(Stroke. 2000;31:1032.)
© 2000 American Heart Association, Inc.
Original Contributions |
Home or Hospital for Stroke Rehabilitation? Results of a Randomized Controlled Trial
II: Cost Minimization Analysis at 6 Months
From the Rehabilitation & Ageing Studies Unit (C.A., S.R., M.C.), Department of Medicine, Flinders University of South Australia, Daw Park, South Australia; Clinical Trials Research Unit (C.A., C.N.M.), Department of Medicine, University of Auckland, Auckland, New Zealand; and Southern Domiciliary Care & Rehabilitation Service (C.S., A.W.), Adelaide, South Australia.
Correspondence to Dr Craig Anderson, Department of Medicine, University of Auckland, Private Bag 92019, Auckland, New Zealand. E-mail c.anderson{at}ctru.auckland.ac.nz
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Abstract |
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Background and Purpose—The goal of the present study was to examine the resource and economic implications of an early hospital discharge and home-based rehabilitation scheme for patients with acute stroke.
Methods—A cost minimization analysis in conjunction with a randomized controlled trial was carried out at 2 affiliated teaching hospitals in the southern metropolitan region of Adelaide, South Australia, between 1997 and 1998. Eighty-six hospitalized patients with acute stroke who required rehabilitation were randomized to receive both early hospital discharge and home-based rehabilitation, or conventional in-hospital rehabilitation and community care. Direct and indirect costs related to stroke rehabilitation were calculated, including hospital bed days, home-based intervention program, community services, and personal expenses during the 6 months after randomization.
Results—The mean cost per patient was lower for patients randomized to the early hospital discharge and home-based rehabilitation ($8040) compared with those who received conventional care ($10 054). This cost saving was not statistically significant (P=0.14). However, sensitivity analyses indicated that the cost of home-based rehabilitation was consistently lower than that of conventional care except when hospital costs were assumed to be 50% less than those used in the main analysis. Multiple regression analysis demonstrated that the cost of the home-based program was significantly related to a patient’s level of disability after adjustment for age, comorbidity, and the presence or absence of a caregiver.
Conclusions—The early hospital discharge and home-based rehabilitation scheme was less costly than conventional hospital care for patients with stroke. Limitation of the provision of such services to patients with mild disability is likely to be most cost effective.
Key Words: costs and cost analysis • randomized controlled trials • rehabilitation • stroke management
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Introduction |
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In developed countries, a recent trend in health care has been the development of community-based alternatives to hospital care.1 2 Interest in the establishment of such "hospital at home" schemes stems from a new emphasis on primary and community care, on offering a greater choice to consumers, and in being an attractive solution to the rising costs of rehabilitation for patients in hospital and the pressure to maximize productivity.3 4 Although considerable heterogeneity exists within the framework of hospital-at-home schemes, broadly speaking, they can be divided into 2 groups: those that avoid admission and the inappropriate use of a hospital bed and those that achieve early hospital discharge from an acute or a planned admission and use home settings within an episode of care. The evidence to date indicates that these schemes can reduce the demand on hospital resources, but there remains uncertainty about the cost-effectiveness of hospital-at-home compared with in-hospital care.2 5 6 Most randomized trials have been small, follow-up has generally been short, and few have incorporated detailed economic evaluations.2
The provision of home-based nursing and rehabilitation services to facilitate early discharge from hospital is an attractive health care model for the management of patients with stroke.7 8 9 10 Not only is there an opportunity for a coordinated and seamless pathway of care for patients from hospital to home, but also there is the potential to reduce the risk of iatrogenic illness, distress associated with prolonged hospital stay, and travel to outpatient clinics for rehabilitation. In the United Kingdom and Sweden, such schemes have been shown to be cost effective, safe, and acceptable to patients and their families,7 8 9 10 11 but more data are required to determine the generalizability of these data within the context of other health care systems.
The present study was carried out in parallel with a pragmatic randomized controlled trial to evaluate the effectiveness and acceptability of early hospital discharge and home-based stroke rehabilitation. We concluded that the scheme does not have an adverse impact on clinical patient outcomes, although it may worsen the mental health of caregivers.12 Here, we report details of the economic consequences of a shift in the balance of care for patients with stroke.
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Subjects and Methods |
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A comparison was made of continued care and rehabilitation in hospital with early discharge from hospital and rehabilitation at home for patients with acute stroke who had been admitted to hospital and required rehabilitation for residual disability. Because both forms of care were found to be equally effective for clinical patient outcomes,12 a cost-minimization study was the appropriate form of economic analysis. The evaluation was conducted from the perspective of both the health care system and the patients and their families. Inclusion of costs from the latter 2 viewpoints was considered important because a reduction in hospital costs could simply be offset by an increase in the costs to patients and families.
Full details of recruitment and randomization are outlined in the accompanying report.12 In brief, patients randomized to the hospital arm (n=44) received the usual care in hospital and in the community, whereas patients randomized to early discharge from hospital (n=42) received any necessary aids and adaptations in the home to facilitate early discharge and input from a community rehabilitation team. The team consisted of a full-time program coordinator, a consultant in rehabilitation, and physiotherapists, occupational therapists, social workers, speech therapists, and rehabilitation nurses, whose time was contracted by the service according to demand. Discharge from both groups occurred when the patient was deemed to have made a satisfactory recovery so he or she could manage within the existing support system and by using community services where necessary. All patients were followed up at 3 and 6 months after randomization by a research nurse, who was independent of the rehabilitation team and blind to treatment allocation. Information obtained for each patient included health-related outcomes and economic outcomes such as the use of health and community services. Economic data collected at 3 and 6 months were amalgamated, and the overall economic outcomes at 6 months are presented here.
Assessment of Costs
A summary of the types of costs and sources of costing
information is provided in Table 1
. Data on the direct costs of health
care and community services were calculated for each patient in the 6
months after randomization. Where possible, information on actual
individual use of resources was used, such as the number of sessions of
community services. The staff time (direct and indirect) and travel
costs of the community rehabilitation team were estimated directly as
they were routinely collected. However, detailed information for all
patients in all aspects of care could not be recorded. An average
per-patient cost was therefore used for certain health and community
services, including any payments made by patients. The indirect costs
incurred by caregivers were estimated on a self-report questionnaire
developed for the study. Pharmaceutical costs were excluded for both
groups of patients because of the difficulties in the accurate
assessment. All of these costing assumptions are crucial to the final
results and therefore were checked in a sensitivity analysis.
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Hospital and Residential Care Costs
An average per-day cost for a rehabilitation bed was obtained
from the hospital finance department based on actual expenditure for
the fiscal year 1997 to 1998. This cost also included overhead costs
such as management, heating, and laundry. The costs of medical care
vary according to the intensity of nursing care, investigations, and
treatment and are usually the most costly in the first few days in the
hospital. In the present study, patients were entered into the
trial only when they were considered suitable for rehabilitation (and
"safe" for early discharge), and therefore the average cost per bed
day in rehabilitation is also likely to be a valid estimate of actual
marginal (ie, end-of-stay) acute bed day costs. Average per-episode (or
per-visit) costs were used to calculate for each patient the costs
associated with a readmission to an acute hospital bed and visits to
outpatient medical (or rehabilitation) clinics, with data provided from
national costs data for the fiscal year 1997 to 1998. These data were
augmented with the assignment of the cost of "urgent" and
"nonurgent" transport by ambulance over 10 km for each readmission
and outpatient visit, respectively.
Early Discharge and Home-Based Rehabilitation Program
Individual patient records were used to determine the costs
incurred by the home-based rehabilitation team while treating patients
randomized to this scheme. This included time spent with the patient
plus any additional time (travel, administration, and so on)
attributable to that particular case. An average cost was assigned to
each patient for those costs not directly attributable to individual
patients, such as time spent by staff in multidisciplinary meetings,
plus nonstaff administration and overhead costs (stationery, telephone,
vehicle maintenance, and so on). The standard mileage rate for
health services at the time of the study ($Aust 0.51/ km) was used to
place a value on all travel for the team. Market prices were used to
place a value on all aids and adaptations. For the coordinator costs,
research time (eg, randomization and consent) was excluded. A
proportion of the coordinator’s time and associated costs (20%) was
allocated to the conventional care group based on the assumption that
in any such service, time would be spent by the coordinator in
screening patients for early discharge and home-based rehabilitation.
Community Services
Community services that were examined included visits to the
general practitioner, community therapy services that were
outside of the experimental program (eg, physiotherapy, occupational
therapy, dietitian), alternative therapy services (eg, chiropractor,
naturopathologist), district nursing, attendance at community day
centers, Meals on Wheels, and admission to hostel or nursing home
facilities for either short-term respite or permanent care. The use of
these services was recorded for each patient on a per-visit or
per-bed-day basis. Assumed costs were applied to items for which it was
not possible to obtain accurate information.
Other Health Patient and Family Costs
Patients were asked whether they had made any changes to their
mode of transport, if any additional modifications had been made to
their home, or if they had required any special equipment after the
stroke, but these costs were not estimated. Similarly, caregivers were
asked whether they had taken time off work to provide care, but no
attempt was made to measure or to value these costs because it was
assumed that these would be absorbed within employment contracts.
However, caregivers were also asked to estimate what proportion of
their time during the preceding 24 hours was spent providing help or
supervision in everyday activities for the patient. With the assumption
that caregivers were crucial in the prevention of the admission of
patients to residential care, an estimate was made for each patient of
the cost of informal care based on the cost of hostel-level residential
care.
Sensitivity Analysis
The inclusion of an average per-day cost in the valuation of
hospital care may overstate the actual hospital costs. To approximate
the marginal (ie, end-of-stay) costs and therefore potential savings
from the release of hospital beds, sensitivity analysis assumed
that resources released would be either 75% or 50% of the average
per-day cost. Because the home-based rehabilitation program was a
service with input from predominantly part-time staff who were
contracted from existing services according to demand, the costs of
staff, travel, and overhead might prove to be higher for a stand-alone
specialty service. Therefore, for sensitivity analysis,
alternative increased costs of 25% and 50% for the home-based
rehabilitation team were assumed as well as a reduced cost (75% of
baseline) based on the assumption that a new service would become more
efficient and cost effective as it developed over time. Finally, the
effect on costs according to patient level of disability was also
determined.
Statistical Analysis
The sample size was determined specifically for clinical rather
than economic evaluations.12 Because the resource use
distributions were positively skewed, median and interquartile range
values are reported. The cost data distributions were also positively
skewed. However, the provision of information about median costs is not
helpful for service providers who require estimates of costs per
patient. Therefore, mean costs were calculated and compared with the
use of independent sample t tests, and mean differences were
expressed with 95% CIs. For such skewed data, however, care must be
exercised in the interpretation of SDs. Categorical variables were
compared with use of the 
2 test. Multiple
regression analysis was undertaken to explore the relationship
between the dependent variable cost and baseline demographic and
other independent variables (age, level of disability, living
arrangements, and comorbidity) for the early hospital discharge and
home-based rehabilitation program. All analyses were performed
with SPSS for Windows version 6.0 and Arcus Quickstat (Longman Software
Publishing)..
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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All 86 patients who participated in the randomized controlled trial were included in the economic evaluation. Table 2
shows the time and costs of the
different services provided by the home-based rehabilitation team and
costs related to travel, equipment, and modifications to the homes of
patients. The total cost of the home-based intervention program was
$128 853, and the mean cost per patient was estimated to be $3068.
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Table 3 presents estimates of the
median use of resources by each group. Apart from a reduced length of
initial hospital stay and input of the home-based rehabilitation team
for the experimental group, there were no significant differences in
community services and other resource use between the 2 groups.
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Table 4 shows the results of combining
resource use with information on valuation in terms of mean cost per
patient across the major health service domains. The cost of hospital
care was greatly reduced in the experimental group, but this was
counterbalanced by additional direct and indirect costs associated with
home-based rehabilitation. The mean overall cost difference between
intervention groups was $2013, or approximately one fifth of the cost
of conventional rehabilitation for patients with stroke. This
difference, however, was not statistically significant.
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Multiple regression analysis demonstrated that functional status, as defined with the modified Barthel Index (BI),13 was an independent predictor of cost in the home-based intervention program. When patients were grouped according to "mild" (scores 91 to 100) or "moderate" (scores 50 to 90) grades of disability, those in the former category had lower costs after adjustment for age, comorbidity (history of hypertension, angina, heart failure, diabetes, or arthritis), and presence or absence of a caregiver (regression coefficient -1446 [95% CI -2417 to -476], SE 479, P=0.005).
Table 5 shows the results of the
sensitivity analysis. The results obtained are robust to
changes in the costing data and assumptions. Only when the costs of
care in hospital were assumed to be 50% of baseline did the
conventional care scheme become cheaper. Limitation of the
between-group analysis to patients with mild disability (BI
scores 91 to 100) showed the home-based program to be more cost
effective than conventional care.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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This economic analysis of early hospital discharge and home-based rehabilitation for patients with stroke found the cost of rehabilitation in the home to be less than the cost of conventional in-hospital rehabilitation and care in the community during the 6 months after randomization. The mean reduction in overall cost for patients allocated to the home-based rehabilitation scheme was
Aust$2000, or one fifth of the cost of conventional care and
rehabilitation. Although the overall cost savings were not
statistically significant, this clinically meaningful effect was mainly
a result of a significant reduction in the initial length of stay in
the hospital and the consequent reduction in hospital costs. Hospital-at-home schemes involve a transfer of care from the secondary to primary sector and thus have the great potential to increase the use of community services and shift the costs of care onto family members and other informal caregivers. This is particularly relevant to rehabilitation services aimed at older patients with disabling conditions such as stroke. A strength of the present study compared with other studies2 8 9 is the inclusion of detailed analyses of the cost of community care. No significant difference was found in the use of routine community services between the 2 groups, and the associated costs for these services were less in the home-based rehabilitation group. This may reflect a better adjustment to residual disability on the part of patients who received rehabilitation in the home and, therefore, have less need for support from community services at the completion of the program.
Because more than half of patients indicated that they had a caregiver at the time of the stroke, it was important to measure the cost of informal care for patients after their discharge from hospital. On the assumption that the cost of caregiver time for patients in the home was equivalent to the cost of residential care at the hostel level for persons with a mild to moderate level of physical disability, the cost of informal care was higher for patients in the home-based rehabilitation scheme. However, this may simply reflect an early discharge from hospital and a longer period in the community for this group rather than an actual increase in costs for caregivers. Even so, taken together with the finding of worse mental health on the part of caregivers as reported in the accompanying report,12 the potential for an adverse impact of home-based schemes is clearly important and must be considered in the development of these services.
The early hospital discharge and home-based rehabilitation scheme was a new service that underwent development during the study. In particular, much of the coordinator’s time was spent in publicity and in screening and recruiting patients. The cost per patient seen in this study would, therefore, be expected to reduce over time and is likely to be less for an established scheme. The crucial sensitivity analyses indicate that the finding of a cost advantage for home-based rehabilitation over conventional in-hospital rehabilitation is robust. The cost of the new scheme was also strongly related to the patient’s level of physical disability, which is at variance with the findings of McNamee et al.8 However, this may relate to differences between the studies in the set-up costs and cost estimates for the services. In the present study, therapists were contracted to provide care based on need and data were collected prospectively, whereas the study of McNamee et al included full-time staff as part of a stand-alone service, and the costs for hospital and therapy were estimated retrospectively. No such analyses were undertaken in the study of Beech et al.10
In conclusion, early hospital discharge and home-based rehabilitation in our health care system proved to be a less costly alternative to conventional care and rehabilitation for patients with stroke. Although the reduction in cost was not statistically significant, the economic results indicate that an established scheme could play an important role in the release of hospital beds and be a cost-effective approach to the rehabilitation of patients with stroke.
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Acknowledgments |
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We are grateful to Sue McKechnie and the Ambulatory Care Unit of the South Australian Health Commission, who supported this project through a grant from the federal government. We are indebted to the following members of the community rehabilitation team for their dedication: Robyn Lister and Nicki Hayball (consecutive project coordinators), Heather Jesshope, Jan Van Emden, Penny Jacomos, Naomi Brill, Marion Reece, John Stanfield, Robyn Burnett, Belinda Magor, Edwina Reid, Martine Ledger, Colleen Gleeson, Helen Reid, Marline Reece, Margi Smart, Donna Lawrence, Claire Morris, and Beth Stronach. We thank Sara Laubscher and Kerry Clifford for their support in the study and Derrick Bennett and Paul Brown of the University of Auckland for their advice on statistical and economical analyses. We acknowledge the support of M. Bennett, A. Crockett, A. Darzins, B. Dodd, P. Finucane, J. Harvey, E. Hobbin, P. Lavelle, D. Law, M. McTab, M. Russell, H. Trenorden, L. White, and B. Wilson and our colleagues and staff at the Flinders Medical Center, Repatriation General Hospital, and Southern Domiciliary Care and Rehabilitation Service, South Australia.
Received November 9, 1999; revision received February 3, 2000; accepted February 24, 2000.
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