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WP6 Effectiveness of Intervention

Assessment of effectiveness of the intervention

Workpackage leader - University Of Birmingham (BHAM), United Kingdom

 

Objectives

The aim of this workpackage is to assess the impact of the model and training modules in different settings.

 

Description of work and role of participants

Activities

This workpackage comprises the following activities:

  • Assessment of effectiveness of the tools:  Assessment of the clinical and educational impact of hand off the identified intervention strategies, as laid down in the communication model and subsequent tools, on patient welfare.
  • Cost effectiveness study: Assessment of the financial impact of hand off the identified intervention strategies, as laid down in the communication model and subsequent tools, on patient welfare.

This WP aims to generate economic evidence to inform policy and practice about the costs of ineffective handoffs and to estimate the economic impact of tools to effect handoff processes. The work described above will identify opportunities for improvement and this in turn will prompt the development of targeted interventions to benefit continuity of clinical care.  Some interventions may be cost-free, but others will require upfront resources, for example in staff time.  Such interventions may be cost releasing, and even if not they may still be cost-effective.  However, this cannot be taken for granted – opportunity cost may outweigh benefits.  For this reason we will measure the resource implications of interventions and offset these against potential gains (of a financial or health related type). 
In the conventional health economic analysis a cost utility or cost benefit calculation would be carried out on the basis of measured effectiveness – for example the upfront costs (i.e. the costs of the intervention itself) could be analysed in relation to costs saved (perhaps due to a lower risk of readmission) and mobility and mortality avoided.  However, in this study we will establish ‘proof of principle’ rather than direct comparative measurements of downstream costs and clinical effectiveness measurements.  Direct measurements of plausible differences in mortality and morbidity would be imprecise unless extremely large and expensive cluster studies could be done.  We will approach this problem of a lack of direct comparative evidence by:

1.Measuring upfront costs (i.e. costs of implementation);

2.Determining how effective the intervention would have to be, given these costs, to make it cost-effective (at various national thresholds for willingness to pay for a unit of health benefit);

3.Eliciting expert opinion on the expected effectiveness of interventions, using methods described below.  This will allow cost effectiveness to be modelled against expected effectiveness.


Methods

1.Intervention (up-front) costs will be measured.  Given different cost structures in different countries and over time we will enumerate and publish resources consumed.  This will enable our results to be extrapolated over space and time.  We will also convert the documented resource requirements to costs in the different participating countries according, for example, to the cost of health service staff of relevant types.  In many instances this will require careful direct observation of staff involved in handovers under conventional circumstances and under intervention conditions.  The latter will be based on pilot ‘proof of principle’ studies of the interventions.

2.We will then calculate how effective an intervention would need to be to justify intervention costs.  For example, an intervention that consumed a mean of 5% of the time of a nurse costing 50,000 euros per year to employ, would repay the investment if this yielded a gain of one additional life year every nine years (at the English threshold of about 45,000 euros per healthy life year).  Similarly, the investment would break even at one 5-day re-admission averted per year, assuming a mean cost of about 500 euros per day, for hospital care.

3.We will then ask a series of experts to provide their best judgement about effectiveness.  First we will ascertain the dimensions of improvement that they would expect.  The experts would consist of five risk managers, senior ward physicians, community physicians and hospital physicians who will be interviewed in each country.  They will first be introduced to the results of existing world literature on this topic and the nature of this intervention and the results of proof of principle studies will be described.  Then they will be asked to state the dimensions of improvement they would expect for various interventions – reduced bed days, morbidities and mortality avoided.  The consistent themes will be abstracted and then used in a second round of interviews to elicit probabilistic statements about the extent of the improvement they think will be most likely as well as the limits of the plausible range.  We will follow the tenets for elicitation of such Bayesian prior probability densities as laid down by O’Hagan et al. (2007).  For example we will use established methods to avoid anchoring.  If any answers are ‘incoherent’, for example if the central estimate lies outside the plausible limits, the respondent will be given an opportunity to amend their response.

The central estimate of an amalgamated Bayesian prior will be used to model cost effectiveness of interventions in the base case.  The 2½ and 97½ centile limits will be used for sensitivity analysis.

We will also conduct sensitivity analysis to take into account (any) premium that people might be found to place on safety net of health states themselves.  This will build on Professor Martin Buxton’s work (mentioned above).  Professor Buxton’s project is part of a UK Engineering and Physics Research Council grant of which Professor Richard Lilford is a co-applicant and collaborator.

 

Deliverables

D2 Report on the likely cost of the various prototype interventions, based on a model of the likely costs
D7 Report quantifying the expected benefits of the interventions that will be implemented
D11 Report quantifying resources actually consumed in each country by type of intervention