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  • ECO1: What types of resources are used when delivering Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, usual care' without STS (resource-use identification)?
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What types of resources are used when delivering Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, usual care' without STS (resource-use identification)?

Authors: Neill Booth, Taru Haula and Heidi Stuerzlinger (supported by Ingrid Rosian-Schikuta).

Internal reviewers: Matthias Schwenkglenks, Nadine Berndt and Fabio Trimaglio

Acknowledgments: We would like to thank information specialist Jaana Isojärvi (THL, Finland) for development of systematic literature search strategies for the ECO domain, and for performing those searches in the available databases. We would also like to acknowledge her generous contribution in helping to construct a Refworks database and in sourcing numerous published articles for review.

For this section we used results from the domain search (including domain searches from EFF and ORG; search strategy and selection criteria are described in the general methodology description) as well as results from additional hand searching, e.g. within study references. Also results from the TEC domain regarding description of the interventions were used.

Two studies were identified which include a cost effectiveness analysis on structured telephone support (STS) vs. usual care for heart failure (HF) patients and also include intervention costs. From the same research project, both Pandor et al. (2013) and Thokala et al. (2013) ({4} and {5}) used the perspective of the National Health System of the United Kingdom and included estimates of resource use associated directly with the interventions themselves as well as the estimates of resource use associated with hospitalization. Miller et al. (2009) {3} also took a healthcare system perspective and included resource utilisation based on a clinical trial {8}.

As characterized by Pandor et al. (2013) resource consumption directly associated with the intervention can be divided into three parts:

  1. Resources used at the patient’s home
  2. Resources used at the support centre
  3. Other health care resources used to deal with events or alerts (e.g., office visits or home visits at, or by, family practitioners or specialists, emergency room visits)

It should be noted that interventions in this field are heterogeneous and rarely described in detail (see also TEC domain). The same applies to the comparator (usual care). Pandor et al. (2013) used data from a randomised study conducted across 16 hospitals in Germany, the Netherlands and the UK (in the years of 2000 to 2002) comparing home telemonitoring, nurse telephone support, and usual care {9} to estimate the amounts of health care resources used to deal with events/alerts. Miller et al. (2009) include ‘additional costs for the administration of the disease management program’ without specifying individual cost components.

None of the identified cost effectiveness analysis studies includes potential indirect resource consumption due to any negative effects or adverse events associated with STS. This may be partly explained by the absence of significant evidence of adverse events but, alternatively, could just be a simplifying assumption.

The following table lists resource items identified by the authors as potentially relevant, together with the units by which they can be measured, and indicates if they have been included in Pandor et al. {4}. This is done – here and further below - using the study by Pandor et al. (2013) as the other study (Miller et al. (2013)) does not provide sufficient methodological and other details.

Table 1: Resource consumption for STS and usual care: resource items identified as potentially relevant

Structured telephone support (human to human)

Resources

Unit

Included in Pandor et al. 2013

AT THE PATIENT'S HOME

Telephone

device

X

Telephone call minutes

minute

 

Scale

device

X

Pedometer

device

 

PC

device

 

Internet connection

month

 

Blood pressure measurement device

device

X

2 channel ECG

device

 

Measures of patient education

depends (e.g. hours, telephone call minutes, DVD)

 

IN THE SUPPORT CENTRE

Employed nurse* (telephone calls, triage, decision making)

hour

X

Specific training for involved nurse (or other providers)

training course

 

Specialist / general practitioner (supervision/consultation)

hour

 

Telephone

device

 

Telephone call minutes

minute

 

Data management software

site licence

X

Maintenance

month

 

Internet connection

month

 

Measures of healthcare data protection

depends (e.g., month)

 

* the type of nurse(s) or other person(s) providing STS, e.g., medical practitioner would also normally be relevant.

 

Structured telephone support and usual care

OTHER HEALTH CARE RESOURCES

Family practitioner

office visits

X

 

home visits

X

 

consultation service (to the support centre)

 

Specialist

office visits

X

 

home visits

X

 

consultation service (to the support centre)

 

Nurse and other

office visits

X

 

home visits

X

Pharmaceuticals

e.g., defined daily dose (DDD)

 

Emergency room

emergency room visits

X

Other outpatient services

outpatient visits

 

 

In addition to these resource items, a cost-effectiveness analysis usually attempts to take account of other changes in the consumption of health care resources which are relevant to the chosen perspective. In the case of STS, one of the most important effects or outcomes is estimated to be on the number of hospitalizations, since heart failure is an important cause of hospitalizations. However, hospitalizations are only an intermediate outcome indicator and although each hospitalization utilises health care resources, hospitalizations do not necessarily provide a robust measure of either costs or effectiveness. Three of the identified studies included the effect on hospitalizations into their analysis {1, 3, 4}. Klersy et al. 2011 {1} took the perspective of a third-party payer and (only) included healthcare resource consumption caused by HF related hospitalization (this was based on the assumption that expenditures for included patients are dominated by HF hospitalization costs).

Within a model analysis that takes lifetime perspective, other costs may also be relevant. Pandor et al. (2013), for example, modelling a 30-year time horizon, include routine clinical assessments as well as laboratory tests into their analysis with regard to long-term health care costs.

The above-mentioned resource items refer to resource consumption from a payer’s perspective. It can be argued that telemedicine interventions generate cost savings outside the healthcare system (e.g., through reduced patient travel costs) {10}, which would be highlighted, e.g., when including a patients’ perspective. Another related question is whether or not to include indirect costs in terms of productivity losses through, e.g., taking a societal perspective. The average age of the included study populations however usually lies between 60 and 75 years. Although a societal perspective is sometimes recommended, it may be argued that the proportion of people either retired or being off work because of their HF may be very high (thus estimates of, e.g., production losses would likely be rather negligible, even though, ideally, sensitivity analysis would be able to be performed surrounding such ‘productivity costs’) {10}, {3}.

The following table lists the identified resource items according to the cost and resource categories above.

Table 2: Resource items according to different cost (and resource) categories

Resource/cost category

Klersy et al. 2011**

Miller et al. 2009***

Pandor et al. 2013 / Thokala et al. 2013*

2.1 Direct costs

 

 

 

2.1.1 Public health care costs

Included resource items

Included resource items

Included resource items

Medical devices

Not included

Disease  management program costs are included, not specified further

Blood pressure measurement devices

Pharmaceuticals

Not included

Non-cardiovascular and cardiovascular drugs

Not included

Remark: costs assumed to be the same between usual care and intervention

Laboratory tests

Not included

Included (not specified)

Serum urea, electrolytes, creatinine, estimated glomerular filtration rate

Remark: included for (long term) ”usual care” after intervention period has ended

Primary care staff

Not included

Included (office visits, not specified further)

 

   Family practitioner

 

 

Office visits, home visits

   Specialist

 

 

Office visits, home visits

   Nurse and other

 

 

Office visits, home visits, telephone calls and triage

Hospital services

 

 

 

   Outpatient

Not included

Emergency room visits, outpatient procedures

Emergency room visits

   Inpatient

HF hospitalizations per person year

HF related inpatient admissions, other-cause inpatient admissions, inpatient procedures

HF related inpatient admissions, other-cause inpatient admissions

2.1.2 Private health care costs

Included resource items

 

Included resource items

Medical devices

Not included

Not included

Not included

Pharmaceuticals

Not included

Not included

Not included

Laboratory tests

Not included

Not included

Not included

Primary care staff

Not included

Not included

Not included

   Family practitioner

 

 

 

   Specialist

 

 

 

   Nurse and other

 

 

 

Hospital services

Not included

Not included

Not included

   Outpatient

   

   Inpatient

   

2.1.3 Public non-health-care costs

 

 

 

Devices / hardware

Not included

Disease  management program costs are included, not specified further

Telephone, scale

Non-physical assets / software

Not included

 

Data management software (at the support centre)

2.1.4 Private non-health-care costs

Not included

Not included

Not included

Devices / hardware

 

 

 

Non-physical assets / software

 

 

 

Time costs / opportunity costs

 

 

 

Travel costs

 

 

 

2.2 Indirect costs

 

 

 

2.2.1 Productivity lossses

Not included

Not included

Not included

*perspective: UK NHS, time horizon: 30 years, ** perspective: third-party payer, time horizon: 1 year, *** healthcare system perspective, time horizon: lifetime HF=heart failure

Further information concerning the types of costs associated with ‘STS’ and ‘usual care’ can be found in Appendix ECO-4, this appendix attempts to summarise the information from the TEC domain, from the viewpoint of the ECO domain.

Critical
Completely
Booth N, . T Result Card ECO1 In: Booth N, . T Costs and economic evaluation In: Jefferson T, Cerbo M, Vicari N [eds.]. Structured telephone support (STS) for adult patients with chronic heart failure [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali ; 2015. [cited 16 June 2021]. Available from: http://corehta.info/ViewCover.aspx?id=305