The twelve nurse case managers representing four different models
(community matrons, nurse practitioners, nurse specialists, district nurses)
across the three sites recruited a total of 51 patients to the study. Patients, and carers where applicable, and if consented to participate, were assessed by the study researchers once every month over the nine month period, either through face to face interviews (at baseline (month 1), middle (month 5) and end (month 9)) or by telephone (months 2, 3, 4, 6, 7, 8).
The interviews were semi-structured and data for the economic evaluation were extracted from responses and entered into a purpose-designed SPSS database. The database consisted of eighty variables covering:
Patient background information and clinical factors: age, gender, ethnicity, main language and education level, living and carer situation, main condition, number of co-morbidities and medications, aids, Barthel (dependency) Index, EQ5D (health related quality of life – thermometer (0 worst imaginable – 100 best imaginable), and utility score (-.59 – 1.0), Kingshill Cognitive Test (CIT), Geriatric Depression Scale (GDS), Self Efficacy Scale
Patient use of services/practitioner contacts: nurse case manager;
other health care professionals including nurse specialists, district nurses, practice nurses, GPs, allied health professionals; hospital based services including outpatient clinics, A&E, day and inpatient admissions;
other, including hospice stays; transport; social care including Careline, meals on wheels, care assistance; voluntary services; privately
purchased help, including home help, professional consultations; unpaid informal care from family and friends
Carer background information: age, gender, relationship, living arrangements, health status, hours spent caring, Carer Strain Index Measures were entered at baseline, and changes were recorded on a month by month basis, as necessary. Data reported by patients/carers were checked through nurse case manager interviews at the start and end of the observation period. Information on tests conducted by nurse case managers was also obtained by this method and entered into the database to further inform the type of services delivered to patients. Plans for nurse case managers to keep records of their activity with each patient they recruited (i.e. visits, telephone calls, meetings, correspondence etc) were dropped because piloting showed the task to be too time consuming and onerous.
NHS and social care costs per month were calculated from available data on resource use. The mean monthly utilisation of each item of service use was calculated for each patient in the analysis. Unit costs were obtained from validated national sources (Curtis 2008, DH 2008) and applied to each category. In hospital costs were estimated according to the reason for admission. Full details of the computational methods are given in Appendix 7. The total monthly cost per patient was obtained by summing the cost of each individual service use item. Use of voluntary services and informal caring were not included in the costing exercise. Similarly, private (patient) expenditures on aids, home help, travel etc were not estimated.
7.3.1 Findings
Eighteen of the 51 patients recruited to the main study were not included in the economic analysis because less than three months of service use data were available: six died within 3 months of entering the study and the
remaining twelve withdrew from the study (one due to the death of the partner, and the others for unknown reasons). Hence, the economic analysis was undertaken on 33 patients, all of whom had supplied data for more than three months (Site 1 n=12 [community matron 5, NS 5, nurse practitioner 1, DN 1]; Site 2 n=15 [community matron 9, NS 4, DN 2]; Site 3 n=6 [community matron 2, DN 4]). Of the remaining 33 patients, 27 completed the full nine month observation period, while eight months of data were available for a further two participants.
Background social and demographic information about patients included in the economic analysis, organised by site and nurse type, is shown in Table 60. Data showing health status variables are shown in Table 61. Although measures of Barthel (dependency), CIT (cognition), GDS (depression), and Self Efficacy were collected at each of the three face to face interviews (start, middle, end), there were many missing observations and only baseline data (or the nearest available observation) are shown. EQ5D (health-related quality of life) scores were collected monthly (by phone and face to face interview), and values from the earliest, middle and latest available observations are shown. A comparison of characteristics of the 33 patients included in the economic analysis with those of the main sample of 51 patients at baseline is shown in Table 62. The sample in the economic analysis contained a larger proportion of men. On average they reported less co-morbidity and fewer prescribed medications than the total sample.
However, statistical tests of difference between the groups were non-significant for all variables.
Use of health and social care, nurse case managers, tests, other healthcare professionals, hospital care, social services, care assistants, voluntary services, privately purchased services and informal (unpaid) care are shown in Tables 63, 64 and 65. Consistent with smaller caseloads and exclusive focus on case management, community matrons provided greater input to their patients than did the other nurse case manager models. The highest contact time recorded per month was by the community matrons in Site 2 (coast), who spent approximately 800 minutes/month with some individual clients. The lowest contact time recorded per month was by patients who were case managed by specialist or district nurses (less than 20 minutes per month).
Variability between sites in use of other healthcare resources is observed.
District nurses were used by more patients in Sites 2 and 3, and patients reported more use of GPs in Site 1. Generally, patients in Sites 2 and 3 were more likely to see healthcare professionals in their own homes. There were no planned hospitalisations in Site 1. Some patients in each site were admitted for unplanned hospital care during the course of the study. There were scattered missing service use data amongst the sample, particularly in the areas of social care and the voluntary sector. The live-in partners of six patients did not take part in the study so the details of the informal care that they provided were not available.
The total monthly costs per case managed patient over the study period, and the cost components, are shown in Table 66. Total costs ranged from
£4315 (Site 1, Nurse 1, Patient 6: a 79 year old male, main diagnosis heart failure, managed by a cardiac nurse specialist, with 40 unplanned hospital days) to £65 (Site 1, Nurse 1, Patient 3: a 73 year old woman, main diagnosis heart failure, managed by the same nurse specialist), with no unplanned hospital days. The mean monthly cost of the 33 patients in the study was £854 (SD 995).
Two main factors account for high patient costs over the study period:
hospitalisations and intensive case management. The mean monthly cost of nurse case managers in this study is £302, but considerable variability was observed (SD 358; Range £8 – £1190). The community matrons in site 2 (coast) spent time valued at over £1000 per month on each of four of their patients, and the costs of a further two patients were over £700 each per month. Some, but not all of the patients receiving intensive nurse case management input reported lower use of other services. The association between patient demographic and health factors and service use and costs is explored in more detail in the next section.
HEALTH DEMOGRAPHICS SOCIAL
CMCommunity matron, CNSCardiac Nurse Specialist, DNDistrict Nurse, NPNurse Practitioner, TNSTissue Nurse Specialist, RIPDeceased, COPDChronic obstructive pulmonary disease, HFHeart Failure, MDMacular Degeneration, DMDiabetes Mellitus, CVACardiovascular accident/stroke, No.Number,
langEnglish 1st language, Educ levelEducation level, <12To age 12 or less, <16To age 16, <18To age 18, FEFurther/higher education, IndIndependent,
SupSupported, SDStandard Deviation, MinMinimum value, MaxMaximum value
*
Raw
HEALTH STATUS: Baseline HEALTH RELATED QUALITY OF LIFE: EQ5D
Baseline Patient ID Nurse Case
manager type Barthel (0-20, low is
NPNurse Practitioner, TNSTissue Nurse Specialist, BarthelBarthel Index, CITKingshill Cognitive Test, GDSGeriatric Depression Scale, Self EfficacySelf Efficacy Scale, UWUtility Weight, BBaseline (month 1), MMid-point (month 5), EEnd-point (month 9), SDStandard Deviation, MinMinimum value, MaxMaximum value
Table 62. Comparison of patients included in the economic analysis (n=33) with the full sample (n=51)
Variable Value for full sample of 51 patients
Value for 33 patients in the economic analysis Mean months on caseload prior to
study
3.4 3.9
Gender, % male 39 48
Mean age in years 78 78
Mean number of co-morbidities 3.3 2.9
Mean number of medications 7.6 7.2
% live alone 57 61
% receiving disability benefits 78 82
Mean baseline CIT score 5.0 4.5
Mean baseline GDS score 7.8 7.3
Mean baseline Barthel score 18.9 18.8 Mean baseline EQ-5D thermometer
score
0.63 0.61
Mean baseline EQ-5D utility score 59.1 59.0 Mean baseline Self Efficacy raw
(mean) score
40.6 (7.3) 41.0 (6.9)
NURSE CASE MANAGER USAGE OTHER HEALTHCARE PROFESSIONAL USAGE: Total number of contacts (Mean/month)
Contacts aContact time/minutes Nurses consultations GP consultations Other (including AHPs)
NS cDN PN
*100% case management, CMCommunity matron, CNSCardiac Nurse Specialist, DNDistrict Nurse, NPNurse Practitioner, TNSTissue Nurse Specialist,
OHOutside home, IHInside home, aFace-to-face contact time (no extra travel time accounted for in IH visits), bContact time calculated based on average length of time recorded for various sessions (no distinction was given between OH and IH visits), NSNurse Specialist, cIncludes IH visits from Palliative Care Team, PNPractice Nurse, GPGeneral Practitioner, hrshours, AHPAlliedHealth Professional, PoPodiatrist/Chiropodist, CoCounsellor,
PTPhysiotherapist, SPUSensory Perception Unit, PRCPulmonary Rehabilitation Clinic, PhlPhlebotomist, OptOptician, OTOccupational therapist,
PhaPharmacist delivery, DenDentist, SDStandard Deviation MinMinimum value, MaxMaximum value
Site3N9P3 *CM 0 4 4 180 45 180 - - - 78 (19.5) - 0 0 0 0 - 1OT (1) Site3N9P5 *CM 1 5 6 312 52 312 0 0 49 (5.44) 0 0 5 (.56) 0 1 (.11) 0 0 0
Site3N10P1 DN 5 1 6 102 17 102 0 0 29 (3.22) 0 0 0 0 1 (.11) 0 0 1Opt (.11), 1Den (.11) Site3N10P2 DN 1 12 13 221 17 221 0 0 34 (3.78) 0 0 0 0 1 (.11) 4 (2) 0 4PT (.44) Site3N10P3 DN 0 1 1 12 12 12 0 0 67 (7.44) 0 86
(9.56)
2 (.22) 0 0 0 24PT (2.7) 9Pha (1)
Site3N10P4 DN 0 4 4 68 17 68 0 0 58 (6.44) 0 0 0 0 0 0 0 0
Mean 3.2 7.0 10.2 394.2 37.0 217.6 1.1 (.1) .1 (.01) 21.8 (2.4) 20.7 (3.6) 3.1 (.35)
2.6 (.4) 2.1 (.25)
.4 (.1) .79 (.4) 1.5 (.17) 3.1 (.4)
SD 3.87 9.39 9.14 429.02 16.41 252.39 4.77 (.55) .42 (.048)
26.34 (2.93)
54.42 (8.51) 16.24 (1.80)
6.46 (.86) 6.80 (.76)
.87 (.20) 1.87 (.8)
4.69 (.54) 7.92 (.90)
Min 0 0 1 12 12 5.3 0 0 0 0 0 0 0 0 0 0 0
Max 15 41 42 2032 60 832 26 (2.89) 2 (.22) 68 (7.56) 240 (30) 86 (9.56)
36 (1.11) 36 (4) 4 (1) 7 (2.5) 24 (2.7) 36 (4)
Table 64. Services used by the 33 patients included in the economic analysis
NHS USAGE: Total (Mean/month) SOCIAL SERVICES SOCIAL CARE: Paid care
assistance
No. of hospital days CARELINE MEALS
ON
Site2N7P4 TNS 8BT (.89) 1C (.11), 1VS (.11) 0 0 0 0 0 0 0 - - - Site2N7P5 TNS 1BT (.11), 1BP
(.11), 1UT (.11)
1C (.33), 2VS (.66) - - - - 0 0 0 - - -
Site2N8P1 DN 8BT (.89) 2C (.22), 1Rh (.11), 1GM (.11)
0 0 0 0 0 0 0 - - -
Site2N8P5 DN 3BT (.75), 3BP (.75), 3UT (.75)
4U (1) - - - - 0 0 0 - - -
Site3N9P3 CM 4BT (.44), 2UT (.22)
- - - - - 0 0 0 112 28 SS all
Site3N9P5 CM 6BT (.67) 1GM (.11) 0 0 12COPD (1.33), 4Inv
(.44)
0 9 0 NHS/ SS 2 (SS) - - -
Site3N10P1 DN 5BT (.56) 0 0 0 0 0 0 0 NHS/ SS 0 - - -
Site3N10P2 DN 1UT (.11) 3Oph (.33), 1DMed (.11), 1Or (.11)
0 2Ca (.22) 6Falls (.67) 0 9 0 NHS/ SS 0 12 12 Pt some
Site3N10P3 DN 8BS (.89) 1C (.11), 1N (.11) 0 0 2Falls (.22), 3Obs (.33), 3TIA (.33)
0 9 0 NHS/ SS 0 12 12 Pt some
Site3N10P4 DN 2BT (.22), 1BS (.11)
2DMed (.22), 1GM (.11) 0 2Obs (.22) 4CRe (.44) 1 (.11) 0 0 NHS/ SS 0 96 12 Pt some
Mean 5.6 (.68) 3.2 (.47) .2 (.03) 1.2 (.13) 4.8 (.78) .03 (.004) 3.2 .5 .09 686.8 83.6 SD 2.91 (.452)
2.43 (.375)
.60 (.114)
2.74 (.303) 8.54 (1.465) .185 (.020)
4.08 1.52 .384 1888.75 207.15
Min 0 0 0 0 0 0 0 0 0 12 12
Max 9 (2.25) 12 (1.71) 3 (.6) 13 (1.44) 40 (5.71) 1 (.11) 9 6 2 6048 672
*Only BT and UT used in costing, CMCommunity matron, CNSCardiac Nurse Specialist, DNDistrict Nurse, NPNurse Practitioner, TNSTissue Nurse Specialist, BTBlood Test, UTUrine Test, BSBlood Sugar, BPBlood Pressure, NHSNational Health Service, AAudiology, AC
Anti-coagulation clinic, CCardiology, DMedDiabetic Medicine, EchoEchocardiogram, GMGeriatric Medicine, NNeurology, OphOphthalmology,
OrOrthopaedics, PsyPsychiatrist, RMRespiratory Medicine, RhRheumatology, TVTissue Viability clinic, UUrology, VSVascular Surgery,
VAUVisual Aids Unit, A&EAccident and Emergency, No.Number, CaCataract surgery, ComComplications, HIHead Injury, LobLobectomy,
ObsObservations, PMFPacemaker Fitting, CPainChest Pain, COPDChronic Obstructive Pulmonary Disease exacerbation, CHDCoronary Heart Disease exacerbation, CReEyelid Cyst Removal, HFHeart Failure, InvInvestigations, PnPneumonia, TIATransient Ischaemic Attack, Subs
mthsMonths of subscription to service, mthsmonths, SSSocial Service, PtPatient, SDStandard Deviation MinMinimum value, MaxMaximum value
Table 65. Services used by the 33 patients included in the economic analysis
UNPAID ASSISTANCE PRIVATE PAID ASSISTANCE
CARER INFORMATION Paid cleaner
CSI Hours per day
HELP (all Age Concern) Mean hrs/
month
*Where patient indicated not living alone (Table ECON3), but carer did not consent to participate in study, 1values calculated from mid-point of range, CMCommunity matron, CNSCardiac Nurse Specialist, DNDistrict Nurse, NPNurse Practitioner, TNSTissue Nurse Specialist, OFOther family, MMale, FFemale, probsproblems, CSICarer Strain Index, BBaseline (month 1), EEndpoint (month 9), hrshours,
mthsmonths, PtPatient, SSSocial Services, SDStandard Deviation MinMinimum value, MaxMaximum value
Site3N9P3 CM - - - 0 SS some
Site3N9P5 CM 12 - - 0 -
Site3N10P1 DN Yes full time Spouse 60 F Serious 12 10 1-2 20 live in/9 mths (672)
- - 0 -
Site3N10P2 DN - - - 0 Pt all
Site3N10P3 DN - - - 0 Pt all
Site3N10P4 DN Yes full time Spouse 79 M Serious 4 4 1-2 1-2 - - - 0 SS some
Mean 70.3 5.9 5.8 12.5 15.3 200 102.4 0.18
SD 7.81 3.64 3.69 1.67 7.29 277.69 77.23 1.04
Min 60 2 0 1.5 1.5 12 56 0
Max 81 12 11 5.5 20 672 240 6
Table 66. Costs of service provision for 33 case managed patients
NHS RESOURCE USE: Costs (£) per month SS RESOURCE USE: Costs (£) per month
based on data in Curtis, 2008, including overheads and qualifications; and DH 2008, All calculations rounded to the nearest £,
NHSNational Health Service, SSSocial Services, acalculated per hour, pro rata for home (IH) and clinic (OH) visits, bcalculated per visit, pro rata for IH and OH visits for nurse specialist, district nurse and practice nurse, GPGeneral Practitioner, cincludes costs for surgery, home (normal and out of hours) and telephone consultations, donly used blood and urine tests in calculation, inc.including,
AHPallied health professional, ecalculated based on means of first and follow up attendance costs derived from National Reference Costs Index for specific outpatients clinics which could be consultant or non-consultant led with multidisciplinary team (MDT) input or without (non-MDT), A&EAccident and Emergency, fonly MDT costs considered in total overall costs, CLCareline, MOWMeals on wheels, gTotal cost = Nurse case manager costs + Total NHS resource use + Total SS resource use, exc.excluding SDStandard Deviation MinMinimum value, MaxMaximum value
Site3N9P3 CM 274 495 0 49 2 0 0 0 0 0 0 0 546 0 0 672 672 1492 1218 Site3N9P5 CM 456 71 27 0 2 14 24 0 0 554 554 0 668 17 38 0 55 1179 723
Site3N10P1 DN 95 42 6 13 2 0 0 0 0 0 0 0 63 0 0 0 0 158 63
Site3N10P2 DN 268 49 50 22 0 79 55 0 323 174 496 0 696 17 0 288 305 1269 1001 Site3N10P3 DN 15 202 8 128 0 42 32 0 0 320 320 0 700 17 0 288 305 1020 1005 Site3N10P4 DN 84 84 0 0 1 69 57 0 125 142 267 56 477 0 0 288 288 849 765
Mean 302 118 41 21 1.6 60 56 2.81 116 285 401 1.7 648 6.7 2.3 198 207 1156 854 SD 358 202 49 37 1.3 46 43 11.9 302 718 798 9.7 900 8.4 9.2 500 500 1125 995
Min 8 0 0 0 0 0 0 0 0 0 0 0 34 0 0 0 0 65 46
Max 1190 762 232 144 5 157 157 67 1464 3345 3345 56 4126 17 38 2587 2604 4315 4143
7.4 Demographic and health factors associated with resource