The Back to Life Project - Evaluering og forandring af en kompleks intervention

Abstract

Titel: The Back to Life Project – Evaluering og forandring af en kompleks intervention Baggrund: The Back to Life Project (BTL) er et rehabiliteringstilbud til personer med funktionsnedsættelse som følge af en ulykke eller sygdom. BTL søger at tilbyde et rehabiliteringsforløb, der er bedre og mere helhedsorienteret, end hvad der tilbydes i kommunen. For at kunne tilbyde en helhedsorienteret rehabiliteringsindsats til så mange som muligt, ønsker folkene bag BTL mere finansiering og udbredelse. På nuværende tidspunkt er evidens for tilbuddet usikkert, hvilket kan være en barriere for en fremtidig kommunal finansiering. Formål: Formålet med indeværende speciale er at evaluere BTL, mhp. at analysere om BTL er en effektiv og omkostningseffektiv tilgang til rehabilitering. På baggrund af den usikre evidens for interventionen stilles et udviklingsforslag for øget dokumentering af BTL’s rehabiliteringstilbud, der bedre belyser tilgangens effekter og omkostninger og på sigt muliggør en mere sikker evaluering af indsatsen. Metode: Dette speciale tager udgangspunkt i MRC-modellen for evaluering af komplekse interventioner og anvender en kombination af systematisk litteratursøgning og sundhedsøkonomisk metode. Den systematiske litteratursøgning bidrager med en effektevaluering af de centrale elementer i tilbuddet. For at beskrive omkostninger forbundet med BTL, og for at vurdere om tilgangen er et omkostningseffektivt alternativ til rehabilitering af ulykkesramte sammenlignet med kommunal praksis, anvendes en cost-minimization analyse og en tærskelværdi-analyse. For at imødekomme den usikre evidens fra de to evalueringer, anvendes en Context-Mechanism-Outcome (CMO) tilgang til at kortlægge de vigtigste mekanismer i interventionen, hvilket fører til udviklingsforslag om øget dokumentation af interventionen. Resultater: Litteratursøgningen finder en begrænset mængde evidens, der indikerer at rehabiliteringstilgangen i BTL har sammenlignelig eller bedre effekt end konventionelle alternativer. Den sundhedsøkonomiske evaluering finder, at et rehabiliteringsforløb i BTL er 5.881 kroner dyrere end hos kommunen, hvorfor BTL skal opnå en inkrementel effekt på 0,024 QALY per deltager for at være et omkostningseffektivt alternativ. For at fastslå om den effekt er tilstede, stiller indeværende speciale et udviklingsforslag bestående af øget dokumentation, i form af: A) EQ-5D-3L spørgeskema og øget dokumentation af omkostninger og B) ICF spørgeskema til muskuloskeletale sygdomme. Konklusion: Den nuværende evidens er ikke tilstrækkelig til at anbefale finansiering og udbredelse af BTL. Dette kan potentielt adresseres gennem øget dokumentation vha. ICF og EQ-5D-3L spørgeskemaerne.

Title: The Back to Life Project – Evaluating and changing a complex intervention Background: The Back to Life Project (BTL) is a small enterprise offering free rehabilitation services to persons with reduced level of functioning as a consequence of accident or disease. BTL aims to offer a better and more comprehensive rehabilitation service than what is currently provided by the Danish municipalities. To increase the availability of the service to a larger demographic, BTL is looking to secure stable funding. Currently the evidence for the BTL approach to rehabilitation is lacking which could be a barrier to further funding. Aims: The aim of this thesis is to evaluate the effectiveness and cost-effectiveness of the BTL rehabilitation service. Due to uncertainty in the investigated evidence, we propose that BTL increase the level of documentation, to facilitate further documentations of costs and effects. This would furthermore be beneficial to subsequent evaluations. Methods: This thesis is based on the MRC approach to developing and evaluating complex interventions. The use of a systematic review of literature and a health economic evaluation, is included in this thesis. The systematic review of literature contributes with evidence concerning the central elements of BTL. In order to investigate costs attributed to BTL and furthermore assess whether the intervention is a cost-effective alternative to the rehabilitation of individuals with reduced functioning, a cost-minimization and threshold analysis is used. To accommodate the uncertainty of the evidence underlying the two evaluations, a Context-Mechanism-Outcome approach is employed to investigate the most important mechanisms of the intervention, which ultimately results in a proposal to increase documentation within BTL. Results: The review of literature finds limited evidence to indicate that the BTL approach is equal to or more beneficial than conventional approaches to rehabilitation. The health economic evaluation finds that the incremental costs per participant in BTL amounts to 5.881 DKK. As a result, BTL needs to produce an incremental effect of 0,024 QALY per participant to be considered cost-effective at a willingness-to-pay threshold of 250.000 DKK/QALY. As the true incremental effects of BTL has not been established, this thesis proposes to increase the level of documentation in BTL using A) the EQ-5D-3L health questionnaire alongside increased documentation of costs, and B) the ICF-classification coreset for musculoskeletal disease. Conclusion: At present there is insufficient evidence to recommend public funding and expansion of BTL, however increased documentation, using the ICF-classification and the EQ-5D-3L health questionnaire, might assist in addressing this issue.

A master thesis from Aalborg University

The Back to Life Project - Evaluering og forandring af en kompleks intervention

[The Back to Life Project - Evaluating and changing a complex intervention]