Evaluation Of Care And Case Management
6.7 Data Requirements
In order to perfectly fulfil all three functions, complete information is needed on the following:
the old/current system of managed care – the resources it consumed and what outcomes it achieved
the new/proposed system – the resources it will consume and the outcomes it is projected to achieve/is achieving.
In reality, some of this information may be impossible to obtain, in other cases it may not be feasible. In all cases one seeks to utilise the best available relevant information. In terms of the above functions and information required it can be broken down as follows:
budgeting and planning: information required on resource usage of new system (system inputs)
funding justification: new system inputs and some measure of new system outcomes
decision making (between different projects): new system inputs, old system inputs, new system outcomes and old system outcomes.
Note that, at the very least, information on new system inputs is required, with the inclusion of the other data dependent on which functions are to be exercised. It is generally the case that much of the information regarding the existing/old system would have to be estimated. The inclusion of an analysis of the cost-outcomes of the existing system as it stands can also play an important role in justification.
Just how broad and inclusive the analysis should be, and the degree to which this is feasible, needs careful consideration. There may be costs (and indeed benefits) which are not immediately apparent and which may be difficult to quantify in monetary terms. The following general costs would have to be calculated or estimated:
direct costs of care such as hospital care, nursing home care, primary care services, medications, equipment and appliances, home help, service administration
procedures, diagnostic tests etc.
indirect costs of morbidity and mortality including the value of lost productivity through morbidity, disability or premature mortality
opportunity cost to the individual and/or family may not be immediately apparent on preliminary investigation of the service, however the substitution of formal for informal care and any associated loss of earnings of a family carer are relevant in this instance
intangible non-financial costs such as pain, anxiety and reduction in quality of life can affect both the care recipient and society at large.
The costs listed above can be grouped further under the general headings of staff, consumables, equipment and buildings:
staff: those employed by the system, hours they work, compensation they receive and breakdown of work time, i.e. time spent in transit, actual contact time with clients, time spent in administration, etc.
consumables: all consumables used in execution of service
equipment: all equipment/appliances used in execution of service, depreciation on same
buildings: physical space required to run service, rent of this space.
The above describes in general terms the range of information which could be collected. It may either be impossible or unnecessary to take a very broad view of costs and outcomes; nevertheless it must be acknowledged that there are items of cost associated with Care Management which are not borne by the system directly.
Many of the direct costs can easily be collected using relatively straightforward resource analysis. The estimation of indirect costs is more complex, though its exclusion could significantly bias any conclusions.
Economic evaluation projects have the potential to be very complex, particularly when it is necessary to reflect the variety of systems which may develop within a country to service overlapping needs. For example, Canada has undertaken a national evaluation of the cost-effectiveness of home care. It involves fifteen separate studies and three service themes: a) home care as maintenance of the status quo, b) home care as a substitute for long-term care, and c) home care as a substitute for acute care. Thus we must consider what function we wish the evaluation to serve, its depth and scope and its feasibility.
6.7.1 Prerequisites For Economic Evaluations
First, what is the goal of the evaluation? Is it to inform budgeting and planning, justify continued funding or a decision-making aid in choosing between two alternatives? The requirements of each are outlined below:
evaluations for budgeting and planning: good management requires good
information. The ability to accurately gauge service needs and the various resources required to satisfy them is fundamental to the efficient provision of any service. Budgeting and planning is not a form of economic evaluation; however, this is a vital function which economic evaluation can fulfil during the course of its normal operation. The information required to undertake service planning provides the core information for any ongoing economic evaluation. This includes investment in relevant information technology and the collection and analysis of data beyond that of accounting purposes
evaluations for funding justification: as discussed above, access to financial and other resources cannot be guaranteed beyond the short term. At the very least a structured economic evaluation of Care Management will provide solid evidence in an easily understood form of true costs and benefits of the services
evaluations for decision-making: one of the main problems faced in undertaking an economic evaluation of Care Management at this time is the lack of information which in turn reflects the lack of structure in the current system. We have little information on how the existing service delivery methods have performed in the past and what resources they have commanded. An attempt to reconstruct the inputs and outputs of the existing system so that it may be compared to the costs and benefits of an alternative method of delivery is both unfeasible and
unnecessary. Consistent collection of relevant information on any new system of service provision from implementation will not only provide sufficient data for service planning and advocacy, but will also facilitate decision-making in the future when adjustment, additions or alternative methods of service delivery are
considered. At a minimum, good management and good planning should require that objective A is realised as a matter of course. The formalised collection and analysis of the information collected to achieve this primary objective will, over time, naturally satisfy the requirements for objective B. The same scope and quality of data thus routinely collected and collated will, when necessary, provide sufficient information to inform decisions under objective C.