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Table 1 Characteristics of included studies

From: Advancing aged care: a systematic review of economic evaluations of workforce structures and care processes in a residential care setting

Source, country Intervention/comparator Facility n Participant n Study design Type of economic evaluation; analytic viewpoint Time horizon Date/source/currency of economic data Dementia specific Setting Economic outcome
Structures of care
 Dorr et al. [20], USA Registered Nurse (RN) direct care time per resident per day:
30–40 min
Less than 10 min
82 1376 Retrospective cohort study Cost-benefit analysis; societal; institutional 1 year 2001;
Secondary sources including national databases, with true costs obtained where possible;
USD
No NH Annual net societal benefit of $3191 per resident per year in nursing home units with 30–40 min of RN direct care time per resident per day compared to less than 10 min
 Grabowski and O’Malley [ 34], USA Off-hours physician coverage via telemedicine vs. on-call physician 11 N/A Cluster randomised controlled trial Cost-benefit analysis; insurance provider (medicare) 2 years Oct 2009–Sep 2011;
Estimated cost of hospitalizations to Medicare from recent literature;
USD
No NH 15.1 hospitalisations avoided. Net savings of $120,000 per facility per year
 Jenkens et al. [36], USA Green House model
Usual care
7 N/A Cross-sectional Cost analysis; institutional N/A 2009;
Wages derived from salary.com and payscale.com with 5% increase applied to Green House CNA wage;
USD
No SNF GH facilities use 1.97–2.49% more staff than traditional nursing homes
 Maas et al. [23]; Swanson et al. [38]; Swanson et al. [44], USA Special care unit
Traditional unit
1 44 Prospective cohort study Cost analysis; health care 1 year Date not disclosed;
Resource use measured and unit costs assigned—source of unit cost data not disclosed;
USD
Yes NH Costs of care for residents with dementia in special care units were 29% higher than cost of care on traditional units
 Mehr and Fries [24], USA Special care unit
Traditional unit
177 6663 Cross-sectional Cost analysis; institutional N/A Date not disclosed;
Resource use data from the resident status measure database, a preliminary version of the national nursing home minimum Data set;
USD
Yes NH Unadjusted resource use was 18% lower on SCUs than other units in the facility; when adjusted for case mix no significant difference in resource use was found
 Przybylski et al. [28], CAN Physical Therapy (PT) & Occupational Therapy (OT) staffing levels:
1.0 FTE PT and 1.0 FTE OT per 50 beds
1.0 FTE PT and 1.0 FTE OT per 200 beds
1 115 Randomised controlled trial Cost analysis; institutional 2 years 1993/1994;
Direct care nursing costs calculated based on the Alberta resident classification system (case mix measure) which estimates average amount of nursing care required per category. Source of wage data not disclosed;
Currency not disclosed.
No NH PT/OT delivered at a 1:50 ratio was more effective at promoting, maintaining, or limiting decline in functional status. The resulting reduction in required care delivery resources was estimated to provide an annual cost saving of $283 per bed (a 1% cost reduction)
 Schneider et al. [35], GBR 1.0 FTE occupational therapist
Usual care
8 190 Non-randomised experimental trial Cost analysis; health and social services 1 year 2002–2003;
Published unit costs, inflated to 2005;
GBP
No CH Intervention group showed a significant increase in the likelihood of using social services. At 2005 levels, net cost of providing occupational therapy was £16 per resident per week
 Sharkey et al. [37], USA Green House model
Usual care
27 240 Cross-sectional Cost analysis; institutional N/A 2008–2009;
Observational, interview, and survey methods at participating facilities;
N/A
No SNF Total staffing time (excluding administration) in Green House facilities was 18 min less per resident per day that traditional facilities. CNAs in Green House facilities spent 24 min per resident per day more time in direct care activities than CNAs in traditional facilities
 Teresi et al. [29], USA Implementation of an evidence-based education and best practice program:
Training staff vs. training staff and nursing home inspectors vs. usual training
45 N/A Quasi-experimental Cost-benefit analysis; Societal 2.5 years 2008;
Aggregate cost data based on local estimates and published literature;
USD
No NH Training staff was associated with a 15% reduction in annual falls, while training staff and inspectors was associated with a 10% reduction in falls.
Range of estimates for the cost-benefit analysis is between a net loss of $26,000 and a net savings of $52,000
Processes of care
 Chenoweth et al. [39], AUS Person-centred care (PCC)
Person-centred environment (PCE)
Both PCC + PCE
Usual care
38 601 Cluster randomised controlled trial Cost analysis; institutional 8 months 2009–2011;
Resource use measured and unit costs assigned using market rates;
AUD
Yes RACF PCC: 7169 per home; PCE: 9198 per home; PCC + PCE: 22,857 per home. Reduced agitation and improvements in resident quality of life for care homes which instituted PCC and PCE. The PCC + PCE intervention produced significant improvements in quality of care interactions and care responses, but no improvements in agitation or quality of life
 Chenoweth et al. [31]; Norman et al. [32], AUS Person-centred care (PCC)
Dementia-care mapping (DCM)
Usual care
15 289 Cluster randomised controlled trial Cost-effectiveness analysis; institutional 8 months 2008;
Pharmaceutical costs: Australian pharmaceutical benefit schedule
Training costs: Bradford University, UK
Staff costs: Commonwealth Government Aged Care Nurses’ Award;
AUD
Yes RACF Dementia care mapping was found to be a more expensive and less effective intervention than person-centred care. The cost per negative behaviour averted in the person-centred care group was $8.01 post-intervention and $6.43 at follow-up relative to usual care
 MacNeil Vroomen et al. [22], NED Multidisciplinary Integrated Care (MIC)
Usual care
10 301 Cluster randomised controlled trial Cost-effectiveness analysis; societal 6 months 2007;
Health care utilisation collected via patient/proxy interview and medical records. Source of cost data not disclosed. CPI figures sourced from the Dutch bureau of statistics;
EUR
No RH For functional health and QALYs, multidisciplinary integrated care was not found to be cost-effective compared to usual care. For patient-related quality of care, the probability that the intervention was cost-effective compared to usual care was 0.95 or more for ceiling ratios greater than €129
 Molloy et al. [25], CAN Advance Directive program
Usual care
6 1292 Cluster randomised controlled trial Cost analysis; health care 1.5 years Date not disclosed;
Unit prices sourced from local and provincial fee schedules;
CAD
No NH Intervention nursing homes reported 44% fewer hospitalisations per resident (0.27 versus 0.48), and 33% less resource use ($3490 versus $5239) than the control facilities.
 Müller et al. [33], DEU Multifactorial fracture prevention program
Usual care
N/A N/A Markov-based simulation model Cost-utility analysis; insurance provider 20 years 2012;
Retrospective dataset of costs for NH residents from an insurance fund (n = 60,091), a public German dataset for fracture treatment costs, and catalogue of non-physician care for physical therapy costs;
EUR
No NH Base-case analysis of multifactorial fall prevention resulted in a cost-effectiveness ratio of €21,353 per QALY
 Ouslander et al. [43], USA INTERACT II tools (Interventions to Reduce Acute Care Transfers) 36 N/A Controlled before-and-after Cost analysis; institutional 6 months 2010;
Wages based on national data;
USD
No NH Intervention group reported 17% reduction in hospitalisation rates. The average cost of the 6-month intervention was $7700 per facility
 Paulus et al. [21], NED Integrated care
Traditional care
2 342 Quasi-experimental Cost analysis; societal 1.2 years Date not disclosed;
Activity based costing, data obtained from participating nursing homes and a published guide for cost research;
EUR
No NH Integrated care had 31% lower informal direct care costs per resident. Total average costs per resident were on average 4% higher in integrated care than traditional care
 Rantz et al. [26], USA Multilevel intervention with expert nurses vs. monthly info packs on ageing and physical assessment 58 N/A Cluster randomised controlled trial Cost analysis; institutional 2 years Date not disclosed;
Medicaid cost reports;
USD
No SNF Total costs per resident per day increased 6% in the intervention group, and decreased 3% in the control. The intervention demonstrated improvements in quality of care, pressure ulcers and weight loss
 Rovner et al. [27], USA A.G.E. dementia care program (activities, medication guidelines, educational rounds) vs. usual care 1 81 Randomised controlled trial Cost analysis; institutional 6 months Date not disclosed;
Monthly billing records;
USD
Yes ICF At 6 months, intervention residents were more than 10 times more likely to participate in activities than controls. Additional cost of the intervention was $8.94 per resident per day
 van de Ven et al. [30], NED Dementia-care mapping (DCM)
Usual care
11 318 Cluster randomised controlled trial Cost-minimisation analysis; health care 1.5 years 2010–2012;
Data collected over a period of 18 months. Sources included the Dutch manual of health care cost, and cost prices delivered by a pharmacy and a nursing home;
USD (EUR 1.00 = USD 1.318)
Yes NH No significant effect on total costs for the intervention
  1. Countries AUS Australia; CAN Canada; CHE Switzerland; DEU Germany; GBR United Kingdom; NED Netherlands; USA United States
  2. Settings CH care home; ICF intermediate care facility; SNF skilled nursing facility; NH nursing home; RACF residential aged care facility; RH residential home