A comparative cost and outcome analysis with residential care
Baumker T Journal of Service Science and Management, 40, 523-539. 2011

Extra care housing is a housing model that has considerable potential to support older people in leading active, independent lives.

A structured training programme for caregivers of inpatients after stroke (TRACS): a cluster randomised controlled trial and cost-effectiveness analysis
Forster A, et al Lancet, 382, 2069-2076. 2013

BACKGROUND:
Most patients who have had a stroke are dependent on informal caregivers for activities of daily living. The TRACS trial investigated a training programme for caregivers (the London Stroke Carers Training Course, LSCTC) on physical and psychological outcomes, including cost-effectiveness, for patients and caregivers after a disabling stroke.

METHODS:
We undertook a pragmatic, multicentre, cluster randomised controlled trial with a parallel cost-effectiveness analysis. Stroke units were eligible if four of five criteria used to define a stroke unit were met, a substantial number of patients on the unit had a diagnosis of stroke, staff were able to deliver the LSCTC, and most patients were discharged to a permanent place of residence. Stroke units were randomly assigned to either LSCTC or usual care (control group), stratified by geographical region and quality of care, and using blocks of size 2. Patients with a diagnosis of stroke, likely to return home with residual disability and with a caregiver providing support were eligible. The primary outcome for patients was self-reported extended activities of daily living at 6 months, measured with the Nottingham Extended Activities of Daily Living (NEADL) scale. The primary outcome for caregivers was self-reported burden at 6 months, measured with the caregivers burden scale (CBS). We combined patient and caregiver costs with primary outcomes and quality-adjusted life-years (QALYs) to assess cost-effectiveness. This trial is registered with controlled-trials.com, number ISRCTN 49208824.

FINDINGS:
We assessed 49 stroke units for eligibility, of which 36 were randomly assigned to either the intervention group or the control group. Between Feb 27, 2008, and Feb 9, 2010, 928 patient and caregiver dyads were registered, of which 450 were in the intervention group, and 478 in the control group. Patients’ self-reported extended activities of daily living did not differ between groups at 6 months (adjusted mean NEADL score 27·4 in the intervention group versus 27·6 in the control group, difference -0·2 points [95% CI -3·0 to 2·5], p value=0·866, ICC=0·027). The caregiver burden scale did not differ between groups either (adjusted mean CBS 45·5 in the intervention group versus 45·0 in the control group, difference 0·5 points [95% CI -1·7 to 2·7], p value=0·660, ICC=0·013). Patient and caregiver costs were similar in both groups (length of the initial stroke admission and associated costs were £13,127 for the intervention group and £12,471 for the control group; adjusted mean difference £1243 [95% CI -1533 to 4019]; p value=0·380). Probabilities of cost-effectiveness based on QALYs were low.

INTERPRETATION:
In a large scale, robust evaluation, results from this study have shown no differences between the LSCTC and usual care on any of the assessed outcomes. The immediate period after stroke might not be the ideal time to deliver structured caregiver training.

FUNDING:
Medical Research Council.

Adults with intellectual disabilities and challenging behaviour: the costs and outcomes of in- and out-of-area placements
Perry J, Allen DG, Pimm C et al Journal of Intellectual Disability Research, 57, 139-152. 2013

Background People with severe challenging behaviour are vulnerable to exclusion from local services and removal to out-of-area placements if locally available supported accommodation is insufficient to meet their needs. There are concerns about the high costs and potentially poorer outcomes of out-of-area placements but relatively little is known about how costs and outcomes compare with provision for a similar population placed locally.

Methods Costs, quality of care and a wide range of quality of life outcomes for 38 people with intellectual disabilities and challenging behaviour living in-area and 38 similar people living out-of-area were compared. The two groups were matched as far as possible on risk factors for out-of-area placement. The out-of-area group represented two-thirds of the total number of people who originated from the territory served by the largest specialist health service in Wales and were placed in residential settings at least 10 miles beyond its boundaries.

Results There was a mixed pattern of quality of care and quality of outcome advantages between the two types of setting, although in-area placements had a greater number of advantages than out-of-area placements. Unexpectedly, out-of-area placements had lower total costs, accommodation costs and daytime activity costs.

Conclusions No overall conclusion could be reached about cost-effectiveness. A number of potential reasons for the differences in cost were identified. Although additional resources may be needed to provide in-area services for those currently placed out-of-area, government policy to provide comprehensively for those who want to live locally, irrespective of their needs, appears to be attainable.

Cost effectiveness of a manual based coping strategy programme in promoting the mental health of family carers of people with dementia (the START (STrAtegies for RelaTives) study): a pragmatic randomised controlled trial.
Knapp M, King D, Romeo R, et al British Medical Journal, 347, f6342. 2013

Objective To assess whether the START (STrAtegies for RelatTives) intervention added to treatment as usual is cost effective compared with usual treatment alone.

Design Cost effectiveness analysis nested within a pragmatic randomised controlled trial.

Setting Three mental health and one neurological outpatient dementia service in London and Essex, UK.

Participants Family carers of people with dementia.

Intervention Eight session, manual based, coping intervention delivered by supervised psychology graduates to family carers of people with dementia added to usual treatment, compared with usual treatment alone.

Primary outcome measures Costs measured from a health and social care perspective were analysed alongside the Hospital Anxiety and Depression Scale total score (HADS-T) of affective symptoms and quality adjusted life years (QALYs) in cost effectiveness analyses over eight months from baseline.

Results Of the 260 participants recruited to the study, 173 were randomised to the START intervention, and 87 to usual treatment alone. Mean HADS-T scores were lower in the intervention group than the usual treatment group over the 8 month evaluation period (mean difference −1.79 (95% CI −3.32 to −0.33)), indicating better outcomes associated with the START intervention. There was a small improvement in health related quality of life as measured by QALYs (0.03 (−0.01 to 0.08)). Costs were no different between the intervention and usual treatment groups (£252 (−28 to 565) higher for START group). The cost effectiveness calculations suggested that START had a greater than 99% chance of being cost effective compared with usual treatment alone at a willingness to pay threshold of £30 000 per QALY gained, and a high probability of cost effectiveness on the HADS-T measure.

Conclusions The manual based coping intervention START, when added to treatment as usual, was cost effective compared with treatment as usual alone by reference to both outcome measures (affective symptoms for family carers, and carer based QALYs).

Cost effectiveness of pilot self-assessment sites in community care services in England
Clarkson P Australian Health Review, 37, 666-674. 2013

OBJECTIVE:
Self-assessment has been advocated in community care but little is known of its cost effectiveness in practice. We evaluated cost effectiveness of pilot self-assessment approaches.

METHODS:
Data were collected from 13 pilot projects in England, selected by central government, between October 2006 and November 2007. These were located within preventative services for people with low-level needs, occupational therapy, or assessment and care management. Cost effectiveness, over usual care, was assessed by incremental cost-effectiveness ratios (ICERs), in British pounds per unit gain in assessment satisfaction. A public-sector perspective was adopted; the provider costs of the agencies taking part.

RESULTS:
At 2006-07 prices, including start-up and on-going costs, only three pilots demonstrated cost effectiveness. Two pilots in assessment and care management had ICERs of £3810 and £755 per satisfaction gained, well below a benchmark from a trial of usual assessment of £18296 per satisfaction gained. When extrapolating uptake to numbers accessing assessments over 1 year, one occupational therapy pilot, of £123/satisfaction gained, also fell below this benchmark in sensitivity analysis. There was less evidence for preventative services.

CONCLUSIONS AND IMPLICATIONS:
Most pilot projects were not cost effective. However, self assessment is potentially cost effective in assessment and care management and occupational therapy services. Better quality cost data from pilot sites would have permitted more detailed analysis. Measuring downstream effects in terms of users’ well being from receipt of self-assessment would also be beneficial.

Cost-effectiveness of a pilot social care service for UK military veterans
Clarkson P Journal of Care Services Management, 7, 95-106. 2014

This paper investigates the cost-effectiveness of a pilot social care service for military veterans, a group relatively ill-served by traditional forms of social and health care. The service involved caseworkers signposting veterans, experiencing multiple difficulties, to sources of advice designed to assist with issues such as employment and training, education, debt, legal problems, and housing. Routinely generated data were collected on 202 veterans, concerning their characteristics, types of problem, and resources identified, and on a sub-set (n = 21) of these, regarding their outcomes in terms of well-being, measured by routine administration of the General Health Questionnaire. Costs, in terms of caseworkers’ time commitments, were modelled across this sample of veterans. The additional costs as against the additional effects of the service, against usual care (the standard primary care response to this population), were modelled in terms of the Incremental Cost Effectiveness Ratio. There was a statistically significant reduction in symptoms after receipt of the service at an average cost of £155 per unit improvement in well-being. Analysis of uncertainty revealed a high probability of cost-effectiveness when set against a benchmark value of standard social care for adults. These findings are discussed in terms of the future priority given to the after-care of veterans, in particular regarding social care interventions, which remain under-evaluated.

Cost-effectiveness of telecare for people with social care needs: the Whole Systems Demonstrator cluster randomised trial
Henderson C, Knapp M, Fernandez JL, et al Age and Ageing, 43, 794-800. 2014

Purpose of the study: to examine the costs and cost-effectiveness of ‘second-generation’ telecare, in addition to standard support and care that could include ‘first-generation’ forms of telecare, compared with standard support and care that could include ‘first-generation’ forms of telecare.

Design and methods: a pragmatic cluster-randomised controlled trial with nested economic evaluation. A total of 2,600 people with social care needs participated in a trial of community-based telecare in three English local authority areas. In the Whole Systems Demonstrator Telecare Questionnaire Study, 550 participants were randomised to intervention and 639 to control. Participants who were offered the telecare intervention received a package of equipment and monitoring services for 12 months, additional to their standard health and social care services. The control group received usual health and social care.

Primary outcome measure: incremental cost per quality-adjusted life year (QALY) gained. The analyses took a health and social care perspective.

Results: cost per additional QALY was £297,000. Cost-effectiveness acceptability curves indicated that the probability of cost-effectiveness at a willingness-to-pay of £30,000 per QALY gained was only 16%. Sensitivity analyses combining variations in equipment price and support cost parameters yielded a cost-effectiveness ratio of £161,000 per QALY.

Implications: while QALY gain in the intervention group was similar to that for controls, social and health services costs were higher. Second-generation telecare did not appear to be a cost-effective addition to usual care, assuming a commonly accepted willingness to pay for QALYs.

Cost-effectiveness of telehealth for patients with long term conditions (Whole Systems Demonstrator telehealth questionnaire study): nested economic evaluation in a pragmatic, cluster randomised controlled trial
Henderson C, Knapp M, Fernandez JL, et al British Medical Journal, 346, f1035. 2014

OBJECTIVE:

To examine the costs and cost effectiveness of telehealth in addition to standard support and treatment, compared with standard support and treatment.
DESIGN:

Economic evaluation nested in a pragmatic, cluster randomised controlled trial.
SETTING:

Community based telehealth intervention in three local authority areas in England.
PARTICIPANTS:

3230 people with a long term condition (heart failure, chronic obstructive pulmonary disease, or diabetes) were recruited into the Whole Systems Demonstrator telehealth trial between May 2008 and December 2009. Of participants taking part in the Whole Systems Demonstrator telehealth questionnaire study examining acceptability, effectiveness, and cost effectiveness, 845 were randomised to telehealth and 728 to usual care.
INTERVENTIONS:

Intervention participants received a package of telehealth equipment and monitoring services for 12 months, in addition to the standard health and social care services available in their area. Controls received usual health and social care.
MAIN OUTCOME MEASURE:

Primary outcome for the cost effectiveness analysis was incremental cost per quality adjusted life year (QALY) gained.
RESULTS:

We undertook net benefit analyses of costs and outcomes for 965 patients (534 receiving telehealth; 431 usual care). The adjusted mean difference in QALY gain between groups at 12 months was 0.012. Total health and social care costs (including direct costs of the intervention) for the three months before 12 month interview were £1390 (€1610; $2150) and £1596 for the usual care and telehealth groups, respectively. Cost effectiveness acceptability curves were generated to examine decision uncertainty in the analysis surrounding the value of the cost effectiveness threshold. The incremental cost per QALY of telehealth when added to usual care was £92 000. With this amount, the probability of cost effectiveness was low (11% at willingness to pay threshold of £30 000; >50% only if the threshold exceeded about £90 000). In sensitivity analyses, telehealth costs remained slightly (non-significantly) higher than usual care costs, even after assuming that equipment prices fell by 80% or telehealth services operated at maximum capacity. However, the most optimistic scenario (combining reduced equipment prices with maximum operating capacity) eliminated this group difference (cost effectiveness ratio £12 000 per QALY).
CONCLUSIONS:

The QALY gain by patients using telehealth in addition to usual care was similar to that by patients receiving usual care only, and total costs associated with the telehealth intervention were higher. Telehealth does not seem to be a cost effective addition to standard support and treatment.

REMCARE: reminiscence groups for people with dementia and their family caregivers? Effectiveness and cost-effectiveness pragmatic multicentre randomised trial
Woods R et al Health Technology Assessment, 16, 1-121. 2012

Abstract
OBJECTIVES:
The aim of the REMiniscence groups for people with dementia and their family CAREgivers (REMCARE) study was to assess the effectiveness and cost-effectiveness of joint reminiscence groups for people with dementia and their family caregivers as compared with usual care.

DESIGN:
A multicentre, pragmatic randomised controlled trial with two parallel arms – an intervention group and a usual-care control group – was carried out. A restricted dynamic method of randomisation was used with an overall allocation ratio of 1 : 1, restricted to ensure intervention groups of a viable size. Assessments, blind to treatment allocation, were carried out at baseline, 3 months and 10 months (primary end point).

SETTING:
Most participants were recruited through NHS Memory Clinics and Community Mental Health Teams for older people. Assessments were usually carried out in the person’s home, and treatment groups were held in a variety of community settings.

PARTICIPANTS:
A total of 488 individuals (mean age 77.5 years) with mild to moderate dementia (meeting Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition criteria), who were initially living in the community, and who had a relative or other caregiver maintaining regular contact, who could act as an informant and was willing and able to participate in the intervention, were recruited to the study. Most carers were spouses (71%). A total of 350 dyads completed the study.

INTERVENTIONS:
The intervention consisted of joint reminiscence groups held weekly for 12 consecutive weeks, followed by monthly maintenance sessions for a further 7 months. The sessions followed a treatment manual, and were led by two trained facilitators in each centre, supported by a number of volunteers. Up to 12 dyads were invited to attend each group.

MAIN OUTCOME MEASURES:
The primary outcome measures were self-reported quality of life for the person with dementia and psychological distress for the carer [General Health Questionnaire-28 item version (GHQ-28)]. Secondary outcome measures included autobiographical memory and activities of daily living for the person with dementia, carer stress for the carer and mood, relationship quality and service use and costs for both parties.

RESULTS:
The intention-to-treat analysis identified no differences in outcome between the intervention and control conditions on primary or secondary outcomes [self-reported quality of life in Alzheimer’s disease: mean difference 0.07, standard error (SE) 0.65; F = 0.48; p = 0.53]. Carers of people with dementia allocated to the reminiscence intervention reported a significant increase in anxiety on a subscale of the GHQ-28 at the 10-month end point (mean difference 1.25, SE 0.5; F = 8.28; p = 0.04). Compliance analyses suggested some benefits for people with dementia who attended more reminiscence sessions; however, carers attending more groups showed increased caregiving stress. Use of health- and social-care services was modest, with no significant difference in service use between conditions. Owing to negligible difference in quality-adjusted life-year gains (derived from European Quality of Life-5 Dimensions) between the conditions the planned full economic analysis was curtailed.

CONCLUSIONS:
This trial does not provide support for the effectiveness or cost-effectiveness of joint reminiscence groups for people with dementia and their carers. Although there may be some beneficial effects for people with dementia who attend sessions as planned, this must be viewed in the context of raised anxiety and stress in their carers. The reasons for these discrepant outcomes need to be explored further, and may necessitate reappraisal of the movement towards joint interventions.

TRIAL REGISTRATION:
Current Controlled Trials ISRCTN42430123.

FUNDING:
This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 48. See the HTA programme website for further project information.

Targeting, care management and preventative services for older people: The cost-effectiveness of a pilot self-assessment approach in one local authority
Clarkson P British Journal of Social Work, 40, 2255-2273. 2010

As social services councils face a more constrained economic environment and as eligibility criteria tighten, the issue of targeting becomes increasingly relevant. This paper presents findings from a pilot project in one local authority that aimed to target access to assessment for older people with low-level needs who would normally have fallen under eligibility thresholds. Self-assessment was used as a tool whereby these older people could identify, with assistance, their preferences for a range of preventative services. Via a randomised design, the study evaluated the costs and benefits, in terms of reported satisfaction, of the approach compared with the usual care management assessment. Although self-assessed cases were offered more advice as to a wider range of preventative services, which generated greater costs, total costs were lower for this group. This cost saving arose from the use of staff with a lower unit cost who also spent less time on administrative duties and gathering information. Satisfaction with self-assessment was comparable to a professional assessment, therefore representing a cost-effective approach. The project offers evidence of how councils can target resources through assessment and how self-assessment approaches may be appropriately configured to offer value for these users whilst also generating resource savings.