Discussion
chronic diseases, COPD, Diabetes
COPD, DISEASE, CHRONIC DISEASES, DIABETES
Participants in the intervention group experienced fewer hospital admissions with a reduced LOS over 12 months compared to the control group, contributing to overall savings in the hospitalisation of $6,550 per person. This result was statistically significant, and based on this result, the savings to Barwon Health from hospital costs alone would have been $550K in 2014/15. However, the savings in hospitalisation did not offset the costs of the intervention, with the overall result being a non-significant difference in the mean total cost of $714 per person in favour of the control group. In 2014 a similar Danish study for COPD patients over 12 months showed a statistically significant mean cost of $1880 (95%CI:-1447;5207) between study groups [The intervention resulted in a saving of 344 acute hospital bed days over 12 months. The average LOS for overnight separations in Australian public and private hospitals was 5.5 days in 2015/16 [The mean change in QOL between groups was both statistically and clinically significant and above the minimally important difference of 0.06 [The cost-effectiveness analysis showed an ICER of $7,993 per QALY saved. This means that the cost of a gain of one additional year in full health would be $7,993. While there is no publicly stated willingness-to-pay threshold for a QALY in Australia, $50,000 per QALY [Modelled analysis suggested that increasing the scale of the intervention would result in a savings of $28,189 per QALY. The high fixed costs of the intervention and efficiency savings in staffing spread over an increased number of patients were accounted for in the modelled analysis where the original target population was assumed. Under this assumption, the savings in hospitalisation would offset the fixed costs of the intervention and would have resulted in an average savings of $2,532 per person.The major strengths of this economic analysis are the inclusion of the actual intervention costs and staffing using a bottom-up costing approach to determine the real staff time to deliver the program. In addition, access to patient-level clinical costing data from Barwon Health enabled the cost of hospitalisation to be included in the analysis rather than a modelled costs based on DRG pricing for Victoria.One limitation to the evaluation was the small study population compared to the initially planned population. Although we have tried to make assumptions for this in the modelled analysis, we cannot be sure that the assumptions concerning staffing levels are accurate. It is possible that staffing levels would need to increase to allow for increased patient numbers. Nevertheless, the mean cost per person could be reduced if the capital costs of the intervention were attributed to a larger population.Most patients with chronic diseases have their own monitoring devices. Equipment cost was an out-of-pocket cost for the control group. However, the cost of equipment such as blood glucose monitors is unlikely to be totally out-of-pocket because some of these costs are covered under the National Diabetes Services Scheme [A limitation in costing hospital episodes was not being able to cost admissions to private hospitals due to lack of access to private administrative data. If we had these data, we would be able to cost the private hospital admissions using actual costs for Barwon Health hospital episodes. We have not included the costs of non-admitted ED attendances to Barwon Health. Where patients were admitted, these costs are included in the admitted episode costs; however, patient-level cost data for non-admitted ED patients were not available. If non-admitted ED attendances mirror the admitted patient episodes, then both utilisation and costs are likely to be higher in the control group. Further to support this assumption is that where patients are managed in their home environment, it is likely that presentation to the ED without ward admission is the more likely outcome of earlier management of disease exacerbation. Alternatively, staff monitoring patients remotely may have encouraged presentation to the ED where symptoms suggested urgency.