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RESEARCH: Jacqueline O'Reilly, Karin Lowson, John Young, Anne Forster, John Green, and Neil Small A cost effectiveness analysis within a randomised controlled trial of post-acute care of older people in a community hospital BMJ 2006; 333: 228 [Abstract] [Full text]

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Broad economic perspective and excluding informal care: contradiction in terms

Bernard Van den Berg   (30 July 2006)

Broad economic perspective and excluding informal care: contradiction in terms 30 July 2006
Bernard Van den Berg, Post Doctoral Research Fellow Centre for Health Economics Research and Evaluation UTS Australia (2007) Send response to journal: Re: Broad economic perspective and excluding informal care: contradiction in terms	E-mail: Bernard.vandenBerg@chere.uts.edu.au O’Reilly et al. claim in this journal that “a locality based community hospital is as cost effective as a district general hospital for post-acute care of older people.”1 The strength of their study is its randomised design with six months follow up and they claim also the chosen broad economic perspective of the whole system of health and social care costs. In the same breath, however, they write that they excluded informal care from their study. They seem to excuse themselves by referring another study that showed similar carer burden between the community hospital and control groups. The only valid reason to exclude informal care from a cost effectiveness analysis is the expectation or reasoning that carer costs are minor or do not differ between the comparators.2 It is suggested to include carers’ costs and effects in economic evaluations.3 They include time and financial costs. Time use should be measured preferably with a diary or alternatively with a recall method.4 Two methods are proposed to value carer time: opportunity cost method valuing time at the forgone wages of the carer; and proxy good method valuing carer time at the price of a professional.5 Excluding these costs as might bias reported cost- effectiveness ratios. Suggesting that exclusion of informal care is not a problem because carer burden did not differ between the community hospital and control groups is not a sufficient solution. Carer burden might be not sensitive to measure corresponding changes to be appropriate carer measures in cost effectiveness analyses.6 Van den Berg et al. discuss a wide range of alternative outcome measures in informal care.3 The use of different outcome measures for carers and care recipients might, however, involve interpretation problems in cost effectiveness analyses. Therefore, and because of the suspected lack of sensitivity of burden measures in economic evaluations alternative monetary valuation methods are proposed and empirically tested to value both carers’ costs and effects.7, 8, 9 Main advantage of these methods is that they can be included in the cost side of cost effectiveness analyses, just like the inclusion of productivity costs.10 Adopting a broad economic perspective and excluding informal care without presenting valid evidence that legitimates this exclusion is a contradiction in terms. Unfortunately, O’Reilly et al. do not present sufficient evidence to support their claim of a similar cost effective ratio of a locality based community hospital and a district general hospital for post-acute care of older people.1 1 O’Reilly J, Lowson K, Young J, Forster A, Green J, Small N. A cost effectiveness analysis within a randomised controlled trial of post-actute care of older people in a community hospital. BMJ 2006; in press. 2 Drummond MF, Sculpher MJ, Torrance GW, O’Brien BJ, Stoddart GJ. Methods for the Economic Evaluation of Health Care Programmes. Oxford: Oxford University Press 2004. 3 Van den Berg B, Brouwer WBF, Koopmanschap MA. Economic valuation of informal care: an overview of methods and applications. Eur J of Health Econ 2004; 5:36-45. 4 Van den Berg B, Spauwen P. Measurement of informal care: an empirical study into the valid measurement of time spent on informal caregiving. Health Econ 2006; 15:447-60. 5 Van den Berg B, Brouwer WBF, Koopmanschap MA, Van Exel JAJ, Van den Bos GAM, Rutten FFH. Economic valuation of informal care: Lessons from the application of the opportunity cost and proxy good methods. Social Science & Medicine 2006;62(4):835-845. 6 Drummond MF, Mohide EA, Tew M, Streiner DL, Pringle DM, Gilbert JR. Economic evaluation of a support program for caregivers of demented elderly. Int J Technol Assess Health Care 1991; 7: 209–19. 7 Van den Berg B, Brouwer WBF, Van Exel JAJ, Koopmanschap MA. Economic valuation of informal care: the contingent valuation method applied to informal caregiving. Health Econ 2005;14(2):169-183. 8 Van den Berg B, Bleichrodt H, Eeckhoudt L. The economic value of informal care: A study of informal caregivers’ and patients’ willingness to pay and willingness to accept for informal care. Health Econ 2005;14(4):363-76. 9 Van den Berg B, Al M, Brouwer W, Van Exel J, Koopmanschap, M. Economic valuation of informal care: The conjoint measurement method applied to informal caregiving. Social Science & Medicine 2005; 61(6):1342-55. 10 Torrance GW. Measurement of health state utilities for economic appraisal: a review. J Health Econ 1985; 5:1-30. Competing interests: None declared