Cost-effectiveness of a quality improvement project, including simulation-based training, on reducing door-to-needle times in stroke thrombolysis

Abstract

BackgroundRapid revascularisation in acute ischaemic stroke is crucial to reduce its total burden including societal costs. A quality improvement (QI) project that included streamlining the stroke care pathway and simulation-based training was followed by a significant reduction in median door-to-needle time (27 to 13 min) and improved patient outcomes after stroke thrombolysis at our centre. Here, we present a retrospective cost-effectiveness analysis of the QI project.MethodsCosts for implementing and sustaining QI were assessed using recognised frameworks for economic evaluations. Effectiveness was calculated from previously published outcome measures. Cost-effectiveness was presented as incremental cost-effectiveness ratios including costs per minute door-to-needle time reduction per patient, and costs per averted death in the 13-month post-intervention period. We also estimated incremental cost-effectiveness ratios for a projected 5-year post-intervention period and for varying numbers of patients treated with thrombolysis. Furthermore, we performed a sensitivity analysis including and excluding costs of unpaid time.ResultsAll costs including fixed costs for implementing the QI project totalled US$44 802, while monthly costs were US$2141. We calculated a mean reduction in door-to-needle time of 13.1 min per patient and 6.36 annual averted deaths. Across different scenarios, the estimated costs per minute reduction in door-to-needle time per patient ranged from US$13 to US$29, and the estimated costs per averted death ranged from US$4679 to US$10 543.ConclusionsWe have shown that a QI project aiming to improve stroke thrombolysis treatment at our centre can be implemented and sustained at a relatively low cost with increasing cost-effectiveness over time. Our work builds on the emerging theory and practice for economic evaluations in QI projects and simulation-based training. The presented cost-effectiveness data might help guide healthcare leaders planning similar interventions.

Advances in Stroke: Quality Improvement

“…Two studies undertook economic evaluations of QI interventions and both found that implementation of QI programs was cost-effective. Ajmi et al 24 reported on the cost-effectiveness of implementing a multifaceted QI project that included process mapping and redesign, engaging stakeholders, education, and simulation-based training at a large stroke center in Norway to improve thrombolysis care. The fixed costs of implementing the QI program was US$44 802 (2019 prices); the estimated costs per minute reduction in door-to-needle time per patient ranged from US$13 to US$29 and the estimated costs per death averted ranged from US$4679 to US$10 543; cost-effectiveness increased over time.…”

Cost-effectiveness of quality improvement intervention to reduce time between CT-detection and ureteroscopic laser fragmentation in acute symptomatic ureteric stones management

“…The purpose of this study was to assess clinical and cost effectiveness of the changes executed to shorten treatment episodes of obstructing stones by reducing the time interval between CT-detection and ureteroscopic laser-fragmentation. The approach to use time interval as marker of efficiency was modelled on the similar quality improvement project such as door to needle or door to balloon in other specialities [ 12 ]. The changes in pathway added value to patient journey and reduced clinical wastage.…”

The Evolving Economics of Implementation

“…[1][2][3] Studies that evaluate the cost of implementation strategies remain rare, and often these studies only estimate the implementation costs without connecting those investments to patient outcomes. In this issue of BMJ Quality & Safety, in a cost-effectiveness evaluation of a quality improvement project to improve thrombolysis door-toneedle times in a large Norwegian stroke centre, Ajmi and colleagues 4 report that their implementation strategies cost $44 802 (US$) in fixed costs and $2141 per month in recurring costs. Further, they report an incremental cost per life-year saved that ranged from $4961-$10 543 (US$) over a 5-year period, with the range reflecting different assumptions made in a sensitivity analysis.…”

“…However, using economic models to make individual decisions, whether that is for a single patient or a whole hospital, is fraught with difficulty. 7 In the paper, Ajmi and colleagues 4 discuss reasons why they likely saw favourable outcomes as a result of their implementation efforts but stopped short of exploring in more detail how these outcomes may be affected by varying mechanisms. Efforts to link the economic results more tightly to mechanisms of action will help guide decision makers to decide whether replication is warranted.…”

“…Personnel (ie, labour) typically represents a variable cost because the cost varies by the scale of production. Ajmi and colleagues 4 reported that the majority of costs were fixed and attributable to personnel, which may confuse some readers. It is possible that Ajmi and colleagues used the terms programme costs synonymously with fixed costs, but programme costs often vary at some level, and for interdisciplinary work, clearly explaining key terms will therefore pay dividends.…”