Background
Methods
Search strategy
SEARCH 1: economic or evaluation or cost effect* or “cost saving” AND improv* or ‘behaviour change’ or ‘willingness to change’ or accept* or ‘roll out’ or change or adhere* AND ‘clinical guideline*’ or ‘education outreach’ or evidence or ‘evidence based’ or ‘quality improv*’ or ‘service improv* or local impl*’ AND clinical or doctor or nurse or ‘allied health professionals’ or clinician or pathway or ‘decision make*’ or ‘local govern*’ or ‘clinical commiss*’ or ‘commissioners’ o Including limited related terms SEARCH 2: economic or evaluation or ‘cost effect*’ or ‘cost saving’ AND improv* or ‘behavior change’ or ‘willingness to change’ or accept* or ‘roll out’ or change or adhere* AND ‘clinical guideline*’ or ‘education outreach’ or evidence or ‘evidence based’ or ‘quality improv*’ or ‘service improv*’ or ‘local impl*’ AND clinical or doctor or nurse or ‘allied health professionals’ or clinician or pathway or ‘decision make*’ or ‘local govern*’ or ‘clinical commiss*’ or ‘commissioners’ o Including related terms SEARCH 3: search 1 without related terms SEARCH 4: search 2 without related terms |
Screening
Inclusion and exclusion criteria
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Were published in the English language
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Reported on a completed study
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Study protocols, methodological papers or conference abstracts were excluded (after additional searches had been performed to ensure that full papers had not been subsequently published).
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Were published after 2003 and before 16th March 2016
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Were conducted in public health, primary, secondary or tertiary care
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Implementation
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Quality/service improvement
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Health or clinical service delivery
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Staff behaviour change
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Patient behaviour change
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Had patient focused outcomes or outcomes as overall service improvement that would improve patient outcomes or care, expressed as quantifiable outcomes
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Had economic elements, expressed as quantifiable outcomes
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Reported one of the following health economic methodologies:
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Cost effectiveness analysis
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Cost-utility analysis
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Cost-benefit analysis
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Cost-consequence analysis
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Burden of disease
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Randomised controlled trials
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Hybrid effectiveness-implementation trials
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Comparative controlled trials without random assignment
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Before and after studies
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Systematic reviews
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Time series study design
Data extraction
Cost-consequences analysis (CCA): compares costs and multiple measures of patient outcome of alternatives under evaluation. Cost-effectiveness analysis (CEA): compares costs and outcomes of alternatives using a single primary measure of patient outcome (e.g. life-years gained; cases of disease avoided; improvements in clinical functioning; improvements in quality of care experience). Cost-utility analysis (CUA): compares costs and outcomes of alternatives with outcomes measured as quality-adjusted life years (QALYs) gained. Cost-benefit analysis (CBA): compares costs and outcomes of alternatives, with patient outcomes valued monetarily. Cost-analysis (CA): costs implications only of relevant alternatives evaluated with no consideration of impact on quality of care and patient outcomes (not strictly a full economic evaluation). |
Quality appraisal
Results
Studies included
Descriptive analysis of the evidence base
Author | Year | Country | Improvement or implementation focus | Care setting | Improvement intervention focus | Sample size | Main study outcomes | Type of economic analysis | Quality appraisal score for economic modelling (out of 100) |
a: Improvement studies | |||||||||
Afzali et al | 2013 | Australia | Improvement | Endocrinology | Staff mix reformulation (nurse-led) | 3642 | EQ-5D (EuroQol 5 dimension scale) | CEA | 100 |
Albers-Heitner et al | 2010 | Netherlands | Improvement | Primary Care | Staff mix reformulation (nurse-led) | 384 | EQ-5D | CEA | 74 |
Bauer | 2010 | USA | Improvement | N/A | Staff mix reformulation (nurse-led) | 160 | Resource use | CEA | N/A |
Dawes et al | 2007 | UK | Improvement | Gynaecology | Staff mix reformulation (nurse-led) | 111 | SF-36 (36-Item Short Form Health Survey), Length of Stay | CCA | 66.5 |
Faulkener et al | 2003 | UK | Improvement | Primary Care | Improved referral | N/A | Review | Review | N/A |
Furze et al | 2011 | UK | Improvement | Cardiology | Staff mix reformulation (peer support) | 142 | EQ-5D | CUA | 84.5 |
Hernandez et al | 2014 | UK | Improvement | Intensive Care | Staff mix reformulation (nurse-led) | 286 | EQ-5D | CUA | 90.5 |
Karnon et al | 2016 | Australia | Improvement | Cardiology | Service Reconfiguration (funding sources) | 603 | N/A | CCA | 44.5 |
Kilpatrick et al | 2014 | Canada | Improvement | Hospital General Medicine | Staff mix reformulation (nurse-led) | 2147 | Review | CEA | N/A |
Latour et al | 2007 | Netherlands | Improvement | Hospital wards | Staff mix reformulation (nurse-led) | 208 | SF-36, HADS (Hospital Anxiety and Depression Scale) | CEA | 81.5 |
Mdege et al | 2012 | Sub-Saharan Africa | Improvement | HIV | Staff mix reformulation (multiple scenarios) | 19,767 | N/A | Review | N/A |
Tappenden et al | 2012 | UK | Improvement | Geriatrics | Staff mix reformulation (nurse-led) | N/A | Review | CEA | N/A |
Walsh et al | 2005 | UK | Improvement | General Medicine | Staff mix reformulation (nurse-led) | 238 | Bed days | CA | 65 |
Williams et al | 2006 | UK | Improvement | Gastroenterology | Staff mix reformulation (nurse-led) | 1500 | EQ-5D | CEA | 94 |
Williams et al | 2005 | UK | Improvement | Urology | Staff mix reformulation (nurse-led) | 3746 | EQ-5D | CEA | 51 |
Yarbrough et al | 2015 | USA | Improvement | General Medicine | New pathway | 677 | Resource use | CEA | N/A |
b: Implementation studies | |||||||||
Author | Year | Country | Improvement or implementation focus | Care setting | Implementation intervention focus | Main study outcomes | Type of economic evaluation | Sample size | Quality appraisal score for economic modelling (out of 100) |
Brunenberg et al | 2005 | Netherlands | Implementation | Orthopaedics | Pathway implementation | EQ-5D, Length of stay | CEA | 160 | 71 |
Burr et al | 2007 | UK | Implementation | Ophthalmology | Screening programme implementation | EQ-5D | CUA | 207–32,918 | 89.5 |
Burr et al | 2012 | UK | Implementation | Ophthalmology | Surveillance programme implementation | EQ-5D, Willingness to pay | CUA | 800 | 92.5 |
Judd et al | 2014 | USA | Implementation | Hospital wards | Early intervention implementation | Length of Stay | CA | 181 | 37 |
Kifle et al | 2010 | Ethiopia | Implementation | All hospital specialities | Referral system implementation | Resource use | CEA | 532 | N/A |
Maloney et al | 2012 | Australia | Implementation | Physiotherapy | Health professional education | Costs only | CEA | 85 | 94.5 |
Mortimer et al | 2013 | Australia | Implementation | General Practice | Implementation methods (active vs guideline dissemination) | EQ-5D, X rays avoided | CEA | 112 | 81.5 |
Purshouse et al | 2013 | UK | Implementation | Public Health | Screening programme implementation | EQ-5D | CEA | N/A | 82 |
Rachev | 2015 | USA | Implementation | Public Health | General methods of health service transformation | Resource use | CEA | N/A | N/A |
Robertson et al | 2011 | UK | Implementation | Oncology | Surveillance programme implementation | EQ-5D | CUA | N/A | 94 |
Tappenden et al | 2013 | UK | Implementation | Oncology | Resource allocation decision making | EQ-5D | CUA | N/A | 84 |
Umscheid et al | 2010 | Canada | Implementation | N/A | Comparative effectiveness centre | None | Review | N/A | N/A |
Vestergaard et al | 2015 | Denmark | Implementation | Cardiology | Guideline adherence vs observed treatment | EQ-5D | CEA | N/A | 57.5 |
Yee and Shafie | 2013 | Malaysia | Implementation | Respiratory | Asthma management implementation | EQ-5D | Review | N/A | N/A |
Improvement or implementation interventions across studies (N of studies and %) | ||
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Staffing reconfiguration | 13 | 43% |
Pathway implementation | 4 | 14% |
Review of practice | 3 | 10% |
Improvement in patient screening | 3 | 10% |
Service reconfiguration | 2 | 7% |
Improvement in follow up procedures | 2 | 7% |
Monitoring activity | 1 | 3% |
Guideline adherence | 1 | 3% |
Education | 1 | 3% |
Quality appraisal
Study | Costs considered | Scenarios considered | Conclusion: intervention cost-effective? |
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Furze et al. 2011 | Training costs | None | Yes |
Judd et al. 2014 | None | Scaling scenarios | Yes |
Kifle et al. 2010 | Indirect costs of patients and carers; project costs; impacts on staff | None | Yes |
Maloney et al. 2012 | Training and set up costs | Roll out scenarios | Yes |
Mdege et al. 2012 | Training costs | Roll out scenarios | Yes |
Mortimer et al. 2013 | Development costs; amortisation; delivery costs; roll out costs | Roll out scenarios | No |
Purshouse et al. 2013 | None | Roll out scenarios | Yes, although sensitive to rollout costs |
Rachev 2015 | Outlining of costs | None | Inconclusive |
Tappenden et al. 2013 | None | Funding scenarios | N/A |
QHES dimension | Average score | Highest possible score | Percentage achieving highest possible score |
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Was the study objective presented in a clear, specific and measurable manner? | 6.0 | 7 | 65% |
Were the perspective of the analysis (societal, thirdparty, payer, etc.) and reasons for its selection stated? | 2.4 | 4 | 28% |
Were variable estimates used in the analysis from the best available source (i.e. randomised control trial—best, expert opinion—worst)? | 7.4 | 8 | 83% |
If estimates came from a subgroup analysis, were the groups prespecified at the beginning of the study? | 0.4 | 1 | 33% |
Was uncertainty handled by (1) statistical analysis to address random events, (2) sensitivity analysis to cover a range of assumptions? | 5.8 | 9 | 33% |
Was incremental analysis performed between alternatives for resources and costs? | 5.4 | 6 | 94% |
Was the methodology for data extraction (including the value of health states and other benefits) stated? | 4.0 | 5 | 78% |
Did the analytic horizon allow time for all relevant and important outcomes? Were benefits and costs that went beyond 1 year discounted (3% to 5%) and justification given for the discount rate? | 4.7 | 7 | 39% |
Was the measurement of costs appropriate and the methodology for the estimation of quantities and unit costs clearly described? | 3.9 | 8 | 0% |
Were the primary outcome measure(s) for the economic evaluation clearly stated and did they include the major short-term? Was justification given for the measures/scales used? | 4.7 | 6 | 67% |
Were the health outcomes measures/scales valid and reliable? If previously tested valid and reliable measures were not available, was justification given for the measures/scales used? | 5.0 | 7 | 72% |
Were the economic model (including structure), study methods and analysis, and the components of the numerator and denominator displayed in a clear, transparent manner? | 6.7 | 8 | 83% |
Were the choice of economic model, main assumptions, and limitations of the study stated and justified? | 5.6 | 7 | 78% |
Did the author(s) explicitly discuss direction and magnitude of potential biases? | 3.9 | 6 | 56% |
Were the conclusions/recommendations of the study justified and based on the study results? | 8.0 | 8 | 100% |
Was there a statement disclosing the source of funding for the study? | 2.4 | 3 | 78% |