Raftery J P, Addington-Hall J M, MacDonald L D, Anderson H R, Bland J M, Chamberlain J, Freeling P
Department of Epidemiology and Public Health, University College London, UK.
Palliat Med. 1996 Apr;10(2):151-61. doi: 10.1177/026921639601000210.
The objective of this paper is to compare the cost effectiveness of a co-ordination service with standard services for terminally ill cancer patients with a prognosis of less than one year. We designed a randomized controlled trial, with patients randomized by the general practice with which they were registered. Co-ordination group patients received the assistance of two nurse coordinators whose role was to ensure that patients had access to appropriate services. The setting was in a South London health authority. Complete service use and outcome data were collected on 167 patients, 86 in the co-ordination group, and 81 in the control group. Our results, as previously reported, show that no differences in outcomes were detected between the co-ordination and control groups; the mean total costs incurred by the co-ordination group were significantly less than those of the control group. The co-ordinated group used significantly fewer inpatient days (mean 24 versus 40 inpatient days; t = 2.4, p = 0.002) and nurse home visits (mean 14.5 versus 37.5 visits; t = 0.3, p = 0.01). Mean cost per co-ordinated patient was almost half that of the control group patients 4774 pounds versus 8034 pounds, t = 2.8, p = 0.006). Although the unit cost data were relatively crude, these cost reductions were insensitive to a wide range of unit costs. These differences persisted when, in order to control for any putative differences in severity between the two groups, the analysis was restricted to patients who had died by the end of the study. The ratio of potential cost savings to the cost of co-ordination service was between 4:1 and 8:1. In conclusion, the co-ordination service for cancer patients who were terminally ill with a prognosis of less than one year was more cost effective than standard services, due to achieving the same outcomes at lower service use, particularly inpatient days in acute hospital. Assuming that the observed effects are real, improved co-ordination of palliative care offers the potential for considerable savings. Further research is needed to explore this issue.
本文的目的是比较为预后不到一年的晚期癌症患者提供的协调服务与标准服务的成本效益。我们设计了一项随机对照试验，患者由其注册的全科诊所进行随机分组。协调组患者接受两名护士协调员的协助，他们的职责是确保患者能够获得适当的服务。研究地点在伦敦南部的一个卫生当局。收集了167名患者的完整服务使用情况和结局数据，其中协调组86人，对照组81人。正如我们之前所报告的，我们的结果表明，协调组和对照组在结局方面未发现差异；协调组产生的平均总成本显著低于对照组。协调组的住院天数（平均24天对40天；t = 2.4，p = 0.002）和护士家访次数（平均14.5次对37.5次；t = 0.3，p = 0.01）明显更少。每名接受协调服务患者的平均成本几乎是对照组患者的一半（4774英镑对8034英镑，t = 2.8，p = 0.006）。尽管单位成本数据相对粗略，但这些成本降低对广泛的单位成本并不敏感。为了控制两组之间可能存在的严重程度差异，当分析仅限于研究结束时已死亡的患者时，这些差异仍然存在。潜在成本节约与协调服务成本的比率在4:1至8:1之间。总之，对于预后不到一年的晚期癌症患者，协调服务比标准服务更具成本效益，因为在较低的服务使用量下取得了相同的结局，尤其是急性医院的住院天数。假设观察到的效果是真实的，改善姑息治疗的协调有可能节省大量费用。需要进一步研究来探讨这个问题。
