A Cost-Effectiveness Analysis of a Multimedia Learning Education

Programs for Stoma Patients

Tzu Chi College of TechnologyNational Taiwan University

Shu-Fen Lo

RN,MSN, Instructor, Department of Nursing ,Tzu Chi College of Technology & Doctoral St

udent, Graduate Institute of Nursing National Taiwan University

May 4,2007 2

Why do we need the relevance of economic evaluation?

Colon Ca top 3

Physical impacts

Psychological impacts

Social impacts

Quality of care=Quality of life

Body disfigurement, leakage, skin problems, and od

or

fear of leakage Lifestyle restrictions

May 4,2007 3

Why do we need the relevance of economic evaluation?

Quality of care ≠ Quality of life

Colon Ca Patients

• 8 internationally certified enterostomal therapists

• No comprehensives training programs

Staff burden(1:8-10)

Note:*National Health Insurance (NHI)

NHI* payment

May 4,2007 4

Why do we need the relevance of economic evaluation?

Quality of care = Quality of life

Colon Ca Patients

• 8 internationally certified enterostomal therapists

• No comprehensives training programs

Staff burden(1:8-10)

NHI* payment

MLEP

Provide patients information

knowledge of illness

Staff burden

Family burden

May 4,2007 5

We want to do……..• To evaluate that MLEP was more or less

costly than CESP*• To get the CE** ratios of MLEP and CESP.

– Hypothesized• Each patient in MLEP (intervention group)

– Spend less care costs– Have more knowledge– Positive attitudes– Better self-care behaviors

Note: * CESP: Conventional Education Service Program **CE ratio: cost-effectiveness ratio

May 4,2007 6

Table1. The Conceptual CEA in MLEP and CESP with Stoma patients

Item/ Groups MLEP group CESP group

P NP S P NP S

Cost (Monetary)

Health care cost 0 + + 0 + +

Film making cost 0 + + 0 0 0

Family burdens 0 0/+ 0/+ 0 0/+ 0/+

Effectiveness ( Non- Monetary)

KSC + 0 + + 0 +

ASC + 0 + + 0 +

BSC + 0 + + 0 +

Note: CEA: Cost and Effectiveness Analysis; MLEP: Multimedia Learning Education Program; CESP: Conventional Education Service Program ;P: Participant;; NP: Non- Participant ;S: Society; KSC: knowledge of self-care ;ASC: Attitude of self-care; BSC: Behavior of Self-Care; +: positive value; +/0: positive value/ zero; 0: zero

Boardman A. et al. Cost-Benefit Analysis: Concepts and Practice, NJ: Prentice-Hall, 1996: 258– 60, 395-402.Gramlich EM.A Guide to Benefit-cost Analysis, 2nd edition. NJ: Prentice-Hall, 1990: 150–70.

May 4,2007 7

Materials and Methods

• selection criteria included– Stoma patient admitted to the surgical unit– 18 years or older– speak and read Chinese.

•Tzu Chi Medical Center’s IRB

•Data collection was performed by one researcher

May 4,2007 8

Materials and Methods

Multimedia Learning Education Programs

•MLEP intervention

• Type of stoma

• Anatomy

• Indications

• Stoma care

• Irrigation with post-surgery

• 30-45 minutes

(Kao& Ku,1997; Su, Dai, Chang, &KP,2001)

May 4,2007 9

Assessed for eligibility (n=60)

EnrollmentExcluded (n=3)Did not meet inclusion criteria (n=2)Refused to participate (n=1)

Randomly assigned (n=54)

MLEP group (n=27) CESP group (n=27)

Total Stoma from February to November 2006 (n=68)

Instruments Group Pre-test Post-test

D0 D3 D5 D7

Demographics data E +

C +

Intervention E － + + +

C － － － －

CEA E + + + +C + + + +

KSC(22 items) E + + + +C + + + +

ASC(11 items) E + + + +C + + + +

BSC(12 items ) E + + + +C + + + +

May 4,2007 10

Reliability & Validity

Instrument KSC BSC ASC

Cronbach’s alpha coefficient

.75 .77 .70

Test-retest correlation .78 .79 .73

Content Validity Index .97 .95 .95

Content validity According to the suggestions of the experts

Note: KSC: knowledge of self-care ;ASC: Attitude of self-care; BSC: Behavior of Self-Care

May 4,2007 11

Statistical analysis• SPSS 14.0 to do statistical analysis

.

Descriptive statistics–frequency– percentage– mean–standard deviation

Describe the personal characteristics and scoring of each part.

•A p value < .05. was deemed statistically significant.•Cost were converted to US dollars (e.g. US$1= NT$ 32.53)

Inferential statistics –independent sample t-test –Chi-square–Average cost and effectiveness ratio (ACER)–Sensitivity analysis

Explore the related factors for CEA of a MLEP for Stoma Patients

May 4,2007 12

Results• 54 patients enrolled( MLEP=27;CESP=27)

• Ages ranged from 18 to 90 years

• Ages mean was 60.44 years (SD=17.60).

• 63% received elementary school or below education

• 57% were male

• Fifty-two percent were married

• 80% were living with families.

• 72% not employed

• 48.2%physical status was acceptable or good

• No significant difference in demographic variables between

two groups.

May 4,2007 13

Item/ Groups MLEP (n =27) CESP (n = 27)

P NP S P NP S

Cost (Monetary) (US$)

Health care cost

Education

spending time fee

0 7.14 7.14 0 12.19 12.19

Enema training

time fee

0 3.85 3.85 0 21.71 21.71

Stoma bag fee 0.87 6.2A5 7.12 3.13 17.89 21.02

Changing

dressing fee

0 9.44 9.44 0 18.44 18.44

Medical fee 540.00 6760.13 7,396.90

465.52 7918.50 8384.0

2

Table1.Cost and Effectiveness Analysis between two groups (unit: per person)

May 4,2007 14

Item/ Groups MLEP (n =27) CESP (n = 27)

P NP S P NP S

Film making cost

Copying CD-ROM fee

0 0.92 0.92 0 0 0

Making CD-ROM fee

0 565.76 565.76 0 0 0

Equipment fee 0 0.17 0.17 0 0 0

Family burdens

Families’ salary loss due to absence for work

0 34.61 34.61 0 88.12 88.12

Traffic expenses 0 12.07 12.07 0 25.00 25.00

Total cost 540.87 7400.84 7941.71 468.65 8101.89

8570.54

Table2.Cost and Effectiveness Analysis between two groups

May 4,2007 15

Table 3. Comparison of main outcome variables between MLEP and CESP Groups ＊

VariablesMLEP (n=27) CESP (n=27)

t pM SD M SD

Self-care knowledge

Pretest 7.30 3.97 5.04 3.56 2.20 0.321

Posttest 20.81 1.90 14.74 1.56 12.83 0.000

Self-care attitude

Pretest 23.78 6.66 26.48 4.96 1.69 0.097

Posttest 50.81 3.10 41.04 2.55 12.65 0.000

Self-care behavior

Pretest 20.22 3.73 21.19 4.76 0.83 0.412

Posttest 47.26 0.94 40.59 4.77 7.13 0.000 ＊ The numbers in this table are all original scores.

May 4,2007 16

Item/ Groups MLEP (n =27) CESP (n = 27)

P NP S P NP S

Effectiveness ( Non- Monetary)

KSC 61.34 0 61.34 44.04 0 44.04

ASC 49.19 0 49.19 26.50 0 26.50

BSC 56.24 0 56.24 40.35 0 40.35

Total Effectiveness score

166.89 166.89 110.89 110.89

C/E Ratios 3.24 44.32 4.23 77.23

Table2.Cost and Effectiveness Analysis between two groups

May 4,2007 17

Table4. Sensitivity Analysis of MLEP and CESP Groups in totally 5 years (N=54)

Group Cost (C; US$) Effectiveness Score (E) C/E Ratio

MLEP group 44816.01 1000.62 44.21

CESP group 51423.24 665.34 77.23

Note:MLEP: [=US$7941.71+ (US$7941.71- US$0.92- US$565.76- US$0.17) × 5] CESP: [=US$8570.54 × 6].Total Effectiveness Scores:1000.62 (=166.77 × 6) and 665.34 (=110.89 × 6)

May 4,2007 18

Discussion

Quality of care = Quality of life

Colon Ca Patients

• 8 internationally certified enterostomal therapists

• No comprehensives training programs

Staff burden(1:8-10)

NHI* payment

MLEP one week

Greater cost-effectiveness

KSC,ASC, and BSC

Cost

Family burden

May 4,2007 19

Key points• Using MLEP to educate individuals with stoma p

rovides a cost savings • The family burden in MLEP was less costly than

that in CESP

• The MLEP group is significantly higher level of KSC,ASC, and BSC

May 4,2007 20Taiwan

May 4,2007 21

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