Economic evaluations of community-based care: lessons from twelve studies in Ontario

A series of 12 studies (five historic cohort and seven randomized trials) e xamined clients in community settings in Southern Ontario suffering from a variety of chronic physical and mental health conditions. These studies are appraised using a framework for evaluating possible outcomes of economic e valuation. In the 12 studies, sample composition and size varied. Each stud y was designed to quantify the well-being outcomes and expenditures associa ted with different community-based approaches to care provided in the conte xt of a system of national health insurance. As a collective, these studies represent increasing methodological rigour. Multiple-perspective client we ll-being outcome measures were used. In two studies, caregiver burden also was analysed. A common approach to quantification and evaluation of expendi tures for service consumption was used in all 12 studies. The nature of com munity-based health services (health vs. disease care orientation) was foun d to have direct and measurable impact on total expenditures for health ser vice utilization and client well-being outcomes. In most cases, a recurring pattern of equal or better client outcomes, yet lower expenditures for use of community based health services, was associated with well-integrated he alth oriented services. Integrated services aimed at factors which determin e health are superior when compared to individual, fragmented, disease orie nted, and focused approaches to care, The main lessons from the 12 studies are that it is as or more effective and as or less expensive to offer compl ete, proactive, community health services to persons living with chronic ci rcumstance than to provide focused, on-demand, piecemeal services. Complete services would have a psychosocial and mental health focus included with t he physical care approach. Furthermore, people with coexisting risk factors (age, living arrangements, mental distress and problem-solving ability) ar e the ones who most benefit at lower expense from health oriented, proactiv e interventions.