Health economics, healthcare funding and service evaluation: International and Australian perspectives

Benefit: AUD$7106/PWDBCR: 7.25 (3.63–10.88) to 1
AUD$20,825/DALY averted (AUD$13,883–AUD$41,650), i.e. very cost-effective by WHO benchmark of less than GDP per capita/DALY. Dementia Training Service CentresAUD$1320 per studentThis cost was not directly comparable with Effective Full-Time Student Units (EFTSU), but for comparison they were AUD$1326. Dementia Collaborative Research CentresAUD$52,677 per publication (AUD$43,897 to AUD$65,846)These were very broad definitions, but were compared to the NHMRC benchmark of AUD$62,735 per publication.

PWD, person with dementia; BCR, benefit/cost ratio; DALY, disability adjusted life year; EFTSU, equivalent full-time student units.

Broadly, measure 1 projects were cost-effective and compared favourably with benchmarks. In the NDSP project, the Helpline cost less than the average of similar phone and other help services at AUD$162–AUD$191/hour. The Dementia and Memory Community Centres and early intervention/counselling elements were also less costly than alternatives provided through allied health, medical or specialist delivery models. There was no comparator for the information, awareness, education and training element of NDSP.

DBMAS showed a very favourable benefit/cost ratio of 7.25 to 1, costing an estimated AUD$20,825 per DALY averted, ranked ‘very cost-effective’ by the WHO benchmarks. This was subject to the caveat of there being a study design and measurement of quality of life that was aimed at assessing primarily the response of the residential care facility to their experience with the DBMAS and only secondarily the response of the person with dementia.

The cost per student of DTSCs, at AUD$1320 per student, although broadly aligned, is not strictly comparable with the cost/EFTSU in other Australian universities, since the DTSCs deliver a broad range of materials rather than standard tertiary education modules. It would be useful for future economic evaluations if DTSCs (or similar organisations) could measure and report their own outcomes in-terms of EFTSU.

For the DCRCs, the cost per publication was estimated as somewhat less than the NHMRC comparator, although the evaluation depended on a number of assumptions about outcomes that would occur in the future.

The second measure, the new community support programme EACHD (measure 2) was found to be cost-saving relative to RAC, the alternative model of care for people with high-level care needs, dementia and behavioural and psychological symptoms. The cost-effectiveness of EACHD was challenging to measure due to the intangible nature of many of the benefits of care, such as the provision of choice (see Table 10.3). Furthermore, due to the lack of availability of an appropriate control group, the benefits that were included in the analysis may have been underestimated (i.e. the person with dementia may have deteriorated relative to the measured outcomes were it not for the EACHD package).

Table 10.3 Summary of Economic Key Performance Indicators (KPI) relative to evaluation benchmarks, Measure 2 (Source: Reference [23]. Reproduced in part with permission of the Australian Government.)

Project/Sub-project	Economic KPIs	Evaluation
Extended Aged Care at Home Dementia (EACHD)	AUD$7199 per client saving relative to RAC (2007–2008)	The overall conclusion was that the services provided in this programme were better value for money than RAC.
	AUD$27.5 million total programme saving relative to RAC (to June 2008)
	AUD$0.39 in QoL benefits per AUD$ spent (2007–2008)
	AUD$0.44 in QoL benefits per AUD$ spent (to June 2008)

RAC, residential aged care; QoL, quality of life.

Two final projects were evaluated under the third measure – the Dementia Caring Pilot (DCP) and the Dementia Care Essentials (DCE) programme, which provided dementia care education and skills training for family carers and aged care workers respectively. Both were evaluated through cost-effectiveness analysis using natural units, given data limitations – with extensions to cost-utility and cost-benefit analysis. Cost data comprised government funding information supplemented by data on co-contributions where applicable and numbers trained. The main benefits measured were workload reductions (i.e. productivity gains), work quality improvements and changes in quality of life for carers. Quality of life was measured using the Goal Attainment Scaling (GAS) tool.¹ Table 10.4 provides a summary of the results.

Table 10.4 Summary of Economic Key Performance Indicators (KPI) relative to evaluation benchmarks, Measure 3 (Source: Reference [23]. Reproduced in part with permission of the Australian Government.)

Project/Sub-project	Economic KPIs	Evaluation
Dementia Caring Pilot (DCP)	AUD$2741 per session	Based on the descriptors in the GAS scale, it appeared likely that the cost-effectiveness measured for this programme met the standard of ≤AUD$155,200/QALY and so was a cost-effective programme. It was noted though that there is no established conversion for the GAS into a QALY measure.
	AUD$969 per participant
	AUD$1253–AUD$1407 per participant that received an improvement in wellbeing
	AUD$2092–AUD$2510 per GAS point
Dementia Care Essentials (DCE)	AUD$1437 per student trained	We found that the DCE training was both cost-saving (netting AUD$3.55 in productivity gains for each dollar spent) and quality-enhancing (by around 4.5% per annum sustained for 3 years). When considered together, the same costs are producing an improvement in both workload and work quality.
	AUD$0.22 per AUD$improvement in workload [BCR: 4.55 (1.54–7.45) to 1]
	AUD$4.72 per 1% improvement in work quality