Economic evidence with respect to cost-effectiveness of the transitional care model among geriatric patients discharged from hospital to home: a systematic review

Kast, Kristina; Wachter, Carl-Philipp; Schöffski, Oliver; Rimmele, Martina Article — Published Version Economic evidence with respect to cost-effectiveness of the transitional care model among geriatric patients discharged from hospital to home: a systematic review The European Journal of Health Economics Provided in Cooperation with: Springer Nature Suggested Citation: Kast, Kristina; Wachter, Carl-Philipp; Schöffski, Oliver; Rimmele, Martina (2021) : Economic evidence with respect to cost-effectiveness of the transitional care model among geriatric patients discharged from hospital to home: a systematic review, The European Journal of Health Economics, ISSN 1618-7601, Springer, Berlin, Heidelberg, Vol. 22, Iss. 6, pp. 961-975, https://doi.org/10.1007/s10198-021-01301-4 This Version is available at: https://hdl.handle.net/10419/286768 Standard-Nutzungsbedingungen: Die Dokumente auf EconStor dürfen zu eigenen wissenschaftlichen Zwecken und zum Privatgebrauch gespeichert und kopiert werden. 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If the documents have been made available under an Open Content Licence (especially Creative Commons Licences), you may exercise further usage rights as specified in the indicated licence. https://creativecommons.org/licenses/by/4.0/ Vol.:(0123456789) 1 3 The European Journal of Health Economics (2021) 22:961–975 https://doi.org/10.1007/s10198-021-01301-4 ORIGINAL PAPER Economic evidence withrespect tocost‑effectiveness ofthetransitional care model amonggeriatric patients discharged fromhospital tohome: asystematic review KristinaKast1 · Carl‑PhilippWachter1· OliverSchöffski1· MartinaRimmele2 Received: 30 July 2020 / Accepted: 26 March 2021 / Published online: 10 April 2021 © The Author(s) 2021 Abstract Background The German hospital-to-home discharge management of geriatric patients has long been criticized. The implementation of the American Transitional Care Model (TCM) could help to reduce readmissions and costs. The objective of this review was to check the scientific evidence of the cost-effectiveness of the TCM. Methods A systematic literature search in six databases for the time period of 26years was conducted. The studies had to meet all pre-defined inclusion criteria. The data extraction is based on a criteria chart from literature. The methodological quality was assessed using the tools of the National Heart, Lung, and Blood Institute as well as the Consensus Health Economic Criteria list. The results transferability to German health care system was explained based on the criteria from the literature. Results Three American studies met all criteria. They showed partial cost analyses but no full economic analyses. It could be assumed that the economic effect of the TCM changes over time. The costs of a care coordinator could not be determined because few detailed information was reported. The TCM may have negative consequences for hospitals. The results are not transferable to Germany. Conclusion There is no scientific evidence for the cost-effectiveness of the defined TCM. The optimal TCM duration still needs to be clarified. A detailed overview with units and prices and an additional consideration of the hospital perspective could help to make the information more transparent when deciding about the TCM implementation. A full economic analysis under German conditions or for similar European countries is necessary. Keywords Transitional care· Geriatric patients· Hospital discharge· Cost-effectiveness· Economic analysis· Budget impact analysis JEL Classification I1 Health Abbreviations APN Advanced practice nurse BIA Budget impact analysis BHCS Baylor Health Care System BMCG Baylor Medical Center Garland CG Control group IG Intervention group NR Not reported RCT Randomized controlled trial TCM Transitional care model TCP Transitional care program VN Visiting nurse Introduction andbackground About 20 million patients are being discharged from German hospitals every year [1]. One in ten of them requires further outpatient care [2]. The transition of patients from the inpatient to the outpatient setting represents an interruption of the continuity of care that is associated with * Kristina Kast [email protected] 1 Chair ofHealth Care Management, Law andEconomics Faculty oftheFriedrich-Alexander University ofErlangen- Nuremberg, Lange Gasse 20, 90403Nuremberg, Germany 2 Medical Faculty oftheFriedrich-Alexander University ofErlangen-Nuremberg, Institute forBiomedicine ofAging, Kobergerstr. 60, 90408Nuremberg, Germany 962 K.Kast et al. 1 3 poor post-discharge outcomes. This problem is especially relevant for geriatric patients because they are exposed to high mental and physical stress after discharge from the hospital. For example, they have more difficulties to cope with everyday life, are affected by longer healing periods, and develop new acute or chronic health problems [3, 4]. This can result in hospital readmissions and causes high costs for the health care system. Consequently, the German legislator introduced discharge management by law in 2007 [5]. It includes an assessment of risk for poor outcomes shortly before discharge, contacting the relatives of the patient, the execution of the discharge measures, and a brief check of the realization of the execution of the measures at discharge [3, 6]. However, the problems of the interruption of the continuity of care and of the high inpatient costs, caused by readmissions, seem to be unsolved, and the discharge management by law is still being criticized [6]. Considering the prognosis that the proportion of people aged 65years or older will grow by approximately 20% by 2030 [7], it can be assumed that the problem will exacerbate. An improved solution for the transitional care of geriatric patients in Germany is therefore necessary. An enhancement of the German discharge management with the components of the American Transitional Care Model (TCM) could be one such solution. The TCM has been developed and evaluated in several studies by Naylor etal. [8]. After that, the core components of the model were summarized by Hirschman etal. [9]. Following this model, a patient to be discharged from a hospital is supported by a qualified permanent contact person for a certain period after discharge who makes regular home visits and is also available by telephone. This person coordinates the entire interdisciplinary and integrated care, involves the relatives, supports the patients to perform their activities of daily living, and increasingly promotes the activation of self-management [8]. Since 2017 (running until 2021) in a project funded by the Federal Joint Committee (the highest decision-making body of care deliverers in Germany) researchers compare the TCM with the German routine care in a randomized controlled trial (RCT) [10]. Depending on the success of the project intervention in terms of its effectiveness and cost-effectiveness, it will be decided whether it will also be implemented in Germany as a reimbursable service of the statutory health insurance funds. In addition to the future project results, the results of previous studies can help decision-makers to make an informed decision. There are already some systematic reviews that examined the effectiveness [11, 12] and costs of different models of transitional care [13–16]. To the best of the authors’ knowledge, however, there are no reviews available that address the cost-effectiveness with a narrow focus on the TCM and at the same time on geriatric patients. The objective of this review was therefore to check which scientific evidence already exists concerning the cost-effectiveness of the defined TCM (as planned for Germany). Methodology Search strategy anddatabases A systematic literature search was conducted in databases dealing with both medical and economic issues: PubMed, Science Direct, Scopus, EconBiz, Cochrane Library, and CINAHL. A search term was defined that covered three thematic areas (see supplementary information, TableS1): geriatric, TCM, costs. The operators AND as well as OR were used. The search covered the period from 1January 1995 to 31December2020 and the following filters were used: Search in titles, abstracts, and full texts as well as studies in English or German. The last filter means, that the research studies from other countries were allowed but they had to be written in one of the both languages understandable for the authors and to meet inclusion criteria mentioned below. Selection criteria After the duplicates were removed, the remaining articles were screened independently by two authors. Pre-defined selection criteria were applied to identify citations relevant to the review objective. For inclusion in the review, the subjects of the potentially relevant studies had to be geriatric patients. These are defined as patients at a very high age (80years or older) or as patients aged 65 or older who also have multiple diseases or at least one chronic disease [4, 17]. The hospitalized patients had to be discharged to home, but not to some other settings like nursing home or palliative care facilities. The readmissions had to be unplanned. The intervention needed to be provided as home visits combined with telephone calls. The care coordination had to be carried out by only one responsible person. Furthermore, the examined intervention had to include at least two additional core components of TCM [9], and should not be finished with discharge. The costs needed to be stated in a quantitative form. If one of the criteria was not met, the respective study was excluded. Articles were also excluded if they had no reference to the topic or were grey literature. The transitional care reviews, however, were checked whether they included studies relevant to the objective of the present work. The differences in screening results were then resolved by discussion of the authors. The process of the literature screening was documented in a PRISMA flow chart as recommended by Moher etal. [18]. 963 Economic evidence withrespect tocost‑effectiveness ofthetransitional care model among… 1 3 Data extraction andanalysis The data were extracted by one author and checked by another. The contents were extracted using a prepared data collection form based on the recommendations from the literature [19] and included information such as author, objective, study type, setting, economic perspective, key results of the respective studies. It would be of no value to pool data of different study types because it would lead to false conclusions. This is also not recommended for studies of the same type (here RCTs) if they used different methodological approaches to the economic analysis or different outcomes [20]. For these reasons, it was not possible to perform a meta-analysis in this review, and the extracted data were descriptively analyzed in Excel based on frequencies and, if necessary, own calculations and comparisons. Quality assessment The methodological quality of the included studies was assessed separately regarding the methodology of the clinical and the economic evaluation. For the former, the assessment based on tools for RCTs [21] and for observational studies [22] recommended by the National Heart, Lung, and Blood Institute. These tools contain 14 questions per study type that seems to be an acceptable number compared to other very short or very long checklists [23]. Furthermore, it covers the most important methodological criteria of the respective study types [24, 25]. For the economic part, the Consensus Health Economic Criteria (CHEC) list [26] was used for all studies. This tool is appropriate for the assessment of economic studies carried out in the context of clinical studies and for both full and partial economic analyses [27]. The questions of the respective checklist were answered with "yes", "no" or "unclear". No points were awarded, since according to the literature the scale formation is not considered as an appropriate procedure for valid quality checks [23]. However, to be able to assess the overall result on methodological quality, a reference value of at least 75% of fulfilled criteria of the respective quality assessment instrument was considered high and thus acceptable quality. A criterion was fulfilled if the answer to the question could be clearly “yes”. Data presentation anddiscussion The results of this review are limited to general characteristics of the studies, patient-related outcomes, resource use, and financial outcomes. Patient-related outcomes are those that are important for an individual patient (e.g. comorbidity-related readmission, satisfaction). The resource use is defined as those outcomes that indicate the consumption of resources in the health care system and are therefore relevant for the statutory health insurance funds (e.g. number of readmissions in total, number of outpatient visits). Financial outcomes include all resource consumptions that are valued in monetary units and stated in quantitative form. The text of the review describes the results starting with the variables that were investigated in all included studies. This is followed by the description of variables that appear in a maximum of two studies and ends with the description of variables examined in a single study. In addition to the results presented in the text, reference is made to the supplementary information at the relevant point if more detailed information is available. The key results of the review are discussed afterwards and their transferability to the German health care system is explained. The transferability assessment is based on criteria recommended by Welte etal. [28]. Compared to other criteria sets [29] this one represents an acceptable number of assessment questions that moreover do not overlap with the criteria of the quality assessment tools used in this review. Results Literature search The objective of this review was to check which scientific evidence already exists concerning the cost-effectiveness of the defined TCM among geriatric patients. Through the systematic literature search in six databases, a total of 3 850 potentially relevant citations were identified (see Fig.1). 2 861 of them were screened. Most of the articles (n = 2 604) were excluded by screening the titles and abstracts. Further 257 studies had to be screened in full text. In both screening phases, most of the articles (n = 1 001 and n = 80) were excluded because they were from a different program (e.g. case management, disease management). Other reasons that were often responsible for exclusions was the lack of cost consideration (n = 366 and n = 68) or addressing other topics (n = 433), e.g. flight simulation, dermatological or pharmaceutical issues. In addition, one potentially relevant study was identified through the hand search. Finally, three studies met all criteria and were included in the review: Naylor etal. [30], Naylor etal. [31], and Stauffer etal. [32]. General characteristics The general characteristics of the included studies are summarized in Table1. All three studies were conducted in the USA, two [30, 31] of them by Naylor and colleagues, who designed the TCM. Two studies were RCTs [30, 31], and one an observational study [32]. On average the included studies had 247 subjects while the smallest sample size (N = 140) 964 K.Kast et al. 1 3 was reported by Stauffer etal. The studies were conducted between 1992 and 2010. The duration of the individual studies ranged from 8months [32] to almost 4years [30, 31] with the follow-ups ranging from 2weeks to 1year. In all of them, the main focus was on the investigation of the effectiveness of the certain TCM, while the economic consideration was clearly stated as a secondary objective (with an indication of the economic perspective) only in Stauffer etal. and was only generally mentioned in Naylor etal. [31]. All the studies conducted partial cost analyses, but none of them carried out a full economic analysis with a comparison of costs and outcomes. In the quality assessment, none of the studies fulfilled 75% of the quality criteria (for more details see supplementary information, TableS2). Programs androutine care All three studies fulfilled at least five TCM components (see Table2). In all programs, the care coordination was carried out by an advanced practice nurse (APN). Furthermore, the components of education, engagement of patients and caregivers, maintaining of relationships, as well as assessment and management of risks and symptoms were fulfilled. The other TCM components were only mentioned in the two RCTs according to Naylor etal. The qualification of the APNs (e.g. in terms of degree, specialization, and experience) was described to different extents in the included studies (e.g. an APN with master´s degree as well as qualification and experience in care coordination of elders [30, 31]). In all of them, the first home visit by APN took place within three days after discharge. The 1-month intervention Fig. 1 Flow chart for the systematic review process to select studies. a For more information see online supplementary information, TableS1. b More than one care coordinator or calls without home visits. c Economic part of the study mentioned, but not available Literature idenfied from search strategya) N=3 850 (PubMed n=1 538, Scopus n=1 005, Cochrane n=840, CINAHL n=130, Science Direct n=197, EconBiz n=140) Studies excluded based on tle and abstract n=2604 Other program (n=1 001) Other topic (n=433) No cost analysis (n=366) Not transional care (n=293) Not geriatric (n=244) Other seng (n=217) Review (n=37) Methods (n=9)b) Other language (n=4) Duplicates deleted n=989 Studies excluded not meeng inclusion criteria n=255 Other program (n=80) No cost analysis (n=68) Not geriatric (n=60) Review (n=18) Other seng (n=12) Methods (n=8)b) Other reasons (n=5)c) Other language (n=4) Studies to screen n=2 861 Potenally relevant studies n=257 Studies included based on hand search n=1 Studies included in the review n=3 965 Economic evidence withrespect tocost‑effectiveness ofthetransitional care model among… 1 3 Table 1 General characteristics of the studies NR, Not reported a Ø247.333 (= (363 + 239 + 140)/3) b For more information see online supplementary information, TableS2 Author (year) Naylor etal. [30] Naylor etal. [31] Stauffer etal. [32] Title Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial Transitional care of older adults hospitalized with heart failure: A randomized controlled trial Effectiveness and cost of a transitional care program for heart failure: A prospective study with concurrent controls Country USA USA USA Objective(s) To examine the effectiveness To examine the sustained effect of the intervention on time to first readmission, […] and medical costs 1) To assess the effectiveness […] in the real-world setting 2) To perform a budget impact analysis for the intervention using costs and reimbursement experience from the intervention Study type RCT Multisite RCT Before-and-after study with concurrent controls (observational study) Setting Hospital of the University of Pennsylvania and the Presbyterian Medical Center of the University of Pennsylvania Health System Philadelphia academic and community hospitals Baylor Medical Center Garland […] within the Baylor Health Care System, […] in North Texas Timeline August 1992–March 1996 February 1997–January 2001 August 24, 2009–April 30, 2010 Follow-up points At 2, 6, 12 and 24weeks At 2, 6, 12, 26, 52weeks At 30, 60days SampleaN = 363 N = 239 N = 140 Economic perspective NR NR Budget holder perspective (hospital) Full economic evaluation No (description of costs and outcomes) No (description of costs and outcomes) No (description of consequences (readmissions, savings)) Sources of funding National Institute for Nursing Research of the National Institutes of Health National Institutes of Health funded this study Supported by the Baylor Health Care System Office of the Chief Quality Officer Competing interests NR NR NR Quality of clinical partb < 75%: Yes (7/14); no (2/14); unclear (5/14) < 75%: Yes (7/14); no (2/14); unclear (5/14) < 75%: Yes (6/14); no (4/14); unclear (4/14) Quality of economic partb < 75%: Yes (8/16); no (7/16); unclear (1/16) < 75%: Yes (8/16); no (7/16); unclear (1/16) < 75%: Yes (6/16); no (9/16); unclear (1/16) 966 K.Kast et al. 1 3 Table 2 Programs and routine care of the studies 1 Screening: Targets adults transitioning from hospital to home who are at high risk for poor outcomes 2 Staffing: Uses an advanced practice registered nurse who assume primary responsibility for care management throughout episodes of acute illness 3 Fostering coordination: Promotes communication and connections between healthcare and community-based practitioners 4 Promoting continuity: Prevents breakdowns in care from hospital to home by having same clinician involved across these sites 5 Educating/promoting self-management: Prepares older adults and family caregivers to identify and respond quickly to worsening symptoms 6 Engaging patients and caregivers: Engages older adults in design and implementation of the plan of care aligned with their preferences, values and goals 7 Collaborating: Promotes consensus on plan of care between older adults and members of the care team 8 Maintaining relationships: Establishes and maintains a trusting relationship with the patient and family caregivers involved in the patients’ care 9 Assessing/managing risks and symptoms: Identifies and addresses the patient’s priority risk factors and symptoms Author Intervention Control Duration Personnel qualification Initial home visit Further visits APN availability TCM components Naylor etal. [30] 1month APN, master´s degree, gerontological specialist, experience in hospital and/ or home care for elderly Within 48h Second visit 7–10days after discharge At least 2 home visits 7days a week (8 am to 10pm on weekdays and 8 am to noon on weekends) by telephone 1–9 Discharge planning routine for adult patients at study hospitals If referred, standard home care consistent with Medicare regulations Visiting nurse with bachelor´s degree Naylor etal. [31] 3months APN, master´s degree, general expertise in care conditions of elderly, participated in 2-months program for developing competencies related to recognition and treatment of heart failure in elders Within 24h Weekly home visits during the first month, bimonthly during the second and third months, additional visits based on individual needs Hospital visit within 24h of initial admission and at least daily At least 8 home visits 7days per week (8 am to 8pm weekdays and 8 am to noon weekends) by telephone 1–9 Care routine for the admitting hospital, including sitespecific heart failure patient management and discharge planning critical paths If referred, standard home agency care consisting of comprehensive skilled home health services 7days a week On-call registered nurse availability 24h per day Stauffer etal. [32] 3months APN Within 72h At least 8 home visits 7days a week by telephone 2,5,6,8,9 Routine care, including care management assistance with discharge planning and referral for home health care services if appropriate 967 Economic evidence withrespect tocost‑effectiveness ofthetransitional care model among… 1 3 scheduled at least two home visits [30] and each of the 3-month interventions [31, 32] scheduled at least eight home visits. The APNs were available by telephone 7days a week. The respective interventions were compared with routine care. In the first study it was discharge planning that was routine at the University Hospital of Pennsylvania accomplished by Medicare home care [30]. The routine care of the second study was care at the Philadelphia Academic Hospital with management and discharge planning specifically for heart failure patients, comprehensive skilled home health services seven days a week, and a registered nurse with a telephone availability of 24h a day [31]. The last study defined the routine care as care management assistance with discharge planning and home health care services [32]. In Naylor etal. [30] a person with a bachelor’s degree was the visiting nurse (VN), and in Naylor etal. [31] a registered nurse carried out the routine care. Outcomes Patient‑related outcomes All three studies reported that there were no significant differences in mortality between the subjects in the intervention (IG) and control (CG) groups (see Table3, and TableS3 of the supplementary information for more details on outcomes). According to both RCTs, no significant improvements in functional status were observed, and patient satisfaction either did not improve [30] or was significantly better only in the first 3months in the IG [31]. Both the number of patients requiring single and multiple readmissions were lower in the IG (significant [31]), and the length of hospital stay per patient was significantly lower in the IG, according to the RCTs. Readmissions related to new health problems were either not significantly higher [31] or only significantly lower at the 10% level [30]. Resource use All three studies reported that readmissions in total were significantly more frequent without the intervention (see Table3). In both RCTs, the IG subjects spent significantly fewer days in hospital than the CG subjects (270 vs. 760 [30] and 588 vs. 970 [31]). While the average number of total visits and the average number of included home visits was higher in the IGs, both studies reported that the intervention reduced the average number of acute care visits (emergency room, outpatient doctors). According to both studies, on average more APN home visits per patient (see supplementary information, TableS3) were made than scheduled (4.5 vs. 2 [30] and 12.1 vs. 8 [31]). None of the studies provided information on the number of telephone calls made. Financial outcomes All three studies reported that the costs per patient were lower in the IGs. However, only two [30, 31] of them reported a significant effect (see Table3). In addition, the RCTs showed that the total costs in the IGs were about half of those of the CGs. According to these two studies, this effect could also be shown in relation to the total readmission costs (significant [30]). After half a year of follow-up both RCTs had significantly lower readmission costs in the IGs. In addition, both reported that the direct program costs (defined as visits by APNs and VNs) in the IGs were just over $100 000. The CG in Naylor etal. [30] showed slightly lower costs than the IG, while the CG by Naylor etal. [31] was half as expensive as the IG. According to these two studies, the total costs for all visits—and explicitly for home visits (including other service providers such as physiotherapists)—were always higher in the IGs of the respective study. The costs of APNs were $61 600 after 1-month intervention in Naylor etal. [30], and were almost twice as high after the 3-month intervention in the Naylor etal. [31] study. Cost savings were reported in both RCTs. Naylor etal. [30] reported $596 333 in total and $3 031 per patient, and Naylor etal. [31] reported $437 907 in total and $3 466 per patient (despite more expensive APNs and lower costs for acute care visits). Only Stauffer etal. reported program costs as $1 110 per patient considering the perspective of the hospital as the budget holder. According to this study, the program did not save the money from the hospital perspective, but the hospital recorded a loss of contribution margin of $227 per patient over 30days, which was considered “significant” [32]. Discussion Patient‑related outcomes andresource use With regard to patient-related outcomes, the included studies reported that there were no differences in mortality [30–32], and that the programs led to significantly shorter hospital length of stay and significantly longer time to first readmission [30, 31]. No tendencies are discernible in other outcomes, as these were investigated either in two studies with different results (e.g. satisfaction) or in only one study (e.g. quality of life). Regarding the resource use, it was found that readmissions were about half as often at a significant level [30–32], and hospital days were reduced by one to two thirds [30, 31]. No significant difference in the number of outpatient resources (total visits) was reported in one study [30], while another showed a significant increase by one-third [31]. Since the resource use in the latter study corresponds to the sum of the total visits but is reported as home visits by the service providers, the effect size and the associated 968 K.Kast et al. 1 3 Table 3 Results of the studies Study outcomesa Studies Naylor etal. [30] Naylor etal. [31] Stauffer etal. [32] IG (n = 177) CG (n = 186) p-value IG (n = 118) CG (n = 121) p-value TCP patients (n = 56) Nonintervention patients (n = 84) BMCG (n = 140) BHCS (n = 885) p-value Patient-related outcomes Patients died 11 11 NR 11 13 0.83 0bNR 2bNR NR Patient satisfaction "No significant group differences" 0.92 "Short-term improvements" in IGc < 0.001 NR NR NR NR – Functional status "No significant group differences" 0.33 "Statistically significant group differences […] did not emerge" NR NR NR NR NR – Patients needed readmission (at least 1 time) 20.3%d37.1%d < 0.01 44.9% 55.4% < 0.121 NR NR NR NR – Patients needed multiple readmissions (more than 1 time) 6.2% 14.5% 0.01 28.2% 36.4% < 0.218 NR NR NR NR – Time to first readmission for any reason "Increased" in IG < 0.001 "Longer" in IGc0.026 NR NR NR NR – Index related readmissions 30 64 .005 40 72 < 0.184 NR NR NR NR – Comorbidity related readmissions 10 25 0.06 23 50 < 0.013 NR NR NR NR – New health problem related readmissions 9 18 0.10 41 40 < 0.881 NR NR NR NR – Time in hospital per patient Ø1.53 Ø4.09 < 0.001 Ø5.0 Ø8.0 < 0.071 NR NR NR NR – Time in hospital per readmitted patient Ø7.5 Ø10.1 < 0.001 Ø11.1 Ø14.5 < 0.411 NR NR NR NR – 975 Economic evidence withrespect tocost‑effectiveness ofthetransitional care model among… 1 3 32. 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