The primary objective of this study was to determine if decreasing inappropriate preventive tests and increasing appropriate testing performance could offset the cost of an outreach facilitation intervention to improve preventive practice. The significant reduction in inappropriate testing and increase in appropriate testing resulted in net savings of $191,733 per year in 2003 dollars to the government or a return on investment of 40%. The limitations of the cost analysis are typical to this type of economic evaluation [37
]. They include:
• the perspective of the government necessitated not having included all possible costs in the model. For example, the cost for patient time, travel or patient discomfort and anxiety associated with the manoeuvre were not included;
• the total indirect costs associated with hospitalizations averted were not included;
• the estimate of the frequency of downstream events was based on a panel of experts;
• the estimate for screening for cervical cancer was based on a yearly screening rather than once every three years;
• downstream costs were estimated and included in the model for follow-up visits as a result of a false positive test only. Other possible downstream costs such as visits to other allied health professionals or consults to specialists were not included;
• the benefit of inappropriate screening tests for some patients and the associated cost savings have been ignored; and
• rates of delivery for preventive screening tests were from a randomized controlled trial in a HSO setting. Therefore, caution must be used when generalizing the potential cost savings to other settings.
Our cost estimates in this analysis are conservative since patient costs and other downstream costs were not included. Nonetheless, the analysis shows that all of the costs of the outreach facilitator intervention can be recouped as a result of having reduced inappropriate testing and increased appropriate testing for the manoeuvres under study. Similarly, McCowan et. al. were able to show that a facilitation intervention was able to improve primary care asthma management and that the cost savings to the health care system could completely offset the annual salary of one facilitator serving a large number of family physicians [28
]. McCowan's study also included the costs associated with hospital admissions and secondary costs and involved the improvement in treatment of an acute illness and not prevention in primary care. Including the downstream costs associated with inappropriate tests averted for the outreach facilitator intervention has allowed for an additional 35% in estimated cost savings and the inclusion of costs averted associated with appropriate testing has completely offset the cost of outreach facilitation.
The successful outreach facilitator intervention described in this study was a very intensive intervention with each practice being visited an average of 33 times over 18 months. This compares to other successful trials such as Dietrich et. al. [23
] where outreach facilitators visited only 3 times over a three-month period at an average of 120 minutes per visit and Hulscher et. al. [32
] where facilitators visited practices an average of 25 times with an average duration of only 73 minutes. Both of these studies used outreach facilitation to improve preventive practice for a number of different maneuvres. Unfortunately, the cost of outreach facilitation was not included in these less intensive studies.
The cost of an outreach facilitator in our study per year was over $4,497 per physician but resulted in an overall net savings to the government of $3,289 per physician. In comparison, Cockburn et. al. tested an educational outreach facilitator intervention to improve physician smoking cessation counselling performance which cost $A142 in 1992 per practitioner [27
]. However, the facilitator only visited each physician twice at an average of 12 minutes per visit or $A72 per visit and achieved very little in the way of improved outcomes. As a consequence, unsuccessful outreach facilitation was shown to be not cost-effective compared to other alternatives. In our intervention the cost per visit was $590 and nothing after having adjusted for cost savings associated with a successful intervention. Our intervention was targeted at changing the entire practice and not just physician behaviour for a number of preventive measures, and as a result more time was spent on-site and more visits were required. More research is necessary to determine the most appropriate intensity of intervention for a given level of outcome.
The Cochrane Effective Practice and Organization of Care Group has compiled evidence that supports outreach visits combined with additional interventions as effective in improving professional practice and health outcomes [13
]. Our study has demonstrated the effectiveness of outreach facilitation in improving overall preventive care performance. This is the first cost-consequences analysis of an outreach facilitation intervention that we are aware of and we have shown that the savings attributable to the reduction in inappropriate testing and increases in appropriate testing can offset all of the intervention cost and in fact result in a net savings to the government of approximately two dollars for every rostered patient. Further, the sensitivity analysis has revealed that the likelihood of net savings to the government is substantial despite variation in the inputs. However, it has also revealed that the appropriate primary preventive manoeuvres such as vaccination of the elderly contribute more to net savings to the government than some secondary preventive manoeuvres such as Pap testing and mammography. The net savings associated with primary prevention help to cover the net costs to the government associated with secondary prevention. As well, in the case of PSA testing even greater cost savings may be possible by significantly reducing this and other inappropriate tests and the consequent downstream costs.
Filak et. al. [52
] calculated the lifetime charges of office visits, procedures, laboratory tests, and patient purchases required to comply with the US Preventive Services Task Force screening recommendations. They determined that the lifetime charges in 1999 US Dollars for all required preventive services ranged from $5,432.60 to $7,529.60 for men and from $15,307.10 to $18,525.10 for women. If physicians could deliver all the necessary preventive care to their patients, the costs over a lifetime are very reasonable in comparison to all of the costs associated with treating a stage I ($14,000) or stage IV ($64,000) cancer of the breast in a woman over 50 [53
] or a case of pneumonia ($35,700) caused by influenza in a person 65 years old [54
]. The outreach facilitator intervention was effective in improving the uptake of preventive manoeuvres shown to be very cost-effective with the added benefit of reducing preventive manoeuvres that are less cost-effective. If the estimated 9,850 family physicians in Ontario received the benefit of outreach facilitation, the estimated savings to the government equate to $36.3 million (2003 dollars). However, this study involved HSO physicians who may not be representative of all family physicians and research has demonstrated that the intervention does not work in chaotic practices [59