Comparing the cost-effectiveness and clinical effectiveness of a new community in-reach rehabilitation service with the cost-effectiveness and clinical effectiveness of an established hospital-based rehabilitation service for older people: a pragmatic randomised controlled trial with microcost and qualitative analysis – the Community In-reach Rehabilitation And Care Transition (CIRACT) study
| Title: | Comparing the cost-effectiveness and clinical effectiveness of a new community in-reach rehabilitation service with the cost-effectiveness and clinical effectiveness of an established hospital-based rehabilitation service for older people: a pragmatic randomised controlled trial with microcost and qualitative analysis – the Community In-reach Rehabilitation And Care Transition (CIRACT) study |
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| Authors: | Opinder Sahota, Ruth Pulikottil-Jacob, Fiona Marshall, Alan Montgomery, Wei Tan, Tracey Sach, Pip Logan, Denise Kendrick, Alison Watson, Maria Walker, Justin Waring |
| Source: | Health Services and Delivery Research, Vol 4, Iss 7 (2016) |
| Publisher Information: | National Institute for Health Research, 2016. |
| Publication Year: | 2016 |
| Collection: | LCC:Public aspects of medicine LCC:Medicine (General) |
| Subject Terms: | care transition, transition coach, community rehabilitation, in-reach, physiotherapy, microcosting, Public aspects of medicine, RA1-1270, Medicine (General), R5-920 |
| More Details: | Background: Older people represent a significant proportion of patients admitted to hospital as a medical emergency. Compared with the care of younger patients, their care is more challenging, their stay in hospital is much longer, their risk of hospital-acquired problems is much higher and their 28-day readmission rate is much greater. Objective: To compare the clinical effectiveness, microcosts and cost-effectiveness of a Community In-reach Rehabilitation And Care Transition (CIRACT) service with the traditional hospital-based rehabilitation (THB-Rehab) service in patients aged ≥ 70 years. Methods: A pragmatic randomised controlled trial with an integral health economic study and parallel qualitative appraisal was undertaken in a large UK teaching hospital, with community follow-up. Participants were individually randomised to the intervention (CIRACT service) or standard care (THB-Rehab service). The primary outcome was hospital length of stay; secondary outcomes were readmission within 28 and 91 days post discharge and super spell bed-days (total time in NHS care), functional ability, comorbidity and health-related quality of life, all measured at day 91, together with the microcosts and cost-effectiveness of the two services. A qualitative appraisal provided an explanatory understanding of the organisation, delivery and experience of the CIRACT service from the perspective of key stakeholders and patients. Results: In total, 250 participants were randomised (n = 125 CIRACT service, n = 125 THB-Rehab service). There was no significant difference in length of stay between the CIRACT service and the THB-Rehab service (median 8 vs. 9 days). There were no significant differences between the groups in any of the secondary outcomes. The cost of delivering the CIRACT service and the THB-Rehab service, as determined from the microcost analysis, was £302 and £303 per patient respectively. The overall mean costs (including NHS and personal social service costs) of the CIRACT and THB-Rehab services calculated from the Client Service Receipt Inventory were £3744 and £3603 respectively [mean cost difference £144, 95% confidence interval –£1645 to £1934] and the mean quality-adjusted life-years for the CIRACT service were 0.846 and for the THB-Rehab service were 0.806. The incremental cost-effectiveness ratio (ICER) from a NHS and Personal Social Services perspective was £2022 per quality-adjusted life-year. Although the CIRACT service was highly regarded by those who were most involved with it, the emergent configuration of the service working across organisational and occupational boundaries was not easily incorporated by the current established community services. Conclusions: The CIRACT service did not reduce hospital length of stay or short-term readmission rates compared with the standard THB-Rehab service, although it was highly regarded by those who were most involved with it. The estimated ICER appears cost-effective although it is subject to much uncertainty, as shown by points spanning all four quadrants of the cost-effectiveness plane. Microcosting work-sampling methodology provides a useful method to estimate the cost of service provision. Limitations in sample size, which may have excluded a smaller reduction in length of stay, and lack of blinding, which may have introduced some cross-contamination between the two groups, must be recognised. Reducing hospital length of stay and hospital readmissions remains a priority for the NHS. Further studies are necessary, which should be powered with larger sample sizes and use cluster randomisation (to reduce bias) but, more importantly, should include a more integrated community health-care model as part of the CIRACT team. Trial registration: Current Controlled Trials ISRCTN94393315. Funding: The National Institute for Health Research Health Services and Delivery Research programme. |
| Document Type: | article |
| File Description: | electronic resource |
| Language: | English |
| ISSN: | 2050-4349 2050-4357 |
| Relation: | https://doaj.org/toc/2050-4349; https://doaj.org/toc/2050-4357 |
| DOI: | 10.3310/hsdr04070 |
| Access URL: | https://doaj.org/article/fb407211f8b647ebbafabc299350c9f9 |
| Accession Number: | edsdoj.fb407211f8b647ebbafabc299350c9f9 |
| Database: | Directory of Open Access Journals |
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| Items | – Name: Title Label: Title Group: Ti Data: Comparing the cost-effectiveness and clinical effectiveness of a new community in-reach rehabilitation service with the cost-effectiveness and clinical effectiveness of an established hospital-based rehabilitation service for older people: a pragmatic randomised controlled trial with microcost and qualitative analysis – the Community In-reach Rehabilitation And Care Transition (CIRACT) study – Name: Author Label: Authors Group: Au Data: <searchLink fieldCode="AR" term="%22Opinder+Sahota%22">Opinder Sahota</searchLink><br /><searchLink fieldCode="AR" term="%22Ruth+Pulikottil-Jacob%22">Ruth Pulikottil-Jacob</searchLink><br /><searchLink fieldCode="AR" term="%22Fiona+Marshall%22">Fiona Marshall</searchLink><br /><searchLink fieldCode="AR" term="%22Alan+Montgomery%22">Alan Montgomery</searchLink><br /><searchLink fieldCode="AR" term="%22Wei+Tan%22">Wei Tan</searchLink><br /><searchLink fieldCode="AR" term="%22Tracey+Sach%22">Tracey Sach</searchLink><br /><searchLink fieldCode="AR" term="%22Pip+Logan%22">Pip Logan</searchLink><br /><searchLink fieldCode="AR" term="%22Denise+Kendrick%22">Denise Kendrick</searchLink><br /><searchLink fieldCode="AR" term="%22Alison+Watson%22">Alison Watson</searchLink><br /><searchLink fieldCode="AR" term="%22Maria+Walker%22">Maria Walker</searchLink><br /><searchLink fieldCode="AR" term="%22Justin+Waring%22">Justin Waring</searchLink> – Name: TitleSource Label: Source Group: Src Data: Health Services and Delivery Research, Vol 4, Iss 7 (2016) – Name: Publisher Label: Publisher Information Group: PubInfo Data: National Institute for Health Research, 2016. – Name: DatePubCY Label: Publication Year Group: Date Data: 2016 – Name: Subset Label: Collection Group: HoldingsInfo Data: LCC:Public aspects of medicine<br />LCC:Medicine (General) – Name: Subject Label: Subject Terms Group: Su Data: <searchLink fieldCode="DE" term="%22care+transition%22">care transition</searchLink><br /><searchLink fieldCode="DE" term="%22transition+coach%22">transition coach</searchLink><br /><searchLink fieldCode="DE" term="%22community+rehabilitation%22">community rehabilitation</searchLink><br /><searchLink fieldCode="DE" term="%22in-reach%22">in-reach</searchLink><br /><searchLink fieldCode="DE" term="%22physiotherapy%22">physiotherapy</searchLink><br /><searchLink fieldCode="DE" term="%22microcosting%22">microcosting</searchLink><br /><searchLink fieldCode="DE" term="%22Public+aspects+of+medicine%22">Public aspects of medicine</searchLink><br /><searchLink fieldCode="DE" term="%22RA1-1270%22">RA1-1270</searchLink><br /><searchLink fieldCode="DE" term="%22Medicine+%28General%29%22">Medicine (General)</searchLink><br /><searchLink fieldCode="DE" term="%22R5-920%22">R5-920</searchLink> – Name: Abstract Label: Description Group: Ab Data: Background: Older people represent a significant proportion of patients admitted to hospital as a medical emergency. Compared with the care of younger patients, their care is more challenging, their stay in hospital is much longer, their risk of hospital-acquired problems is much higher and their 28-day readmission rate is much greater. Objective: To compare the clinical effectiveness, microcosts and cost-effectiveness of a Community In-reach Rehabilitation And Care Transition (CIRACT) service with the traditional hospital-based rehabilitation (THB-Rehab) service in patients aged ≥ 70 years. Methods: A pragmatic randomised controlled trial with an integral health economic study and parallel qualitative appraisal was undertaken in a large UK teaching hospital, with community follow-up. Participants were individually randomised to the intervention (CIRACT service) or standard care (THB-Rehab service). The primary outcome was hospital length of stay; secondary outcomes were readmission within 28 and 91 days post discharge and super spell bed-days (total time in NHS care), functional ability, comorbidity and health-related quality of life, all measured at day 91, together with the microcosts and cost-effectiveness of the two services. A qualitative appraisal provided an explanatory understanding of the organisation, delivery and experience of the CIRACT service from the perspective of key stakeholders and patients. Results: In total, 250 participants were randomised (n = 125 CIRACT service, n = 125 THB-Rehab service). There was no significant difference in length of stay between the CIRACT service and the THB-Rehab service (median 8 vs. 9 days). There were no significant differences between the groups in any of the secondary outcomes. The cost of delivering the CIRACT service and the THB-Rehab service, as determined from the microcost analysis, was £302 and £303 per patient respectively. The overall mean costs (including NHS and personal social service costs) of the CIRACT and THB-Rehab services calculated from the Client Service Receipt Inventory were £3744 and £3603 respectively [mean cost difference £144, 95% confidence interval –£1645 to £1934] and the mean quality-adjusted life-years for the CIRACT service were 0.846 and for the THB-Rehab service were 0.806. The incremental cost-effectiveness ratio (ICER) from a NHS and Personal Social Services perspective was £2022 per quality-adjusted life-year. Although the CIRACT service was highly regarded by those who were most involved with it, the emergent configuration of the service working across organisational and occupational boundaries was not easily incorporated by the current established community services. Conclusions: The CIRACT service did not reduce hospital length of stay or short-term readmission rates compared with the standard THB-Rehab service, although it was highly regarded by those who were most involved with it. The estimated ICER appears cost-effective although it is subject to much uncertainty, as shown by points spanning all four quadrants of the cost-effectiveness plane. Microcosting work-sampling methodology provides a useful method to estimate the cost of service provision. Limitations in sample size, which may have excluded a smaller reduction in length of stay, and lack of blinding, which may have introduced some cross-contamination between the two groups, must be recognised. Reducing hospital length of stay and hospital readmissions remains a priority for the NHS. Further studies are necessary, which should be powered with larger sample sizes and use cluster randomisation (to reduce bias) but, more importantly, should include a more integrated community health-care model as part of the CIRACT team. Trial registration: Current Controlled Trials ISRCTN94393315. 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| RecordInfo | BibRecord: BibEntity: Identifiers: – Type: doi Value: 10.3310/hsdr04070 Languages: – Text: English Subjects: – SubjectFull: care transition Type: general – SubjectFull: transition coach Type: general – SubjectFull: community rehabilitation Type: general – SubjectFull: in-reach Type: general – SubjectFull: physiotherapy Type: general – SubjectFull: microcosting Type: general – SubjectFull: Public aspects of medicine Type: general – SubjectFull: RA1-1270 Type: general – SubjectFull: Medicine (General) Type: general – SubjectFull: R5-920 Type: general Titles: – TitleFull: Comparing the cost-effectiveness and clinical effectiveness of a new community in-reach rehabilitation service with the cost-effectiveness and clinical effectiveness of an established hospital-based rehabilitation service for older people: a pragmatic randomised controlled trial with microcost and qualitative analysis – the Community In-reach Rehabilitation And Care Transition (CIRACT) study Type: main BibRelationships: HasContributorRelationships: – PersonEntity: Name: NameFull: Opinder Sahota – PersonEntity: Name: NameFull: Ruth Pulikottil-Jacob – PersonEntity: Name: NameFull: Fiona Marshall – PersonEntity: Name: NameFull: Alan Montgomery – PersonEntity: Name: NameFull: Wei Tan – PersonEntity: Name: NameFull: Tracey Sach – PersonEntity: Name: NameFull: Pip Logan – PersonEntity: Name: NameFull: Denise Kendrick – PersonEntity: Name: NameFull: Alison Watson – PersonEntity: Name: NameFull: Maria Walker – PersonEntity: Name: NameFull: Justin Waring IsPartOfRelationships: – BibEntity: Dates: – D: 01 M: 02 Type: published Y: 2016 Identifiers: – Type: issn-print Value: 20504349 – Type: issn-print Value: 20504357 Numbering: – Type: volume Value: 4 – Type: issue Value: 7 Titles: – TitleFull: Health Services and Delivery Research Type: main |
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