Economic evaluation of an integrated care programme for patients with hand dermatitis.

BACKGROUND: Hand dermatitis has a large impact on society as a whole. OBJECTIVES: To evaluate the cost-effectiveness of integrated, multidisciplinary care as compared with usual care (UC) for patients with moderate to severe chronic hand dermatitis after 52 weeks. METHODS: Patients (n = 196) visiting the dermatology department at one of the participating hospitals for hand dermatitis were randomized to integrated care (IC) or UC. IC was provided by a multidisciplinary team, and integrated clinical and occupational care to optimize treatment of hand dermatitis. Effect outcomes were clinical assessment of hand dermatitis with the Hand Eczema Severity Index (HECSI), and disease-specific quality of life, work performance and quality-adjusted life-years with the EQ-5D. Incremental cost-effectiveness ratios (ICERs) were calculated. The ICER indicates the additional investment needed to gain one unit of effect. RESULTS: The HECSI difference between both groups after 52 weeks was 8.7 (standard error 5.3, 95% confidence interval -1.8-18.9). No differences were found on secondary outcome measures. Mean total costs with IC (€ 3613; SD 798) were significantly higher than with UC (€ 1576, SD 430). The ICER for improvement in HECSI score was -247. IC was not considered to be cost-effective as compared with UC. The probability that IC was cost-effective was 90% at a ceiling ratio of € 1500 per additional point improvement in HECSI score. CONCLUSION: Integrated care was neither cost-effective, nor effective after 12 months follow-up, in contrast to our findings after 6 months. Decision makers should decide whether the clinical benefits of integrated care on the short term outweigh the higher costs compared to usual care.

A simple tool with which to study the course of chronic hand eczema in clinical practice: a reduced-item score.

BACKGROUND: Physicians need a simple, disease-specific tool with which to assess disease severity and the effect of therapeutic intervention in patients with chronic hand eczema. The currently available clinical scoring systems include numerous items, which makes them laborious to complete and limit their use in daily practice. OBJECTIVE: To develop a simple tool with which to assess disease severity of patients with chronic hand eczema. METHODS: We evaluated two tools, the Hand Eczema Severity Index (HECSI) and the Hand Eczema Area and Severity score, to determine their ability to predict the Investigator's Global Assessment (IGA) of disease severity in patients with moderate to severe hand eczema. We used a stepwise reduction analysis to determine a minimal set of significantly contributing items for predicting IGA. RESULTS: A three-item score, based on the highest observed value of induration, fissuring, and scaling, predicted IGA with a correlation of 0.667. The HECSI predicted the IGA with a correlation of 0.675. CONCLUSION: On the basis of this analysis, we propose a simple tool for clinical decision-making and evaluation of therapeutic intervention in daily practice.

The effectiveness of integrated care for patients with hand eczema: results of a randomized, controlled trial.

OBJECTIVES: To evaluate the effectiveness of integrated, multidisciplinary care as compared with usual care for patients with moderate to severe, chronic hand eczema after 26 weeks of follow-up. BACKGROUND: This study was designed as a randomized, controlled trial. METHODS: Patients who visited one of the participating hospitals were randomized to integrated care or usual care. Integrated care was carried out by a multidisciplinary team, and integrated clinical and occupational care to optimize treatment, and the patient's quality of life and social functioning. Outcome variables were clinical assessment of hand eczema with the Hand Eczema Severity Index (HECSI) (primary outcome), quality of life, patient's global assessment of hand eczema, and sick leave. RESULTS: Average improvement on the HECSI was 22.4 points in the intervention group and 11.7 points in the control group. The mean difference in improvement on the HECSI between both groups after 26 weeks was 10.7 points in favour of the integrated care group (standard error 5.3, 95% confidence interval 0.3-21.1, p = 0.044). No differences in improvement between the groups were found for any of the other outcomes. CONCLUSIONS: The integrated care programme significantly improved clinical outcome measures as compared with usual care, and was effective for treating patients with chronic hand eczema.

Process evaluation of an integrated, multidisciplinary intervention programme for hand eczema.

UNLABELLED: BACKGROUND. Over the last decade, few randomized controlled trials of high methodological quality have been carried out to evaluate the effectiveness of interventions for patients with hand eczema. Little to no attention has been paid to the feasibility of these interventions. This process evaluation was carried out to gain insight in the barriers to and facilitators for implementation of an intervention for hand eczema. The aims of this process evaluation were to examine the feasibility and the satisfaction of the patients and the professionals with the integrated care programme, and the perceived barriers to and facilitators for the use of the programme. METHODS: Eligible for this study were patients with moderate to severe chronic hand eczema who completed the integrated care programme. This programme is an intervention provided by a multidisciplinary team, consisting of a dermatologist, a specialized nurse, and a clinical occupational physician. Data were collected from the patients and the healthcare professionals, by means of semistructured telephone interviews, questionnaires, and a patient tracking system. Implementation, satisfaction and expectations were investigated. RESULTS: Ninety-three patients completed the integrated care programme. Compliance with the integrated care programme was good. The results indicate good satisfaction of both patients and healthcare professionals with the integrated care programme. However, with regard to the process and feasibility of the integrated care programme, there is room for improvement. The clinical occupational physician was only involved in a very limited number of cases, the protocol was not flexible, and the intervention period was too compact. Most of the perceived barriers in the present study are at the organizational level. CONCLUSION: Satisfaction with the integrated care programme was high among both patients and healthcare professionals. The involvement of the clinical occupational physician in the treatment, when indicated, should be optimized. With the multidisciplinary approach and good communication as a basis for the programme, and a more flexible protocol to avoid unnecessary consultations by the healthcare professionals, integrated care could be a useful treatment from a process evaluation perspective.

Effectiveness of prevention programmes for hand dermatitis: a systematic review of the literature.

Hand dermatitis is a prevalent disease with an episodic, chronic character. The use of medical resources is high and is often related to reduced (work) functioning. The burden is therefore high for patients and society. Management of hand dermatitis is often unsatisfactory, and for this reason prevention is important. The effectiveness of prevention programmes is, however, unknown. This study evaluates if comprehensive prevention programmes for hand dermatitis, that include worker education as an element, are effective on occurrence, adherence to preventive measures, clinical outcomes and costs compared to usual care or no intervention. The literature was systematically searched using PubMed and Embase, from the earliest to January 2010 for relevant citations. The methodological quality was assessed by two reviewers using the Cochrane criteria. The GRADE approach was used to determine the level of evidence. After reading the full text articles, 7 publications met our inclusion criteria. We found that there is moderate evidence for the effect of prevention programmes on lowering occurrence and improving adherence to preventive measures, and low evidence for the effect on improving clinical outcomes and self-reported outcomes. No studies reporting on costs were found. It can be concluded that there is moderate evidence for the effectiveness of prevention programmes of hand dermatitis versus usual care or no intervention. However, more high quality studies including cost-effectiveness are needed.

Integrated, multidisciplinary care for hand eczema: design of a randomized controlled trial and cost-effectiveness study.

BACKGROUND: The individual and societal burden of hand eczema is high. Literature indicates that moderate to severe hand eczema is a disease with a poor prognosis. Many patients are hampered in their daily activities, including work. High costs are related to high medical consumption, productivity loss and sick leave. Usual care is suboptimal, due to a lack of optimal instruction and coordination of care, and communication with the general practitioner/occupational physician and people involved at the workplace. Therefore, an integrated, multidisciplinary intervention involving a dermatologist, a care manager, a specialized nurse and a clinical occupational physician was developed. This paper describes the design of a study to investigate the effectiveness and cost-effectiveness of integrated care for hand eczema by a multidisciplinary team, coordinated by a care manager, consisting of instruction on avoiding relevant contact factors, both in the occupational and in the private environment, optimal skin care and treatment, compared to usual, dermatologist-led care. METHODS: The study is a multicentre, randomized, controlled trial with an economic evaluation alongside. The study population consists of patients with chronic, moderate to severe hand eczema, who visit an outpatient clinic of one of the participating 5 (three university and two general) hospitals. Integrated, multidisciplinary care, coordinated by a care manager, including allergo-dermatological evaluation by a dermatologist, occupational intervention by a clinical occupational physician, and counselling by a specialized nurse on optimizing topical treatment and skin care will be compared with usual care by a dermatologist. The primary outcome measure is the cumulative difference in reduction of the clinical severity score HECSI between the groups. Secondary outcome measures are the patient's global assessment, specific quality of life with regard to the hands, generic quality of life, sick leave and patient satisfaction. An economic evaluation will be conducted alongside the RCT. Direct and indirect costs will be measured. Outcome measures will be assessed at baseline and after 4, 12, 26 and 52 weeks. All statistical analyses will be performed on the intention-to-treat principle. In addition, per protocol analyses will be carried out. DISCUSSION: To improve societal participation of patients with moderate to severe hand eczema, an integrated care intervention was developed involving both person-related and environmental factors. Such integrated care is expected to improve the patients' clinical signs, quality of life and to reduce sick leave and medical costs. Results will become available in 2011.