Is self-care a cost-effective use of resources? Evidence from a randomized trial in inflammatory bowel disease.

OBJECTIVES: To determine if a whole-system approach to self-management in inflammatory bowel disease (IBD), using a guidebook developed with patients and physicians trained in patient-centred care, leads to cost-effective use of health system resources. METHODS: Cost-effectiveness analysis over a one-year time horizon comparing the whole systems self-management approach to treatment with usual treatment. Nineteen hospitals in the northwest England were randomized to the intervention or to be controls; 651 patients (285 at intervention sites and 366 at control sites) with established IBD were included. The economic evaluation related differential health service costs, from a UK NHS perspective, to differences in quality-adjusted life years (QALYs) based on patients' responses to the EQ-5D. RESULTS: The intervention was associated with a mean reduction in costs of 148 pounds sterling per patient and a small mean reduction in QALYs of 0.00022 per patient compared with the control group. This resulted in an incremental cost per QALY gained of 676,417 pounds sterling for treatment as usual and a probability of around 63% that the whole-system approach to self-management is cost-effective, assuming a willingness to pay up to 30,000 pounds sterling for an additional QALY. CONCLUSIONS: Although there is uncertainty associated with these estimates, more widespread use of this method in chronic disease management seems likely to reduce health care costs without evidence of adverse effect on patient outcomes.

Cost-effectiveness of implementing new guidelines for treatment of hypertension in general practice.

BACKGROUND: Hypertension is a major public health concern and, as the population ages, the size of the problem is likely to increase. However, detection rates and treatment of hypertension have been low. The introduction of new guidelines for the detection and treatment of hypertension have been encouraged but without any consideration to their cost-effectiveness. AIM: To assess the potential cost-effectiveness of implementing new guidelines for the treatment of hypertension in general practice. DESIGN OF STUDY: Model examining the incremental costs and effects of the new guidelines compared with the old. SETTING: A large general practice in north Yorkshire. METHOD: Two thousand and twenty-three patients reporting for a new health patient check had the costs and outcomes under the old and new guidelines estimated. RESULTS: Implementing new guidelines for the detection, management, and treatment of hypertension in a primary care setting is more costly than the implementation of previous guidelines, but more effective in reducing the risk of cardiovascular disease. The incremental cost per cardiovascular disease event avoided is ?30 000, although sensitivity analysis shows that the estimate is subject to considerable uncertainty. CONCLUSIONS: Compared with previous guidelines, introducing new guidelines for the management and treatment of hypertension in new patients in general practice is likely to be cost-effective. However, the workforce implications for general practitioners (GPs) and practice nurses should be considered.

Calculation of quality adjusted life years in the published literature: a review of methodology and transparency.

Economic evaluations alongside randomised controlled trials (RCTs) are increasingly being designed to prospectively collect patient-specific resource use and preference-based health status (utility) data. This paper examines the ways in which preference-based health status (utility) data are used to generate quality adjusted life years (QALYs). A literature review was carried out which identified 23 published cost utility analyses suitable for inclusion. The methodology employed to calculate QALYs was not always consistent, as well as being poorly reported. The use of different methodologies in the calculation of QALYs may influence the magnitude and direction of results of evaluations. Analysts need to be consistent and fully transparent in the methodology chosen to calculate QALYs.

Succinic acid adsorption from fermentation broth and regeneration.

More than 25 sorbents were tested for uptake of succinic acid from aqueous solutions. The best resins were then tested for successive loading and regeneration using hot water. The key desired properties for an ideal sorbent are high capacity, complete stable regenerability, and specificity for the product. The best resins have a stable capacity of about 0.06 g of succinic acid/g of resin at moderate concentrations (1-5 g/L) of succinic acid. Several sorbents were tested more exhaustively for uptake of succinic acid and for successive loading and regeneration using hot water. One resin, XUS 40285, has a good stable isotherm capacity, prefers succinate over glucose, and has good capacities at both acidic and neutral pH. Succinic acid was removed from simulated media containing salts, succinic acid, acetic acid, and sugar using a packed column of sorbent resin, XUS 40285. The fermentation byproduct, acetate, was completely separated from succinate. A simple hot water regeneration successfully concentrated succinate from 10 g/L (inlet) to 40-110 g/L in the effluent. If successful, this would lower separation costs by reducing the need for chemicals for the initial purification step. Despite promising initial results of good capacity (0.06 g of succinic/g of sorbent), 70% recovery using hot water, and a recovered concentration of >100 g/L, this regeneration was not stable over 10 cycles in the column. Alternative regeneration schemes using acid and base were examined. Two (XUS 40285 and XFS-40422) showed both good stable capacities for succinic acid over 10 cycles and >95% recovery in a batch operation using a modified extraction procedure combining acid and hot water washes. These resins showed comparable results with actual broth.

Nurse telephone triage for same day appointments in general practice: multiple interrupted time series trial of effect on workload and costs.

OBJECTIVE: To compare the workloads of general practitioners and nurses and costs of patient care for nurse telephone triage and standard management of requests for same day appointments in routine primary care. DESIGN: Multiple interrupted time series using sequential introduction of experimental triage system in different sites with repeated measures taken one week in every month for 12 months. SETTING: Three primary care sites in York. PARTICIPANTS: 4685 patients: 1233 in standard management, 3452 in the triage system. All patients requesting same day appointments during study weeks were included in the trial. MAIN OUTCOME MEASURES: Type of consultation (telephone, appointment, or visit), time taken for consultation, presenting complaints, use of services during the month after same day contact, and costs of drugs and same day, follow up, and emergency care. RESULTS: The triage system reduced appointments with general practitioner by 29-44%. Compared with standard management, the triage system had a relative risk (95% confidence interval) of 0.85 (0.72 to 1.00) for home visits, 2.41 (2.08 to 2.80) for telephone care, and 3.79 (3.21 to 4.48) for nurse care. Mean overall time in the triage system was 1.70 minutes longer, but mean general practitioner time was reduced by 2.45 minutes. Routine appointments and nursing time increased, as did out of hours and accident and emergency attendance. Costs did not differ significantly between standard management and triage: mean difference pound 1.48 more per patient for triage (95% confidence interval -0.19 to 3.15). CONCLUSIONS: Triage reduced the number of same day appointments with general practitioners but resulted in busier routine surgeries, increased nursing time, and a small but significant increase in out of hours and accident and emergency attendance. Consequently, triage does not reduce overall costs per patient for managing same day appointments.

Economic impact of a specialist outreach team in residential and nursing home settings.

BACKGROUND: The results of a randomized controlled trial have indicated that a training and educational programme for staff in nursing or residential homes may result in reductions in levels of depression and levels of cognitive impairment for residents presenting with an active management problem. The training and educational intervention consisted of members of a hospital outreach team who presented a series of 1 hour seminars on topics which staff had indicated would improve their knowledge and skills. AIMS OF THE STUDY: The aim of this study was to present an exploratory analysis of the impact on costs associated with providing an old age psychiatry outreach team giving training and education for staff in nursing and residential homes. METHOD: For the economic study, a societal perspective was employed. Measures of resource use and costs to the health service, social and community services and the nursing and residential homes were analysed for 120 residents from 12 nursing or residential homes, as part of a randomized controlled trial to assess a training package provided in residential and nursing homes. Cost estimates were based on estimates from generalized estimated equations. To allow for clustering effects within homes, the unit of randomization was the home as opposed to the individual. To ensure models were correctly specified, several tests including the Ramsey RESET test were employed. RESULTS: There were no significant differences in the total cost per person in the homes that received the intervention and the control homes. This study has shown that the additional cost of providing the specialist outreach team was likely to be covered by reductions in the use of other resources such as GP visits to nursing and residential homes. Therefore, though the study had limitations, it appeared that improved care could be provided at little or no extra cost. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The evidence presented suggests that the specialist outreach team was unlikely to add to the total cost of caring for residents in nursing and residential homes. This finding combined with the benefits in terms of lower levels of depression and cognitive impairment suggested that the intervention was good value for money. The intervention should be considered for use in other nursing and residential homes.