NR 552 Week 5 Economic Evaluation Appraisal Example

Economic Evaluation Appraisal: The 2004 Randomized Trial of Transitional Care Led by Advanced Practice Nurses for Older Adults With Heart Failure, Its Parameters Gathered in One Block and Tested Against the Question a Hospital Would Ask

Student Name

College of Nursing, Chamberlain University

NR 552: Economics of Healthcare Policy

Instructor Name

Month Day, Year

Economic Evaluation Appraisal: The 2004 Randomized Trial of Transitional Care Led by Advanced Practice Nurses for Older Adults With Heart Failure, Its Parameters Gathered in One Block and Tested Against the Question a Hospital Would Ask

Why This Study

Our hospital is considering nurse-led follow-up for people going home after a heart failure stay. The study most often cited in support of such programs is a randomized controlled trial of a three-month transitional care intervention directed by advanced practice nurses for older adults hospitalized with heart failure (Naylor et al., 2004). It reported fewer readmissions and lower total costs. Before relying on it, this appraisal asks whether its economic findings hold up and whether they apply to our proposed program.

The Parameters, Pulled Together

The study's economic parameters, as far as the published abstract and article report them, are collected here so they can be questioned together.

Design: Randomized controlled trial, six academic and community hospitals in Philadelphia. Participants: 239 adults aged 65 or older hospitalized with heart failure; 118 in the intervention group and 121 in the control group; mean age 76; 43% male; 36% African American. Intervention: A three-month program of discharge planning and home follow-up directed by advanced practice nurses. Comparator: Usual care. Horizon: 52 weeks after the index discharge. Outcomes: Time to first readmission or death, number of readmissions, quality of life, function, costs and satisfaction. Cost measure: Mean total costs per patient over the year, including the cost of the intervention. Results: 104 readmissions in the intervention group against 162 in the control group; mean total costs of $7,636 against $12,481 (Naylor et al., 2004).

Several standard parameters are not stated in the abstract and would need to be confirmed from the full article: the perspective, the price year, whether costs were discounted over the year and how readmission costs were valued. National recommendations on cost-effectiveness analysis call for each of these to be reported explicitly (Sanders et al., 2016).

Is the Comparator Real

The comparator was usual care at the participating hospitals in the late 1990s and early 2000s. That is a genuine alternative, not a straw option, but it is not the usual care our patients receive today. Since then, hospitals have faced readmission penalties and many have added discharge follow-up calls, earlier clinic appointments and medication reconciliation as standard. A program compared against the richer usual care of today would probably show a smaller difference. The trial's comparator was real for its time; for our decision, it overstates the gap between the program and what we already do.

The Horizon and the Benefit

The 52-week horizon is a strength. It is long enough to show whether the reduction in readmissions persisted after the three-month program ended, and the results suggest it did: the intervention group had longer time to first readmission or death and fewer readmissions over the year. A 30-day horizon would have missed any delayed benefit and any readmissions merely postponed. For our program, which lasts only 30 days, the trial's year-long benefit cannot be assumed, because our intervention is shorter and less intensive.

Size and Uncertainty

The difference in mean total costs was large, about $4,845 per patient, and statistically significant. With 239 patients, however, the estimate is imprecise. Healthcare costs are highly skewed, with a few patients accounting for much of the total, so a handful of expensive readmissions in either group could move the means substantially. The abstract reports a significance test but not a confidence interval for the cost difference, which would show the plausible range. The readmission difference was statistically significant at the conventional level but not by a wide margin.

What the Study Is and Is Not

The study is a cost-consequence analysis within a randomized trial, not a formal cost-effectiveness analysis with a ratio. That is appropriate here because the intervention was both less costly and more effective on readmissions, a situation in which it dominates usual care and no ratio is needed (Drummond et al., 2015). It did not measure quality-adjusted life years, and its quality-of-life benefits were short-lived, limited to the first weeks. A payer seeking to compare this program with interventions for other conditions would need an outcome measure that permits that comparison.

Transfer to Our Setting

Four differences limit transfer. First, the intervention used advanced practice nurses over three months; ours uses registered nurses over 30 days. Second, the comparator was usual care of two decades ago. Third, our patients are younger on average, with more comorbidity. Fourth, prices and payment rules have changed, including readmission penalties that did not exist when the trial ran.

The study supports three conclusions for our decision. It shows that a nurse-led transitional program can reduce readmissions and total costs in older adults with heart failure. It suggests the benefit can last beyond the program itself. And it indicates that a shorter, less intensive program should be expected to produce a smaller effect, which is why our cost-effectiveness comparison assumed a 25% relative reduction rather than the larger effect seen in the trial.

Questions to Put to the Full Article

Before the study's cost findings are presented to our finance committee, five questions should be answered from the full article. First, whose costs were counted: the payer's, the hospitals', or both, and were costs measured from charges, reimbursements or resource use? Second, what price year were the costs expressed in, since dollars from the early 2000s would need adjusting to compare with our current figures? Third, did the intervention cost include the advanced practice nurses' full time, supervision and travel? Fourth, were deaths handled in the cost comparison, since patients who die early accrue fewer costs? Fifth, how were costs outside the enrolling hospitals captured, such as readmissions to other hospitals?

The answers would not change the direction of the finding, since the intervention group had both fewer readmissions and lower costs, but they could change its size. A finance committee is likely to ask exactly these questions, and the appraisal should be able to answer them.

Verdict

The trial is strong evidence that transitional care of this kind can be cost saving, and weak evidence about the size of the effect our shorter program would achieve. It is a good reason to try the program, with a plan to measure our own readmission rates and costs, and not a basis for promising the hospital's finance committee a specific saving.

References

Drummond, M. F., Sculpher, M. J., Claxton, K., Stoddart, G. L., & Torrance, G. W. (2015). Methods for the economic evaluation of health care programmes (4th ed.). Oxford University Press.

Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society, 52(5), 675-684. https://doi.org/10.1111/j.1532-5415.2004.52202.x

Sanders, G. D., Neumann, P. J., Basu, A., Brock, D. W., Feeny, D., Krahn, M., Kuntz, K. M., Meltzer, D. O., Owens, D. K., Prosser, L. A., Salomon, J. A., Sculpher, M. J., Trikalinos, T. A., Russell, L. B., Siegel, J. E., & Ganiats, T. G. (2016). Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: Second Panel on Cost-Effectiveness in Health and Medicine. JAMA, 316(10), 1093-1103. https://doi.org/10.1001/jama.2016.12195