A cost effectiveness analysis within a randomised controlled trial of post-acute care of older people in a community hospitalBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38887.558576.7C (Published 27 July 2006) Cite this as: BMJ 2006;333:228
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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
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-
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
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
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;
10 Torrance GW. Measurement of health state utilities for economic
appraisal: a review. J Health Econ 1985; 5:1-30.
Competing interests: No competing interests