and Care Excellence are applied.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT01984840, 14 November 2013.

INTroducing A Care bundle To prevent pressure injury (INTACT) in at-risk patients: A protocol for a cluster randomised trial

BACKGROUND

Pressure injuries are a significant clinical and economic issue, affecting both patients and the health care system. Many pressure injuries in hospitals are facility acquired, and are largely preventable. Despite growing evidence and directives for pressure injury prevention, implementation of preventative strategies is suboptimal, and pressure injuries remain a serious problem in hospitals.

OBJECTIVES

This study will test the effectiveness and cost-effectiveness of a patient-centred pressure injury prevention care bundle on the development of hospital acquired pressure injury in at-risk patients.

DESIGN

This is a multi-site, parallel group cluster randomised trial. The hospital is the unit of randomisation.

METHODS

Adult medical and surgical patients admitted to the study wards of eight hospitals who are (a) deemed to be at risk of pressure injury (i.e. have reduced mobility), (b) expected to stay in hospital for ≥48h, (c) admitted to hospital in the past 36h; and (d) able to provide informed consent will be eligible to participate. Consenting patients will receive either the pressure injury prevention care bundle or standard care. The care bundle contains three main messages: (1) keep moving; (2) look after your skin; and (3) eat a healthy diet. Nurses will receive education about the intervention. Patients will exit the study upon development of a pressure injury, hospital discharge or 28 days, whichever comes first; transfer to another hospital or transfer to critical care and mechanically ventilated. The primary outcome is incidence of hospital acquired pressure injury. Secondary outcomes are pressure injury stage, patient participation in care and health care costs. A health economic sub-study and a process evaluation will be undertaken alongside the trial. Data will be analysed at the cluster (hospital) and patient level. Estimates of hospital acquired pressure injury incidence in each group, group differences and 95% confidence interval and p values will be reported.

DISCUSSION

To our knowledge, this is the first trial of an intervention to incorporate a number of pressure injury prevention strategies into a care bundle focusing on patient participation and nurse-patient partnership. The results of this study will provide important information on the effectiveness and cost-effectiveness of this intervention in preventing pressure injuries in at-risk patients. If the results confirm the utility of the developed care bundle, it could have a significant impact on clinical practice worldwide.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613001343796.

Cost-effectiveness of integrated care in frail elderly using the ICECAP-O and EQ-5D: does choice of instrument matter?

Economic evaluations likely undervalue the benefits of interventions in populations receiving both health and social services, such as frail elderly, by measuring only health-related quality of life. For this reason, alternative preference-based instruments have been developed for economic evaluations in the elderly, such as the ICECAP-O. The aim of this paper is twofold: (1) to evaluate the cost-effectiveness using a short run time frame for an integrated care model for frail elderly, and (2) to investigate whether using a broader measure of (capability) wellbeing in an economic evaluation leads to a different outcome in terms of cost-effectiveness. We performed univariate and multivariate analyses on costs and outcomes separately. We also performed incremental net monetary benefit regressions using quality adjusted life years (QALYs) based on the ICECAP-O and EQ-5D. In terms of QALYs as measured with the EQ-5D and the ICECAP-O, there were small and insignificant differences between the instruments, due to negligible effect size. Therefore, widespread implementation of the Walcheren integrated care model would be premature based on these results. All results suggest that, using the ICECAP-O, the intervention has a higher probability of cost-effectiveness than with the EQ-5D at the same level of WTP. In case an intervention's health and wellbeing effects are not significant, as in this study, using the ICECAP-O will not lead to a false claim of cost-effectiveness of the intervention. On the other hand, if differences in capability QALYs are meaningful and significant, the ICECAP-O may have the potential to measure broader outcomes and be more sensitive to differences between intervention and comparators.

Mind the Gap! A Multilevel Analysis of Factors Related to Variation in Published Cost-Effectiveness Estimates within and between Countries

Background. Published cost-effectiveness estimates can vary considerably, both within and between countries. Despite extensive discussion, little is known empirically about factors relating to these variations. Objectives. To use multilevel statistical modeling to integrate cost-effectiveness estimates from published economic evaluations to investigate potential causes of variation. Methods. Cost-effectiveness studies of statins for cardiovascular disease prevention were identified by systematic review. Estimates of incremental costs and effects were extracted from reported base case, sensitivity, and subgroup analyses, with estimates grouped in studies and in countries. Three bivariate models were developed: a cross-classified model to accommodate data from multinational studies, a hierarchical model with multinational data allocated to a single category at country level, and a hierarchical model excluding multinational data. Covariates at different levels were drawn from a long list of factors suggested in the literature. Results. We found 67 studies reporting 2094 cost-effectiveness estimates relating to 23 countries (6 studies reporting for more than 1 country). Data and study-level covariates included patient characteristics, intervention and comparator cost, and some study methods (e.g., discount rates and time horizon). After adjusting for these factors, the proportion of variation attributable to countries was negligible in the cross-classified model but moderate in the hierarchical models (14%−19% of total variance). Country-level variables that improved the fit of the hierarchical models included measures of income and health care finance, health care resources, and population risks. Conclusions. Our analysis suggested that variability in published cost-effectiveness estimates is related more to differences in study methods than to differences in national context. Multinational studies were associated with much lower country-level variation than single-country studies. These findings are for a single clinical question and may be atypical.

Multilevel models for cost-effectiveness analyses that use cluster randomised trial data: An approach to model choice

Multilevel models provide a flexible modelling framework for cost-effectiveness analyses that use cluster randomised trial data. However, there is a lack of guidance on how to choose the most appropriate multilevel models. This paper illustrates an approach for deciding what level of model complexity is warranted; in particular how best to accommodate complex variance-covariance structures, right-skewed costs and missing data. Our proposed models differ according to whether or not they allow individual-level variances and correlations to differ across treatment arms or clusters and by the assumed cost distribution (Normal, Gamma, Inverse Gaussian). The models are fitted by Markov chain Monte Carlo methods. Our approach to model choice is based on four main criteria: the characteristics of the data, model pre-specification informed by the previous literature, diagnostic plots and assessment of model appropriateness. This is illustrated by re-analysing a previous cost-effectiveness analysis that uses data from a cluster randomised trial. We find that the most useful criterion for model choice was the deviance information criterion, which distinguishes amongst models with alternative variance-covariance structures, as well as between those with different cost distributions. This strategy for model choice can help cost-effectiveness analyses provide reliable inferences for policy-making when using cluster trials, including those with missing data.

Cost-effectiveness of nurse-led versus doctor-led antiretroviral treatment in South Africa: pragmatic cluster randomised trial

OBJECTIVE

To estimate the cost-effectiveness of nurse-led versus doctor-led antiretroviral treatment (ART) for HIV-infected people.

DESIGN

Cost-effectiveness analysis alongside a pragmatic cluster randomised controlled trial in 31 primary care clinics (16 intervention, 15 controls) in Free State Province, South Africa. Participants were HIV-infected patients, aged ≥16 years. Cohort 1 (CD4 count ≤350 cells/μl, not yet receiving ART at enrolment): consisted of 5 390 intervention patients and 3 862 controls; Cohort 2 (already received ART for ≥6 months at enrolment) of 3 029 intervention patients and 3 202 controls. Nurses were authorised and trained to initiate and represcribe ART. Management and ART provision were decentralised to primary care clinics. In control clinics, doctors initiated and re-prescribed ART, nurses monitored ART. Main outcome measure(s) were health service costs, death (cohort 1) and undetectable viral load (<400 copies/ml) (cohort 2) during the 12 months after enrolment.

RESULTS

For Cohort 1, the intervention had an estimated incremental cost of US$102.52, an incremental effect of 0.42% fewer deaths and an incremental cost-effectiveness ratio (ICER) of US$24 500 per death averted. For Cohort 2, the intervention had an estimated incremental cost of US$59.48, an incremental effect of 0.47% more undetectable viral loads and an ICER of US$12 584 per undetectable viral load.

CONCLUSIONS

Nurse-led ART was associated with higher mean health service costs than doctor-led care, with small effects on primary outcomes, and a high associated level of uncertainty. Given this, and the shortage of doctors, further implementation of nurse-led ART should be considered, although this may increase health service costs.

Developing appropriate methods for cost-effectiveness analysis of cluster randomized trials

AIM

Cost-effectiveness analyses (CEAs) may use data from cluster randomized trials (CRTs), where the unit of randomization is the cluster, not the individual. However, most studies use analytical methods that ignore clustering. This article compares alternative statistical methods for accommodating clustering in CEAs of CRTs.

METHODS

Our simulation study compared the performance of statistical methods for CEAs of CRTs with 2 treatment arms. The study considered a method that ignored clustering--seemingly unrelated regression (SUR) without a robust standard error (SE)--and 4 methods that recognized clustering--SUR and generalized estimating equations (GEEs), both with robust SE, a "2-stage" nonparametric bootstrap (TSB) with shrinkage correction, and a multilevel model (MLM). The base case assumed CRTs with moderate numbers of balanced clusters (20 per arm) and normally distributed costs. Other scenarios included CRTs with few clusters, imbalanced cluster sizes, and skewed costs. Performance was reported as bias, root mean squared error (rMSE), and confidence interval (CI) coverage for estimating incremental net benefits (INBs). We also compared the methods in a case study.

RESULTS

Each method reported low levels of bias. Without the robust SE, SUR gave poor CI coverage (base case: 0.89 v. nominal level: 0.95). The MLM and TSB performed well in each scenario (CI coverage, 0.92-0.95). With few clusters, the GEE and SUR (with robust SE) had coverage below 0.90. In the case study, the mean INBs were similar across all methods, but ignoring clustering underestimated statistical uncertainty and the value of further research.

CONCLUSIONS

MLMs and the TSB are appropriate analytical methods for CEAs of CRTs with the characteristics described. SUR and GEE are not recommended for studies with few clusters.

Multi-professional clinical medication reviews in care homes for the elderly: study protocol for a randomised controlled trial with cost effectiveness analysis

BACKGROUND

Evidence demonstrates that measures are needed to optimise therapy and improve administration of medicines in care homes for older people. The aim of this study is to determine the clinical and cost effectiveness of a novel model of multi-professional medication review.

METHODS

A cluster randomised controlled trial design, involving thirty care homes. In line with current practice in medication reviews, recruitment and consent will be sought from general practitioners and care homes, rather than individual residents. Care homes will be segmented according to size and resident mix and allocated to the intervention arm (15 homes) or control arm (15 homes) sequentially using minimisation. Intervention homes will receive a multi-professional medication review at baseline and at 6 months, with follow-up at 12 months. Control homes will receive usual care (support they currently receive from the National Health Service), with data collection at baseline and 12 months. The novelty of the intervention is a review of medications by a multi-disciplinary team. Primary outcome measures are number of falls and potentially inappropriate prescribing. Secondary outcome measures include medication costs, health care resource use, hospitalisations and mortality. The null hypothesis proposes no difference in primary outcomes between intervention and control patients. The primary outcome variable (number of falls) will be analysed using a linear mixed model, with the intervention specified as a fixed effect and care homes included as a random effect. Analyses will be at the level of the care home. The economic evaluation will estimate the cost-effectiveness of the intervention compared to usual care from a National Health Service and personal social services perspective.The study is not measuring the impact of the intervention on professional working relationships, the medicines culture in care homes or the generic health-related quality of life of residents.

DISCUSSION

This study will establish the effectiveness of a new model of multi-professional clinical medication reviews in care homes, using novel approaches to recruitment and consent. It is the first study to undertake an examination of direct patient outcomes, together with an economic analysis.

TRIAL REGISTRATION

ISRCTN: ISRCTN90761620.

Statistical methods for cost-effectiveness analyses that use data from cluster randomized trials: a systematic review and checklist for critical appraisal

INTRODUCTION

The best data for cost-effectiveness analyses (CEAs) of group-level interventions often come from cluster randomized trials (CRTs), where randomization is by cluster (e.g., the hospital attended), not by individual.

METHODS

for these CEAs need to recognize both the correlation between costs and outcomes and that these data may be dependent on the cluster. General checklists and methodological guidance for critically appraising CEA ignore these issues. This article develops a new checklist and applies it in a systematic review of CEAs that use CRTs.

METHODS

The authors developed a checklist for CEAs that use CRTs, informed by a conceptual review of statistical methods. This checklist included criteria such as whether the analysis allowed for both clustering and the correlation between individuals' costs and outcomes. The authors undertook a systematic literature review of full economic evaluations that used CRTs. The quality of studies was assessed with the new checklist and by the "Drummond checklist."

RESULTS

The authors identified 62 papers that met the inclusion criteria. On average, studies satisfied 9 of the 10 criteria for the checklist but only 20% of criteria for the new checklist. More than 40% of studies adopted statistical methods that completely ignored clustering, and 75% disregarded any correlation between costs and outcomes. Only 4 studies employed appropriate statistical methods that allowed for both clustering and correlation.

CONCLUSIONS

Most economic evaluations that use data from CRTs ignored clustering or correlation. Statistical methods that address these issues are available, and their use should be encouraged. The new checklist can supplement generic CEA guidelines and highlight where research practice can be improved.

Gonadotropin-releasing hormone antagonist use in controlled ovarian stimulation and intrauterine insemination cycles in women with polycystic ovary syndrome

OBJECTIVE

To observe the effects of ganirelix on controlled ovarian stimulation and intrauterine insemination (COS/IUI) cycles in women with polycystic ovary syndrome (PCOS).

DESIGN

Prospective, randomized, controlled clinical study.

SETTING

An academic clinical research center.

PATIENT(S)

Women with PCOS and anovulatory infertility undergoing COS/IUI.

INTERVENTION(S)

Recombinant FSH therapy was started on day 3. In women assigned to the control group (n = 47), treatment was continued up to the day of hCG administration. In patients assigned to receive GnRH antagonist (n = 42), ganirelix was added when the leading follicle was > or =14 mm.

MAIN OUTCOME MEASURE(S)

Pregnancy rates, serum E(2), P, and LH levels, and follicle numbers at hCG day, prevalence of premature luteinization, and cost of stimulation.

RESULT(S)

Serum E(2), P, and LH levels were significantly lower in the ganirelix group. Although premature luteinization and cycle cancellation was encountered less in the ganirelix group, the pregnancy rates per cycle were similar (15.4% vs. 10.7%). Patients would pay 6,153 dollars more for each pregnancy when using ganirelix.

CONCLUSION(S)

Gonadotropin-releasing hormone antagonist resulted in more monofollicular development, less premature luteinization, and less cycle cancellation in IUI cycles of patients with PCOS; however, the cost of stimulation increased without an improvement in pregnancy rates.

Cost-effectiveness of educational outreach to primary care nurses to increase tuberculosis case detection and improve respiratory care: economic evaluation alongside a randomised trial

OBJECTIVE

To evaluate the cost-effectiveness of an educational outreach intervention to improve primary respiratory care by South African nurses.

METHODS

Cost-effectiveness analysis alongside a pragmatic cluster randomised controlled trial, with individual patient data. The intervention, the Practical Approach to Lung Health in South Africa (PALSA), comprised educational outreach based on syndromic clinical practice guidelines for tuberculosis, asthma, chronic obstructive pulmonary disease, pneumonia and other respiratory diseases. The study included 1999 patients aged 15 or over with cough or difficult breathing, attending 40 primary care clinics staffed by nurses in the Free State province. They were interviewed at first presentation, and 1856 (93%) were interviewed 3 months later.

RESULTS

The intervention increased the tuberculosis case detection rate by 2.2% and increased the proportion of patients appropriately managed (that is, diagnosed with tuberculosis or prescribed an inhaled corticosteroid for asthma or referred with indicators of severe disease) by 10%. It costs the health service $68 more for each extra patient diagnosed with tuberculosis and $15 more for every extra patient appropriately managed. Analyses were most sensitive to assumptions about how long training was effective for and to inclusion of household and tuberculosis treatment costs.

CONCLUSION

This educational outreach method was more effective and more costly than usual training in improving tuberculosis, asthma and urgent respiratory care. The extra cost of increasing tuberculosis case detection was comparable to current costs of passive case detection. The syndromic approach increased cost-effectiveness by also improving care of other conditions. This educational intervention was sustainable, reaching thousands of health workers and hundreds of clinics since the trial.

Handling uncertainty in economic evaluations of patient level data: A review of the use of Bayesian methods to inform health technology assessments

Objectives: Due to potential advantages (e.g., using all available evidence), Bayesian methods have been proposed to assist healthcare decision making. This review provides a detailed description of how Bayesian methods have been applied to economic evaluations of patient level data. The results serve both as a reference and as a means by which to examine the appropriate application of Bayesian methods to inform decision making.

Methods: MEDLINE, EMBASE, and Cochrane Economic Evaluation databases were searched to identify studies, published up to November 2007, meeting three inclusion criteria: (i) the study conducted an economic evaluation, (ii) sampling uncertainty was incorporated using Bayesian methods, (iii) the likelihood function was informed by patient level data from a single source. Data were collected on key study characteristics (e.g., prior distribution, likelihood function, presentation of uncertainty).

Results: The search identified 366 potentially relevant studies, from which 103 studies underwent full-text review. Sixteen studies met the inclusion criteria. Half of the studies used uninformative priors; most studies incorporated the potential dependence between costs and effects, and presented cost-effectiveness acceptability curves. Results were sensitive to changes in the priors and likelihoods.

Conclusions: Limited use of informative priors, among the included studies, gives policy makers little guidance on one of the main benefits of Bayesian methods, the ability to integrate all available evidence to capture the uncertainty inherent in decision making.

Bayesian Hierarchical Models for Cost-Effectiveness Analyses that Use Data from Cluster Randomized Trials

Cost-effectiveness analyses (CEA) may be undertaken alongside cluster randomized trials (CRTs) where randomization is at the level of the cluster (for example, the hospital or primary care provider) rather than the individual. Costs (and outcomes) within clusters may be correlated so that the assumption made by standard bivariate regression models, that observations are independent, is incorrect. This study develops a flexible modeling framework to acknowledge the clustering in CEA that use CRTs. The authors extend previous Bayesian bivariate models for CEA of multicenter trials to recognize the specific form of clustering in CRTs. They develop new Bayesian hierarchical models (BHMs) that allow mean costs and outcomes, and also variances, to differ across clusters. They illustrate how each model can be applied using data from a large (1732 cases, 70 primary care providers) CRT evaluating alternative interventions for reducing postnatal depression. The analyses compare cost-effectiveness estimates from BHMs with standard bivariate regression models that ignore the data hierarchy. The BHMs show high levels of cost heterogeneity across clusters (intracluster correlation coefficient, 0.17). Compared with standard regression models, the BHMs yield substantially increased uncertainty surrounding the cost-effectiveness estimates, and altered point estimates. The authors conclude that ignoring clustering can lead to incorrect inferences. The BHMs that they present offer a flexible modeling framework that can be applied more generally to CEA that use CRTs.

Cost-Effectiveness and Resource Allocation (CERA) - directions for the future

The journal Cost-Effectiveness and Resource Allocation (CERA) is now in its seventh year, and is an excellent example of how open access publishing can improve dissemination. Now the journal is through its infancy, it is time to reflect on its orientation and to define the strategy for the years to come. Firstly, the journal will pay particular attention to stimulating and publishing studies originating from low- and middle-income countries. Second, CERA will continue to solicit contributions originating from high-income countries, but with the caveat that such studies should be of interest to the broad international readership of the journal. Third, the journal encourages submissions on methodological work from any setting, that is generalisable between low-, middle-, and high income countries. Fourth, CERA recognizes the development of national health accounts and expenditure tracking as a first step to improved resource allocation, and solicit manuscripts of this nature. Finally, CERA recognizes that cost and cost-effectiveness analysis alone may not provide sufficient information to decision makers to guide their choices on the allocation of resources, and therefore encourages submission of studies that advance the broader field of priority-setting.

Effectiveness and cost-effectiveness of an educational intervention for practice teams to deliver problem focused therapy for insomnia: rationale and design of a pilot cluster randomised trial

BACKGROUND

Sleep problems are common, affecting over a third of adults in the United Kingdom and leading to reduced productivity and impaired health-related quality of life. Many of those whose lives are affected seek medical help from primary care. Drug treatment is ineffective long term. Psychological methods for managing sleep problems, including cognitive behavioural therapy for insomnia (CBTi) have been shown to be effective and cost effective but have not been widely implemented or evaluated in a general practice setting where they are most likely to be needed and most appropriately delivered. This paper outlines the protocol for a pilot study designed to evaluate the effectiveness and cost-effectiveness of an educational intervention for general practitioners, primary care nurses and other members of the primary care team to deliver problem focused therapy to adult patients presenting with sleep problems due to lifestyle causes, pain or mild to moderate depression or anxiety.

METHODS AND DESIGN

This will be a pilot cluster randomised controlled trial of a complex intervention. General practices will be randomised to an educational intervention for problem focused therapy which includes a consultation approach comprising careful assessment (using assessment of secondary causes, sleep diaries and severity) and use of modified CBTi for insomnia in the consultation compared with usual care (general advice on sleep hygiene and pharmacotherapy with hypnotic drugs). Clinicians randomised to the intervention will receive an educational intervention (2 x 2 hours) to implement a complex intervention of problem focused therapy. Clinicians randomised to the control group will receive reinforcement of usual care with sleep hygiene advice. Outcomes will be assessed via self-completion questionnaires and telephone interviews of patients and staff as well as clinical records for interventions and prescribing.

DISCUSSION

Previous studies in adults have shown that psychological treatments for insomnia administered by specialist nurses to groups of patients can be effective within a primary care setting. This will be a pilot study to determine whether an educational intervention aimed at primary care teams to deliver problem focused therapy for insomnia can improve sleep management and outcomes for individual adult patients presenting to general practice. The study will also test procedures and collect information in preparation for a larger definitive cluster-randomised trial. The study is funded by The Health Foundation.