Cost analysis of The Heart Manual Author Barbara J M Graham Information & Statistics Division, Edinburgh September 2002 Summary Cost analysis of the Heart Manual Cardiac Rehabilitation Programme showed it to offer a cost effective form of provision of care. Results were sensitive to the grade of staff and staff mix used to deliver the package thus it is important to ensure that this aspect of care delivery is stressed in order to maintain efficient use of resources. Background Further to a request from the Heart Manual team, a cost analysis of this cardiac rehabilitation programme (HMCRP) 1 was carried out. The analysis has drawn on findings from a trial by Lewin et al 2 and on information concerning current practice in Scotland, 2002, supplied by members of the Heart Manual team. Methods The perspective of the cost analysis was that of the National Health Service. Delivery of the Heart Manual Cardiac Rehabilitation Programme (HMCRP) consists of two main cost drivers, namely the acquisition price of the Manual and audiotapes at 22 per copy (includes the cost of a trainer to train a local facilitator), and the staff time involved to introduce the HMCRP to the patient and to follow-up the use of the HMCRP with the patient. Calculations of costs entailed modelling a number of scenarios that are currently being be used to provide the staff input necessary to deliver the HMCRP to the patient. It is understood that all these scenarios are used, however information as to the likelihood of any particular scenario being used compared to the other ones is not available. Costs were calculated by taking a combination of the cost of purchasing the manual (which includes the cost of training a local facilitator for delivery of the HMCRP) and a range of staff costs from published sources for 2000/01. The results from a trial of the HMCRP were extrapolated to the Scottish setting and potential cost savings calculated from published sources. 1
Results 1. Cost of the Manual and Audiotapes The price has been set on a sliding scale that offers volume discounts with the minimum order of 50 priced at 22 per copy. This price includes the training cost for a facilitator to deliver the HMCRP locally. 2. Cost of staff time (facilitator) A number of possible scenarios for delivery of the HMCRP were provided by the Heart Manual team comprising combinations of a range of hospital and community staff. In all cases patients receive a one hour introductory session in the acute hospital setting with one of the following: a) Grade G nurse for 1 hour contact visit in the acute hospital @ 55 per hour patient contact 3 b) Senior 1 Physiotherapist for 1 hour contact visit in the acute hospital @ 41 per hour patient contact 4 c) Senior Occupational Therapist for 1 hour contact visit in the acute hospital @ 41 per hour patient contact 5 d) Grade E nurse for 1 hour contact visit in the acute hospital @ 39 per hour patient contact 6 Followed by either a single one hour follow-up visit at home or two x one hour follow-up visits at home by one of the following staff: e) Grade G nurse (e.g. Health Visitor) for 1 hour contact visit at home @ 87 per hour (including travel) 7 f) Grade F nurse (e.g. Practice Nurse) for 1 hour contact visit at home @ 38 per hour (including travel) 8 g) Grade G nurse (e.g. District Nurse) for 1 hour contact visit at home @ 55 per hour (including travel) 9 All staff costs quoted above include wages, salary oncosts, qualifications, and overheads. 2
Table 1: Scenarios for delivery Scenario Combination Staff Cost ( /patient) Total Cost ( /patient) inc. manual I (a) + (e) 55+87 = 142 164 II (a) + (ex2) 55+174 = 229 251 III (a) + (f) 55+38 = 93 115 IV (a) + (fx2) 55+76 = 131 153 V (a) + (g) 55+55 = 110 132 VI (a) + (gx2) 55+110 = 165 187 VII (b) + (e) 41+87 = 128 150 VIII (b) + (ex2) 41+174 = 215 237 IX (b) + (f) 41+38 = 79 101 X (b) + (fx2) 41+76 = 117 139 XI (b) + (g) 41+55 = 96 118 XII (b) + (gx2) 41+110 = 151 173 XIII (c) + (e) 41+87 = 128 150 XIV (c) + (ex2) 41+174 = 215 237 XV (c) + (f) 41+38 = 79 101 XVI (c) + (fx2) 41+76 = 117 139 XVII (c) + (g) 41+55 = 96 118 XVIII (c) + (gx2) 41+110 = 151 173 XIX (d) + (e) 39+87 = 126 148 XX (d) + (ex2) 39+174 = 213 235 XXI (d) + (f) 39+38 = 77 99 XXII (d) + (fx2) 39+76 = 115 137 XXIII (d) + (g) 39+55 = 94 116 XXIV (d) + (gx2) 39+110 = 149 171 MEAN 156 Note that all staff costs are based on England and Wales figures, whilst being considered to be applicable in Scotland. The main cost driver of staff costs is sensitive to both the grade of staff that delivers the care and the number of follow-up home visits that are provided; this generates a range of possible costs from 99 to 251 per person (including the cost of the manual and audio tapes), with a mean value of 156 per person. 3. Extrapolating the trial results The results of the trial published in the Lancet 2 showed that patients in receipt of the Heart Manual experienced both a reduction in GP consultation rates and a reduction in hospital readmission rate in the first six months. Although the trial reported in the Lancet is based on staff delivery of the Heart Manual in 10 minute sessions as opposed to one hour sessions, the results indicated the potential for health service savings realised through these 3
reductions in utilisation; these savings may well more that offset the additional cost of providing the HMCRP. It was assumed that the reductions in health service useage reported in the trial would be realised in the current form of HMCRP delivery (in fact this is a conservative assumption as the savings would probably be greater). Results of the trial show that in Heart Manual rehabilitation patients (n=88) 6 were readmitted to hospital in the first six months, whilst in control patients (n=88) 18 were readmitted to hospital in the first six months and all patients in this group had 1.8 more GP consultations per person than those in the Heart Manual rehabilitation group. Extrapolating these findings to the Scottish context show that the additional cost per person for increased health care utilisation in the control group are: Additional GP consultation costs 1.8 x cost of a GP consultation 10 = 1.8 x 19 = 34.20 For patients readmitted to the Coronary Care Unit 11 Average stay of 2 days = 1224 per patient Risk of readmission = (12 x 1/88) = 0.136 Additional cost per patient = 1124 x 0.136 = 167 For patients readmitted to a General Medical ward 11 Average stay of 5 days = 1169 per patient Risk of readmission = (12 x 1/88) = 0.136 Additional cost per patient = 1169 x 0.136 = 160 Therefore a mean additional readmission cost for control patients is 164/pt Total additional health care costs for control patients = 198 per patient Figure 1 4
Cost of delivery of the HMCRP 300 250 cost per person ( ) (including manual) 200 150 100 50 0 XXI IX XV III XXIII XI XVII V XXII X XVI XIX VII XIII IV I XXIV XII XVIII VI XX VIII XIV II Scenario for delivery This line represents the additional health care costs per person of 198 for those not in receipt of the HMCRP therefore all scenarios that fall below this reference line can be considered to be cost effective (or cost-saving). Discussion When considered in the context of the Scottish average cost 11 of inpatient care in a coronary care unit of 612 per day and in a Rehabilitation Medicine ward of 171 per day the mean cost of the HMCRP of 156 per patient is relatively small. The wide range of staff costs of 77-229 per person indicate that if care is taken to deliver the HMCRP using the scenarios for delivery that provide the greatest value for money, savings are potentially achievable. It can be argued that that the mean cost of the HMCRP of 156 per patient can be offset in terms of savings in hospital readmission and reduced GP consultations ( 198 per patient) realising a potential mean cost saving for those patients rehabilitated using the HMCRP of 42 per patient. These savings are in addition to the improved well-being of the patient in the HMCRP group. 5
It should be noted that the HMCRP is more costly for 4 of the 24 scenarios for delivery therefore it is recommended that, where possible, these scenarios are avoided (II, VIII, XIV, XX). Ideally the least cost scenario (XXI) should be used, thereby maximising cost savings to 99 per patient. One consideration that is operationally important is that the budgets for primary care and secondary care are not unified, therefore savings made in one sector will not be realised in the other sector making it difficult to persuade decision makers in the primary care sector to invest in outlays that will result in savings that will accrue primarily to the secondary care sector. Conclusion The HMCRP offers a cost effective form of care providing delivery of the package is via the scenarios described, avoiding (or minimising) where possible the most costly scenarios. The results of the trial of the HMCRP described in the literature indicate that this is an effective package, however, as the mode of introduction and followup of the package in current use are significantly different to that described in the trial it would be helpful to collect both effectiveness and cost data prospectively alongside similar data for alternative cardiac rehabilitation packages to allow a full economic evaluation to be carried out. 6
References 1. Lothian Primary Care NHS Trust. The Heart Manual, 2 nd ed. Edinburgh; 2002. 2. Lewin B, Robertson IH, Cay EL, Irving JB and Campbell M. Effects of self-help post-myocardial-infarction rehabilitation on psychological adjustment and use of health services. Lancet 1992;339:1036-1040. 3. University of Kent at Canterbury, Personal Social Services Research Unit. Unit Costs of Health and Social Care 2001, Schema 12.2 Ward manager, 24-hour ward. 4. University of Kent at Canterbury, Personal Social Services Research Unit. Unit Costs of Health and Social Care 2001, Schema 11.1 Hospital Physiotherapist 5. University of Kent at Canterbury, Personal Social Services Research Unit. Unit Costs of Health and Social Care 2001, Schema 11.2 Hospital Occupational Therapist 6. University of Kent at Canterbury, Personal Social Services Research Unit. Unit Costs of Health and Social Care 2001, Schema 12.4 Staff nurse, 24-hour ward 7. University of Kent at Canterbury, Personal Social Services Research Unit. Unit Costs of Health and Social Care 2001, Schema 8.3 Health Visitor 8. University of Kent at Canterbury, Personal Social Services Research Unit. Unit Costs of Health and Social Care 2001, Schema 8.6 Practice nurse 9. University of Kent at Canterbury, Personal Social Services Research Unit. Unit Costs of Health and Social Care 2001, Schema 8.1 District nurse 10. University of Kent at Canterbury, Personal Social Services Research Unit. Unit Costs of Health and Social Care 2001, Schema 8.7b General Practitioner 11. Scottish Health Service Costs 2000/01 http://www.isdscotland.org/isd/info3.jsp?p_applic=ccc&p_service=content.show &pcontentid=797 7