Seven Day Services
Cost-Benefit Analysis - Approach and Key Issues
David Halsall
Clinical Quality and Efficiency Analytical Team
20th January 2012
Clinical Quality & Efficiency Analytical team
Overview
• What is economic analysis and how might we frame the problem
• Evidence to point us towards were we might find the best cost benefit
• An example of how levelling out a service can improve quality to
patients, staff and improve cost benefit
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Clinical Quality & Efficiency Analytical team
What sort of economic analysis shall we do?
Making the economic case for the reduction the difference between
the weekday and weekend level of service requires an evaluation of
the costs and benefits of any re-configuration
• Economic evaluation in principle is straight forward
QALY
Health
Benefits
Extra Cost
Cost/benefit
QIPP savings
Cash savings
• Can we show that increasing services at the weekend has
– An overall cost benefit?
– And is possibly overall cost saving (a QIPP saving)
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Would we expect incremental changes to resources to have a direct
linear link to patient care or would we guess that there is a non-linear
relationship ?
A conceptual model of the link between access to care and benefits care brings
100
A measure of the benefit care brings
For example level of disability following a stroke
Clinical Quality & Efficiency Analytical team
Looking at benefits
90
Best
Practice ?
80
Normal weekday
working ?
70
60
50
Weekend
Working?
40
30
20
1/3 cost
1/3 cost
1/3 cost
10
0
0
10
20
30
40
50
60
70
80
90
A measure of access to care
For example time between admission and senior review
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Clinical Quality & Efficiency Analytical team
How do you eat an elephant?
As with any complex problem the trick is to cut it to down to a
manageable size…
The first thing we do is state what we want to achieve
• On the ground of equality and effectiveness a hospital
should not unduly delay or otherwise restrict access to
services to patients admitted at the weekend compared to
those admitted on a weekday.
And then we collect evidence to suggest how we best
allocate resources to achieve our aim
• In this case we can look at the weekend demand and
performance measures and see how they compare to a
weekday
• So what evidence do we have?
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Fewer people are admitted to hospital as an emergency at the
weekend but the chances of dying are noticeably higher
National figures, England 2010/11
900
4.1%
800
4.0%
700
3.9%
Discharges (000's)
Clinical Quality & Efficiency Analytical team
Evidence 1
600
500
3.8%
400
3.7%
300
3.6%
200
Emerency admissions
3.5%
100
Percentage who are discharged dead
3.4%
MON
TUE
WED
THU
Day of admission
FRI
SAT
SUN
DH analysis of HES data 2010/11
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Clinical Quality & Efficiency Analytical team
Evidence 2
Or to put it another way the drop in the number of deaths is a lower
percentage than the drop in admissions. Could this be a case mix
effect?
Emergency admission by
weekend and weekday admission
Change from weekday to weekend admission
15%
10%
5%
0%
admissions
deaths
chance of death
-5%
-10%
-15%
-20%
-25%
DH analysis of HES data 2010/11
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Stroke, heart failure, some cancers and renal failure seems to make
up the biggest contribution to the difference in death rates
Acute cerebrovascular
disease
6,000
5,000
Weekend mortality
Clinical Quality & Efficiency Analytical team
Evidence 4
4,000
Congestive heart
failure nonhypertensive
Cancers*
3,000
2,000
Acute & Unspecified
renal failure
1,000
Other lower
respiratory diseases
Cardiac dysrhythmias
-
5,000
10,000
15,000
20,000
Weekend admissions
Causes where the difference between mortality rates between weekday and weekend admissions is statistically significant
Aylin et al, BMJ Quality & Safety (2010)
* Cancer or stomach,, oesophagus, prostate and pancreas.
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Clinical Quality & Efficiency Analytical team
Evidence 4
Admission by specialty shows that general medicine has double the
increase of percentage deaths compared to the average weekday to
weekend rate.
Percentage of patients who are discharged dead by day of the week of admission
7.0%
T&O
All Specialities
Cardiology
General Medicine
6.0%
20%
5.0%
4.0%
10%
3.0%
2.0%
1.0%
0.0%
MON
TUE
WED
THU
FRI
SAT
SUN
DH analysis of HES data 2010/11
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Clinical Quality & Efficiency Analytical team
Example
So lets look at an example were extra resources are added to
general medicine at the weekend and see if the economic case
stacks up
• In 2007 Heartland Hospital instigated early consultant review to reduce the risk
to patients when AMU patients are transferred to specialist medical wards at
weekends.
• They replaced weekend on-call “safari” consultant cover with two acute
physicians to provide early senior review of newly admitted patients.
• This reduced delays in having a clear clinical management plan and reduced
LoS for patients admitted towards the end of the week.
• In particular it was identified that opportunities were being missed to discharge
some patients in the subsequent 24-72 hours after admission
• In common with many acute trusts discharges at weekends were less than on
weekdays
• Seven day working of key clinical and social service staff is required to
achieve a levelling out discharge pathways.
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Clinical Quality & Efficiency Analytical team
Example
The case can be made that the cost of the extra consultants could
be offset but increasing the weekend discharge rate
•
•
•
•
A consultant (including overheads) could cost £150,000/year
A patient awaiting discharge will cost around £250/day
So £300,000 is equal to around 1200 patient days
Or in other words if 23 patients are discharged 1 day earlier each weekend
that would cover the cost of the 2 extra consultants.
• In effect one ward would have to be close for a day a week to recover the
cost.
• The other changes to weekend working patterns are achieved by negotiated
HR processes
£300,000/year
23 patients a
week have their LoS
reduced by 1 day
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Although it is impossible to attribute the improvement in
performance to the change in the weekend working pattern it is
consistent with what you would expect
Percentage of Deaths in Hospital Following Emergency Admission
(Birmingham trust and England)
5.0%
RR1 2006/07
Weekday = 4.5%
Weekend = 5.4%
4.8%
Deaths as a percentage of emergency admissions
Clinical Quality & Efficiency Analytical team
Example
+20%
4.6%
4.4%
England 2006/07
Weekday = 4.5%
Weekend = 4.8%
4.2%
+6%
England
England 2006/07
Weekday = 3.7%
+10%
Weekend = 4.0%
4.0%
Birmingham Heartlands & Solihull NHS Trust (RR1)
3.8%
RR1
England
3.6%
RR1 20010/11
Weekday = 3.5%
+14%
Weekend = 3.9%
3.4%
3.2%
3.0%
2005/06
2006/07
2007/08
2008/09
2009/10
2010/11
Source DH analsys - of HES data
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Clinical Quality & Efficiency Analytical team
In addition to the direct costs and benefits there are a range of
additional benefits which also could be used to evaluate the change
in practice.
•
•
•
•
Improved patient satisfaction
Better training of junior doctors
Enhance patient quality and safely
Ward staff feel more supported
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Clinical Quality & Efficiency Analytical team
Summary
• There is the suggestion that the evening and weekend shutdown of normal
service in acute hospitals leaves too many patient in limbo for too long.
• With targeted interventions and good HR practices the difference between
weekend and weekday service can be reduced showing overall cost benefit.
• It is also possible that by keeping the discharge rate close to the weekday rate
at the weekend the levelling up the weekend service could be cost saving.
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