Economic evaluation of an acute paediatric hospital at home clinical trial

Abstract

Aims: To compare the privately borne and NHS costs of hospital at home (HAH) and conventional inpatient care for children with selected acute conditions. Methods: Prospective economic evaluation using cost minimisation analysis within a randomised controlled trial, in paediatric wards of a district general hospital, and private homes in the local catchment area in Wirral, Merseyside. Subjects were children who fulfilled the criteria for admission to HAH, suffering from breathing difficulties (n = 202), diarrhoea and vomiting (n = 125), or fever (n = 72). Results: Direct costs borne by families are reduced by 41% for HAH patients (£23.31 v £13.76, p = 0.001). There is no evidence that HAH transfers the burden of care to parents, and there is no difference in absence rates from paid employment. Patients and their carers expressed a strong preference for HAH. Comparison of NHS costs is equivocal, depending on how HAH is implemented alongside the conventional hospital service. Conclusion: Paediatric HAH schemes are unlikely to reduce NHS costs and do not increase privately borne costs. They will, however, significantly increase patient and carer satisfaction with care provision for sick children with appropriate conditions. I t has long been accepted that hospital admission of children should be avoided unless therapeutically necessary.1 Although Hospital at Home (HAH) schemes have been shown to provide a cost effective alternative to hospital care (HC) in some adult patients, [2][3][4][5] there is no such evidence for paediatric HAH schemes, which may merely transfer the burden of care from publicly funded health services to private and informal carers.We report results from a prospective economic evaluation of a paediatric HAH scheme compared to traditional hospital inpatient care, based on data collected as part of a randomised controlled trial. The economic evaluation addressed two questions:• Does paediatric HAH care increase costs borne by parents and their families? • Does paediatric HAH care reduce costs to the health service? METHODSDetails of patient recruitment and randomisation are reported in the accompanying paper. 6 As the principal clinical outcome (readmission rate) did not differ significantly between the trial arms, a cost minimisation analysis was undertaken. Our principal interest was the suggestion of cost shifting from the NHS to parents and families, but we also considered differences in NHS costs.Patients were recruited from three groups of children (breathing difficulties, diarrhoea/vomiting, and fever) requiring acute admission and meeting clinical suitability criteria for HAH care. Patients were further classified by time of randomisation: either immediately, or at first subsequent medical review (within 24 hours). Data collection Patient/carer costs and burdenThe level of burden experienced by carers was assessed using questionnaires on private expenditure (travel, food, phone calls, and other direct costs), and absences from paid employment. A diary card captured details of parent/carer...

Comparison of the costs of care during acute illness by two community children's nursing teams

“…This suggests that system and service organisation can also affect the cost to families and society of caring for an acutely ill child. Assuming a working day of 7.5 h, on average, the responding parents spent approximately 2 days off work to care for their child while they were sick, which is comparable with reports in other studies of children with similar conditions 7 11. If care can reduce the need for parents to take time off work it has the potential to be cost effective at the societal level.…”

“…However, there is little evidence about either the effectiveness or the costs of CCNT 5. A randomised controlled trial suggested that home care can be safe for children with acute medical conditions and is preferred by parents and children,6 but firm conclusions could not be drawn about whether it was more or less costly than hospital care 7…”

Methods for assessing the cost-effectiveness of public health interventions: Key challenges and recommendations

“…A similar conclusion was reached in an earlier review of economic evaluations in healthcare more generally by Sassi et al [33]. Occasionally studies considered private costs [34] or explored equity-relevant sub-groups [24]. To consider equity explicitly within economic evaluations, a useful first step would be a narrative review of the equity considerations at stake [35].…”

The first eighteen months of a paediatric ambulatory and community service

“…In addition, the reduction in length of stay may be due to other factors such as a change in casemix over that time. Studies of paediatric nurse home-visiting services have found a variable impact on inpatient service utilisation with some studies showing no change in general readmission rates 2 and others showing a reduction for specific diagnosis related groups such as asthma. 12 Importantly, one consistent finding in the literature has been parental preference for such services, 13,14 which is in keeping with our experience.…”

“…1 There is substantial evidence supporting the use of non-inpatient hospital services for the provision of care to sick children and adults at home or in their local environment. [2][3][4][5][6][7][8] One such model of service has specialist paediatric nurses who support the sick child and their family by providing clinical review in the home and working in partnership with the child' s parents, general practitioner or paediatrician. [2][3][4][5] The home visits increase opportunities for reinforcement of important health messages, involvement of parents in decision making and the identification of other health issues in the home.…”