Cost effectiveness analysis of an intervention to prevent by pptfiles

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									Cost effectiveness analysis of an
intervention to prevent pressure
ulcers
MPH Health economics
Spring 2012
Methodology
• Method:
 ▫ Model: Decision tree, comparison with no
   intervention
 ▫ Uncertainty analysis (model/data)
• Input data: Based on observation
  (litterature)+interview
• Measure of effectiveness: No of reduced pressure
  ulcers, No of prevented deaths
• Costs: Direct cost
• Perspective: Societal perspective: Both hospital
  and home care costs are included.
Epidemiology
• It is estimated that 13-43 % of inpatients in
  Danish hospitals have a pressure ulcer
• 7-7,3% of these are estimated to be acquired
  during hospitalization
• Most pressure ulcers are preventable if
  appropriate measures are taken.
Patophysiology
• HAPU occurs typically under
  immobilisation
• Pressure on the skin makes an
  ischaemia, which ultimately can
  develop an ulcer
• Pressure ulcers are graded into 4
  stages, where 4 is most severe.
Guidelines to prevent pressure
ulcers
• To prevent hospital acquired pressure ulcers
  (HAPU), Dansk Selskab for Patientsikkerhed has
  developed a set of guidelines:
 ▫ Risk screening of all new patients (Braden/Norton
   Scale) except for women giving birth.
 ▫ Patients at risk are daily assessed for HAPU
 ▫ Patients at risk are nutrition screened
 ▫ Patients at risk are repositioned frequently and get
   support surfaces
• Target is to reduce HAPUs with 50 %
Actions to prevent HAPU in a
Danish surgical department
• Hand-out of patient information: all patients,
  once per hospitalisation
• Journal writing: all patients, once a day
• Risk screening: all patients, once a day
• Repositioning: at-risk patients, every second day
• Notes in EPJ: at-risk patients, every second day
Why conduct a CEA study?
• Prevention of HAPUs take additional time for
  nurses on the hospitals and in homecare – it is
  therefore not evident, that it is a good business
  to introduce prevention.
                       New
                       intervention
                       more costly




  New                              PREVENTION   New
  intervention less                OF HAPUs     intervention
  effective                        below the    more effective
                                   maximum
                                   acceptable
                                   ICER?
                        New
                        intervention less
                        costly
   Model: Descision tree
                                                            Death
                                           HAPU grade III   P=0,35
                                               -IV
                                  HAPU        P=0,15        No death
                                 P=0,035   HAPU grade I-     P=0,35
                  Intervention                 II
                                 No HAPU      P=0,85
                                 P=0,965

                                                            Death
Hospitalization
                                           HAPU grade III   P=0,35
                                               -IV
                                 HAPU         P=0,15        No death
                                 P=0,07    HAPU grade I-     P=0,65
                   Standard                    II
                   treatment
                                 No HAPU      P=0,85
                                  P=0,93
Cost assessed in the hospital and
in the primary sector
• A health sector (primary and secondary)
  perspective is chosen
• Cost in hospital:
 ▫ Added nurse time spent on documentation,
   information and repositioning of patients
 ▫ Special matresses, sheets, pillows, chairs
 ▫ Education of nurses

• Cost in primary health care
 ▫ Home care nurses home visits
Calculation of prevention costs per
patient (average LOS)
Activity     Share of   Time      Wage/hr   Frequenc    Cost,
             patients             DKK       y/hospita   DKK
                                            lisation
Hand-out     100        0.0833    277,3     1           23,1
of
informatio
n
Journal      100        0.0167    277,3     4           18,4
writing
Screening    100        -         277,3     4           0
Notes in EPJ 40         0.0333    277,3     2           7,4
Repositionin 40         0.833 3   277,3     2           184,9
g, time pr
24h
TOTAL                                                   233,9
Calculation of implementation
costs pr. stay per patient
Impleme     Share pr.   Time        Addi-       Discounti   Cost DKK
ntation     patient                 tional      ng, years   per
measure                             price/uni               patient
                                    t DKK                   per
                                                            average
                                                            stay (4
                                                            days)
Education   0.10        7.5 hrs+7.5 277,3       0.33        1,50
of nurses               hrs
                        (substitute)
Mattresses, 0.4         -           650         0.25        2,22
pillows,
chairs etc
TOTAL                                                       3,72
Total cost, prevention of HAPU at
hospital
Preventive measure                  Cost DKK
Implementation measures             3,72
(mattresses, pillows, chairs etc)
Cost of staff pr. intervention      233,9
TOTAL                               236,1
Direct cost of HAPU on hospitals
             Grade    Distri   Hospit Frequ      Cost
                      bution   al     ency
  HAPU       I-II     85%      15 min   Every    138,7
  care pr.                              second
  patient                               day
  HAPU       III-IV   15%      20 min   Daily    332,8
  care pr.
  patient
  Weigth                                         167,8
  ed cost
  of
  HAPUs
Is it a good business for hospitals
to prevent HAPUs?
• 50 % reduction => from 7 % to 3,5% of all patients
• No of inpatients in DK hospitals minus obstetric patients:
  1.203.746 (2010)
• No of HAPUs prevented: 3,5 % eq. to 42.131 per year
• No of deaths prevented: Mortality rate*50%: 2.211 per year
• Cost of intervention x inpatient/year= 284.206.606 DKK
• Gain for HAPUs saved x 3,5% of patients = 7.068.445 DKK
• Conclusion: No, it is not a good business: More expensive
  for hospitals to prevent HAPUs than to leave the patients
  with standard treatment.
   What about cost in the primary
   sector?
           Grade    Weighte   Home     Transp    Freque   Cost, DKK
                    d         care     ortatio   ncy
                    healing            n
                    time
HAPU       I-II     48 days   15 min   20 min    Every
care pr.                                         second
patient                                          day      2.667,29
HAPU       III-IV   20 days   20 min   20 min    Daily
care pr.
patient                                                   2.432,52
Weigthed                                                   5.099,81
cost of
HAPUs
   CEA of preventing HAPUs in hospitals:
   It is not cost effective to prevent 50%
   of the HAPUs
           Cost of          Gain of        Gain of       Total cost
           prevention,      prevention,    prevention,
           hospitals, DKK   hospitals      Primary
                                           sector
In total   -284.206.606     7.068.445     214.860.496    62.277.664


                                                         1478 pr.
                                                         HAPU
Uncertainty analysis: 1478 -/+25%
Unit           Confidential Interval   Break-even
               (per HAPU
               prevented)
Time spent     1124; 1832
Salary         1161; 1796
Healing days   2753; 203
HAPUs          3726; 129               (64 % prevented
prevented                              instead of 50%: +28%)
Is it a good business for society to
prevent HAPUs?

• Conclusion: From a societal point of view, it is not a
  good business, the loss from preventing each HAPU
  in hospitals is 1478 DKK.

• However, the estimate is based on a 50 % reduction
  of HAPUs. If the reduction is 64 %, the intervention
  breaks even. This is very likely, since there has been
  good results on interventions abroad.

								
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