Health economic evaluation of digital nursing technologies: a review of methodological recommendations.

BACKGROUND: Health economic evaluation of digital nursing technologies (DNT) is important to provide information that helps avoid undesirable developments and implementations as well as increase the chances of success of developed applications. At the same time, studies and evidence on cost-effectiveness are still very rare in this field. Review studies in related technology areas such as telemedicine frequently criticise the quality and comparability of health economic evaluations conducted in this field. Based on a content analysis of methodological literature on the economic evaluation of innovative (digital) technologies in health and nursing, this article aims to identify specific challenges in this research area and offers recommendations on how to address these challenges to promote more sound health economic evaluations in the future. METHODS: A rapid review was conducted, consisting of a systematic search in the Pubmed database as well as Google Scholar. In addition, the literature lists of the analysed texts were scoured for additional texts to be included. Methodological literature, single studies, and reviews were included. A total of 536 studies were screened, of which 29 were included in the full text analysis. RESULTS: Based on the systematic content analysis of the studies under consideration, 10 specific methodological challenges are identified, and the methodological recommendations were examined for consideration. A particular focus was given to whether specific methodological approaches might be needed in the context of evaluating the efficiency of DNT. CONCLUSION: Many of the challenges identified for the health economic evaluations of digital nursing technologies are comparable to those of other complex health care interventions. The recommendations discussed can help to alleviate those challenges. Future research should focus on alternative approaches to assessing causality in different phases of technology development while maintaining high evidence standards. High-evidence economic assessment of technologies in nursing care should be carried out in routine use, especially if they are intended to be reimbursed by the social insurance.

Effectiveness of Digital Technologies to Support Nursing Care: Results of a Scoping Review.

BACKGROUND: The field of digital technologies being developed or applied to support nursing care is extensive. The aim of this scoping review is to provide an overview on technologies for which results on positive or negative effects on persons in need of care, caregivers or care institutions are available and to appraise the reliability of these results. METHODS: A scoping review design has been used to identify studies focussing on the effectiveness of digital technologies in nursing care for persons in need of care, caregivers or care institutions. The screening process included 19,510 scientific publications from 9 databases. RESULTS: A total of 123 single studies and 31 reviews were subjected to the analysis. The included technologies comprise nursing and health information technologies, such as assistive devices, information and communication technologies, sensors and robotics. The results show that there are many studies that demonstrate positive effects, but the level of evidence is mostly low and study sizes are often small. Hardly any technology has been researched intensively enough to produce conclusive results. Studies on a high level of evidence (RCTs) lack for most technological areas. Heterogeneous results in some areas indicate that effects may depend strongly on the mode and specific context into which the technologies are introduced. CONCLUSION: Due to the limited evidence on effectiveness of digital technologies in nursing care, it is not surprising that care institutions are reluctant to put innovative technologies into practice. The scoping review indicates technology areas that should be subject to future research with higher quality studies. Research on outpatient, informal and cross-sectoral care should be intensified to further exploit the potential of digital technologies with a view to improving independence of care-recipients and unburdening formal and informal carers.

Application of digital technologies in nursing practice: Results of a mixed methods study on nurses' experiences, needs and perspectives.

INTRODUCTION: Even though the importance of nurses' participation in the process of technology development is frequently stressed by stakeholders, participation has been described as negligible and limited by nurses' abilities to identify and communicate their needs and ideas for application scenarios or the improvement of digital nursing technologies (DNT) in everyday care practice. Prior research often uses hypothetical scenarios or laboratory settings with little real-world relevance, and the number of studies investigating needs for technology development, application scenarios or requested technologies from the perspective of nurses with experience in technology use is exceedingly small. Against this background, this study aims to investigate needs, application scenarios and perspectives of nurses with practical experience in real-world DNT application in a range of different care settings. METHODS: An explanatory sequential mixed methods design including an online survey (QUANT) and focus group (FG) discussions (qual) was used to explore nurses' perspectives and experiences. A convenience sample of participants was accessed via 19,000 e-mail contacts of directors of nursing (DONs) in care facilities and hospitals throughout Germany. Preliminary results of the online survey were discussed and elaborated in depth in three FGs. Quantitative results of the online survey were included in the development of the interview guideline for and data collection from the FGs. Descriptive, setting-specific analysis was conducted for quantitative data, and qualitative data was analysed by identifying key aspects. RESULTS: A total of 1,335 participants took part in the online survey, most of whom worked in ambulatory care institutions and held management positions such as DON or team leader. There were 14 FG participants. Ninety-five per cent of the participants of the online survey reported having experience in the use of DNT, predominantly with information and communication technologies (ICT). Overall, DNT were deemed to make work easier, and participants concurred on other positive effects such as increased efficiency or saved time and improved quality of care. Negative effects or concerns were reported less frequently. Reasons for non-adoption included technology-related (e.g. usability, functionality) and non-technology-related (e.g. competencies and context factors) issues, and facilitators for adoption were discussed in the FGs. Key aspects of application scenarios were enhanced technological support of direct nursing care tasks to reduce physical burden and mental stressors. Specifically, participants of the FGs expressed their wish for participative development and a general openness for nurses to be included in the development and testing of digital technologies. DISCUSSION AND CONCLUSION: Although efforts in development, research and theory-building have been increasing over recent years, DNT that go beyond more traditional or common applications within the ICT category (such as electronic nursing records or process planning) are rare. There are already technologies available for many of the expressed needs for which, however, adoption fails or does not happen. The reported barriers and facilitators indicate issues that should be taken into account when developing DNT for application in nursing practice. The study reveals a distinct need for information, counselling, facilitation and organizational development, and brings to light broad opportunities for the collaborative development of guided DNT implementation and evaluation processes. Future development and research activities should preferably be conducted by interdisciplinary research groups.

[Equity in the health economic evaluation of public health: An overview]. / Gerechtigkeit in der gesundheitsökonomischen Evaluation von Public Health ­ Überblicksartikel.

AIM: Starting from the claim that public health interventions should aim to improve health equity, the article examines which methodological approaches of health economic evaluation exist to support the analysis of equity-related outcomes of different interventions. METHOD: Critical review of the relevant literature. RESULTS: Against the background of the normative foundations of health economic evaluation, three methodological approaches and three practical methods are presented that allow for considering health equity concerns in health economic evaluations. Implications of the different approaches and references to the German context are discussed. CONCLUSION: The use of the instruments presented offers good potential to improve transparency with respect to distributive effects of different allocation decisions. This appears to be necessary in order to meet demands for health equity improving public health interventions - especially in the context of the German Prevention Act.

Measuring the effectiveness of digital nursing technologies: development of a comprehensive digital nursing technology outcome framework based on a scoping review.

BACKGROUND: Digital nursing technologies (DNT) comprise an expanding, highly diverse field of research, explored using a wide variety of methods and tools. Study results are therefore difficult to compare, which raises the question how effectiveness of DNT can be adequately measured. Methods currently used might not be sufficient for certain specific nursing contexts. A comprehensive outcome framework that shows the multitude of possible outcome areas could be useful to generate more comparable results. The aim of the present study is to develop an outcome framework for DNT and to indicate which outcome areas have been most frequently evaluated in previous studies and how this has been done. METHODS: We combined an inductive and deductive approach to develop the framework. The numerical analysis is based on a scoping review focussing on the effectiveness of DNT for persons in need of care, formal or informal caregivers or care institutions. Nine databases were included in the screening: Medline, Scopus, CINAHL, Cochrane Library, ACM Digital Library, IEEE Xplore, the Collection of Computer Science Bibliographies, GeroLit and CareLit. Additional literature searches and expert interviews were included. RESULTS: The developed framework comprises four outcome target groups and 47 outcome areas. There are considerable differences in the researched outcome areas for the individual outcome target groups. Persons in need of care were by far the most frequently surveyed, particularly with respect to their psychological health. There are much fewer studies on formal and informal caregivers, and it is particularly noticeable that the quality of life of both groups has rarely been investigated. Care process quality was most frequently researched for organisations. CONCLUSION: We were able to provide a comprehensive DNT outcome framework, thereby identifying the outcome tools used and the less researched outcome areas. We recommend a detailed investigation of all areas and tools in future research projects with a view to initiating a discussion on the differing importance of existing outcome areas and on a standardisation of outcome tools. We also recommend the development of outcome areas for the macro level of effectiveness assessment.

Digital technology and nursing care: a scoping review on acceptance, effectiveness and efficiency studies of informal and formal care technologies.

BACKGROUND: The existence, usage and benefits of digital technologies in nursing care are relevant topics in the light of the current discussion on technologies as possible solutions to problems such as the shortage of skilled workers and the increasing demand for long-term care. A lack of good empirical overviews of existing technologies in the present literature prompted us to conduct this review. Its purpose was to map the field of digital technologies for informal and formal care that have already been explored in terms of acceptance, effectiveness and efficiency (AEE), and to show the scope of the used methods, target settings, target groups and fields of support. METHODS: A systematic literature search was conducted using Medline, Scopus, CINAHL, Cochrane Library, ACM Digital Library, IEEE Xplore, the Collection of Computer Science Bibliographies, GeroLit and CareLit. In addition, project websites were manually screened for relevant publications. RESULTS: Seven hundred fifteen papers were included in the review. Effectiveness studies have been most frequently performed for ICT, robots and sensors. Acceptance studies often focussed on ICT, robots and EHR/EMR. Efficiency studies were generally rare. Many studies were found to have a low level of evidence. Experimental designs with small numbers and without control groups were the most common methods used to evaluate acceptance and effectiveness. Study designs with high evidence levels were most commonly found for ICT, robots and e-learning. Technologies evaluated for informal caregivers and children or indicated for formal care at home or in cross-sectoral care were rare. CONCLUSION: We recommend producing high-quality evaluations on existing digital technologies for AEE in real-life settings rather than systematic reviews with low-quality studies. More focus should be placed on research into efficiency. Future research should be devoted to a closer examination of the applied AEE evaluation methods. Policymakers should provide funding to enable large-scale, long-term evaluations of technologies in the practice of care, filling the research gaps for technologies, target settings and target groups identified in this review.

Economic evaluation of health promotion interventions for older people: do applied economic studies meet the methodological challenges?

BACKGROUND: In the light of demographic developments health promotion interventions for older people are gaining importance. In addition to methodological challenges arising from the economic evaluation of health promotion interventions in general, there are specific methodological problems for the particular target group of older people. There are especially four main methodological challenges that are discussed in the literature. They concern measurement and valuation of informal caregiving, accounting for productivity costs, effects of unrelated cost in added life years and the inclusion of 'beyond-health' benefits. This paper focuses on the question whether and to what extent specific methodological requirements are actually met in applied health economic evaluations. METHODS: Following a systematic review of pertinent health economic evaluations, the included studies are analysed on the basis of four assessment criteria that are derived from methodological debates on the economic evaluation of health promotion interventions in general and economic evaluations targeting older people in particular. RESULTS: Of the 37 studies included in the systematic review, only very few include cost and outcome categories discussed as being of specific relevance to the assessment of health promotion interventions for older people. The few studies that consider these aspects use very heterogeneous methods, thus there is no common methodological standard. CONCLUSION: There is a strong need for the development of guidelines to achieve better comparability and to include cost categories and outcomes that are relevant for older people. Disregarding these methodological obstacles could implicitly lead to discrimination against the elderly in terms of health promotion and disease prevention and, hence, an age-based rationing of public health care.

Economic evaluation of health promotion and primary prevention actions for older people-a systematic review.

Background: Healthy ageing and health promotion (HP) actions for older people have become an important health sector priority. At the same time, the application of economic evaluation methods in the field of health interventions in order to support allocative decision processes is of growing importance. The aims of the review were to analyze what the existing evidence is on cost-effectiveness of HP and/or primary prevention (PP) programmes for older people whilst providing deeper insight into methodological aspects of such studies, their overall quality and issues related to practical implementation of results. Methods: Systematic review of contemporary evidence (2000-15). Studies' eligibility criteria included target population 65 years old or older; interventions classified as HP or PP; a full economic evaluation conducted. The search strategy included five electronic databases and Internet websites of institutions or projects related to the topic. Quality assessment of the studies was based on the 'Drummond checklist'. Results: After screening 6450 records, 29 papers were included, the vast majority of which (22) focus on fall prevention strategies. In this area, there are examples of good and moderate quality studies which confirm the cost-effectiveness of diverse physical activity interventions in fall prevention. The existing studies are characterized by huge differences in the methods applied as well as overall quality which limits the comparability and generalizability of the results. Conclusions: There is a need for development and implementation of economically driven studies, with methods adjusted to particular character of HP and/or PP strategies for older population.

Economic evaluation of health promotion for older people-methodological problems and challenges.

BACKGROUND: The support of health promotion activities for older people gains societal relevance in terms of enhancing the health and well-being of older people with a view to the efficient use of financial resources in the healthcare sector. Health economic evaluations have become an important instrument to support decision-making processes in many countries. Sound evidence on the cost-effectiveness of health promotion activities would encourage support for the implementation of health promotion activities for older people. This debate article discusses to what extent economic evaluation techniques are appropriate to support decision makers in the allocation of resources regarding health promotion activities for older people. We address the problem that the economic evaluation of these interventions is hampered by methodological obstacles that limit comparability, e.g. with economic evaluations of curative measures. Our central objective is to describe and discuss the specific problems and challenges entailed in the economic evaluation of health promotion activities especially for older people with regard to their usefulness for informing decision making processes. DISCUSSION: Beyond general problems concerning the economic evaluation of health promotion, our discussion focusses on problems that pertain to the analysis of cost and outcomes of health promotion interventions for older people. With regard to costs these are general problems of economic evaluations, namely the actual implementation of a societal perspective, the appropriate measurement and valuation of informal caregiver time, the measurement and valuation of productivity costs and costs incurred in added years of life. The main problems concerning the identification and measurement of outcomes are related to the identification of outcome parameters that, firstly, adequately reflect the broad effects of health promotion interventions, especially social benefits that gain importance for older people, and secondly, ensure a comparability of effects across different age groups. In particular, the limitations of the widely used QALY for older people are discussed and recently developed alternatives are presented. CONCLUSIONS: The key conclusion of the article is that a comparison of the effects of different health promotion initiatives between different age groups by means of economic evaluation is not recommendable. Taking into account the complex outcomes of health promotion interventions it has to be accepted that the outcomes of these interventions will often not be comparable with clinical interventions and have to be assessed differently.

[Cardiovascular risk patients under androgen deprivation therapy: Lower risk with GnRH antagonists compared to LHRH agonists?]. / Kardiovaskuläre Risikopatienten unter Androgenentzugstherapie : Geringeres Risiko mit GnRH-Antagonisten im Vergleich zu LHRH-Agonisten?

BACKGROUND: Androgen deprivation therapy (ADT) with gonadotropin-releasing hormone (GnRH) agonists or GnRH antagonists is the mainstay of treatment for metastatic prostate cancer (mCaP). However, ADT is associated with serious cardiovascular events. Only a few studies that directly compare the cardiovascular risk of LHRH agonists versus GnRH antagonists have been published. OBJECTIVES: This review aims to compare the cardiovascular risk of LHRH agonists versus GnRH antagonists based on the literature. METHODS: A literature search that considered full publications and abstracts published before December 10, 2014 was performed. Due to their high evidence quality, only meta-analyses and pooled studies were included in this review. RESULTS: Four studies were included. These investigated the cardiovascular risk of patients receiving an ADT with LHRH agonists and/or GnRH antagonists. However, only one of these directly compared the cardiovascular risk of ADT with LHRH agonists versus GnRH antagonists. This meta-analysis showed a significant reduction in cardiovascular risk for patients receiving a GnRH antagonist compared to those patients receiving a LHRH agonist (HR: 0.597; 95 % CI: 0.380-0.938; P = 0.0253). Subgroup analyses showed that, in particular, patients with pre-existing cardiovascular diseases who were treated with a GnRH antagonist have a significantly lower risk of experiencing a cardiovascular event when compared with patients receiving a GnRH agonist (HR: 0.44; 95 % CI: 0.26-0.74; P = 0.002). CONCLUSION: In conclusion, GnRH antagonists are associated with a lower risk of cardiovascular events, compared with LHRH agonists, when administered as ADT in CaP patients, and particularly in patients with a history of cardiovascular disease. Thus, patients with a history of cardiovascular disease may benefit from ADT with a GnRH antagonist.