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Clinical and cost-effectiveness of a home-based health promotion intervention for older people with mild frailty in England ..., 2024, Walters et al

Discussion in 'Other health news and research' started by Midnattsol, Apr 1, 2025 at 7:45 AM.

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  1. Midnattsol

    Midnattsol Moderator Staff Member

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    Full Title
    Clinical and cost-effectiveness of a home-based health promotion intervention for older people with mild frailty in England: a multicentre, parallel-group, randomised controlled trial

    Background
    Health promotion for people with mild frailty has the potential to improve health outcomes, but such services are scarce in practice. We developed a personalised, home-based, behaviour change, health promotion intervention (HomeHealth) and assessed its clinical effectiveness and cost-effectiveness in maintaining independent functioning in activities of daily living in older adults with mild frailty.

    Methods
    This trial was an individual, multicentre, parallel-group, randomised controlled trial done in England. Participants were mainly recruited from general practices in three different areas of England (the London north Thames region, east and north Hertfordshire, and west Yorkshire). Participants were individuals residing in the community who were registered with a general practice, 65 years and older with mild frailty (scoring 5 on the CFS), with a life expectancy of more than 6 months, and with capacity to consent to participate. We excluded adults residing in nursing or care homes, those with moderate-to-severe frailty or with no frailty, those receiving palliative care, and those already case managed (eg, receiving a similar ongoing intervention from the voluntary sector or community service). Eligible participants were randomly assigned 1:1 to either the HomeHealth intervention or to treatment as usual. HomeHealth is a multidomain health promotion intervention delivered by the voluntary sector at home in six sessions over 6 months. The primary outcome was independent functioning (assessed using the modified Barthel Index [BI]) at 12 months. Outcome assessments were masked and were analysed by intention to treat using linear mixed models. Incremental costs and quality-adjusted life-years (QALYs) were calculated using seemingly unrelated regression and bootstrapping. The trial is registered on the ISRCTN registry (ISRCTN54268283).

    Findings
    We recruited 388 participants between Jan 8, 2021 and July 2, 2022 (mean age 81 years, SD 6·5; 249 (64%) of 388 were women and 139 (36%) were men). 195 participants were randomly assigned to HomeHealth and 193 to treatment as usual. Median follow-up was 363 days (IQR 356–370) in the HomeHealth group and 362 days (IQR 355–373) in the treatment-as-usual group. HomeHealth did not improve BI scores at 12 months (mean difference 0·250, 95% CI –0·932 to 1·432). HomeHealth was superior to treatment as usual with a negative point estimate for incremental costs (–£796; 95% CI –2016 to 424) and positive point estimate for incremental QALYs (0·009, –0·021 to 0·039). There were 55 serious adverse events in the HomeHealth group and 85 in the treatment-as-usual group; none were intervention related.

    Interpretation
    HomeHealth is a safe intervention with a high probability of cost-effectiveness, driven by a reduction in unplanned hospital admissions. HomeHealth should be considered as a health promotion intervention for older people with mild frailty.

    LINK
     
    Midnattsol, Apr 1, 2025 at 7:45 AM
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  2. Midnattsol

    Midnattsol Moderator Staff Member

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    Another study where the intervention (health promotion, ie. helping people set goals, be physically active, socialize etc.) didn't really do much but is still promoted in the conclusion. Somewhat worrying was that the intervention is done by volunteers with little to no education in health, which I guess is part of why it would be cost-effective.

    The intervention period was during different COVID-19 restrictions, so that could have influenced a lot of things seeing as the age group (65+) would be at higher risk of adverse outcomes from infections going around.
     
    Midnattsol, Apr 1, 2025 at 7:48 AM
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  3. Utsikt

    Utsikt Senior Member (Voting Rights)

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    ​
    The mean total cost per participant of the HomeHealth intervention was £457 (SD 170), with a total cost of training, supervision, and consumables of £49 per participant. This cost includes time taken for trial-related administrative tasks (eg, completing fidelity checklists and uploading audio recordings).

    Using a caseload model based on each full-time HomeHealth support worker having a caseload of 120 people per year (typical caseload data provided by our voluntary-sector partners), and employed as NHS band-5 workers, the delivery cost including training and supervision would be £295 per participant.

    When intervention costs were added to other health and social care costs, total health and social care costs were lower in the HomeHealth intervention group than the treatment-as-usual group, although this difference was not statistically significant (adjusted mean £5064, SE 354, vs £5833, 535; mean difference –£769, 95% CI –2017 to 480; p=0·23).
    ​
    They then went on to look at the individual components of the cost and claim that it’s cost effective because some were different by a statistically significant margin. Mainly a difference in unplanned hospital admissions.

    Our efforts to maintain masking of outcome assessments were mostly successful at our primary endpoint, with researchers unable to guess group status for 284 (85%) of 333 participants at 12 months.​

    This section stands out to me. If you guess randomly, wouldn’t you expect 50 % correct guesses instead of 15 %? So what could have made them guess wrongly so often?
     
    Utsikt, Apr 1, 2025 at 8:48 AM
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  4. Midnattsol

    Midnattsol Moderator Staff Member

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    Wanting to believe in the treatment?
     
    Midnattsol, Apr 1, 2025 at 10:18 AM
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  5. Utsikt

    Utsikt Senior Member (Voting Rights)

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    The researchers were blinded. If the researchers guess that everyone received the treatment, they would get 50 % right.

    So something must have made them guess wrong a lot of times.
     
    Utsikt, Apr 1, 2025 at 10:43 AM
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  6. Midnattsol

    Midnattsol Moderator Staff Member

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    I meant believing in the treatment is one such thing that can make you guess wrong. When you look at the data you might guess the patients that does "well" are in the treatment group and those that do "poor" in the control.
     
    Midnattsol, Apr 1, 2025 at 10:51 AM
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  7. rvallee

    rvallee Senior Member (Voting Rights)

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    Well, they could always look at what the US is doing and just shut down entire health departments. If you don't have clinics, if no one can see a doctor, they can save a lot of money if all you count is direct health care expenses.

    The cheapest health care regions in the world can be found in the health care deserts of the US, where no one can see a physician because there aren't any, and sometimes they have those tent festivals where people maybe get to have a tooth extracted, or whatever.

    It doesn't actually save anything, but it can seem like it does. Like not paying your rent. As long as no one actually counts or cares. After all, tariffs are basically tax cuts when you don't think about it. Same idea, really.

    Also: stop medical tests. All of them. If you don't know what the problem is, then you won't have to spend money trying to fix it. Money saved, easy peasy. It's so simple that a fool could think of it. Only a fool would actually believe it, though. But you just label that biopsychosocial and it all becomes smart and so on.
     
    rvallee, Apr 1, 2025 at 4:53 PM
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