Doing Realist Research by unknow

Doing Realist Research by unknow

Author:unknow
Language: eng
Format: epub
Tags: Nonfiction, Social & Cultural Studies, Social Science, Methodology, Reference & Language, Reference, Research
ISBN: 9781526451699
Publisher: SAGE Publications
Published: 2018-06-18T04:00:00+00:00


Cost-effectiveness by tailoring care – evidence and key contexts

In two of the evaluations of shared care for mental health in the United States, better tailoring of care to needs was an explicit aim of shared care (Rost et al., 2005; von Korff et al., 1998). In Rost et al. this was expressed more as what could be called ‘temporal tailoring’; more regular scheduled contact with patients was primarily to encourage ‘continued treatment adherence when symptoms were resolving, to adjust treatment if symptoms were not resolving, and to terminate treatment which patients in remission did not require’ (p. 8). These studies suggested this was especially important for the effective treatment of people with depression.

In von Korff et al., the expression of tailoring was less explicit and (in the care model aims) more couched in the terms of ‘improved management’ (von Korff et al., 1998). However, there was also evidence of a care-tailoring mechanism at work: ‘Collaborative Care patients were more likely to be switched to new medications, often a selective serotonin reuptake inhibitor [SSRI], as their care progressed because of the closer follow-up that Collaborative Care patients received’ (p. 145). So, in this case (assuming the previous medications were older, cheaper and less effective than SSRIs) tailoring could be viewed as ‘tailoring up’.

The potential patient benefits of tailoring could be limited or non-existent if the actual range of treatments or levels of treatment were not available. For example, in the Pyne et al. study, treatment tailoring was limited to altering medication, without any opportunities for offering psychological or counselling-based therapies (for which there are known patient preferences). Also, in the same study, the authors believed that the effectiveness of the stepped collaborative care model was limited because it did not tackle common co-morbidities of depression (such as pain, anxiety and substance abuse) (Pyne et al., 2010: 819).

In some studies there was some data on the measures of variance (e.g. standard error/deviation) for numbers of visits or other units of service use. Wider variances might provide indirect support that shared care is leading to more tailoring – that is, perhaps under shared care the same patient group shows wider variation in their service usage rates (implying that either some are getting more or some are getting less than under usual alternative care). Other, more direct, evidence of tailoring would come from documenting the frequency of treatment changes, or changes in the pattern of follow-up monitoring. Whether driven by clinical considerations or by patient preferences, better tailoring to need seems to be a well-recognised mechanism of many models of health care improvement. However, better tailoring of care to need can only, by definition, be as cost-effective as the specific treatments and monitoring strategies that people get at each ‘level’ of care provided.



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