Economic Evaluation of a Reablement Training Program for Homecare Staff Targeting Sedentary Behavior in Community-Dwelling Older Adults Compared to Usual Care: A Cluster Randomized Controlled Trial

Abstract

Purpose

Training and supporting homecare staff in reablement aims to change staff behavior from “doing for” to “doing with” older adults and is assumed to benefit the health and quality of life of older adults and reduce healthcare utilization and costs. This study evaluated the cost-effectiveness and cost-utility of the staff reablement training program “Stay Active at Home” (SAaH) from a societal perspective.

Participants and Methods

An economic evaluation was embedded in a 12-month cluster randomized controlled trial. Ten Dutch homecare nursing teams participated (n = 313 staff members), of which five teams were trained in reablement and the other five provided usual care. Cost and effect data were collected from 264 older adults at baseline, 6 and 12 months. Costs included “intervention,” “healthcare,” and “patient and family” costs (collectively, societal costs) and were assessed using questionnaires and client records or estimated by bottom-up micro-costing. Effects included sedentary behavior and quality-adjusted life years (QALYs). Multiple imputed bootstrapped data were used to generate cost-effectiveness planes and acceptability curves.

Results

No statistically significant differences were observed between the intervention and control group in terms of sedentary time (adjusted mean difference: 4.8 minutes [95% CI –26.4, 36.0]), QALYs ( 0.01 [95% CI –0.03, 0.04]), and societal costs ( €2216 [95% CI –459, 4895]), except lower costs for domestic help in the intervention group ( €–173 [95% CI –299, –50]). The probability that SAaH was cost-effective compared to usual care ranged from 7.1% to 19.9%, depending on the willingness-to-pay (WTP) (€0‒€50,000)/minute of sedentary time averted and was 5.9% at a WTP of €20,000/QALY gained.

Conclusion

SAaH did not improve outcomes or reduce costs and was not cost-effective from a societal perspective compared to usual care in Dutch older adults receiving homecare. Consequently, there is insufficient evidence to justify widespread implementation of the training program in its current form.

Trial Registration

ClinicalTrials.gov: NCT3293303.

Keywords:

• cluster randomized controlled trial
• cost-effectiveness
• cost-utility
• home and community-based care services
• independence
• aged

Acknowledgments

The authors would like to thank all participating homecare clients, homecare staff, and team managers of the healthcare organization MeanderGroep South-Limburg. Furthermore, they would like to thank program trainers José Blezer and Thecla Terken and program champions Marijke Hennen and Mandy Boosten (MeanderGroep South-Limburg) for their contribution to the implementation of the training program; Henny Geelen and Maria Wetzels (Citizen Power Limburg) for their valuable practice insights as representatives of older adults and informal caregivers; Marja Veenstra (Citizen Power Limburg), José van Dorst (Dutch Nurses Association), Bem Bruls (General Practitioners Eastern South-Limburg), Wiro Gruisen (CZ health insurance), Lisette Ars (healthcare organization Envida), Roger Ruijters, Tessa Schreibers, Margreet Bruinsma, and Karin Pieters (Meandergroep Zuid-Limburg) for their guidance and advice as part of the steering group, and Astrid van den Bosch, Ine Hesdahl, Susanne Hanssen, Mariska Machiels, and Wendy Halbach for their contribution to the data collection and/or entry.

Abbreviations

CEAC, cost-effectiveness acceptability curve; CE-plane, cost-effectiveness plane; c-RCT, cluster randomized controlled trial; HRQoL, health-related quality of life; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life year; SAaH, stay active at home; WTP, willingness-to-pay.

Data Sharing Statement

Individual participant data and data dictionaries that underlie the results reported in this article are available from the corresponding author on reasonable request after de-identification. Data will be available beginning 9 months and ending 36 months following article publication for researchers who provide a methodologically sound proposal to achieve aims in the approved proposal. Proposals should be directed to [email protected]. To gain access, data requestors will need to sign a data access agreement.

Ethics Approval and Informed Consent

The study was approved by the Dutch Medical Research Committee Zuyderland (METC #17N110) and conducted in accordance with the Declaration of Helsinki. Participation was voluntary; older adults were informed about the study and asked for written informed consent prior to study commencement. They could withdraw from the study at any time for any reason.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflict of interest in this work.