The potential role of cost-utility analysis in the decision to implement major system change in acute stroke services in metropolitan areas in England

Abstract

BackgroundThe economic implications of major system change are an important component of the decision to implement health service reconfigurations. Little is known about how best to report the results of economic evaluations of major system change to inform decision-makers. Reconfiguration of acute stroke care in two metropolitan areas in England, namely London and Greater Manchester (GM), was used to analyse the economic implications of two different implementation strategies for major system change.MethodsA decision analytic model was used to calculate difference-in-differences in costs and outcomes before and after the implementation of two major system change strategies in stroke care in London and GM. Values in the model were based on patient level data from Hospital Episode Statistics, linked mortality data from the Office of National Statistics and data from two national stroke audits. Results were presented as net monetary benefit (NMB) and using Programme Budgeting and Marginal Analysis (PBMA) to assess the costs and benefits of a hypothetical typical region in England with approximately 4000 strokes a year.ResultsIn London, after 90 days, there were nine fewer deaths per 1000 patients compared to the rest of England (95% CI –24 to 6) at an additional cost of £770,027 per 1000 stroke patients admitted. There were two additional deaths (95% CI –19 to 23) in GM, with a total costs saving of £156,118 per 1000 patients compared to the rest of England. At a £30,000 willingness to pay the NMB was higher in London and GM than the rest of England over the same time period. The results of the PBMA suggest that a GM style reconfiguration could result in a total greater health benefit to a region. Implementation costs were £136 per patient in London and £75 in GM.ConclusionsThe implementation of major system change in acute stroke care may result in a net health benefit to a region, even one functioning within a fixed budget. The choice of what model of stroke reconfiguration to implement may depend on the relative importance of clinical versus cost outcomes.Electronic supplementary materialThe online version of this article (10.1186/s12961-018-0301-5) contains supplementary material, which is available to authorized users.

Variation in quality of acute stroke care by day and time of admission: prospective cohort study of weekday and weekend centralised hyperacute stroke unit care and non-centralised services

“…With this additional level of funding it might be expected that the quality of care in London should improve, though whether it should produce less variation in quality of care and outcomes across the week in London compared with the rest of England depends on the relative levels of funding in both areas. There is some evidence that the reorganisation in London was cost-effective,42 43 but further analyses accounting for the size of the upfront investment, the relatively high costs per day of hyperacute stroke care, the impact on mortality and disability and the lifetime costs incurred by the NHS, social services and families caring for stroke survivors at different levels of disability would be helpful.…”

Conducting Value for Money Analyses for Non-randomised Interventional Studies Including Service Evaluations: An Educational Review with Recommendations

“…If the intention is to use a service evaluation to produce the estimates on treatment effectiveness that will drive the model, then the aforementioned statistical methods described in this section will still be needed when estimating treatment effects from non-randomised data. Examples of CUA modelling studies born of a service evaluation include Franklin and Hunter [108] (fall-screening and fall-prevention intervention) and Hunter et al [109] (major system change in acute stroke services). It should be noted, however, some decision makers may be interested in short-term costs and consequences (monetary or otherwise).…”

Temporal variations in quality of acute stroke care and outcomes in London hyperacute stroke units: a mixed-methods study

“…Measures for which there were variations by time period of admission were included in the cost analysis. In this case, we multiplied the incremental volume of resource use associated with each measure for the three other time periods compared with Monday to Friday 08.00 to 19.59 by its unit cost, taken from two published economic evaluations of acute stroke care in London HASUs 67,68 and inflated to 2017/18 prices. 69 We assumed that unit costs of the non-time-dependent measures did not vary by the time period of admission, because these are typically provided during normal working hours (see Chapter 6, What this analysis adds).…”