The main factor determining the outcome of interest, access to clinical specialist services, is the availability of limited number of specialists in the country. Considering this, the main effectiveness measure which is directly related with our outcome of interest, for this economic evaluation was “number of patients receiving clinical specialist services within a defined time of clinical specialists spent for this purpose”.
As the perspective is societal, the analysis considered the costs encored on different constituents participating in the provision of clinical specialist services. The costs are categorized into five exclusive categories: Direct medical cost, direct non-medical cost on patients and care takers/companions, indirect cost on patients and care takers/companions, indirect cost on voluntary clinical specialists, and Project cost to organize outreach activities.
The gain and loss by participating hospitals associated with mobilization of staff from central referral hospitals to Outreach Hospitals was ignored as we are considering societal perspective which makes the loss by the central referral hospitals to be compensated with the gain by outreach hospitals.
This study has taken two major assumptions: The technical quality of specialist care provided to patients and thus treatment outcomes are assumed to be equal for both of the alternative strategies; and if CSOP was not in place, referral to central referral hospitals would have been the only option to treat the patients.
Timeframe is the period over which intervention costs are calculated and analytic horizon refers to the period over which effects of interventions will be measured. For this particular study both the timeframe and analytic horizon are similar with the implementation period of clinical specialist outreach project which covers the period from 1 April 2007 to 31 December 2008.
Study area and period
Included in the study were four outreach hospitals where the Clinical Specialist Outreach Project was adequately implemented and three central referral hospitals from which clinical specialists were mobilized. The period of data collection was from 4 to 24 February 2009.
Source and Study Populations
Patients who received clinical specialist services with surgical interventions for orthopedic, plastic, urologic or gynecologic problems at outreach hospitals in the regions and central referral hospitals in Addis Ababa were the source population. The study population included two categories of sampled patients selected from the source population: Sample patients who received clinical specialist services most recently in the four outreach and three referral hospitals including those who get operated for problems related to urologic, gynecologic, and orthopedic and plastic surgeries; and Post-operative patients who received clinical specialist services from the four outreach and three referral hospitals during the three weeks period of data collection.
Sample size and sampling technique
Purposive sampling was used to select four outreach hospitals from the ten project hospitals. The purpose was to include hospitals in which the project was adequately implemented and at the same time better represent the geographical distribution in relation to Addis Ababa. Based on these criteria four outreach hospitals were selected: Yirgalem, Adama, Nekemt, and Felege Hiwot Hospitals. For collection of data at central referral hospital level, the three hospitals from which clinical specialists were being mobilized were selected: Black Lion, St Paul and Yekatit Hospitals.
Ten charts for each surgical intervention undertaken through clinical specialist outreach project were taken for chart review. The types of procedures were those surgical procedures performed through the outreach project. Selection of charts of patients was based on date procedure performed; ten charts of patients who received service most recently were included. As the specialist outreach were for five days at a time, two charts of a day were taken.
All post operative patients who get to central referral hospitals through referral from zonal/regional hospitals and received surgical interventions during the three weeks data collection period for reasons similar with those intervened through the clinical specialist outreach project were included for patient interview.
Patients for interview were identified from surgical and gynecology wards of the selected central referral hospitals. The inclusion criteria for patient interview were: Post operative patient after surgical procedure related to the four specialty areas (urologic, gynecologic, and orthopedic and plastic surgeries); and patient coming referred from a hospital outside of Addis Ababa.
The data collection team included the principal investigator, one general practitioner to review patient charts, one nurse to interview patients and one project staff to facilitate field work. All data collectors were trained by the principal investigator prior to the data collection period.
The data collection tools include: Clinical Specialist outreach visit details sheet, Clinical specialist activities summarizing sheet, Patient interview questionnaire, Patient Record reviewing tool, Interview guide for specialists, Project cost estimation tool, and Interview guide for outreach hospital focal persons. Two major methods of data collection were used: Review of documents(patient records, reports, registration books and financial documents) and interview (Patient interview, and Expert interviews).
The proposal has been reviewed and got ethical clearance by the Ethical Review Board of Jimma University to ensure the propriety standards of the evaluation. Informed consent was obtained from all participant patients in the data collection process prior to any attempt to collect data.
Analysis of the cleaned data set was done by using SPSS 16.0. Data from different sources get linked during analysis and Microsoft Excel was used to calculate the final summary values and results were presented in tables, graphs and narrative descriptions. Sensitivity analysis was done to assess how the result of the analysis could change based on the values of some selected independent variables with a potential to change over time and across different contexts.