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Economic evaluation of a swedish medical care program for hypertension
Health Policy, Elsevier
299
5 (1985) 299-306
HPE 00062
Economic evaluation of a Swedish medical care program for hypertension Ingemar
Eckerlund”, Egon Jonssona, Lars RydCnb, Lennart G&an Berglundd and Sven-Olof Isacssone
RBstamc,
aInstitute of the Health Services (Spri), Stockholm, bDepartment of Cardiology, Central Hospital, Sk&de, ‘Department of Health Care, Sk&de, ‘Department of Medicine I, Sahlgren’s Hospital, Giiteborg, ‘Department of Community Health Sciences, Lund University, Lund, Sweden (Accepted
for publication
9 June
1985)
Summary A Hypertension Care Program, developed in cooperation between physicians and nurses in both primary care and at the hospitals in the area, was implemented in the Skaraborg County, Sweden in 1977. The Program, which provided for the establishment of hypertensive clinics at outpatient units and referral to medical clinics, was clearly aimed towards giving nurses increased responsibility for hypertensive care. The Skaraborg Program has been evaluated from several important perspectives. A terminal population study showed better blood pressure control among the hypertensive patients within the program area than within the control area. The economic evaluation indicates that hypertensive care according to the Program is somewhat less resource demanding than conventional hypertensive care. Since the medical effects of hypertensive care were improved without increased demand for resources, the structured Care Program was more cost-effective than conventional care. medical Sweden
care
program;
consensus
statement;
cost-effectiveness;
hypertension;
The concept of a Medical Care Program was promoted during the mid-1970’s and was to be based on scientifically tested experience and contain recommendations for
Address for correspondence: Sweden. 0168-8510/85/$03.30
IngemarEckerlund,
0 1985 Elsevier
Research
Science Publishers
Associate,
Spri, Box 27310, 10254 Stockholm,
B.V. (Biomedical
Division)
300
the best possible health care and service for a defined patient group. The fundamental concern was a desire that all patients should be entitled to a similar, high quality standard of care. An equally fundamental intention was to achieve in the long run a more efficient utilization of resources, If the idea of a Medical Care Program were promoted today one would presumably discuss a locally adapted consensus statement. Medical Care Programs should be developed locally and should serve to support the routine delivery of care, as well as aid the education of various categories of personnel. The Swedish Medical Care Programs were expected, among other things, to facilitate communication between various levels of care, and to prevent unnecessary duplication of labor. The development of Swedish Medical Care Programs was thought to have a certain intrinsic value, where knowledge and experience could be examined and exchanged, routines reviewed, out-dated methods scrutinized and replaced as more effective technologies became available. Follow-up and evaluation were considered to be as essential as the development of the Medical Care Program itself [ 1,2].
The Skaraborg Program During 1976 a Hypertension Care Program was developed for certain municipalities within Skaraborg county [3-51. Its aim was to improve the control of hypertension in the county. The Skaraborg Program was developed in cooperation between physicians and nurses in primary care and at the departments of internal medicine in the area of the county where the program was to be tested. Frequent consultations also took place with specialists from the university hospital in Gothenburg. In the Skaraborg Program diagnosis and treatment are described in detail. Specific recommendations are provided, e.g. concerning blood pressure measurements, laboratory tests, as well as type and quantity of medication. Furthermore, it outlines referral procedures and the organisation of hypertensive care. The Medical Care Program provided for the establishment of hypertension clinics in outpatient units and referral to medical clinics. The Program was clearly aimed towards giving nurses increased responsibility for hypertensive care. Supervision was to be in the hands of the nurses, while the responsibility for diagnosis and treatment remained with the physicians. The target group for the program was limited to hypertensive patients in the age group 40-69 years.
Evaluation of the program Evaluation of the effects of the program was given significant consideration before the program was started. The county of Skaraborg was divided into two parts, each having equal population: one trial area where hypertensive care was delivered according to the program, and one control area where ordinary care was carried out. A baseline population study showed sufficient comparability between the two areas with respect to demographic structure, blood pressure levels and treatment for hypertension. The baseline study was carried out in 1977, and the methods for evaluation were also established at an early stage [6].
301
The Skaraborg Program has been evaluated from several important perspectives [7,g]. The evaluation illustrates essential medical, social, and economic consequences of the Medical Care Program.
Medical and social aspects The results of the medical evaluation are presented in an academic thesis [7]. At baseline the prevalence of hypertension was 15-16% using three subsequent blood pressures above 170/105 mm Hg (and/or) for subjects aged 40-60 years, above 180/l 10 mm Hg for subjects aged > 60 and including patients with ongoing treatment (Table 1). Only 20-25% of the hypertensives were not on treatment. During the five years of trial 3240 hypertensive patients were registered. Most of them were detected and treated prior to admission to the hypertension clinics (73%). The program finally controlled 7% of the population at risk. The drop out rate was 6.3% during the five years. The compliance to the program guidelines for examination and treatment was excellent. For previously known as well as for newly detected patients blood pressure was improved. The decrease of blood pressure was largest during the first year but continued through the complete period of follow-up. A terminal population study showed better blood pressure control among the hypertensive patients within the program area than within the control area. Further analysis credited this to the hypertension clinics. Interviewing matched patient samples from the hypertension clinics in the program area and from primary care in the control area showed more patient confidence in the hypertension clinics where continuity and information were superior to the conditions in the control area.
Economic aspects The economic evaluation has been directed towards an analysis of the cost for providing hypertensive care, both in the presence of, and in the absence of a Medical Care Program [8]. The calculations, however, do not include all costs associated with the delivery of hypertensive care; rather they have been limited to those costs which can
Table
1
Blood pressure Age (years)
limits for diagnostic
evaluation
Blood pressure
(mm Hg)
Normal < 40 40-60 > 60
< IS/<90 < 160/< 95 < 170/< 105
and follow-up
Borderline
in the Skaraborg
Too high > 160/> 95 > 170/> 105 >180/>110
program
302
be expected to vary dependent upon how hypertensive care is structured and organized. Thus the purpose has been to find whether the regular costs for personnel, material, tests and medications, along with the patient’s time have been influenced by the establishment of Medical Care Programs. Originally, the intention was to put identified cost differences in relation to eventual differences in the outcome of hypertensive care as expressed in terms of altered mortality and morbidity. The study period however is too short to permit any direct conclusions in this respect. Method and Material
The basis for the economic calculations has been established partly through questionnaires which have been answered by patients and personnel, and partly from the County Council’s accounting records. The questionnaires were tested in Skaraborg county as well as in several other places in Sweden prior to being used in the study. Through the questionnaires information was obtained concerning the amount of time patients spent in relation to consultations for blood pressure check-ups, which laboratory tests and other examinations were conducted, as well as which anti-hypertensive medications were prescribed for each individual patient. The method is described more fully in two Spri publications [6,8]. The patient material studied consisted of a stratified random sample including 309 individuals, of which 211 were in a trial group (from hypertension clinics in the trial area) and 98 in a control group (from clinics in the control area) with similar age and sex distribution and with a certain controlled spread in regard to the duration of hypertension. The patients who participated in the study all belonged to the 40-69 year age group when treatment was commenced. Only “pure”, i.e. without other concommittant diseases, hypertensives were included, all of them with identified hypertension at least one year prior to the study. Results
The results of the cost calculations are summarized in Table 2. The average total cost per patient per year amounted to SEK 799 in the trial area and SEK 918 in the control area (Swedish Crown 1 SEK = 0.125 USS). The patients in the trial area made more visits per year than those in the control area, which has a certain importance when comparing the cost per visit. This cost was 25% lower in the trial area than in the control area; SEK 75 and SEK 100, respectively. The dominating cost requirement in both areas was medications, which accounted for 73% and 74%, respectively of the total costs. The apparently rather large difference between the two areas regarding average medication costs (SEK 583 vs. SEK 679) is however not statistically significant. The same applies to the differences in costs recorded for laboratory tests and other examinations. The most obvious difference between the trial and control areas is in the distribution of work between physicians and nurses. Total time (per patient) with physicians and nurses was almost exactly the same in both areas. However, the total personnel cosfs
303 Table 2 Costs for hypertensive care per patient per year per visit cost
Control area
Trial area SEK
Physician time Nurses time
SEK
%
%
47
(6)
5-l
(7)
108 34
(12) (4)
Total staff time Lab tests, other exams
104 112
(13) (14)
142 91
(16) (10)
Total visit-related cost Medications
216 583
(27) (73)
239 679
(26) (74)
Total cost Average no. visits per year Cost (excluding medications) per visit
799 2.88
(100)
918 2.40
(100)
100
75
Swedish Crowns (1981 wages & prices) and percent of the total cost.
were significantly lower in the trial area than in the control area. In the trial area the nurses were responsible on average for 78% of the staff rime per patient. The corresponding figure in the control area was 47%. The nurses contribution corresponded to 55% of the personnel costs per patient per year in the trial area compared to 24% in the control area (Fig. 1). The total patient time used for hypertensive care is defined in the study as the sum of travel time to and from the clinic, waiting time at the office, along with time spent with the physician and nurse. The time per visit was shorter in the trial area than in the control area. Above all, the
Time
Utilization,
Costs
Mln
SEK
160 f
142
73
rl (47%)
NlEdS Contribution
rzi_ (22%
rrial Area
Control Area
Fig. 1. Staff time and costs.
Trial
304
waiting time differed. If the time utilization per patient per year is compared, the relationship becomes somewhat different. This can be explained by the higher frequency of visits in the trial area. As demonstrated in Table 3 the average time per patient per year was similar in both areas, slightly over 6 hours. The waiting time was significantly shorter in the trial area, even when calculated per year.
Costs and effects of screening The Medical Care Program also included screening for hypertension. Consequently, all individuals 40-69 years of age who visited any outpatient unit within the trial area, regardless of the reason for consultation, should have had their blood pressure checked. A separate evaluation of the screening activity in the municipality of Skara shows that during the 2-year period of screening 3025 individuals were examined in the 40-69 year age group, which is equivalent to 52% of the total number of individuals in this age group. Most of them had normal blood pressure. The screening results are shown in Fig. 2. Out of 332 previously untreated individuals who in the initial screening showed such an elevated blood pressure that they were called for a check-up, only 65 (20%) were candidates for treatment. The remaining 80% became control cases. The costs for the various check-ups in the screening program (compare Fig. 2) have been estimated as SEK 10 for the initial screening, SEK 35 for check-up I and SEK 180 for check-up II, visits to nurse and physicians examination included. The total cost of screening, including follow-up examinations, in Skara municipality over two years amounted to slightly over SEK 62 000. This input of resources resulted in the identification of 65 new cases for treatment which means a cost of SEK 960 per
Table 3 Average time utilization for hypertensive care per patient per visit per year Time utilization
min/visit Treatment time Physician time Nurses time Waiting time Total time at clinic Travel time to and from the clinic Total time utilization
Control area
Trial area
26
min/yr 14
6 20
% (20)
min/visit 30
17 57
min/yr 12
16 14
% (20)
38 34
39
113
(30)
56
134
(37)
65
187
(50)
86
206
(57)
65
186
(50)
66
159
(43)
130
373
(100)
152
365
(loo)
Minutes and percentages of total time.
305
Fig, 2. Check-ups in the screening program. N = normal blood pressure; B = borderline blood pressure; H = high blood pressure; n = number of individuals.
hypertensive detected. Neither before nor after the Medical Care Program period was there a significant difference between the trial and control areas regarding the percentage of individuals receiving hypertensive treatment. This indicates that the screening method has not been effective.
Conclusions and Discussion The economic analysis indicates that hypertensive care according to the structured program is somewhat less resource demanding than conventional care. The basis for this conclusion is that the differences in personnel costs are statistically significant. Other recorded differences, i.e. costs for laboratory tests and other examinations as well as for medications are not statistically validated. The fact that patients in the trial area visited the outpatient unit more frequently than in the control area could possibly be interpreted as a transfer of costs from the health care system to the patient. That this is not the case is established by the fact that the patient’s yearly time utilization for hypertensive care is equal in both areas. It would of course be desirable in an economic evaluation to be able to relate differences in costs between the two ways of providing care for hypertensives to differences in the benefits, i.e. the final results for the patient, lhe result would then mostly concern changes in survival, or changes in morbidity and quality of life. The latter concept is exceptionally difficult to quantify and relate meaningfully to costs. The patient’s own perception of his state of health was studied in this project but not expressed in terms suitable for a cost-effectiveness analysis. This would have required a more quantitative approach than was used here to assess changes in the quality of life. Concerning the effectiveness measure, survival (lives saved or years of life saved), the study period is too short to record possible changes. However, the medical evaluation demonstrated that the blood pressure levels of the treated hypertensive patients in the trial area were significantly better than for corresponding patients in the control area.
306
References Socialstyrelsen/Spri, Memorandum Concerning Swedish Medical Care Programs. 1975-10-06, Socialstyrelsen/Spri, Stockholm, 1975 (Swedish). Anonymous. No Centralised Control! Llkartidningen, 73 (1976) 3-4 (Swedish). Berglund, G., Isacsson, S.-O. and Ryden, L., Medical Care Program for hypertension, Skaraborgs County Council, Spri Publication 352, Spri, Stockholm, 1977 (Swedish). Berglund, G., Isacsson, S.-O. and Ryden, L., The Skaraborg Project -a controlled trial regarding the effect of structured hypertension care, Acta Medica Scandinavica, Supplement 626 (1979) 64-68. Berglund, G., Isacsson, S.-O. and Rydtn, L., A Medical Care Programme for Arterial Hypertension in Medical Care Programmes, The Scandinavian Hospital Institutes, Copenhagen, 1980. Berglund, G., Isacsson, S.-O., Jonsson, E. and Rydtn, L., Methods for evaluation of hypertension, Skaraborgs County Council. Spri Publication S84, Spri, Stockholm, 1978 (Swedish). R&tam, L., A program for the management of hypertension: an evaluation of structured hypertension care in the County of Skaraborg, Sweden. Spri Report 138, Department of Health Care, Klrnsjukhuset, Sk&de, 1983 (Swedish). Spri, Medical Care Program for hypertension -economic evaluation, Spri Report 159, Spri, Stockholm, 1983 (Swedish).
299
5 (1985) 299-306
HPE 00062
Economic evaluation of a Swedish medical care program for hypertension Ingemar
Eckerlund”, Egon Jonssona, Lars RydCnb, Lennart G&an Berglundd and Sven-Olof Isacssone
RBstamc,
aInstitute of the Health Services (Spri), Stockholm, bDepartment of Cardiology, Central Hospital, Sk&de, ‘Department of Health Care, Sk&de, ‘Department of Medicine I, Sahlgren’s Hospital, Giiteborg, ‘Department of Community Health Sciences, Lund University, Lund, Sweden (Accepted
for publication
9 June
1985)
Summary A Hypertension Care Program, developed in cooperation between physicians and nurses in both primary care and at the hospitals in the area, was implemented in the Skaraborg County, Sweden in 1977. The Program, which provided for the establishment of hypertensive clinics at outpatient units and referral to medical clinics, was clearly aimed towards giving nurses increased responsibility for hypertensive care. The Skaraborg Program has been evaluated from several important perspectives. A terminal population study showed better blood pressure control among the hypertensive patients within the program area than within the control area. The economic evaluation indicates that hypertensive care according to the Program is somewhat less resource demanding than conventional hypertensive care. Since the medical effects of hypertensive care were improved without increased demand for resources, the structured Care Program was more cost-effective than conventional care. medical Sweden
care
program;
consensus
statement;
cost-effectiveness;
hypertension;
The concept of a Medical Care Program was promoted during the mid-1970’s and was to be based on scientifically tested experience and contain recommendations for
Address for correspondence: Sweden. 0168-8510/85/$03.30
IngemarEckerlund,
0 1985 Elsevier
Research
Science Publishers
Associate,
Spri, Box 27310, 10254 Stockholm,
B.V. (Biomedical
Division)
300
the best possible health care and service for a defined patient group. The fundamental concern was a desire that all patients should be entitled to a similar, high quality standard of care. An equally fundamental intention was to achieve in the long run a more efficient utilization of resources, If the idea of a Medical Care Program were promoted today one would presumably discuss a locally adapted consensus statement. Medical Care Programs should be developed locally and should serve to support the routine delivery of care, as well as aid the education of various categories of personnel. The Swedish Medical Care Programs were expected, among other things, to facilitate communication between various levels of care, and to prevent unnecessary duplication of labor. The development of Swedish Medical Care Programs was thought to have a certain intrinsic value, where knowledge and experience could be examined and exchanged, routines reviewed, out-dated methods scrutinized and replaced as more effective technologies became available. Follow-up and evaluation were considered to be as essential as the development of the Medical Care Program itself [ 1,2].
The Skaraborg Program During 1976 a Hypertension Care Program was developed for certain municipalities within Skaraborg county [3-51. Its aim was to improve the control of hypertension in the county. The Skaraborg Program was developed in cooperation between physicians and nurses in primary care and at the departments of internal medicine in the area of the county where the program was to be tested. Frequent consultations also took place with specialists from the university hospital in Gothenburg. In the Skaraborg Program diagnosis and treatment are described in detail. Specific recommendations are provided, e.g. concerning blood pressure measurements, laboratory tests, as well as type and quantity of medication. Furthermore, it outlines referral procedures and the organisation of hypertensive care. The Medical Care Program provided for the establishment of hypertension clinics in outpatient units and referral to medical clinics. The Program was clearly aimed towards giving nurses increased responsibility for hypertensive care. Supervision was to be in the hands of the nurses, while the responsibility for diagnosis and treatment remained with the physicians. The target group for the program was limited to hypertensive patients in the age group 40-69 years.
Evaluation of the program Evaluation of the effects of the program was given significant consideration before the program was started. The county of Skaraborg was divided into two parts, each having equal population: one trial area where hypertensive care was delivered according to the program, and one control area where ordinary care was carried out. A baseline population study showed sufficient comparability between the two areas with respect to demographic structure, blood pressure levels and treatment for hypertension. The baseline study was carried out in 1977, and the methods for evaluation were also established at an early stage [6].
301
The Skaraborg Program has been evaluated from several important perspectives [7,g]. The evaluation illustrates essential medical, social, and economic consequences of the Medical Care Program.
Medical and social aspects The results of the medical evaluation are presented in an academic thesis [7]. At baseline the prevalence of hypertension was 15-16% using three subsequent blood pressures above 170/105 mm Hg (and/or) for subjects aged 40-60 years, above 180/l 10 mm Hg for subjects aged > 60 and including patients with ongoing treatment (Table 1). Only 20-25% of the hypertensives were not on treatment. During the five years of trial 3240 hypertensive patients were registered. Most of them were detected and treated prior to admission to the hypertension clinics (73%). The program finally controlled 7% of the population at risk. The drop out rate was 6.3% during the five years. The compliance to the program guidelines for examination and treatment was excellent. For previously known as well as for newly detected patients blood pressure was improved. The decrease of blood pressure was largest during the first year but continued through the complete period of follow-up. A terminal population study showed better blood pressure control among the hypertensive patients within the program area than within the control area. Further analysis credited this to the hypertension clinics. Interviewing matched patient samples from the hypertension clinics in the program area and from primary care in the control area showed more patient confidence in the hypertension clinics where continuity and information were superior to the conditions in the control area.
Economic aspects The economic evaluation has been directed towards an analysis of the cost for providing hypertensive care, both in the presence of, and in the absence of a Medical Care Program [8]. The calculations, however, do not include all costs associated with the delivery of hypertensive care; rather they have been limited to those costs which can
Table
1
Blood pressure Age (years)
limits for diagnostic
evaluation
Blood pressure
(mm Hg)
Normal < 40 40-60 > 60
< IS/<90 < 160/< 95 < 170/< 105
and follow-up
Borderline
in the Skaraborg
Too high > 160/> 95 > 170/> 105 >180/>110
program
302
be expected to vary dependent upon how hypertensive care is structured and organized. Thus the purpose has been to find whether the regular costs for personnel, material, tests and medications, along with the patient’s time have been influenced by the establishment of Medical Care Programs. Originally, the intention was to put identified cost differences in relation to eventual differences in the outcome of hypertensive care as expressed in terms of altered mortality and morbidity. The study period however is too short to permit any direct conclusions in this respect. Method and Material
The basis for the economic calculations has been established partly through questionnaires which have been answered by patients and personnel, and partly from the County Council’s accounting records. The questionnaires were tested in Skaraborg county as well as in several other places in Sweden prior to being used in the study. Through the questionnaires information was obtained concerning the amount of time patients spent in relation to consultations for blood pressure check-ups, which laboratory tests and other examinations were conducted, as well as which anti-hypertensive medications were prescribed for each individual patient. The method is described more fully in two Spri publications [6,8]. The patient material studied consisted of a stratified random sample including 309 individuals, of which 211 were in a trial group (from hypertension clinics in the trial area) and 98 in a control group (from clinics in the control area) with similar age and sex distribution and with a certain controlled spread in regard to the duration of hypertension. The patients who participated in the study all belonged to the 40-69 year age group when treatment was commenced. Only “pure”, i.e. without other concommittant diseases, hypertensives were included, all of them with identified hypertension at least one year prior to the study. Results
The results of the cost calculations are summarized in Table 2. The average total cost per patient per year amounted to SEK 799 in the trial area and SEK 918 in the control area (Swedish Crown 1 SEK = 0.125 USS). The patients in the trial area made more visits per year than those in the control area, which has a certain importance when comparing the cost per visit. This cost was 25% lower in the trial area than in the control area; SEK 75 and SEK 100, respectively. The dominating cost requirement in both areas was medications, which accounted for 73% and 74%, respectively of the total costs. The apparently rather large difference between the two areas regarding average medication costs (SEK 583 vs. SEK 679) is however not statistically significant. The same applies to the differences in costs recorded for laboratory tests and other examinations. The most obvious difference between the trial and control areas is in the distribution of work between physicians and nurses. Total time (per patient) with physicians and nurses was almost exactly the same in both areas. However, the total personnel cosfs
303 Table 2 Costs for hypertensive care per patient per year per visit cost
Control area
Trial area SEK
Physician time Nurses time
SEK
%
%
47
(6)
5-l
(7)
108 34
(12) (4)
Total staff time Lab tests, other exams
104 112
(13) (14)
142 91
(16) (10)
Total visit-related cost Medications
216 583
(27) (73)
239 679
(26) (74)
Total cost Average no. visits per year Cost (excluding medications) per visit
799 2.88
(100)
918 2.40
(100)
100
75
Swedish Crowns (1981 wages & prices) and percent of the total cost.
were significantly lower in the trial area than in the control area. In the trial area the nurses were responsible on average for 78% of the staff rime per patient. The corresponding figure in the control area was 47%. The nurses contribution corresponded to 55% of the personnel costs per patient per year in the trial area compared to 24% in the control area (Fig. 1). The total patient time used for hypertensive care is defined in the study as the sum of travel time to and from the clinic, waiting time at the office, along with time spent with the physician and nurse. The time per visit was shorter in the trial area than in the control area. Above all, the
Time
Utilization,
Costs
Mln
SEK
160 f
142
73
rl (47%)
NlEdS Contribution
rzi_ (22%
rrial Area
Control Area
Fig. 1. Staff time and costs.
Trial
304
waiting time differed. If the time utilization per patient per year is compared, the relationship becomes somewhat different. This can be explained by the higher frequency of visits in the trial area. As demonstrated in Table 3 the average time per patient per year was similar in both areas, slightly over 6 hours. The waiting time was significantly shorter in the trial area, even when calculated per year.
Costs and effects of screening The Medical Care Program also included screening for hypertension. Consequently, all individuals 40-69 years of age who visited any outpatient unit within the trial area, regardless of the reason for consultation, should have had their blood pressure checked. A separate evaluation of the screening activity in the municipality of Skara shows that during the 2-year period of screening 3025 individuals were examined in the 40-69 year age group, which is equivalent to 52% of the total number of individuals in this age group. Most of them had normal blood pressure. The screening results are shown in Fig. 2. Out of 332 previously untreated individuals who in the initial screening showed such an elevated blood pressure that they were called for a check-up, only 65 (20%) were candidates for treatment. The remaining 80% became control cases. The costs for the various check-ups in the screening program (compare Fig. 2) have been estimated as SEK 10 for the initial screening, SEK 35 for check-up I and SEK 180 for check-up II, visits to nurse and physicians examination included. The total cost of screening, including follow-up examinations, in Skara municipality over two years amounted to slightly over SEK 62 000. This input of resources resulted in the identification of 65 new cases for treatment which means a cost of SEK 960 per
Table 3 Average time utilization for hypertensive care per patient per visit per year Time utilization
min/visit Treatment time Physician time Nurses time Waiting time Total time at clinic Travel time to and from the clinic Total time utilization
Control area
Trial area
26
min/yr 14
6 20
% (20)
min/visit 30
17 57
min/yr 12
16 14
% (20)
38 34
39
113
(30)
56
134
(37)
65
187
(50)
86
206
(57)
65
186
(50)
66
159
(43)
130
373
(100)
152
365
(loo)
Minutes and percentages of total time.
305
Fig, 2. Check-ups in the screening program. N = normal blood pressure; B = borderline blood pressure; H = high blood pressure; n = number of individuals.
hypertensive detected. Neither before nor after the Medical Care Program period was there a significant difference between the trial and control areas regarding the percentage of individuals receiving hypertensive treatment. This indicates that the screening method has not been effective.
Conclusions and Discussion The economic analysis indicates that hypertensive care according to the structured program is somewhat less resource demanding than conventional care. The basis for this conclusion is that the differences in personnel costs are statistically significant. Other recorded differences, i.e. costs for laboratory tests and other examinations as well as for medications are not statistically validated. The fact that patients in the trial area visited the outpatient unit more frequently than in the control area could possibly be interpreted as a transfer of costs from the health care system to the patient. That this is not the case is established by the fact that the patient’s yearly time utilization for hypertensive care is equal in both areas. It would of course be desirable in an economic evaluation to be able to relate differences in costs between the two ways of providing care for hypertensives to differences in the benefits, i.e. the final results for the patient, lhe result would then mostly concern changes in survival, or changes in morbidity and quality of life. The latter concept is exceptionally difficult to quantify and relate meaningfully to costs. The patient’s own perception of his state of health was studied in this project but not expressed in terms suitable for a cost-effectiveness analysis. This would have required a more quantitative approach than was used here to assess changes in the quality of life. Concerning the effectiveness measure, survival (lives saved or years of life saved), the study period is too short to record possible changes. However, the medical evaluation demonstrated that the blood pressure levels of the treated hypertensive patients in the trial area were significantly better than for corresponding patients in the control area.
306
References Socialstyrelsen/Spri, Memorandum Concerning Swedish Medical Care Programs. 1975-10-06, Socialstyrelsen/Spri, Stockholm, 1975 (Swedish). Anonymous. No Centralised Control! Llkartidningen, 73 (1976) 3-4 (Swedish). Berglund, G., Isacsson, S.-O. and Ryden, L., Medical Care Program for hypertension, Skaraborgs County Council, Spri Publication 352, Spri, Stockholm, 1977 (Swedish). Berglund, G., Isacsson, S.-O. and Ryden, L., The Skaraborg Project -a controlled trial regarding the effect of structured hypertension care, Acta Medica Scandinavica, Supplement 626 (1979) 64-68. Berglund, G., Isacsson, S.-O. and Rydtn, L., A Medical Care Programme for Arterial Hypertension in Medical Care Programmes, The Scandinavian Hospital Institutes, Copenhagen, 1980. Berglund, G., Isacsson, S.-O., Jonsson, E. and Rydtn, L., Methods for evaluation of hypertension, Skaraborgs County Council. Spri Publication S84, Spri, Stockholm, 1978 (Swedish). R&tam, L., A program for the management of hypertension: an evaluation of structured hypertension care in the County of Skaraborg, Sweden. Spri Report 138, Department of Health Care, Klrnsjukhuset, Sk&de, 1983 (Swedish). Spri, Medical Care Program for hypertension -economic evaluation, Spri Report 159, Spri, Stockholm, 1983 (Swedish).