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Rapid Responses: Rapid Responses published:
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Economic analysis of patient information systems
- Ray Jones, Neil Craig (31 January 2000)
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Assessment of informed decision making
- Eleri Williams, Andrew Parker, James Stoddard, Simon Bomken, Vikram Prabhu (4 February 2000)
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Ray Jones, Senior Lecturer in Health Informatics, Lecturer in Health Economics University of Glasgow, Neil Craig
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Editor, Wendy Graham and colleagues (15th January) compared a touchscreen system with leaflets for providing women with information on prenatal tests(1). Both Graham, and Wyatt in his commentary (2), may be too conservative in their conclusions from this study. Graham mentions the cost of developing the system in the discussion and Wyatt says that 'With limited evidence of benefit for these expensive tools over well designed leaflets…..use only in the context of rigorous research studies'. However, the study did not include an economic comparison between use of the computer and use of leaflets. A full economic analysis would compare both the estimated development costs of £25,000 and the subsequent maintenance costs, with the development and maintenance costs of the alternative. It would then compare the costs with the marginal benefits over the period in which the system is in use. If the system is readily transferable to another site, development costs at that other site would not be anywhere near £25000. Given the high volume of use that could be achieved in antenatal care, the cost per patient could be small. For example, use of a computer with touchscreen and printer costing £2000 capital with 5% maintenance in years 2-4 might have a four year cost (without discounting) of £2600. Aberdeen Maternity Hospital had 4734 deliveries in 1997 (1), a mean of 13/day. If over 4 years, 10,000 women (53%) used the system, the attributable cost per woman is 26 pence. This may compare favourably with the cost of leaflets. In our own study amongst patients with cancer (3), the cost of maintaining (and replacing after four years) a computer system was cheaper than giving full access to the expensive (typically £3.00) cancer booklets. Although Graham and colleagues found no difference in knowledge they did note a reduction in anxiety in the intervention group. Is the possible reduction in anxiety worth 26 pence per woman? The marginal benefits are attenuated by the fact that, as Graham and Wyatt point out, this group within the Aberdeen population had a good baseline knowledge of prenatal tests so that only minor improvements in knowledge may be achievable in that context. Fifty-five percent of their sample came from affluent areas (deprivation categories 1 and 2). Evaluation of the system in an area of high deprivation, where multimedia may have benefits over the written word amongst a population with lower literacy and knowledge levels, may show different outcomes. Further evaluation, including economic analysis, of use of the system in a area with higher levels of deprivation is certainly worthwhile and would also demonstrate the feasibility of 'technology transfer' for such systems. However, a simple economic costing exercise completed now, may show that Wyatt is wrong, and the system should continue in routine use in Aberdeen. Yours sincerely, Ray Jones, Senior Lecturer in Health Informatics
References 1. Graham W, Smith P, Kamal A, Fitzmaurice A, Smith N, Hamilton N. Randomised controlled trial comparing effectiveness of touch screen system with leaflet for providing women with information on prenatal tests. BMJ 2000;320:155-160. 2. Wyatt J. Commentary: Evaluating electronic consumer health material. 3. Jones R, Pearson J, McGregor S, Cawsey AJ, Barrett A, Craig N, et al. Randomised trial of personalised computer based information for cancer patients. BMJ 1999; 319:1241-1247. |
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Eleri Williams, Third Year Medical Students Department of Epidemiology & Public Health, The Medical School, University of Newcastle, Andrew Parker, James Stoddard, Simon Bomken, Vikram Prabhu
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Editor, Wendy Graham and colleagues (15th January) compared a touch screen system with information leaflets for providing prenatal screening test information to women(1). We acknowledge the role of multimedia technology in conveying information and its potential application in this particular situation. However, we feel that the outcome measures applied did not address the women's ability to make an informed decision on prenatal testing. We question whether uptake of a prenatal test is a reliable indicator of informed decision making. It discounts the possibility that informed women may decide not to undergo testing for reasons other than a lack of understanding of the procedures. We believe that assessing the women's reasons for taking or not taking a test would be a more effective way of gauging their understanding. A further concern is that the questionnaire used appears only to assess knowledge of the purpose of the tests and not understanding of the risks and benefits of a procedure. It would seem more appropriate to assess the women's understanding of the likelihood of complications. We recognise the value of this research but would like to see broader definition of informed decision making. 1. Graham, W., Smith, P., Kamal, A. et al. Randomised controlled trial comparing the effectiveness of touch screen system with leaflet for providing women with information on prenatal tests. |
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