Cost-effectiveness of Team-managed Home Care in the VA: An Update from a Multi-site Randomized Trial

Hughes SL, Weaver FM, Manheim L. Cost-effectiveness of Team-managed Home Care in the VA: An Update from a Multi-site Randomized Trial. Paper presented at: Association for Health Services Research Annual Meeting; 1997 Jun 15; Chicago, IL.

Research Objective: To determine the cost-effectiveness of a new VA home care model that emphasizes continuous care in and outside the hospital.Study Design: Our previous work demonstrated that Va home care was targeted to veterans at risk of repeat hospital use reduced hospital readmission costs by 29%. The current study is using an RCT with pretest and multiple posttests at 16 VA hospitals to determine whether the model is replicable and the previous results generalizable throughout the VA healthcare system. Severely disabled (2 or more ADL impairments), terminally ill (expected survival less than 6 months), congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD) patients are being recruited, stratified by site, age and disease and randomized to treatment or customary care. Primary study outcomes of health care use and cost at 12 months are being monitored continuously using VA and HCFA administrative databases. Secondary outcomes of functional status, health related quality of life, satisfaction with care, and informal caregiver burden are being assessed at 1, 6, and 12 months.Principal Findings: As of January 1, 1997,1663 or 60% of a targeted 2800 subjects were randomized. Most (88%) were enrolled during an acute hospitalization. Currently, 20% of participants are terminal, 75% are disabled, 4% have COPD, and 1% has CHF. Participants have a mean age of 71, 63% are white, and 65% have incomes of $20,000 or less. A substantial number (76%) have been hospitalized in the six month period prior to study enrollment. 76% were deemed to be at moderate to high risk of repeat hospitalization on the Smith Comorbidity Index, and 77% had scores of zero on the SF36 Physical Role Functioning subscale at baseline. The study groups differed significantly at baseline on only 4 of 53 variables assessed. Current VA cooperative study protocol blinds investigators from exposure to study outcomes while patients are being enrolled. Preliminary outcome data not broken down by group indicate that the 12-month rehospitalization rate for the entire sample is about 43%. Process data indicate that the model is being implemented reasonably well at a majority of the sites.Conclusions: This study is using the most rigorous criteria to date to enroll high risk patients in a home care cost effectiveness study. The new model of care that is being tested emphasizes physician evolvement with the home care team in continuous management of patients, including prior approval for non emergent hospital admissions. Preliminary findings indicate that the enrollment criteria have identified a high risk group and that the model is being implemented reasonably well.