The 12 months following the commencement of the EDDIE intervention was associated with a 19% reduction in annual hospital admissions and a 31% reduction in the average length of stay per admission when compared to the previous 12 months. When outcomes were modelled in a cohort of 96 RACF residents the intervention produced an additional 0.06 QALYs while saving $249,000 to the health care system. After accounting for plausible uncertainty in the model, there was an 86% chance of the intervention being cost-effective when adopting a willingness to pay of $28,000 per QALY. When the willingness to pay for health benefits was assumed to be zero, there was still an 85% change of the intervention being cost-effective and in this case, cost-saving to the health care system.
This is the first economic evaluation of a hospital avoidance intervention in the aged care setting. Prospective data were collected on the number of subacute episodes managed within the RACF as well as on the implementation costs of the intervention, including staff time spent on training, stakeholder engagement and project management activities. This information may be valuable to other RACFs considering adopting a similar program.
A notable finding was that the EDDIE program was associated with a shorter length of stay for residents who were admitted. This is despite the reasonable assumption that the residents who were admitted to hospital may be higher acuity or in need of more specialist care. Shorter lengths of stay may be explained in part due to increased hospital staff confidence in the ability of the RACF to provide clinical care for patients with complex health needs. As part of the EDDIE program, the RACF engaged with nearby hospitals and educated hospital staff about the higher level of care and diagnostic equipment available. In one case, a hospitalized resident described as "complex" who required frequent bladder scans was returned to the RACF because the hospital discharge staff knew that the equipment and expertise to manage the patient's care were available.
The study was limited to a single RACF in a regional area, and it is therefore unknown how the results we have reported may translate to other settings. A further limitation was that it was unethical and impractical to randomise intervention provision as it is added to the current model of care provision. As the intervention and usual care cohorts encompassed non-static resident populations it was not feasible to summarise and control for resident characteristics across the pre and post intervention periods. The analysis would have been further strengthened by the collection of prospective utility data which may be more sensitive to changes in the overall quality of care provided within the RACF.
Our findings support the growing body of evidence to suggest that programs allowing for sub-acute care to be provided within the RACF setting improve both resident and health service outcomes. Previous Australian studies have evaluated hospital in the nursing home programs or other hospital or emergency department (ED) led outreach services that assist with the assessment of deteriorating residents[26, 40, 41]. These evaluations have reported significant reductions in ED transfers and hospital admission rates, but did not assess cost-effectiveness. The EDDIE intervention was instead focussed on upskilling existing RACF nursing staff and empowering them to proactively detect and respond to early signs of resident deterioration. In this sense it takes a similar approach to the hospital avoidance program ‘Interventions to Reduce Acute Care Transfers’ (INTERACT II) developed in the United States and reported to have reduced hospital admissions by 17–24% across 24 nursing homes[24]. Length of stay and cost-effectiveness outcomes associated with the INTERACT II program have not been reported. However, the EDDIE intervention is unique in that it was developed in, and driven by, the aged care setting.
The 2011 Australian Productivity Commission inquiry into caring for older Australians identified people in RACFs as being marginalised in terms of access to and quality of appropriate medical care [42]. It was identified that continuity of care for RACF residents with acute healthcare needs and access to information of available services to fulfil their care needs were suboptimal. As identified by Ardents and Howard in their 2010 systematic review, older people living in RACFs have characteristics that distinguish them from the broader elderly population[6]. Notably, they are chronically ill and dependent, and the priority for their medical care is disease management rather than curative. In this context there is the opportunity for professional, accredited nursing staff to deliver appropriate care within the RACF and in turn prevent unnecessary hospital admissions.