Exploring Comparative Effectiveness and Efficiency in Long-term Care

To meet societal and economic challenges, health and care welfare regimes will need to become much more focused on the outcomes that matter to people and deliver these programmes effectively and efficiently. Central to this goal is the need to accurately measure outcomes and reflect the value of those outcomes. We propose a cross-country study to measure outcomes in the field of long-term care (LTC). We will use a care-related outcome tool, ASCOT, to assess the comparative effectiveness and efficiency of non-institutional LTC (e.g. home care) for older adults and their informal carers in Austria, England and Finland.

The study has four analytical workpackages (WPs) with these goals:

  • Establish a valid basis for international comparisons of LTC-outcomes in non-institutional settings, by developing rigorously translated and tested versions of ASCOT.
  • Generate country-specific ASCOT utility weights and explore variations in preferences for ASCOT quality of life domains across countries.
  • Explore variations in ASCOT quality of life (QoL) within and between countries, providing evidence on QoL-outcomes of services for service users and their carers.
  • Explore and compare the relative costs, efficiency and cost-effectiveness of specific LTC services. We will use econometric methods, combining estimates of the effect of services on QoL and service cost.

This study should strengthen the research base and help guide policy-makers and practitioners to make outcomes-focused, economically-sound decisions about LTC. It will also provide useful tools for future evaluations.

One of the applicants will lead each WP, supported by a country lead and team of researchers.

Project Summary

To meet societal and economic challenges, health and care welfare regimes need to become better at understanding how services affect people. There is a need to measure the outcomes of using services, especially in the extent to which they improve the health and quality of life of service users. We proposed a cross-country study to measure quality-of-life outcomes for long-term care (LTC), in particular, personal care in people’s own homes (‘home care’). Three countries were involved, each with a different LTC system: Austria, England and Finland.

The main objectives were:

  • To develop a new ‘outcomes tool’ in Austria and Finland to assess quality of life (as affected by LTC), in the form of a rigorously-tested questionnaire based on an existing English instrument.
  • To develop (for each country) a set of values based on people’s preferences for improvement in different aspects of their (LTC-related) quality of life. These are used to create a numerical ‘outcomes’ scale (called LTC-Qol).
  • Use this outcomes scale to systematically compare the effects of LTC between different people and different care systems.

We found that it was possible to develop the outcomes tool in different languages, but with a consistent underlying meaning.

With regard to people’s relative valuation (preferences), we found that:

  • People in different countries were relatively consistent about the value they placed on aspects of LTC-QoL for service users. For example, people valued improvements in control and occupation more highly that improvements in personal cleanliness and safety.
  • Relative valuations varied according to personal characteristics e.g. age and education.

The LTC-related quality of life of carers was also measured and valued – for example, the most valued aspect by English participants was the occupation attribute at its highest level (‘I’m able to spend my time as I want, doing things I value or enjoy’). Results further showed participants rated having ‘no control over their daily life’ as the least valued outcome.

We also measured the LTC-QoL of a sample of people using home care services and found that LTC-QoL varies between countries and is affected by service user’s characteristics e.g. prior disability, social capital (living circumstances) and financial means. For example, gains in LTC-QoL were lowest in Austria on average when comparing on a like-for-like basis (factoring out personal characteristics). Some characteristics (e.g. degree of impairment) influenced LTC-QoL gain in all countries, whereas other (e.g. people’s living arrangements) only affected people in particular countries. For informal carers, we found that those in Finland reported lower LTC-QoL than carers with the same characteristics in other countries when unweighted LTC-QoL measure was applied. However, this difference vanished when the preference-weighted LTC-QoL measure was applied.

This study should add to our knowledge and help decisions about LTC to become more ‘outcomes-focused’. It provides a means to systematically measure and compare the impact of LTC services, using a fully-tested indicator – which can be used by LTC professionals, policy-makers and researchers for assessment of LTC outcomes in the population, for monitoring of service impact, and for evaluation.