Objective: we estimated the cost-effectiveness of a community falls prevention service compared with usual care from a National Health Service and personal social services perspective over the 12 month trial period.
Design: a cost-effectiveness and cost utility analysis alongside a randomised controlled trial
Participants: people over 60 years of age living at home or in residential care who had fallen and called an emergency ambulance but were not taken to hospital.
Interventions: referral to community fall prevention services or usual health and social care.
Measurements: incremental cost per fall prevented and incremental cost per Quality-Adjusted Life Years (QALYs)
Results: a total of 157 participants (82 interventions and 75 controls) were used to perform the economic evaluation. The mean difference in NHS and personal social service costs between the groups was £-1,551 per patient over 1 year (95% CI: £-5,932 to £2,829) comparing the intervention and control groups. The intervention patients experienced on average 5.34 fewer falls over 12 months (95% CI: −7.06 to −3.62). The mean difference in QALYs was 0.070 (95% CI: −0.010 to 0.150) in favour of the intervention group.
Conclusion: the community falls prevention service was estimated to be cost-effective in this high-risk group. Current Controlled Trials ISRCTN67535605. (controlled-trials.com)
economic evaluation; falls prevention; older people
Background: multifactorial falls prevention programmes for older people have been proved to reduce falls. However, evidence of their cost-effectiveness is mixed.
Design: economic evaluation alongside pragmatic randomised controlled trial.
Intervention: randomised trial of 364 people aged ≥70, living in the community, recruited via GP and identified as high risk of falling. Both arms received a falls prevention information leaflet. The intervention arm were also offered a (day hospital) multidisciplinary falls prevention programme, including physiotherapy, occupational therapy, nurse, medical review and referral to other specialists.
Measurements: self-reported falls, as collected in 12 monthly diaries. Levels of health resource use associated with the falls prevention programme, screening (both attributed to intervention arm only) and other health-care contacts were monitored. Mean NHS costs and falls per person per year were estimated for both arms, along with the incremental cost-effectiveness ratio (ICER) and cost effectiveness acceptability curve.
Results: in the base-case analysis, the mean falls programme cost was £349 per person. This, coupled with higher screening and other health-care costs, resulted in a mean incremental cost of £578 for the intervention arm. The mean falls rate was lower in the intervention arm (2.07 per person/year), compared with the control arm (2.24). The estimated ICER was £3,320 per fall averted.
Conclusions: the estimated ICER was £3,320 per fall averted. Future research should focus on adherence to the intervention and an assessment of impact on quality of life.
cost-effectiveness; accidental falls; screening; comprehensive geriatric assessment; randomised controlled trial; elderly
This study evaluated the cost-effectiveness of multifactorial evaluation and treatment of fall risk factors in community-dwelling older persons at high risk of falling. The intervention and usual care groups did not differ in fall risk or costs. The multifactorial approach was not cost-effective compared to usual care in this group.
International guidelines recommend multifactorial evaluation and tailored treatment of risk factors to reduce falling in older persons. The cost-effectiveness may be enhanced in high-risk persons. Our study evaluates the cost-effectiveness of multifactorial evaluation and treatment of fall risk factors in community-dwelling older persons at high risk of recurrent falling.
An economic evaluation was conducted alongside a randomised controlled trial. Participants (≥65 years) with a high risk of recurrent falling were randomised into an intervention (n = 106) and usual care group (n = 111). The intervention consisted of multifactorial assessment and treatment of fall risk factors. Clinical outcomes were proportions of fallers and utility during 1 year. Costs were measured using questionnaires at 3, 6 and 12 months after baseline and valued using cost prices, if available, and guideline prices. Differences in costs and cost-effectiveness were analysed using bootstrapping. Cost-effectiveness planes and acceptability curves were presented.
During 1 year, 52% and 56% of intervention and usual care participants reported at least one fall, respectively. The clinical outcome measures did not differ between the two groups. The mean costs were Euro 7,740 (SD 9,129) in the intervention group and Euro 6,838 (SD 8,623) in the usual care group (mean difference Euro 902, bootstrapped 95% CI: −1,534 to 3,357). Cost-effectiveness planes and acceptability curves indicated that multifactorial evaluation and treatment of fall risk factors was not cost-effective compared with usual care.
Multifactorial evaluation and treatment of persons with a high risk of recurrent falling was not cost-effective compared to usual care.
Accidental falls; Cost-effectiveness; Multifactorial intervention; Prevention
Borderline personality disorder places a significant burden on healthcare providers and other agencies. This study evaluated the cost-effectiveness of cognitive behavior therapy plus treatment as usual compared to treatment as usual alone for patients with borderline personality disorder. The economic analysis was conducted alongside a multi-center, randomized controlled trial. The costs of primary and secondary healthcare utilization, alongside the wider economic costs, were estimated from medical records and patient self-report. The primary outcome measure used was the quality-adjusted life year (QALY), assessed using EuroQol. On average, total costs per patient in the cognitive behavior therapy group were lower than patients receiving usual care alone (−£689), although this group also reported a lower quality of life (−0.11 QALYs). These differences were small and did not approach conventional levels of statistical significance. The use of cognitive therapy for borderline personality disorder does not appear to demonstrate any significant cost-effective advantage based on the results of this study.
People with Parkinson's disease are twice as likely to be recurrent fallers compared to other older people. As these falls have devastating consequences, there is an urgent need to identify and test innovative interventions with the potential to reduce falls in people with Parkinson's disease. The main objective of this randomised controlled trial is to determine whether fall rates can be reduced in people with Parkinson's disease using exercise targeting three potentially remediable risk factors for falls (reduced balance, reduced leg muscle strength and freezing of gait). In addition we will establish the cost effectiveness of the exercise program from the health provider's perspective.
230 community-dwelling participants with idiopathic Parkinson's disease will be recruited. Eligible participants will also have a history of falls or be identified as being at risk of falls on assessment. Participants will be randomly allocated to a usual-care control group or an intervention group which will undertake weight-bearing balance and strengthening exercises and use cueing strategies to address freezing of gait. The intervention group will choose between the home-based or support group-based mode of the program. Participants in both groups will receive standardized falls prevention advice. The primary outcome measure will be fall rates. Participants will record falls and medical interventions in a diary for the duration of the 6-month intervention period. Secondary measures include the Parkinson's Disease Falls Risk Score, maximal leg muscle strength, standing balance, the Short Physical Performance Battery, freezing of gait, health and well being, habitual physical activity and positive and negative affect schedule.
No adequately powered studies have investigated exercise interventions aimed at reducing falls in people with Parkinson's disease. This trial will determine the effectiveness of the exercise intervention in reducing falls and its cost effectiveness. This pragmatic program, if found to be effective, has the potential to be implemented within existing community services.
The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12608000303347).
Emergency Departments (EDs) are confronted with progressive overcrowding. As a consequence, the workload for ED physicians increases and waiting times go up with the risk of unnecessary complications and patient dissatisfaction. To cope with these problems, Specialized Emergency Nurses (SENs), regular ED-nurses receiving a short, injury-specific course, were trained to assess and treat minor injuries according to a specific protocol.
An economic evaluation was conducted alongside a randomized controlled trial comparing House Officers (HOs) and SENs in their assessment of ankle and foot injuries. Cost prices were established for all parts of healthcare utilization involved. Total costs of health care utilization were computed per patient in both groups. Cost-effectiveness was investigated by comparing the difference in total cost between groups with the difference in sensitivity and specificity between groups in diagnosing fractures and severe sprains. Finally, cost-effectiveness ratios were calculated and presented on a cost-effectiveness plane.
No significant differences were seen between treatment groups for any of the health care resources assessed. However, the waiting times for both first assessment by a treatment officer and time spent waiting between hearing the diagnosis and final treatment were significantly longer in the HO group. There was no statistically significant difference in costs between groups. The total costs were € 186 (SD € 623) for patients in the SEN group and € 153 (SD € 529) for patients in the HO group. The difference in total costs was € 33 (95% CI: – € 84 to € 155). The incremental cost-effectiveness ratio was € 27 for a reduction of one missed diagnosis and € 18 for a reduction of one false negative.
Considering the benefits of the SEN-concept in terms of decreased workload for the ED physicians, increased patient satisfaction and decreased waiting times, SENs appear to be a useful solution to the problem of ED crowding.
To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neck pain.
Economic evaluation alongside a randomised controlled trial.
183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n=60, spinal mobilisation), physiotherapy (n=59, mainly exercise), or general practitioner care (n=64, counselling, education, and drugs).
Main outcome measures
Clinical outcomes were perceived recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques.
The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow up at 52 weeks. The total costs of manual therapy (€447; £273; $402) were around one third of the costs of physiotherapy (€1297) and general practitioner care (€1379). These differences were significant: P<0.01 for manual therapy versus physiotherapy and manual therapy versus general practitioner care and P=0.55 for general practitioner care versus physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care.
Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.
What is already known on this topicThe cost of treating neck pain is considerableMany conservative interventions are available, such as prescription drugs, yet their cost effectiveness has not been evaluatedNo randomised trials of conservative treatment for neck pain have so far included an economic evaluationWhat this study addsManual therapy is more effective and less costly than physiotherapy or care by a general practitioner for treating neck painPatients undergoing manual therapy recovered more quickly than those undergoing the other interventions
Readmissions are costly and have implications for quality of care. Studies have been reported to support effects of transitional care programs in reducing hospital readmissions and enhancing clinical outcomes. However, there is a paucity of studies executing full economic evaluation to assess the cost-effectiveness of these transitional care programs. This study is therefore launched to fill this knowledge gap.
Cost-effectiveness analysis was conducted alongside a randomized controlled trial that examined the effects of a Health-Social Transitional Care Management Program (HSTCMP) for medical patients discharged from an acute regional hospital in Hong Kong. The cost and health outcomes were compared between the patients receiving the HSTCMP and usual care. The total costs comprised the pre-program, program, and healthcare utilization costs. Quality of life was measured with SF-36 and transformed to utility values between 0 and 1.
The readmission rates within 28 (control 10.2%, study 4.0%) and 84 days (control 19.4%, study 8.1%) were significantly higher in the control group. Utility values showed no difference between the control and study groups at baseline (p = 0.308). Utility values for the study group were significantly higher than in the control group at 28 (p < 0.001) and 84 days (p = 0.002). The study group also had a significantly higher QALYs gain (p < 0.001) over time at 28 and 84 days when compared with the control group. The intervention had an 89% chance of being cost-effective at the threshold of £20000/QALY.
Previous studies on transitional care focused mainly on clinical outcomes and not too many included cost as an outcome measure. Studies examining the cost-effectiveness of the post-discharge support services are scanty. This study is the first to examine the cost-effectiveness of a transitional care program that used nurse-led services participated by volunteers. Results have shown that a health-social partnership transitional care program is cost-effective in reducing healthcare costs and attaining QALY gains. Economic evaluation helps to inform funders and guide decisions for the effective use of competing healthcare resources.
Health-social transitional care; Readmission; Cost-effective analysis
OBJECTIVE—To assess the incremental costs and cost effectiveness of implementing a home based muscle strengthening and balance retraining programme that reduced falls and injuries in older women.
DESIGN—An economic evaluation carried out within a randomised controlled trial with two years of follow up. Participants were individually prescribed an exercise programme (exercise group, n=116) or received usual care and social visits (control group, n=117).
SETTING—17 general practices in Dunedin, New Zealand.
PARTICIPANTS—Women aged 80 years and older living in the community and invited by their general practitioner to take part.
MAIN OUTCOME MEASURES—Number of falls and injuries related to falls, costs of implementing the intervention, healthcare service costs resulting from falls and total healthcare service costs during the trial. Cost effectiveness was measured as the incremental cost of implementing the exercise programme per fall event prevented.
MAIN RESULTS—27% of total hospital costs during the trial were related to falls. However, there were no significant differences in health service costs between the two groups. Implementing the exercise programme for one and two years respectively cost $314 and $265 (1995 New Zealand dollars) per fall prevented, and $457 and $426 per fall resulting in a moderate or serious injury prevented.
CONCLUSIONS—The costs resulting from falls make up a substantial proportion of the hospital costs for older people. Despite a reduction in falls as a result of this home exercise programme there was no significant reduction in healthcare costs. However, the results reported will provide information on the cost effectiveness of the programme for those making decisions on falls prevention strategies.
Keywords: falls; exercise; elderly
To evaluate whether exercise treatment based on behavioural graded activity comprising booster sessions is a cost‐effective treatment for patients with osteoarthritis of the hip and/or knee compared with usual care.
An economic evaluation from a societal perspective was carried out alongside a randomised trial involving 200 patients with osteoarthritis of the hip and/or knee. Outcome measures were pain, physical functioning, self‐perceived change and quality of life, assessed at baseline, 13, 39 and 65 weeks. Costs were measured using cost diaries for the entire follow‐up period of 65 weeks. Cost and effect differences were estimated using multilevel analysis. Uncertainty around the cost‐effectiveness ratios was estimated by bootstrapping and graphically represented on cost‐effectiveness planes.
97 patients received behavioural graded activity, and 103 patients received usual care. At 65 weeks, no differences were found between the two groups in improvement with respect to baseline on any of the outcome measures. The mean (95% confidence interval) difference in total costs between the groups was −€773 (−€2360 to €772)—that is, behavioural graded activity resulted in less cost but this difference was non‐significant. As effect differences were small, a large incremental cost‐effectiveness ratio of €51 385 per quality adjusted life year was found for graded activity versus usual care.
This study provides no evidence that behavioural graded activity is either more effective or less costly than usual care. Yielding similar results to usual care, behavioural graded activity seems an acceptable method for treating patients with osteoarthritis of the hip and/or knee.
People with Parkinson’s (PwP) experience frequent and recurrent falls. As these falls may have devastating consequences, there is an urgent need to identify cost-effective interventions with the potential to reduce falls in PwP. The purpose of this economic evaluation is to compare the costs and cost-effectiveness of a targeted exercise programme versus usual care for PwP who were at risk of falling.
One hundred and thirty participants were recruited through specialist clinics, primary care and Parkinson’s support groups and randomised to either an exercise intervention or usual care. Health and social care utilisation and health-related quality of life (EQ-5D) were assessed over the 20 weeks of the study (ten-week intervention period and ten-week follow up period), and these data were complete for 93 participants. Incremental cost per quality adjusted life year (QALY) was estimated. The uncertainty around costs and QALYs was represented using cost-effectiveness acceptability curves.
The mean cost of the intervention was £76 per participant. Although in direction of favour of exercise intervention, there was no statistically significant differences between groups in total healthcare (−£128, 95% CI: -734 to 478), combined health and social care costs (£-35, 95% CI: -817 to 746) or QALYs (0.03, 95% CI: -0.02 to 0.03) at 20 weeks. Nevertheless, exploration of the uncertainty surrounding these estimates suggests there is more than 80% probability that the exercise intervention is a cost-effective strategy relative to usual care.
Whilst we found no difference between groups in total healthcare, total social care cost and QALYs, analyses indicate that there is high probability that the exercise intervention is cost-effective compared with usual care. These results require confirmation by larger trial-based economic evaluations and over the longer term.
Economic evaluation; Cost effectiveness; Parkinson’s; Falls prevention; Rehabilitation
Shoulder complaints are common in primary care and have unfavourable long term prognosis. Our objective was to evaluate the clinical effectiveness of manipulative therapy of the cervicothoracic spine and the adjacent ribs in addition to usual medical care (UMC) by the general practitioner in the treatment of shoulder complaints.
This economic evaluation was conducted alongside a randomized trial in primary care. Included were 150 patients with shoulder complaints and a dysfunction of the cervicothoracic spine and adjacent ribs. Patients were treated with UMC (NSAID's, corticosteroid injection or referral to physical therapy) and were allocated at random (yes/no) to manipulative therapy (manipulation and mobilization). Patient perceived recovery, severity of main complaint, shoulder pain, disability and general health were outcome measures. Data about direct and indirect costs were collected by means of a cost diary.
Manipulative therapy as add-on to UMC accelerated recovery on all outcome measures included. At 26 weeks after randomization, both groups reported similar recovery rates (41% vs. 38%), but the difference between groups in improvement of severity of the main complaint, shoulder pain and disability sustained. Compared to the UMC group the total costs were higher in the manipulative group (€1167 vs. €555). This is explained mainly by the costs of the manipulative therapy itself and the higher costs due sick leave from work. The cost effectiveness ratio showed that additional manipulative treatment is more costly but also more effective than UMC alone. The cost-effectiveness acceptability curve shows that a 50%-probability of recovery with AMT within 6 months after initiation of treatment is achieved at €2876.
Manipulative therapy in addition to UMC accelerates recovery and is more effective than UMC alone on the long term, but is associated with higher costs.
International Standard Randomized Controlled Trial Number Register
Care from a general practitioner (GP) is one of the most frequently utilised healthcare services for people with low back pain and only a small proportion of those with low back pain who seek care from a GP are referred to other services. The aim of this systematic review was to evaluate the evidence on cost-effectiveness of GP care in non-specific low back pain. We searched clinical and economic electronic databases, and the reference list of relevant systematic reviews and included studies to June 2010. Economic evaluations conducted alongside randomised controlled trials with at least one GP care arm were eligible for inclusion. Two reviewers independently screened search results and extracted data. Eleven studies were included; the majority of which conducted a cost-effectiveness or cost-utility analysis. Most studies investigated the cost-effectiveness of usual GP care. Adding advice, education and exercise, or exercise and behavioural counselling, to usual GP care was more cost-effective than usual GP care alone. Clinical rehabilitation and/or occupational intervention, and acupuncture were more cost-effective than usual GP care. One study investigated the cost-effectiveness of guideline-based GP care, and found that adding exercise and/or spinal manipulation was more cost-effective than guideline-based GP care alone. In conclusion, GP care alone did not appear to be the most cost-effective treatment option for low back pain. GPs can improve the cost-effectiveness of their treatment by referring their patients for additional services, such as advice and exercise, or by providing the services themselves.
Low back pain; Cost-effectiveness analysis; Primary health care; Systematic review
Shoulder problems are a common complaint of the musculoskeletal system. Physical therapists treat these patients with different modalities such as exercise, massage, and shoulder taping. Although different techniques have been described, the effectiveness of taping has not yet been established. The aim of this study is to assess the effectiveness and cost-effectiveness of usual physical therapy care in combination with a particular tape technique for subacromial impingement syndrome of the shoulder compared to usual physical therapy care without this tape technique in a primary healthcare setting.
Methods and design
An economic evaluation alongside a randomized controlled trial will be conducted. A sample of 140 patients between 18 and 65 years of age with a diagnosis of subacromial impingement syndrome (SAIS) as assessed by physical therapists will be recruited. Eligible patients will be randomized to either the intervention group (usual care in combination with the particular tape technique) or the control group (usual care without this tape technique). In both groups, usual care will consist of individualized physical therapy care. The primary outcomes will be shoulder-specific function (the Simple Shoulder Test) and pain severity (11-point numerical rating scale). The economic evaluation will be performed using a societal perspective. All relevant costs will be registered using cost diaries. Utilities (Quality Adjusted Life Years) will be measured using the EuroQol. The data will be collected at baseline, and 4, 12, and 26 weeks follow-up.
This pragmatic study will provide information about the effectiveness and cost-effectiveness of taping in patients presenting with clinical signs of SAIS.
Trial registration number: NTR2575
There is insufficient evidence to determine whether acupuncture is a cost-effective treatment for irritable bowel syndrome. The objective of this study is to assess the cost-effectiveness of acupuncture as an adjunct to usual care versus usual care alone for the treatment of Irritable Bowel Syndrome (IBS).
Cost-utility analysis conducted alongside a pragmatic, multicentre, randomised controlled trial. 233 patients with irritable bowel syndrome were randomly allocated to either acupuncture plus usual care, or usual care alone. Cost-effectiveness outcomes are expressed in terms of incremental cost per quality adjusted life year (QALY) at one year after randomisation. Costs were estimated from the UK National Health Service perspective for a time horizon of one year. Cost-utility ratios were estimated based on complete case analysis for the base case analysis, where only patients with available EQ-5D and cost data were included. Sensitivity analyses comprised a multiple imputation approach for missing data and a subgroup analysis for the more severe cases of IBS.
The base case analysis showed acupuncture to be marginally more effective than usual care (gain of 0.0035 QALYs, 95% CI: -0.00395 to 0.0465) and more expensive (incremental cost of £218 per patient (95% CI: 55.87 to 492.87) resulting in an incremental cost-effectiveness ratio of approximately £62,500. Sensitivity analysis using multiple imputation for missing data resulted in acupuncture appearing less effective and more costly than usual care, so usual care is dominant. Subgroup analysis selecting the most severe cases of IBS (Symptom Severity Score of over 300) suggested that acupuncture may be a cost-effective treatment option for this group, with a cost-per-QALY of £6,500.
Acupuncture as an adjunct to usual care is not a cost-effective option for the whole IBS population; however it may be cost-effective for those with more severe irritable bowel syndrome.
Current Controlled Trials ISRCTN08827905
Acupuncture; Irritable bowel syndrome; Economic evaluation; Health technology assessment; Quality of life
Objective To compare the cost effectiveness of social behaviour and network therapy, a new treatment for alcohol problems, with that of the proved motivational enhancement therapy.
Design Cost effectiveness analysis alongside a pragmatic randomised trial.
Setting Seven treatment sites around Birmingham, Cardiff, and Leeds.
Participants 742 clients with alcohol problems; 617 (83.2%) were interviewed at 12 months and full economic data were obtained on 608 (98.5% of 617).
Main economic measures Quality adjusted life years (QALYs), costs of trial treatments, and consequences for public sector resources (health care, other alcohol treatment, social services, and criminal justice services).
Results Both therapies saved about five times as much in expenditure on health, social, and criminal justice services as they cost. Neither net savings nor cost effectiveness differed significantly between the therapies, despite the average cost of social behaviour and network therapy (£221; $385; €320) being significantly more than that of motivational enhancement therapy (£129). If a QALY were worth £30 000, then the motivational therapy would have 58% chance of being more cost effective than the social therapy, and the social therapy would have 42% chance of being more cost effective than the motivational therapy.
Conclusion Participants reported highly significant reductions in drinking and associated problems and costs. The novel social behaviour and network therapy did not differ significantly in cost effectiveness from the proved motivational enhancement therapy.
The objective of this study was to evaluate the cost-effectiveness of a Multidisciplinary Integrated Care (MIC) model compared to Usual Care (UC) in Dutch residential homes.
The economic evaluation was conducted from a societal perspective alongside a 6 month, clustered, randomized controlled trial involving 10 Dutch residential homes. Outcome measures included a quality of care weighted sum score, functional health (COOP WONCA) and Quality Adjusted Life-Years (QALY). Missing cost and effect data were imputed using multiple imputation. Bootstrapping was used to analyze differences in costs and cost-effectiveness.
The quality of care sum score in MIC was significantly higher than in UC. The other primary outcomes showed no significant differences between the MIC and UC. The costs of providing MIC were approximately €225 per patient. Total costs were €2,061 in the MIC group and €1,656 for the UC group (mean difference €405, 95% −13; 826). The probability that the MIC was cost-effective in comparison with UC was 0.95 or more for ceiling ratios larger than €129 regarding patient related quality of care. Cost-effectiveness planes showed that the MIC model was not cost-effective compared to UC for the other outcomes.
Clinical effect differences between the groups were small but quality of care was significantly improved in the MIC group. Short term costs for MIC were higher. Future studies should focus on longer term economic and clinical effects.
To conduct an economic evaluation of the Enabling Self-Management and Coping with Arthritic Knee Pain through Exercise (ESCAPE-knee pain) program.
Alongside a clinical trial, we estimated the costs of usual primary care and participation in ESCAPE-knee pain delivered to individuals (Indiv-rehab) or groups of 8 participants (Grp-rehab). Information on resource use and informal care received was collected during face-to-face interviews. Cost-effectiveness and cost-utility were assessed from between-group differences in costs, function (primary clinical outcome), and quality-adjusted life years (QALYs). Cost-effectiveness acceptability curves were constructed to represent uncertainty around cost-effectiveness.
Rehabilitation (regardless of whether Indiv-rehab or Grp-rehab) cost £224 (95% confidence interval [95% CI] £184, £262) more per person than usual primary care. The probability of rehabilitation being more cost-effective than usual primary care was 90% if decision makers were willing to pay £1,900 for improvements in functioning. Indiv-rehab cost £314/person and Grp-rehab £125/person. Indiv-rehab cost £189 (95% CI £168, £208) more per person than Grp-rehab. The probability of Indiv-rehab being more cost-effective than Grp-rehab increased as willingness to pay (WTP) increased, reaching 50% probability at WTP £5,500. The lack of differences in QALYs across the arms led to lower probabilities of cost-effectiveness based on this outcome.
Provision of ESCAPE-knee pain had small cost implications, but it was more likely to be cost-effective in improving function than usual primary care. Group rehabilitation reduces costs without compromising clinical effectiveness, increasing probability of cost-effectiveness.
Economic evaluation; Rehabilitation; Knee pain
It is under debate whether healthcare costs related to death and in life years gained (LysG) due to life saving interventions should be included in economic evaluations. We estimated the impact of including these costs on cost-effectiveness of cancer screening. We obtained health insurance, home care, nursing homes, and mortality data for 2.1 million inhabitants in the Netherlands in 1998–1999. Costs related to death were approximated by the healthcare costs in the last year of life (LastYL), by cause and age of death. Costs in LYsG were estimated by calculating the healthcare costs in any life year. We calculated the change in cost-effectiveness ratios (CERs) if unrelated healthcare costs in the LastYL or in LYsG would be included. Costs in the LastYL were on average 33% higher for persons dying from cancer than from any cause. Including costs in LysG increased the CER by €4040 in women, and by €4100 in men. Of these, €660 in women, and €890 in men, were costs in the LastYL. Including unrelated healthcare costs in the LastYL or in LYsG will change the comparative cost-effectiveness of healthcare programmes. The CERs of cancer screening programmes will clearly increase, with approximately €4000. However, because of the favourable CER's, including unrelated healthcare costs will in general have limited policy implications.
cost-effectiveness; economic evaluation; screening
Stroke is a common and costly condition where an effective early reatment may be expected to affect patients’ future quality of life, the cost of acute medical treatment, and the cost of rehabilitation and any supportive care needed for their remaining lifetime. To assist in informing discussions on early adoption of potential treatments, economic analyses should accompany investigations that seek to improve outcomes for stroke patients.
The primary aim is to assess whether IV/IA rt-PA therapy is cost-effective at 3 months compared to IV rt-PA, and provides cost-savings or is cost-neutral by 12 months.
Cost-effectiveness of the two treatment arms will be measured at months 3, 6, 9, and 12. Cost-effectiveness will be calculated using 1) standard cost-effectiveness methodology (Incremental Cost-Effectiveness Ratios), and 2) an econometric model to assess multiple outcome measures while controlling for multiple subject and treatment-related factors that are known to affect both outcomes and costs.
Total cost for the initial hospitalization of treating stroke subjects randomized to either IV/IA or IV rt-PA treatment arms will be measured, as will differences in types of resource utilization over 12 months between the two arms of the trial. Quality-of-life data (EuroQol EQ-5D) will be collected over a 12-month period and quality adjusted life years (QALYs) will be used as a morbidity-adjusted measure of effectiveness. Subgroup analyses will include dichotomized NIH Stroke Scale (<20, ≥20), country, time between onset and randomization, and IA devices.
Economic Evaluation; Quality of Life; Cost-effectiveness; Resource Utilization
Estimates of cost and cost-effectiveness are typically based on a limited number of small-scale studies with no investigation of the existence of economies to scale or intra-country variation in cost and cost-effectiveness. This information gap hinders the efficient allocation of health care resources and the ability to generalize estimates to other settings. The current study investigates the intra-country variation in the cost and cost-effectiveness of nationwide school-based treatment of helminth (worm) infection in Uganda. Programme cost data were collected through semi-structured interviews with districts officials and from accounting records in six of the 23 intervention districts. Both financial and economic costs were assessed. Costs were estimated on the basis of cost in US$ per schoolchild treated and an incremental cost effectiveness ratio (cost in US$ per case of anaemia averted) was used to evaluate programme cost-effectiveness. Sensitivity analysis was performed to assess the effect of discount rate and drug price. The overall economic cost per child treated in the six districts was US$ 0.54 and the cost-effectiveness was US$ 3.19 per case of anaemia averted. Analysis indicated that estimates of both cost and cost-effectiveness differ markedly with the total number of children which received treatment, indicating economies of scale. There was also substantial variation between districts in the cost per individual treated (US$ 0.41-0.91) and cost per anaemia case averted (US$ 1.70-9.51). Independent variables were shown to be statistically associated with both sets of estimates. This study highlights the potential bias in transferring data across settings without understanding the nature of observed variations.
cost analysis; cost-effectiveness; economic evaluation; variation; scaling up; helminth control; Uganda
To determine whether, from a healthcare perspective, a specific occupational health intervention is cost effective in reducing sickness absence when compared with usual care in occupational health in workers with high risk of sickness absence.
Economic evaluation alongside a randomised controlled trial. 418 workers with high risk of sickness absence from one corporation were randomised to intervention (n = 209) or to usual care (n = 209). The subjects in the intervention group were invited to occupational health service for a consultation. The intervention included, if appropriate, a referral to specialist treatment. Register data of sickness absence were available for 384 subjects and questionnaire data on healthcare costs from 272 subjects. Missing direct total cost data were imputed using a two-part regression model. Primary outcome measures were sickness absence days and direct healthcare costs up to 12 months after randomisation. Cost effectiveness (CE) was expressed as an incremental CE ratio, CE plane and CE acceptability curve with both available direct total cost data and missing total cost data imputed.
After one year, the mean of sickness absence was 30 days in the usual care group (n = 192) and 11 days less (95% CI 1 to 20 days) in the intervention group (n = 192). Among the employees with available cost data, the mean days of sickness absence were 22 and 24, and the mean total cost €974 and €1049 in the intervention group (n = 134) and in the usual care group (n = 138), respectively. The intervention turned out to be dominant—both cost saving and more effective than usual occupational health care. The saving was €43 per sickness absence day avoided with available direct total cost data, and €17 with missing total cost data imputed.
One year follow-up data show that occupational health intervention for workers with high risk of sickness absence is a cost effective use of healthcare resources.
As studies evaluating substitution of care have revealed only limited evidence on cost-effectiveness, a trial was conducted to evaluate nurse practitioners as a first point of contact in Dutch general practices.
To estimate costs of GP versus nurse practitioner consultations from practice and societal perspectives.
Design of study
An economic evaluation was conducted alongside a randomised controlled trial between May and October 2006, wherein 12 nurse practitioners and 50 GPs working in 15 general practices (study practices) participated. Consultations by study practices were also compared with an external reference group, with 17 GPs working in five general practices without the involvement of nurse practitioners.
Direct costs within the healthcare sector included resource use, follow-up consultations, length of consultations, and salary costs. Costs outside the healthcare sector were productivity losses. Sensitivity analyses were performed.
Direct costs were lower for nurse practitioner consultations than for GP consultations at study practices. This was also the case for direct costs plus costs from a societal perspective for patients aged <65 years. Direct costs of consultations at study practices were lower than those of reference practices, while practices did not differ for direct costs plus costs from a societal perspective for patients aged <65 years. Cost differences are mainly caused by the differences in salary.
By involving nurse practitioners, substantial economic ‘savings’ could be used for redesigning primary care, to optimise the best skill mix, and to cover the full range of primary care activities.
general practitioner; cost analysis; nurse practitioner; randomised controlled trial
Objectives: To estimate the cost effectiveness of on-site antenatal syphilis screening and treatment in Mwanza, Tanzania. To compare this intervention with other antenatal and child health interventions, specifically the prevention of mother to child transmission of HIV (PMTCT).
Methods: The economic costs of adding the intervention to routine antenatal care were assessed. Cost effectiveness (CE) ratios of the intervention were obtained for low birth weight (LBW) live births and stillbirths averted and cost per DALY saved. Cost per DALY saved was also estimated for previous CE studies of syphilis screening. The CE of the intervention at different syphilis prevalence rates was modelled.
Results: The economic cost of the intervention is $1.44 per woman screened, $20 per woman treated, and $187 per adverse birth outcome averted. The cost per DALY saved is $110 with LBW as the only adverse outcome. When including stillbirth, this estimate improves 10-fold to $10.56 per DALY saved. The cost per DALY saved from all syphilis screening studies ranged from $3.97 to $18.73.
Conclusions: Syphilis screening is shown to be at least as cost effective as PMTCT and more cost effective than many widely implemented interventions. There is urgent need for scaling up syphilis screening and treatment in high prevalence areas. The CE of screening interventions is highly dependent on disease prevalence. In combination, PMTCT and syphilis screening and treatment interventions may achieve economies of scope and thus improved efficiency.
Objective To assess the cost effectiveness of adding spinal manipulation, exercise classes, or manipulation followed by exercise (“combined treatment”) to “best care” in general practice for patients consulting with low back pain.
Design Stochastic cost utility analysis alongside pragmatic randomised trial with factorial design.
Setting 181 general practices and 63 community settings for physical treatments around 14 centres across the United Kingdom.
Participants 1287 (96%) of 1334 trial participants.
Main outcome measures Healthcare costs, quality adjusted life years (QALYs), and cost per QALY over 12 months.
Results Over one year, mean treatment costs relative to “best care” were £195 ($360; €279; 95% credibility interval £85 to £308) for manipulation, £140 (£3 to £278) for exercise, and £125 (£21 to £228) for combined treatment. All three active treatments increased participants' average QALYs compared with best care alone. Each extra QALY that combined treatment yielded relative to best care cost £3800; in economic terms it had an “incremental cost effectiveness ratio” of £3800. Manipulation alone had a ratio of £8700 relative to combined treatment. If the NHS was prepared to pay at least £10 000 for each extra QALY (lower than previous recommendations in the United Kingdom), manipulation alone would probably be the best strategy. If manipulation was not available, exercise would have an incremental cost effectiveness ratio of £8300 relative to best care.
Conclusions Spinal manipulation is a cost effective addition to “best care” for back pain in general practice. Manipulation alone probably gives better value for money than manipulation followed by exercise.