Economic evaluations in community aged care: a systematic review

One and the same or different? An empirical comparison of aged care recipient and non-aged care recipient preferences for quality of aged care amongst older Australians

The Quality of Care Experience Aged Care Consumers (QCE-ACC) is a new preference-based instrument recently adopted by the Australian government nationally as a new quality indicator for aged care. This study employed a discrete choice experiment (DCE) approach to develop an aged care user-specific value set for the QCE-ACC instrument. This is crucial for establishing the relative importance of key QCE-ACC dimensions for informing quality assessment and economic evaluation in aged care. We further empirically compared the preferences of aged care recipients and non-aged care recipients amongst the older Australian population (65 years and above) for quality of care experience using the QCE-ACC. A total of 201 older people (age 74.2 ± 6.2; 59.7% female) receiving aged care services completed the DCE survey between August and September 2022. The comparison of relative importance indicated some divergence in the preferences between the aged care recipients and non-aged care recipients. Amongst aged care recipients, being treated with "Respect & Dignity" was the most important quality of care experience defining dimension, with "Health & Wellbeing" ranked second and "Skills & Training" (of staff) ranked third. However, within non-aged care recipients, "Skills Training" (of staff) was considered the most important quality of care dimension. Distinction in the QCE-ACC utility weights distributions and mean values were also observed, suggesting that aged care recipients may have different opinions about the quality of aged care compared to those who have not accessed aged care services. The findings shed light on the unique preferences of aged care recipients, indicating that aged care recipients and non-aged care recipients' preferences for quality of aged care are not interchangeable. The value set developed in this study is specifically tailored for assessing the quality of aged care using the QCE-ACC instrument from the perspective of aged care users in Australia.

Interventions to Prevent Hospital Admissions in Long-Term Care Facilities: A Rapid Review of Economic Evidence

OBJECTIVES

Hospital admissions can be hazardous for older adults, particularly those living in long-term care facilities. Preventing nonessential admissions can be beneficial for this population, as well as reducing demand on health services. This review summarizes the economic evidence surrounding effective interventions to reduce hospital attendances and admissions for people living in long-term care facilities.

DESIGN

Rapid review of economic evidence.

SETTING AND PARTICIPANTS

People living in long-term facilities.

METHODS

We searched MEDLINE, CINAHL, Cochrane CENTRAL, PubMed, and Web of Science on September 20, 2022, and again on January 10, 2023. Full economic evaluations and cost analyses reporting on advanced care planning, goals of care setting, nurse practitioner input, palliative care, influenza vaccinations, and enhancing access to intravenous therapies were eligible. Data were extracted using a prepiloted data extraction form and critically appraised using either the Drummond-Jefferson checklist or an amended NIH Critical Appraisal Tool appended with questions from a critical appraisal checklist for cost analyses. Data were synthesized narratively.

RESULTS

We included 7 studies: 3 full economic evaluations and 4 cost analyses. Because of lack of clarity on the underlying study design, we did not include one of the cost analyses in our synthesis. Advanced care planning, a palliative care program, and a high-dose influenza vaccination reported potential cost savings. Economic evidence for a multicomponent intervention and a nurse practitioner model was inconclusive. The overall quality of the evidence varied between studies.

CONCLUSIONS AND IMPLICATIONS

A number of potentially cost-effective approaches to reduce demand on hospital services from long-term care facilities were identified. However, further economic evaluations are needed to overcome limitations of the current evidence base and offer more confident conclusions.

Health economics in nursing research: what you need to know to include economic evaluation methodology in your research

Due to limited resources and constant, ever-changing healthcare challenges, health economics is essential to support healthcare decisions while improving health outcomes. Economic evaluation methodology facilitates informed decision-making related to the efficient allocation of resources while positively impacting clinical practice. In this paper, we provide an overview of economic evaluation methods and a real-world example applying one method of economic evaluation (cost-utility analysis) in nursing research.

"I'm On My Own, I Need Support": Needs Assessment of Community Aged Care Services

Introduction

Well-integrated community aged care services empower and enable older people to live and thrive in the community by supporting activities of daily living. To inform integrated community aged care service planning and delivery in South Western Sydney Australia, a needs assessment with consumers (i.e., older people), their caregivers, and healthcare providers was conducted. This study details the comprehensive and inclusive needs assessment process undertaken, with a focus on translating the findings into practice to improve integrated care.

Description

Qualitative interviews and community forum-style focus groups engaged 160 stakeholders including GPs, older people, and aged care workers. Transcribed data were thematically coded using an inductive approach. Data were organised into four themes: 1) access to community aged care services; (2) healthcare and medical needs; (3) social concerns and needs; and (4) education and information needs.

Discussion

The needs assessment undertaken identified unmet needs, gaps in service provision, and recommendations for improving integrated community aged care services.

Conclusion

Findings are novel in the context of South Western Sydney, Australia. The study design, methods employed, and lessons learned can be adapted internationally for future needs assessments to inform policy, strategies, and integrated aged care service delivery.

Valuing the Quality-of-Life Aged Care Consumers (QOL-ACC) Instrument for Quality Assessment and Economic Evaluation

OBJECTIVE

This paper reports on the valuation of the classification system for the Quality-of-Life Aged Care Consumers (QOL-ACC) instrument using a discrete choice experiment (DCE) with duration with a large sample of older people receiving aged care services.

METHODS

A DCE with 160 choice sets of two quality-of-life state-survival duration combinations blocked into 20 survey versions, with eight choice sets in each version, was designed and administered through an on-line survey to older Australians receiving aged care services in home and via interviewer facilitation with older people in residential aged care settings. Model specifications investigating preferences with respect to survival duration and interactions between QOL-ACC dimension levels were estimated. Utility weights were developed, with estimated coefficients transformed to the 0 (being dead) to 1 (full health) scale to generate a value set suitable for application in quality assessment and for the calculation of quality-adjusted life-years for use in economic evaluation.

RESULTS

In total, 953 older people completed the choice experiment with valid responses. The estimation results from econometric model specifications indicated that utility increased with survival duration and decreased according to quality-of-life impairment levels. An Australian value set (range - 0.56 to 1.00) was generated for the calculation of utilities for all QOL-ACC states.

CONCLUSION

The QOL-ACC is unique in its focus on measuring and valuing quality of life from the perspective of older people themselves, thereby ensuring that the preferences of aged care service users are the primary focus for quality assessment and economic evaluation.

Do we agree or disagree? A systematic review of the application of preference-based instruments in self and proxy reporting of quality of life in older people

PURPOSE

Quality of life is an important person-centred outcome in health and aged care settings. Due to an increasing prevalence of cognitive decline and dementia in ageing populations, a proportion of older people receiving health and aged care services may not be able to reliably assess their own quality of life, highlighting the need for proxy assessment. This systematic review sought to investigate the level of agreement between self and proxy-report of older people's quality of life using established preference-based instruments of quality of life suitable for economic evaluation.

METHODS

A systematic review was conducted following PRISMA guidelines. Eight databases were searched: Web of Science, Scopus, Medline, Econlit, PsychINFO, CINAHL, Ageline and Cochrane Library. Information was extracted on the instruments, population samples (including any cognitive thresholds applied), mean scores, type of proxy, and measures of inter-rater agreement.

RESULTS

A total of 50 studies using eight different preference-based quality of life instruments were identified. Most studies were cross-sectional (72%) with a wide variety of cognitive assessments and thresholds applied to define older participants with cognitive impairment. The most common proxies were family members, mostly spouses. The level of agreement between self and proxy-report was generally poor - irrespective of the instrument applied or type of proxy - with proxy-report generally indicating lower levels of quality of life than self-report. There was some evidence of stronger agreement on more observable quality of life domains e.g., physical health and mobility, relative to less observable domains e.g. emotional well-being. Few studies tracked self and/or proxy-report of quality of life longitudinally.

CONCLUSIONS

More research is needed to develop evidence to inform guidance on self-report versus proxy-report of quality of life for older people receiving health and aged care services. Until then, the collection of both self and proxy reports as complementary measures is indicated.

Health economic perspective on a community-based intervention for older people at risk of care dependency – results of a prospective quasi-experimental study

This prospective, quasi-experimental study aims to compare healthcare resource utilization (HCRU) and costs of a multi-component care approach for older people in a community setting (intervention group (IG)) with usual care in a matched control group (CG) during a 21-month observation period. The reablement-oriented intervention included a geriatric assessment, a case and network management and digital supporting tools. Regression models were applied to determine intervention effects regarding hospitalization, total hospital length of stay (LOS), number of physician consultations, and healthcare costs using claims data. 872 subjects were included in the IG and 1,768 in the CG. The analyses showed that the intervention did not affect hospitalization ( OR = 1.153; 95% CI: 0.971–1.369, p = .105). However, participating in the IG lead to a small but significant increase of physician contacts by a factor of 1.078 (Exp( ß) = 1.078; 95% CI: 1.011–1.149; p = .022). A non-significant mean difference in costs of €1,183 (95% CI: €−261.6 to €2,627.6, p = .108) per participant was identified. Further research is needed to generate robust evidence on the optimal design of care approaches for older people and the health economic implications of such interventions to improve care and resource allocation decision-making.

Trial registration: The study was registered at the German Clinical Trials Register (DRKS00027866).

Economic Evaluation of a Reablement Training Program for Homecare Staff Targeting Sedentary Behavior in Community-Dwelling Older Adults Compared to Usual Care: A Cluster Randomized Controlled Trial

Purpose

Training and supporting homecare staff in reablement aims to change staff behavior from “doing for” to “doing with” older adults and is assumed to benefit the health and quality of life of older adults and reduce healthcare utilization and costs. This study evaluated the cost-effectiveness and cost-utility of the staff reablement training program “Stay Active at Home” (SAaH) from a societal perspective.

Participants and Methods

An economic evaluation was embedded in a 12-month cluster randomized controlled trial. Ten Dutch homecare nursing teams participated (n = 313 staff members), of which five teams were trained in reablement and the other five provided usual care. Cost and effect data were collected from 264 older adults at baseline, 6 and 12 months. Costs included “intervention,” “healthcare,” and “patient and family” costs (collectively, societal costs) and were assessed using questionnaires and client records or estimated by bottom-up micro-costing. Effects included sedentary behavior and quality-adjusted life years (QALYs). Multiple imputed bootstrapped data were used to generate cost-effectiveness planes and acceptability curves.

Results

No statistically significant differences were observed between the intervention and control group in terms of sedentary time (adjusted mean difference: \documentclass[12pt]{minimal} \usepackage{wasysym} \usepackage[substack]{amsmath} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage[mathscr]{eucal} \usepackage{mathrsfs} \DeclareFontFamily{T1}{linotext}{} \DeclareFontShape{T1}{linotext}{m}{n} {linotext }{} \DeclareSymbolFont{linotext}{T1}{linotext}{m}{n} \DeclareSymbolFontAlphabet{\mathLINOTEXT}{linotext} \begin{document} $$\beta $$ \end{document} 4.8 minutes [95% CI –26.4, 36.0]), QALYs (\documentclass[12pt]{minimal} \usepackage{wasysym} \usepackage[substack]{amsmath} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage[mathscr]{eucal} \usepackage{mathrsfs} \DeclareFontFamily{T1}{linotext}{} \DeclareFontShape{T1}{linotext}{m}{n} {linotext }{} \DeclareSymbolFont{linotext}{T1}{linotext}{m}{n} \DeclareSymbolFontAlphabet{\mathLINOTEXT}{linotext} \begin{document} $$\beta $$ \end{document} 0.01 [95% CI –0.03, 0.04]), and societal costs (\documentclass[12pt]{minimal} \usepackage{wasysym} \usepackage[substack]{amsmath} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage[mathscr]{eucal} \usepackage{mathrsfs} \DeclareFontFamily{T1}{linotext}{} \DeclareFontShape{T1}{linotext}{m}{n} {linotext }{} \DeclareSymbolFont{linotext}{T1}{linotext}{m}{n} \DeclareSymbolFontAlphabet{\mathLINOTEXT}{linotext} \begin{document} $$\beta $$ \end{document} €2216 [95% CI –459, 4895]), except lower costs for domestic help in the intervention group (\documentclass[12pt]{minimal} \usepackage{wasysym} \usepackage[substack]{amsmath} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage[mathscr]{eucal} \usepackage{mathrsfs} \DeclareFontFamily{T1}{linotext}{} \DeclareFontShape{T1}{linotext}{m}{n} {linotext }{} \DeclareSymbolFont{linotext}{T1}{linotext}{m}{n} \DeclareSymbolFontAlphabet{\mathLINOTEXT}{linotext} \begin{document} $$\beta $$ \end{document} €–173 [95% CI –299, –50]). The probability that SAaH was cost-effective compared to usual care ranged from 7.1% to 19.9%, depending on the willingness-to-pay (WTP) (€0‒€50,000)/minute of sedentary time averted and was 5.9% at a WTP of €20,000/QALY gained.

Conclusion

SAaH did not improve outcomes or reduce costs and was not cost-effective from a societal perspective compared to usual care in Dutch older adults receiving homecare. Consequently, there is insufficient evidence to justify widespread implementation of the training program in its current form.

Trial Registration

ClinicalTrials.gov: NCT03293303.

Effectiveness and cost-effectiveness of a people-centred care model for community-living older people versus usual care ─ A randomised controlled trial

BACKGROUND

There is a need for effective and cost-effective interprofessional care models that support older people to maintain their quality of life (QoL) and physical performance to live longer independently in their own homes.

OBJECTIVES

The objectives were to evaluate effectiveness, QoL and physical performance, and cost-utility of a people-centred care model (PCCM), including the contribution of clinically trained pharmacists, compared with that of usual care in primary care.

METHODS

A randomised controlled trial (RCT) with a two-year follow-up was conducted. The participants were multimorbid community-living older people, aged ≥75 years. The intervention comprised an at-home patient interview, health review, pharmacist-led clinical medication review, an interprofessional team meeting, and nurse-led care coordination and health support. At the baseline and at the 1-year and 2-year follow-ups, QoL (SF-36, 36-Item Short-Form Health Survey) and physical performance (SPPB, Short Performance Physical Battery) were measured. Additionally, a physical dimension component summary in the SF-36 was calculated. The SF-36 data were transformed into SF-6D scores to calculate quality-adjusted life-years (QALYs). Healthcare resource use were collected and transformed into costs. A healthcare payer perspective was adopted. Incremental cost-effectiveness ratio (ICER) was calculated, and one-way sensitivity analysis was performed.

RESULTS

No statistically or clinically significant differences were observed between the usual care (n = 126) and intervention group (n = 151) patients in their QoL; at the 2-year follow-up the mean difference was -0.02, (95 % CI -0.07; 0.04,p = 0.56). While the mean difference between the groups in physical performance at the 2-year follow-up was -1.02, (-1.94;-0.10,p = 0.03), between the physical component summary scores it was -7.3, (-15.2; 0.6,p = 0.07). The ICER was -73 638€/QALY, hence, the developed PCCM dominated usual care, since it was more effective and less costly.

CONCLUSIONS

The cost-utility analysis showed that the PCCM including pharmacist-led medication review dominated usual care. However, it had no effect on QoL and the effect towards physical performance remained unclear.

Longitudinal, Interdisciplinary Home Visits vs. Usual Care for Homebound People with Advanced Parkinson's Disease (IN-HOME-PD): Study protocol for a controlled trial

Background

The current understanding of advanced Parkinson disease (PD) and its treatment is largely based on data from outpatient visits. The most advanced and disabled individuals with PD are disconnected from both care and research. A previous pilot study among older, multimorbid patients with advanced PD demonstrated the feasibility of interdisciplinary home visits to reach the target population, improve care quality, and potentially avoid institutionalization.

Objective

The aim of this study protocol is to investigate whether interdisciplinary home visits can prevent a decline in quality of life of patients with PD and prevent worsening of caregiver strain. The protocol also explores whether program costs are offset by savings in health care utilization and institutionalization compared with usual care.

Methods

In this single-center, controlled trial, 65 patient-caregiver dyads affected by advanced PD (Hoehn and Yahr stages 3-5 and homebound) are recruited to receive quarterly interdisciplinary home visits over 1 year. The 1-year intervention is delivered by a nurse and a research coordinator, who travel to the home, and it is supported by a movement disorder specialist and social worker (both present by video). Each dyad is compared with age-, sex-, and Hoehn and Yahr stage–matched control dyads drawn from US participants in the longitudinal Parkinson’s Outcome Project registry. The primary outcome measure is the change in patient quality of life between baseline and 1 year. Secondary outcome measures include changes in Hoehn and Yahr stage, caregiver strain, self-reported fall frequency, emergency room visits, hospital admissions, and time to institutionalization or death. Intervention costs and changes in health care utilization will be analyzed in a budget impact analysis to explore the potential for model adaptation and dissemination.

Results

The protocol was funded in September 2017 and approved by the Rush Institutional Review Board in October 2017. Recruitment began in May 2018 and closed in November 2019 with 65 patient-caregiver dyads enrolled. All study visits have been completed, and analysis is underway.

Conclusions

To our knowledge, this is the first controlled trial to investigate the effects of interdisciplinary home visits among homebound individuals with advanced PD and their caregivers. This study also establishes a unique cohort of patients from whom we can study the natural course of advanced PD, its treatments, and unmet needs.

Trial Registration

ClinicalTrials.gov NCT03189459; http://clinicaltrials.gov/ct2/show/NCT03189459.

International Registered Report Identifier (IRRID)

PRR1-10.2196/31690

An Outreach Rehabilitation Program for Nursing Home Residents After Hip Fracture May Be Cost-Saving

BACKGROUND

We compared the cost-effectiveness of 10 weeks of outreach rehabilitation (intervention) versus usual care (control) for ambulatory nursing home residents after hip fracture.

METHODS

Enrollment occurred February 2011 through June 2015 in a Canadian metropolitan region. Seventy-seven participants were allocated in a 2:1 ratio to receive a 10-week rehabilitation program (intervention) or usual care (control) (46 intervention; 31 control). Using a payer perspective, we performed main and sensitivity analyses. Health outcome was measured by quality-adjusted life years (QALYs), using the EQ5D, completed at study entry, 3-, 6-, and 12-months. We obtained patient-specific data for outpatient visits, physician claims, and inpatient readmissions; the trial provided rehabilitation utilization/cost data. We estimated incremental cost and incremental effectiveness.

RESULTS

Groups were similar at study entry; the mean age was 87.9 ± 6.6 years, 54 (71%) were female and 58 (75%) had severe cognitive impairment. EQ5D QALYs scores were nonsignificantly higher for intervention participants. Inpatient readmissions were two times higher among controls, with a cost difference of -$3,350/patient for intervention participants, offsetting the cost/intervention participant of $2,300 for the outreach rehabilitation. The adjusted incremental QALYs/patient difference was 0.024 favoring the intervention, with an incremental cost/patient of -$621 for intervention participants; these values were not statistically significant. A sensitivity analysis reinforced these findings, suggesting that the intervention was likely dominant.

CONCLUSION

A 10-week outreach rehabilitation intervention for nursing home residents who sustain a hip fracture may be cost-saving, through reduced postfracture hospital readmissions. These results support further work to evaluate postfracture rehabilitation for nursing home residents.

Developing dimensions for a new preference-based quality of life instrument for older people receiving aged care services in the community

Purpose

To identify the salient quality of life characteristics relevant to older people in receipt of community aged care services in order to develop dimensions for a draft descriptive system for a new preference-based quality of life instrument.

Methods

Forty-one in-depth semi-structured interviews were undertaken with older people (65 years and over) receiving community aged care services across three Australian states to explore quality of life characteristics of importance to them. The data were analysed using framework analysis to extract broader themes which were organised into a conceptual framework. The data were then summarised into a thematic chart to develop a framework matrix which was used to interpret and synthesise the data. Care was taken throughout to retain the language that older people had adopted during the interviews to ensure that appropriate language was used when identifying and developing the quality of life dimensions.

Results

The analysis resulted in the identification of five salient quality of life dimensions: independence, social connections, emotional well-being, mobility, and activities.

Conclusion

This research finds that quality of life for older people accessing aged care services goes beyond health-related quality of life and incorporates broader aspects that transcend health. The findings represent the first stage in a multiphase project working in partnership with older people to develop a new preference-based instrument of quality of life for informing quality assessment and economic evaluation in community aged care. In future work, draft items will be developed from these dimensions and tested in face validity interviews before progressing to further psychometric testing.

The World Health Organization (WHO) approach to healthy ageing

•

The ageing global population is the important medical and social demographic problem.

•

WHO underlines the importance of maintaining functional ability in older age.

•

WHO identified strategic objectives and priorities to promote healthy ageing.

•

Person-oriented long-term integrated care is the key issue.

The ageing of the global population is the most important medical and social demographic problem worldwide. The World Health Organization (WHO) has defined healthy ageing as a process of maintaining functional ability to enable wellbeing in older age. The WHO, Member States and Partners for Sustainable Development Goals have created a Global Strategy and Action Plan for Ageing and Health for 2016–2020 and its continuation with the WHO programme The Decade of Healthy Ageing 2020–2030. The WHO has established main priorities such as supporting country planning and action, collecting better global data and promoting research on healthy ageing, aligning health systems to the needs of older people, laying the foundations and ensuring the human resources necessary for long-term integrated care, undertaking a global campaign to combat ageism, and enhancing the global network for age-friendly cities and communities. There are several reports of coordinated preventive health and social health initiatives in well developed countries. However, there is little evidence on the application of the active ageing frameworks in developing countries. Greater national capacities and closer monitoring of the progress through age-disaggregated data is needed to effectively implement the intended programmes on healthy ageing.

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.