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Seven Day Services Cost-Benefit Analysis - Approach and Key Issues. David Halsall Clinical Quality and Efficiency Analytical Team 20 th January 2012. Overview . What is economic analysis and how might we frame the problem
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Seven Day Services Cost-Benefit Analysis - Approach and Key Issues David Halsall Clinical Quality and Efficiency Analytical Team 20th January 2012
Overview • What is economic analysis and how might we frame the problem • Evidence to point us towards were we might find the best cost benefit • An example of how levelling out a service can improve quality to patients, staff and improve cost benefit
What sort of economic analysis shall we do? Making the economic case for the reduction the difference between the weekday and weekend level of service requires an evaluation of the costs and benefits of any re-configuration • Economic evaluation in principle is straight forward • Can we show that increasing services at the weekend has • An overall cost benefit? • And is possibly overall cost saving (a QIPP saving) Cost/benefit QALY Health Benefits QIPP savings Cash savings Extra Cost
Looking at benefits Would we expect incremental changes to resources to have a direct linear link to patient care or would we guess that there is a non-linear relationship ? A conceptual model of the link between access to care and benefits care brings Best Practice ? Normal weekday working ? A measure of the benefit care brings For example level of disability following a stroke Weekend Working? 1/3 cost 1/3 cost 1/3 cost A measure of access to care For example time between admission and senior review
How do you eat an elephant? As with any complex problem the trick is to cut it to down to a manageable size… The first thing we do is state what we want to achieve • On the ground of equality and effectiveness a hospital should not unduly delay or otherwise restrict access to services to patients admitted at the weekend compared to those admitted on a weekday. And then we collect evidence to suggest how we best allocate resources to achieve our aim • In this case we can look at the weekend demand and performance measures and see how they compare to a weekday • So what evidence do we have?
Evidence 1 Fewer people are admitted to hospital as an emergency at the weekend but the chances of dying are noticeably higher National figures, England 2010/11 Day of admission DH analysis of HES data 2010/11
Evidence 2 Or to put it another way the drop in the number of deaths is a lower percentage than the drop in admissions. Could this be a case mix effect? Emergency admission by weekend and weekday admission DH analysis of HES data 2010/11
Evidence 4 Stroke, heart failure, some cancers and renal failure seems to make up the biggest contribution to the difference in death rates Causes where the difference between mortality rates between weekday and weekend admissions is statistically significant Aylin et al, BMJ Quality & Safety (2010) * Cancer or stomach,, oesophagus, prostate and pancreas.
Evidence 4 Admission by specialty shows that general medicine has double the increase of percentage deaths compared to the average weekday to weekend rate. Percentage of patients who are discharged dead by day of the week of admission 20% 10% DH analysis of HES data 2010/11
Example So lets look at an example were extra resources are added to general medicine at the weekend and see if the economic case stacks up • In 2007 Heartland Hospital instigated early consultant review to reduce the risk to patients when AMU patients are transferred to specialist medical wards at weekends. • They replaced weekend on-call “safari” consultant cover with two acute physicians to provide early senior review of newly admitted patients. • This reduced delays in having a clear clinical management plan and reduced LoS for patients admitted towards the end of the week. • In particular it was identified that opportunities were being missed to discharge some patients in the subsequent 24-72 hours after admission • In common with many acute trusts discharges at weekends were less than on weekdays • Seven day working of key clinical and social service staff is required to achieve a levelling out discharge pathways.
The case can be made that the cost of the extra consultants could be offset but increasing the weekend discharge rate Example • A consultant (including overheads) could cost £150,000/year • A patient awaiting discharge will cost around £250/day • So £300,000 is equal to around 1200 patient days • Or in other words if 23 patients are discharged 1 day earlier each weekend that would cover the cost of the 2 extra consultants. • In effect one ward would have to be close for a day a week to recover the cost. • The other changes to weekend working patterns are achieved by negotiated HR processes 23 patients a week have their LoS reduced by 1 day £300,000/year
Example Although it is impossible to attribute the improvement in performance to the change in the weekend working pattern it is consistent with what you would expect
In addition to the direct costs and benefits there are a range of additional benefits which also could be used to evaluate the change in practice. • Improved patient satisfaction • Better training of junior doctors • Enhance patient quality and safely • Ward staff feel more supported
Summary • There is the suggestion that the evening and weekend shutdown of normal service in acute hospitals leaves too many patient in limbo for too long. • With targeted interventions and good HR practices the difference between weekend and weekday service can be reduced showing overall cost benefit. • It is also possible that by keeping the discharge rate close to the weekday rate at the weekend the levelling up the weekend service could be cost saving.
