http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(4): 292–298 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2013.874983
RESEARCH ARTICLE
Interprofessional student clinics: an economic evaluation of collaborative clinical placement education Terry P. Haines1, Fiona Kent2,3 and Jennifer L. Keating4 1
Allied Health Research Unit, Southern Health, Melbourne, Australia, 2HealthPEER, Monash University, Clayton, Australia, 3Department of Physiotherapy, Peninsula Health, Frankston, Australia, and 4Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Australia Abstract
Keywords
Interprofessional student clinics can be used to create clinical education placements for health professional students in addition to traditional hospital-based placements and present an opportunity to provide interprofessional learning experiences in a clinical context. To date, little consideration has been given in research literature as to whether such clinics are economically viable for a university to run. We conducted an economic evaluation based upon data generated during a pilot of an interprofessional student clinic based in Australia. Costminimization analyses of the student clinic as opposed to traditional profession-specific clinical education in hospitals were conducted from university, Commonwealth Government, state government and societal perspectives. Cost data gathered during the pilot study and market prices were used where available, while $AUD currency at 2011 values were used. Per student day of clinical education, the student clinic cost an additional $289, whereas the state government saved $49 and the Commonwealth Government saved $66. Overall, society paid an additional $175 per student day of clinical education using the student clinic as opposed to conventional hospital-based placements, indicating that traditional hospital-based placements are a cost-minimizing approach overall for providing clinical education. Although interprofessional student clinics have reported positive patient and student learning outcomes, further research is required to determine if these benefits can justify the additional cost of this model of education. Considerations for clinic sustainability are proposed.
Economic analysis, evaluation research, interprofessional education, interprofessional evaluation
Introduction The purpose of clinical education is to provide opportunities for students to attain competence at the level of an entry-level practitioner. In workplace practice, students integrate knowledge and skills at progressively higher levels of performance and responsibility under the guidance of qualified practitioners (Lekkas et al., 2007). Ageing populations, coupled with higher expectations for health care services, are creating greater demands for health professionals. However, the availability of placements in a clinical education environment to train increasing numbers of health professionals is finite, and at capacity in some countries (Barnett et al., 2008; Dahlenburg, 2006; Devey, 2005; Leners, Sitzman, & Hessler, 2006; Prideaux, 2009; Thistlethwaite, Kidd, & Hudson, 2007). Strategies to address this impending shortfall have been proposed. One approach has been to offer forms of clinical education that differ from traditional models. For example, simulation-based approaches using high fidelity mannequins and standardised patients (actors) have been proposed and have been shown to produce student learning outcomes that do not differ significantly from outcomes associated with traditional clinical education models (Watson et al., 2012). However, the relative Correspondence: Terry P. Haines, Allied Health Research Unit, Southern Health, Melbourne, Australia. E-mail: [email protected]
History Received 2 May 2013 Revised 17 September 2013 Accepted 6 December 2013 Published online 13 January 2014
cost-effectiveness and longer term viability of these alternatives is not yet clear. Another approach that is receiving growing attention is for student clinics to be established with the primary purpose of providing interprofessional clinical education opportunities for students (Berman et al., 2012; Dubouloz, Savard, Burnett, & Guitard, 2010; Holmqvist, Courtney, Meili, & Dick, 2012; Meah, Smith, & Thomas, 2009). There are several potential educational advantages of clinics of this nature. First, strategies that address specific learning targets may be more easily incorporated in a purpose-designed student clinic than in a typical health care setting due to the ability to select patients within particular diagnostic groupings. Second, there is also the potential to strategically incorporate specific learning elements such as interprofessional education within a student clinic. Recent reports of interprofessional student clinics have been promising, suggesting student participation may contribute to community service learning, an awareness of the roles of others, and positive patient outcomes (Holmqvist et al., 2012; Kent, Drysdale, Martin, & Keating, in press; Kent & Keating, 2013). However, the financial sustainability of these initiatives remains a concern for those involved. Furthermore, there has been a recent call for the economic analysis of interprofessional education initiatives (Reeves, 2010). This study aims to investigate the costeffectiveness of such a clinic based on a pilot clinic operating in Melbourne, Victoria in 2011–2012.
DOI: 10.3109/13561820.2013.874983
Background The Australian health care context comprises a mixture of public and privately provided services. All Australian citizens and permanent residents of Australia are entitled to free public hospital cover (Department of Human Services, 2012). Public hospitals are mostly run by state health departments, though in some states are run by independent boards. They receive funding from the Commonwealth and state governments. Medicare is the name given to Australia’s publicly funded healthcare system since 1984. The Commonwealth Government through the Medicare Benefits Schedule subsidizes primary health care services, with coverage extending over the past decade from services offered by general practitioners to those offered by other health providers and nurses working in primary care (Haines et al., 2010). The Commonwealth Government also fund community health services and other services that complement primary health care services. The Australian tertiary education system is also comprised of a mixture of public and private institutions (Bradley, 2008). University funding is provided through the Commonwealth Government and/ or student contributions, though most universities are established or recognised under State and Territory legislation. Many students contribute to their education by accruing debts paid off in low interest government loans through the Higher Education Loan Programme. The Commonwealth Government subsidizes many placements for Australians, though others (most postgraduate and international places) are paid for in full by students. University and health care systems interact inconsistently between states at present. There are also payments made directly from universities to hospitals for health professional education, though this has tended to occur by private negotiation between hospital departments and universities rather than through federal or state-based regulation leading to payment variations across hospitals, universities and professionals. The multi-stakeholder structure of clinical education in the Australian context complicates the economic evaluation of different clinical education models. Restricting the scope of an evaluation to a single stakeholder perspective is likely to result in important impacts on other stakeholders being missed. In Australia, stakeholder perspectives of patients, health professionals (both those who act as clinical educators and those who do not), hospitals, state government, commonwealth government, universities and society can be considered (Haines, Isles, Jones & Jull, 2011). In this analysis, we consider the perspectives of the university, state government, Commonwealth Government, and a societal perspective that combines perspectives. The university perspective is critical as they are most likely to make the financial investment to develop an interprofessional student clinic. The state government perspective is important as hospitals in some states in Australia receive direct payments from state governments to support workforce training. Both state and commonwealth governments have an interest in student clinics as they have potential to decrease the costs of providing health care services through the public system and increase the availability of workplace training places. We do not consider the perspective of the hospital or its staff or patients in this analysis, though we do recognise that conventional clinical education and a student clinic for providing clinical education may have differing impacts on both costs and consequences for patients and staff (though there is little robust evidence available examining this at present). The societal perspective combines the outcomes of all possible stakeholders, though in this case, we combine the perspectives of university, state and commonwealth governments. This perspective is important as it permits understanding of whether there is
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a net cost across these stakeholder groups for society that is greater or less for the student clinic than for the conventional clinical education.
Methods In this article, we present an economic modelling study where primary data describing the costs of a student clinic and the costs of providing traditional clinical education in hospitals are compared. Although methods for comparing the cost-effectiveness of clinical education strategies on educational outcomes have been recently proposed (Haines et al., 2011) and used (Maloney et al., 2012), analyses such as the Cost per Quality-Adjusted Student Educated comparison ideally require robust data drawn from well-designed trials comparing student learning outcomes. Such data are not yet available for this context; hence, we assumed that both models have equivalent learning outcomes for students, despite the presence of plausible arguments as to why either approach might be superior. In making this assumption, our economic models became cost-minimization analyses. Intervention The student clinic on which this economic evaluation has been modelled was conducted by Peninsula Health and Monash University, Victoria, Australia (Kent et al., in press). The clinic was modelled to run for 3.5 h each week, providing a student clinical education day for up to nine students each week. The clinic was specifically structured to promote interprofessional education, where students were required to work together in interprofessional teams to establish the health care needs of older patients that had recently been discharged from hospital in a community health centre. Although there was variation in professional attendance throughout the year, typical attendance would be nine students. The breakdown of attendance may be three medical students, three nursing and three students from one of the following professional groups: dietetics, occupational therapy, pharmacy, physiotherapy, podiatry, psychology, social work and speech pathology. The clinic was overseen by a general practitioner and a clinical educator (e.g. nurse) who both attended the clinic for 3.5 h each week. The clinic was run between March and September when students were scheduled to be on clinical placements. A clinic co-ordinator was also employed for 4 h per week to undertake the operational governance of the clinic. The student clinic could assess four to six people each week. People were invited to attend the clinic from the acute medical wards of the local hospital if they were 470 years, living independently in the community and would benefit from a review of functional status after hospital discharge. A health professional working at the local hospital was contracted for 12 h per week to recruit these participants and coordinate the student involvement in the clinic. Each patient received a comprehensive, interprofessional screening of health status and a set of referrals/recommendations. Assessment findings were reviewed by the clinical educator and general practitioner prior to the set of referrals/recommendations being developed and later approved. The therapy provided by students did not extend beyond information provision, education and referral. The student teams commonly referred attendees to a wide range of services including physiotherapy, podiatry and home help. The clinic was conducted at a community health centre within Peninsula Health, Frankston, Australia. Three consultation rooms (without beds) were required, and a trolley containing resuscitation equipment was available within the health centre.
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Control The comparator condition in this economic evaluation is conventional profession-specific clinical immersion within a public hospital environment. Hospital-based clinicians provide clinical teaching as a component of their daily activities. Conventional clinical education varies across health professional groups in Australia, though commonly involves students shadowing and eventually taking on aspects of the regular clinical caseload of the clinician. Within the conventional model, education remains focussed on profession-specific knowledge and skills. Detailed descriptions of conventional clinical education and its strengths and limitations in specific professional groups can be found elsewhere (Dahlenburg, 2006; Lekkas et al., 2007; Mannix, Faga, Beale, & Jackson, 2006; Rodger et al., 2012). The key points of difference between the intervention and comparator were that students in the clinic worked in mixed professional teams, interviewing and working together with the patient to establish an appropriate plan of health care. By comparison, the students in the control group learnt and delivered care in profession-specific groups, where dialogue between students from separate professions may not occur. Second, students in the clinic were also exposed to clinical teaching from educators from a range of professions, compared to the usual profession-specific learning, where interprofessional teaching is uncommon. During this trial, the students group spent the morning on the hospital wards in their usual profession-specific education, then the afternoon in the interprofessional clinic. Data collection The costs of running the student clinic were separated into labour costs and capital/venue costs. All costs were taken directly from costs captured in the second half of 2011 in Australian ($AUD) currency. Labour costs were modelled on actual costs accrued during the pilot trial of the clinic. This included payments to the general practitioner overseeing the clinic of $150 per hour (3.5 h per clinic), payments to the health hospital staff member to facilitate recruitment of patients and students to the clinic of $35 per hour with a 1.25 oncosts multiplier (12 h per clinic), payments to the clinical educator of $35 per hour with a 1.25 oncosts multiplier (3.5 h per clinic), and payments to the clinic coordinator of $48 per hour with a 1.25 oncosts multiplier (4 h per clinic). Oncosts are payable in Australia to cover payments for sick leave, annual leave, long service leave, workcover and superannuation. The general practitioner was employed through a consultancy model. The cost of hiring a venue for conduct of this clinic was estimated as a pro-rata (one tenth of the weekly lease rate) amount relative to market rates for ‘‘medical commercial’’ properties in the same region. Local advertising (Realestate, 2012) was examined and rates for comparable rooms as those available in the community health centre were identified. A range of rental prices were identified, driven largely by proximity to existing shopping precincts. This factor was not considered to be important for the establishment of this clinic, thus rentals from properties with less prominent locations were used. A rental of $500 per month per room was identified for a property meeting the minimal needs of the clinic, yielding a pro-rata rate of $12.50 per clinic per room or $37.50 per clinic for three rooms. The costs of providing conventional clinical immersion within a hospital environment were calculated using existing transfer payments and local agreements in place at the time of the clinic. The value of transfer payments from the university to the hospital were different across the medical, nursing, and allied health professional groupings and were commercial in confidence. An average, weighted (per student, assuming three medical,
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three nursing and three allied health per clinic) payment from the university to the hospital per day of student education was $39.66 per student day. The value of transfer payments from the state government to the hospital were also different across medical, nursing and allied health professional groups but were public domain (Department of Health (Victoria), 2011). These values were $74.35 per medical student day, $37.39 per allied health student day and $33.73 per nursing student day. Administration costs for organising a standard clinical immersion placement were not considered in the analysis as it was determined that these costs would still need to be met in full even if one clinic session per week for students could take place in the student clinic. Two further costs were considered to be potentially relevant in this evaluation. First, the cost of a patient seeking an equivalent service through the public hospital system had the student clinic not existed. This was modelled on the service that most closely reflected the service to the patient provided by the student clinic. The investigators determined this to be development of a general practitioner management plan (Medicare Benefits Schedule item number 721 – $138.75 rebate) (Medicare Australia, 2010) and development of a Team Care Arrangement (Medicare Benefits Schedule item number 723 – $109.95 rebate) (Medicare Australia, 2010). The cost of additional health services referred to through these plans was not included, as the student clinic did not offer these treatment services. A base-case probability that a patient who accessed the student clinic would access these services was set at 0.2 (one in five patients was estimated to access these services had they not accessed similar services through the student clinic), which was varied in sensitivity analyses. Second, the student clinic did not charge a payment to the Commonwealth Government through the Medicare Benefits Schedule for the services provided by the general practitioner overseeing the clinic activities. Had this been charged, a short health assessment (Medicare Benefits Schedule item number 701 – $58.20 rebate) (Medicare Australia, 2010) would have been chosen as billing can only be claimed for the small section of the consultation delivered by the general practitioner in a student clinic. Data analysis Although a project grant funded the establishment of this clinic, the analysis was considered from the perspective of the university assuming responsibility for student clinic operation. Four basecase analyses were undertaken to reflect the comparative costs of providing 1 3.5 h clinic per week of student clinic compared to conventional clinical education. The base-case assumed nine students per placement (three medical, three nursing, three from other professions), and six patients per clinic. Each was a costminimisation analysis where the outcome (hours of clinical education experience provided) was assumed to be equivalent between the two education models. A $(AUD) cost per studentday of clinical education provided was calculated where one clinic of 3.5 h was equivalent to one half-day of clinical education. The four base-case analyses varied on the perspective they took and consequently, the costs that were included in each model. The first base-case model took the university perspective and the costs relevant were labour and venue costs of the student clinic, and transfer costs from the university to the hospital per student day of education. A net cost per clinic was calculated by subtracting the cost to the university of providing an equivalent amount of student placement time through a conventional clinical education approach from the cost to the university of providing one student clinic. The second base-case model took the state government perspective. The costs relevant to this analysis were the transfer costs from the state government to the hospital per
DOI: 10.3109/13561820.2013.874983
student day of education. The third base-case model took the commonwealth government perspective, which considered only the charges to the commonwealth government through the Medicare Benefits Schedule for services that would otherwise have been provided had patients not accessed the student clinic. The fourth base-case model adopted a societal perspective that summed the net costs (or savings) from each of the university, state government, and Commonwealth Government models. A set of one-way sensitivity analyses were undertaken to examine their impact on each model. The first sensitivity analysis examined the opportunity cost of the venue hire to conduct the clinic. During the pilot, the Community Rehabilitation Centre at Peninsula Health donated the space required. In the base-case analysis, we used market rates to hire comparable facilities in the same area on a pro-rata basis. However, if the university had decided to use the clinic for alternate activities, then it is realistic to assume a cost would be incurred. Thus one can argue that from the university perspective, this space had no opportunity cost, as there was no next best alternative use for this space for the university. Thus, a sensitivity analysis (1a) was conducted without this additional cost to the university. Conversely, if wanting to extrapolate this analysis to other locations where available of suitable facilities is scarce and a higher market rate is required to hire (e.g. in a inner-city location), a sensitivity analysis (1b) that used an amount four times higher than the market rate identified in the base case was also used. The second sensitivity analysis reduced the cost of hiring a health professional to recruit participants for the student clinic. This cost was anticipated to be higher for the pilot program which these models were based upon due to it being a new pilot program that did not have existing links to clinical services. However, with the subsequent establishment of a more permanent clinic it is anticipated that clinical health professionals would make clinic referrals directly with less need for support such that this cost would be reduced to two thirds of what it was in the pilot. The third sensitivity analysis sought to investigate the impact of the general practitioner who supervises the clinic billing the Commonwealth Government through the Medicare Benefits Scheme for a short health assessment, with these funds transferring to the university. The fourth sensitivity analysis was a series of analyses (4a–4e) that varied the number of patients seen at each clinic (from the base-case of 6). The number of patients seen was varied between 3, 4, 5, 7 and 8. The fifth sensitivity analysis was a series of analyses (5a–5d) that varied the proportion of patients (from the base-case of 20%) who would have gone on to seek similar services to the ones they received from the student clinic from the publicly funded primary health care system. The proportion seeking these services was varied across 5%, 10%, 30% and 40%. Finally, two-way sensitivity analyses were conducted (6a–6e) that combined sensitivity analyses 3 and 4 so that the effect of varying the number of patients seen combined with the general practitioner who supervises the clinic billing the commonwealth government through the Medicare Benefits Scheme for a short health assessment could be examined.
Results The results of the base-case analyses and of the sensitivity analyses are presented in Table I. The base case revealed that the student clinic cost the university an additional $289 per student day of clinical education, whereas the state government saved $49 and the Commonwealth Government saved $66. Overall, society paid an additional $175 per student day of clinical education indicating that this is a more expensive means for
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providing clinical education placements compared to conventional clinical immersion in a hospital. However, these findings were particularly sensitive to whether the general practitioner who supervised the student clinic bills the Commonwealth Government through the Medicare Benefits Schedule for a short health assessment for each patient (sensitivity analysis 3). In this circumstance, the university paid $212 per student day of education, the state government perspective was unchanged, while the Commonwealth Government paid $11 per student-day of education more than they did under the conventional clinical immersion in a hospital model. This finding was itself sensitive somewhat to the number of patients seen, as increasing the numbers reduced the cost to the university ($251 per student-day of education with three patients per clinic down to $186 per student-day of education with eight patients per clinic) and improved the societal cost per student-day of education ($208 per student-day of education with three patients per clinic down to $152 per student-day of education with 8 patients per clinic). The results of the base-case analyses for the societal and Commonwealth Government perspectives were also sensitive to the proportion of patients seen who would otherwise have gone on to receive equivalent services through the publicly-funded primary health care system. Increasing this proportion increased the savings and reduced the costs for the Commonwealth Government and society, respectively.
Discussion The stress on finding sufficient numbers of traditional clinical education placements to meet demand is apparent across health professionals (Barnett et al., 2008; Dahlenburg, 2006; Devey, 2005; Leners et al., 2006; Prideaux, 2009; Thistlethwaite et al., 2007). Interprofessional student clinics offer a promising opportunity to meet some of these demands, however the economic implications to a range of stakeholders in using this approach have previously been unknown. The present economic evaluation, based on a pilot study in Victoria, Australia, has demonstrated that this model yields substantially higher costs per day of student clinical education than the conventional immersion in a hospital setting model. Given the developing evidence for the benefits of interprofessional education (Reeves, Perrier, Goldman, Freeth, & Zwarenstein 2013) consideration needs to be given to approaches that might improve the economic efficiency of interprofessional education initiatives. Modifications to the pilot study approach examined in our sensitivity analyses were shown to make the student clinic more economically viable from the university perspective in some scenarios. This largely involved transfer payments where general practitioner services were charged to the Commonwealth Government via the Medicare Benefits Schedule. However, transfer payments between stakeholder groups do not represent a net gain or loss from the societal perspective. The key factors that drove down net costs from the societal perspective were increasing the number of patients seen in each clinic and increasing the proportion of patients who would have gone on to use publicly funded primary health care services had they not accessed the student clinic. This latter finding indicates that targeting patients who are particularly likely to need to access these services should be a strong consideration when setting patient selection criteria for future clinics. Interprofessional education initiatives have reported superior health care outcomes to profession-specific initiatives for patients with chronic health conditions such as diabetes (Barcelo et al., 2010; Janson et al., 2009; Taylor, Hepworth, Buerhaus, Dittus, & Speroff, 2007) so chronic disease patients might be an appropriate target group for similar clinic initiatives.
153 240 178 112 56 51 0 298
0
281 48 66 166
153 240 178 112 56 51 38 298
0
289 48 66 175
200
314 48 66
0
150 298
51
56
112
153 240 178
525 525
6 9 0.2
1b
136
250 48 66
0
38 298
51
56
112
153 240 178
525 350
6 9 0.2
2
175
212 48 11
349
38 298
51
56
112
153 240 178
525 525
6 9 0.2
3
208
289 48 33
0
38 149
51
56
112
153 240 178
525 525
3 9 0.2
4a
197
289 48 44
0
38 199
51
56
112
153 240 178
525 525
4 9 0.2
4b
186
289 48 55
0
38 249
51
56
112
153 240 178
525 525
5 9 0.2
4c
Positive values indicate that student clinic costs more for this stakeholder than conventional clinical education.
525 525
6 9 0.2
1a
525 525
6 9 0.2
Base case
164
289 48 77
0
38 348
51
56
112
153 240 178
525 525
7 9 0.2
4d
152
289 48 88
0
38 398
51
56
112
153 240 178
525 525
8 9 0.2
4e
224
289 48 17
0
38 75
51
56
112
153 240 178
525 525
6 9 0.05
5a
Sensitivity analyses
208
289 48 33
0
38 149
51
56
112
153 240 178
525 525
6 9 0.1
5b
141
289 48 99
0
38 448
51
56
112
153 240 178
525 525
6 9 0.3
5c
108
289 48 133
0
38 597
51
56
112
153 240 178
525 525
6 9 0.4
5d
208
251 48 6
175
38 149
51
56
112
153 240 178
525 525
3 9 0.2
6a
197
238 48 8
233
38 199
51
56
112
153 240 178
525 525
4 9 0.2
6b
186
225 48 9
291
38 249
51
56
112
153 240 178
525 525
5 9 0.2
6c
164
199 48 13
407
38 348
51
56
112
153 240 178
525 525
7 9 0.2
6d
152
186 48 15
466
38 398
51
56
112
153 240 178
525 525
8 9 0.2
6e
T. P. Haines et al.
a
Number of patients per clinic Number of students per clinic Probability patients would go on and access similar services if not for the student clinic Cost ($AUD 2011 value) General practitioner per clinic Patient and student recruitment per clinic Clinic educator per clinic Clinic administrator per clinic University to hospital transfer payments per student day State government to hospital transfer payment per clinic for medical students State government to hospital transfer payment per clinic for allied health students State government to hospital transfer payment per clinic for nursing students Venue opportunity costs per clinic Commonwealth government savings through MBS for services patients would otherwise have accessed if not for student clinic per clinic Commonwealth government costs through MBS for general practitioner services provided through student clinic per clinic Net-cost per student-day of educationa University perspective State government perspective Commonwealth government perspective Societal perspective
Analysis
Table I. Cost inputs and outcomes of the base-case analysis and sensitivity analyses.
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In no scenario modelled did the interprofessional student clinic reduce the costs of providing clinical education from a societal perspective. However, this finding is based on the assumption that the student clinic and conventional clinical education provide equivalent learning outcomes for students. It is possible that interprofessional education elements specifically incorporated into the student clinic may have improved collaborative team behaviours and professional practices (Reeves et al., 2013). There are also potential advantages to interprofessional education in terms of improved patient care, communication and outcomes (Barcelo et al., 2010; Helitzer et al., 2011; Janson et al., 2009; Taylor et al., 2007). In order to economically justify use of the student clinic on this basis from the societal perspective, the value of this educational advantage would need to exceed $175 per student education day going by the base-case analysis. Economics remain only one factor of many in the consideration of the effectiveness of an educational intervention. The present analysis was limited by the paucity of information available relating to student and patient outcomes from involvement in a student clinic. We used multiple one and two-way sensitivity analyses to examine uncertainty and gauge the impact of varying clinic parameters, including the likelihood that some patients would otherwise go on and seek equivalent health services elsewhere. We did not model the impact the student clinic might have on preventing future hospital admissions or utilisation of other health services or resources. For this analysis, we assumed that future hospitalisations would not be affected by attendance at the student clinic however the World Health Organisation (2010) have reported that collaborative practice may both reduce hospital admissions and reduce patient complications. Hospitalisations can account for very high costs, and their prevention would therefore have the potential to create large savings for multiple stakeholder groups. Such an outcome could swing our current cost-minimization analyses in favour of the student clinics, thus further research on this subject is critical if student clinics are to be shown to be economically justifiable from a societal perspective. Our study was also restricted as the data used and assumptions employed were based upon work conducted in one state in Australia. Other states and countries are likely to have different funding arrangements between the different stakeholder groups. Other cost drivers are also likely to be heavily influenced by variations in health and education policy settings. For example, a key cost of our clinic was that of a health professional to identify, recruit and refer suitable patients though to the student clinic. This task was complicated by the wide array of publicly funded postdischarge and primary healthcare services that many patients were already referred to as a part of usual care in Australia. This task may be easier and less costly in other countries that do not have comparable levels of publicly funded health care services available. There are a large number of medical student clinics in operation in America supporting the health care needs of the uninsured and disadvantaged (Simpson & Long, 2007). For comparison, the medical student clinic in Massachusetts, America reports the employment of one educator to oversee three medical student team consultations, with 12 patients attending per clinic session (Berman et al., 2012). To ensure interprofessional teaching, our model employed two educators from different professions for our three student teams, with up to six patients attending per session. Both the supervision ratio and slower patient throughput contribute to the greater cost of the interprofessional model, although the nature of the consultation is not comparable. Our analysis did not examine the perspective of hospitals, hospital staff or patients in the analyses undertaken. In the current Victorian health care context, transfer payments from state
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government to hospitals, and universities to hospitals are made to compensate hospitals for the resources consumed in provision of this education in proportion to the volume of clinical education provided and the professional groups involved. Our analysis assumed that removal of clinical education time would be accompanied by removal of these payments, resulting in no net gain or loss for hospitals. In summary, conducting a student clinic to provide clinical education opportunities for health professional students creates additional costs on universities and society compared to conventional clinical immersion within the hospital setting. Transfer payments can be made, particularly through the Medicare Benefits Schedule, to help ‘‘even-out’’ the costs of conducting a student clinic between stakeholder groups. It is possible that improved patient outcomes and hospitalisations prevented could make this system economically viable from a societal perspective, however trial data is needed before this could be satisfactorily factored in to this equation. Further research is required to determine if these higher education costs are justified by the short-term benefits of a better-educated workforce, and longer term benefits of better-coordinated, comprehensive patient care.
Acknowledgements The authors thank Peninsula Health and Mornington Peninsula Clinical Placement Network for facilitating this project.
Declaration of interest The authors declare no conflicts of interest. This project was possible due to funding made available by Health Workforce Australia and the Department of Health, Victoria. The authors were responsible for the writing and content of this article.
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training with primary care providers to improve patient-centredness and health risk communication. Patient Education and Counseling, 82, 21–29. Holmqvist, M., Courtney, C., Meili, R., & Dick, A. (2012). Student-run clinics: Opportunities for interprofessional education and increasing social accountability. Journal of Research in Interprofessional Practice and Education, 2.3, 264–277. Janson, S., Cooke, M., McGrath, K., Kroon, L.A., Robinson, S., & Baron, R.B. (2009). Improving chronic care of type 2 diabetes using teams of interprofessional learners. Academic Medicine, 84, 1540–1548. Kent, F., Drysdale, P., Martin, N., & Keating, J.L. (in press). The mixed discipline aged care student clinic: An authentic interprofessional learning initiative. Journal of Allied Health. Kent, F., & Keating, J.L. (2013). Patient outcomes from an interprofessional student led clinic in aged care. Journal of Interprofessional Care, 27, 336–338. Lekkas, P., Larsen, T., Kumar, S., Grimmer, K., Nyland, L., Chipchase, L., Jull, G., et al. (2007). No model of clinical education for physiotherapy students is superior to another: A systematic review. Australian Journal of Physiotherapy, 53, 19–28. Leners, D., Sitzman, K., & Hessler, K.L. (2006). Perceptions of nursing student clinical placement experiences. International Journal of Nursing Education Scholarship, 3, Article 24. Maloney, S., Haas, R., Keating, J.L., Molloy, E., Jolly, B., Sims, J., Morgon, P., & Haines, T. (2012). Breakeven, cost benefit, cost effectiveness, and willingness to pay for web-based versus face-to-face education delivery for health professionals. Journal of Medical Internet Research, 14, e47. Mannix, J., Faga, P., Beale, B., & Jackson, D. (2006). Towards sustainable models for clinical education in nursing: An on-going conversation. Nurse Education in Practice, 6, 3–11. Meah, Y., Smith, E., & Thomas, D. (2009). Student-run health clinic: novel arena to educate medical students on systems-based practice. Mount Sinai Journal of Medicine, 76, 344–356.
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Medicare Australia. (2010). Medicare benefits schedule. Retrieved from: www.health.gov.au/internet/mbsonline/publishing.nsf/Content/ Downloads-201011 [last accessed 4 December2012]. Prideaux, D. (2009). Medical education in Australia: Much has changed but what remains? Medical Teacher, 31, 96–100. Realestate (2012). Real commercial. Retrieved from: http://www.real commercial.com.au [last accessed 4 December2012]. Reeves, S. (2010). Ideas for the development of the interprofessional field. Journal of Interprofessional Care, 24, 217–219. Reeves, S., Perrier, L., Goldman, J., Freeth, D., & Zwarenstein, M. (2013). Interprofessional education: Effects on professional practice and healthcare outcomes (update) (Review). The Cochrane Collaboration. London: Wiley Publications. Rodger, S., Stephens, E., Clark, M., Ash, S., Hurst, C., & Graves, N. (2012). Productivity and time use during occupational therapy and nutrition/dietetics clinical education: A cohort study. PLoS One, 7, e44356. Simpson, S.A., & Long, J.A. (2007). Medical student-run health clinics: important contributors to patient care and medical education. Journal of General Internal Medicine, 22, 352–356. Taylor, C., Hepworth, J., Buerhaus, P., Dittus, R., & Speroff, T. (2007). Effect of crew resource management on diabetes care and patient outcomes in an inner-city primary care clinic. Quality and Safety in Health Care, 16, 244–247. Thistlethwaite, J., Kidd, M., & Hudson, J.N. (2007). General practice: A leading provider of medical student education in the 21st century? Medical Journal of Australia, 187, 124–128. Watson, K., Wright, A., Morris, N., McMeeken, J., Rivett, D., Blackstock, F., Jones, A., et al. (2012). Can simulation replace part of clinical time? Two parallel randomised controlled trials. Medical Education, 46, 657–667. World Health Organisation. (2010). Framework for action on interprofessional education and collaborative practice. Geneva: World Health Organisation.
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RESEARCH ARTICLE
Interprofessional student clinics: an economic evaluation of collaborative clinical placement education Terry P. Haines1, Fiona Kent2,3 and Jennifer L. Keating4 1
Allied Health Research Unit, Southern Health, Melbourne, Australia, 2HealthPEER, Monash University, Clayton, Australia, 3Department of Physiotherapy, Peninsula Health, Frankston, Australia, and 4Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Australia Abstract
Keywords
Interprofessional student clinics can be used to create clinical education placements for health professional students in addition to traditional hospital-based placements and present an opportunity to provide interprofessional learning experiences in a clinical context. To date, little consideration has been given in research literature as to whether such clinics are economically viable for a university to run. We conducted an economic evaluation based upon data generated during a pilot of an interprofessional student clinic based in Australia. Costminimization analyses of the student clinic as opposed to traditional profession-specific clinical education in hospitals were conducted from university, Commonwealth Government, state government and societal perspectives. Cost data gathered during the pilot study and market prices were used where available, while $AUD currency at 2011 values were used. Per student day of clinical education, the student clinic cost an additional $289, whereas the state government saved $49 and the Commonwealth Government saved $66. Overall, society paid an additional $175 per student day of clinical education using the student clinic as opposed to conventional hospital-based placements, indicating that traditional hospital-based placements are a cost-minimizing approach overall for providing clinical education. Although interprofessional student clinics have reported positive patient and student learning outcomes, further research is required to determine if these benefits can justify the additional cost of this model of education. Considerations for clinic sustainability are proposed.
Economic analysis, evaluation research, interprofessional education, interprofessional evaluation
Introduction The purpose of clinical education is to provide opportunities for students to attain competence at the level of an entry-level practitioner. In workplace practice, students integrate knowledge and skills at progressively higher levels of performance and responsibility under the guidance of qualified practitioners (Lekkas et al., 2007). Ageing populations, coupled with higher expectations for health care services, are creating greater demands for health professionals. However, the availability of placements in a clinical education environment to train increasing numbers of health professionals is finite, and at capacity in some countries (Barnett et al., 2008; Dahlenburg, 2006; Devey, 2005; Leners, Sitzman, & Hessler, 2006; Prideaux, 2009; Thistlethwaite, Kidd, & Hudson, 2007). Strategies to address this impending shortfall have been proposed. One approach has been to offer forms of clinical education that differ from traditional models. For example, simulation-based approaches using high fidelity mannequins and standardised patients (actors) have been proposed and have been shown to produce student learning outcomes that do not differ significantly from outcomes associated with traditional clinical education models (Watson et al., 2012). However, the relative Correspondence: Terry P. Haines, Allied Health Research Unit, Southern Health, Melbourne, Australia. E-mail: [email protected]
History Received 2 May 2013 Revised 17 September 2013 Accepted 6 December 2013 Published online 13 January 2014
cost-effectiveness and longer term viability of these alternatives is not yet clear. Another approach that is receiving growing attention is for student clinics to be established with the primary purpose of providing interprofessional clinical education opportunities for students (Berman et al., 2012; Dubouloz, Savard, Burnett, & Guitard, 2010; Holmqvist, Courtney, Meili, & Dick, 2012; Meah, Smith, & Thomas, 2009). There are several potential educational advantages of clinics of this nature. First, strategies that address specific learning targets may be more easily incorporated in a purpose-designed student clinic than in a typical health care setting due to the ability to select patients within particular diagnostic groupings. Second, there is also the potential to strategically incorporate specific learning elements such as interprofessional education within a student clinic. Recent reports of interprofessional student clinics have been promising, suggesting student participation may contribute to community service learning, an awareness of the roles of others, and positive patient outcomes (Holmqvist et al., 2012; Kent, Drysdale, Martin, & Keating, in press; Kent & Keating, 2013). However, the financial sustainability of these initiatives remains a concern for those involved. Furthermore, there has been a recent call for the economic analysis of interprofessional education initiatives (Reeves, 2010). This study aims to investigate the costeffectiveness of such a clinic based on a pilot clinic operating in Melbourne, Victoria in 2011–2012.
DOI: 10.3109/13561820.2013.874983
Background The Australian health care context comprises a mixture of public and privately provided services. All Australian citizens and permanent residents of Australia are entitled to free public hospital cover (Department of Human Services, 2012). Public hospitals are mostly run by state health departments, though in some states are run by independent boards. They receive funding from the Commonwealth and state governments. Medicare is the name given to Australia’s publicly funded healthcare system since 1984. The Commonwealth Government through the Medicare Benefits Schedule subsidizes primary health care services, with coverage extending over the past decade from services offered by general practitioners to those offered by other health providers and nurses working in primary care (Haines et al., 2010). The Commonwealth Government also fund community health services and other services that complement primary health care services. The Australian tertiary education system is also comprised of a mixture of public and private institutions (Bradley, 2008). University funding is provided through the Commonwealth Government and/ or student contributions, though most universities are established or recognised under State and Territory legislation. Many students contribute to their education by accruing debts paid off in low interest government loans through the Higher Education Loan Programme. The Commonwealth Government subsidizes many placements for Australians, though others (most postgraduate and international places) are paid for in full by students. University and health care systems interact inconsistently between states at present. There are also payments made directly from universities to hospitals for health professional education, though this has tended to occur by private negotiation between hospital departments and universities rather than through federal or state-based regulation leading to payment variations across hospitals, universities and professionals. The multi-stakeholder structure of clinical education in the Australian context complicates the economic evaluation of different clinical education models. Restricting the scope of an evaluation to a single stakeholder perspective is likely to result in important impacts on other stakeholders being missed. In Australia, stakeholder perspectives of patients, health professionals (both those who act as clinical educators and those who do not), hospitals, state government, commonwealth government, universities and society can be considered (Haines, Isles, Jones & Jull, 2011). In this analysis, we consider the perspectives of the university, state government, Commonwealth Government, and a societal perspective that combines perspectives. The university perspective is critical as they are most likely to make the financial investment to develop an interprofessional student clinic. The state government perspective is important as hospitals in some states in Australia receive direct payments from state governments to support workforce training. Both state and commonwealth governments have an interest in student clinics as they have potential to decrease the costs of providing health care services through the public system and increase the availability of workplace training places. We do not consider the perspective of the hospital or its staff or patients in this analysis, though we do recognise that conventional clinical education and a student clinic for providing clinical education may have differing impacts on both costs and consequences for patients and staff (though there is little robust evidence available examining this at present). The societal perspective combines the outcomes of all possible stakeholders, though in this case, we combine the perspectives of university, state and commonwealth governments. This perspective is important as it permits understanding of whether there is
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a net cost across these stakeholder groups for society that is greater or less for the student clinic than for the conventional clinical education.
Methods In this article, we present an economic modelling study where primary data describing the costs of a student clinic and the costs of providing traditional clinical education in hospitals are compared. Although methods for comparing the cost-effectiveness of clinical education strategies on educational outcomes have been recently proposed (Haines et al., 2011) and used (Maloney et al., 2012), analyses such as the Cost per Quality-Adjusted Student Educated comparison ideally require robust data drawn from well-designed trials comparing student learning outcomes. Such data are not yet available for this context; hence, we assumed that both models have equivalent learning outcomes for students, despite the presence of plausible arguments as to why either approach might be superior. In making this assumption, our economic models became cost-minimization analyses. Intervention The student clinic on which this economic evaluation has been modelled was conducted by Peninsula Health and Monash University, Victoria, Australia (Kent et al., in press). The clinic was modelled to run for 3.5 h each week, providing a student clinical education day for up to nine students each week. The clinic was specifically structured to promote interprofessional education, where students were required to work together in interprofessional teams to establish the health care needs of older patients that had recently been discharged from hospital in a community health centre. Although there was variation in professional attendance throughout the year, typical attendance would be nine students. The breakdown of attendance may be three medical students, three nursing and three students from one of the following professional groups: dietetics, occupational therapy, pharmacy, physiotherapy, podiatry, psychology, social work and speech pathology. The clinic was overseen by a general practitioner and a clinical educator (e.g. nurse) who both attended the clinic for 3.5 h each week. The clinic was run between March and September when students were scheduled to be on clinical placements. A clinic co-ordinator was also employed for 4 h per week to undertake the operational governance of the clinic. The student clinic could assess four to six people each week. People were invited to attend the clinic from the acute medical wards of the local hospital if they were 470 years, living independently in the community and would benefit from a review of functional status after hospital discharge. A health professional working at the local hospital was contracted for 12 h per week to recruit these participants and coordinate the student involvement in the clinic. Each patient received a comprehensive, interprofessional screening of health status and a set of referrals/recommendations. Assessment findings were reviewed by the clinical educator and general practitioner prior to the set of referrals/recommendations being developed and later approved. The therapy provided by students did not extend beyond information provision, education and referral. The student teams commonly referred attendees to a wide range of services including physiotherapy, podiatry and home help. The clinic was conducted at a community health centre within Peninsula Health, Frankston, Australia. Three consultation rooms (without beds) were required, and a trolley containing resuscitation equipment was available within the health centre.
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Control The comparator condition in this economic evaluation is conventional profession-specific clinical immersion within a public hospital environment. Hospital-based clinicians provide clinical teaching as a component of their daily activities. Conventional clinical education varies across health professional groups in Australia, though commonly involves students shadowing and eventually taking on aspects of the regular clinical caseload of the clinician. Within the conventional model, education remains focussed on profession-specific knowledge and skills. Detailed descriptions of conventional clinical education and its strengths and limitations in specific professional groups can be found elsewhere (Dahlenburg, 2006; Lekkas et al., 2007; Mannix, Faga, Beale, & Jackson, 2006; Rodger et al., 2012). The key points of difference between the intervention and comparator were that students in the clinic worked in mixed professional teams, interviewing and working together with the patient to establish an appropriate plan of health care. By comparison, the students in the control group learnt and delivered care in profession-specific groups, where dialogue between students from separate professions may not occur. Second, students in the clinic were also exposed to clinical teaching from educators from a range of professions, compared to the usual profession-specific learning, where interprofessional teaching is uncommon. During this trial, the students group spent the morning on the hospital wards in their usual profession-specific education, then the afternoon in the interprofessional clinic. Data collection The costs of running the student clinic were separated into labour costs and capital/venue costs. All costs were taken directly from costs captured in the second half of 2011 in Australian ($AUD) currency. Labour costs were modelled on actual costs accrued during the pilot trial of the clinic. This included payments to the general practitioner overseeing the clinic of $150 per hour (3.5 h per clinic), payments to the health hospital staff member to facilitate recruitment of patients and students to the clinic of $35 per hour with a 1.25 oncosts multiplier (12 h per clinic), payments to the clinical educator of $35 per hour with a 1.25 oncosts multiplier (3.5 h per clinic), and payments to the clinic coordinator of $48 per hour with a 1.25 oncosts multiplier (4 h per clinic). Oncosts are payable in Australia to cover payments for sick leave, annual leave, long service leave, workcover and superannuation. The general practitioner was employed through a consultancy model. The cost of hiring a venue for conduct of this clinic was estimated as a pro-rata (one tenth of the weekly lease rate) amount relative to market rates for ‘‘medical commercial’’ properties in the same region. Local advertising (Realestate, 2012) was examined and rates for comparable rooms as those available in the community health centre were identified. A range of rental prices were identified, driven largely by proximity to existing shopping precincts. This factor was not considered to be important for the establishment of this clinic, thus rentals from properties with less prominent locations were used. A rental of $500 per month per room was identified for a property meeting the minimal needs of the clinic, yielding a pro-rata rate of $12.50 per clinic per room or $37.50 per clinic for three rooms. The costs of providing conventional clinical immersion within a hospital environment were calculated using existing transfer payments and local agreements in place at the time of the clinic. The value of transfer payments from the university to the hospital were different across the medical, nursing, and allied health professional groupings and were commercial in confidence. An average, weighted (per student, assuming three medical,
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three nursing and three allied health per clinic) payment from the university to the hospital per day of student education was $39.66 per student day. The value of transfer payments from the state government to the hospital were also different across medical, nursing and allied health professional groups but were public domain (Department of Health (Victoria), 2011). These values were $74.35 per medical student day, $37.39 per allied health student day and $33.73 per nursing student day. Administration costs for organising a standard clinical immersion placement were not considered in the analysis as it was determined that these costs would still need to be met in full even if one clinic session per week for students could take place in the student clinic. Two further costs were considered to be potentially relevant in this evaluation. First, the cost of a patient seeking an equivalent service through the public hospital system had the student clinic not existed. This was modelled on the service that most closely reflected the service to the patient provided by the student clinic. The investigators determined this to be development of a general practitioner management plan (Medicare Benefits Schedule item number 721 – $138.75 rebate) (Medicare Australia, 2010) and development of a Team Care Arrangement (Medicare Benefits Schedule item number 723 – $109.95 rebate) (Medicare Australia, 2010). The cost of additional health services referred to through these plans was not included, as the student clinic did not offer these treatment services. A base-case probability that a patient who accessed the student clinic would access these services was set at 0.2 (one in five patients was estimated to access these services had they not accessed similar services through the student clinic), which was varied in sensitivity analyses. Second, the student clinic did not charge a payment to the Commonwealth Government through the Medicare Benefits Schedule for the services provided by the general practitioner overseeing the clinic activities. Had this been charged, a short health assessment (Medicare Benefits Schedule item number 701 – $58.20 rebate) (Medicare Australia, 2010) would have been chosen as billing can only be claimed for the small section of the consultation delivered by the general practitioner in a student clinic. Data analysis Although a project grant funded the establishment of this clinic, the analysis was considered from the perspective of the university assuming responsibility for student clinic operation. Four basecase analyses were undertaken to reflect the comparative costs of providing 1 3.5 h clinic per week of student clinic compared to conventional clinical education. The base-case assumed nine students per placement (three medical, three nursing, three from other professions), and six patients per clinic. Each was a costminimisation analysis where the outcome (hours of clinical education experience provided) was assumed to be equivalent between the two education models. A $(AUD) cost per studentday of clinical education provided was calculated where one clinic of 3.5 h was equivalent to one half-day of clinical education. The four base-case analyses varied on the perspective they took and consequently, the costs that were included in each model. The first base-case model took the university perspective and the costs relevant were labour and venue costs of the student clinic, and transfer costs from the university to the hospital per student day of education. A net cost per clinic was calculated by subtracting the cost to the university of providing an equivalent amount of student placement time through a conventional clinical education approach from the cost to the university of providing one student clinic. The second base-case model took the state government perspective. The costs relevant to this analysis were the transfer costs from the state government to the hospital per
DOI: 10.3109/13561820.2013.874983
student day of education. The third base-case model took the commonwealth government perspective, which considered only the charges to the commonwealth government through the Medicare Benefits Schedule for services that would otherwise have been provided had patients not accessed the student clinic. The fourth base-case model adopted a societal perspective that summed the net costs (or savings) from each of the university, state government, and Commonwealth Government models. A set of one-way sensitivity analyses were undertaken to examine their impact on each model. The first sensitivity analysis examined the opportunity cost of the venue hire to conduct the clinic. During the pilot, the Community Rehabilitation Centre at Peninsula Health donated the space required. In the base-case analysis, we used market rates to hire comparable facilities in the same area on a pro-rata basis. However, if the university had decided to use the clinic for alternate activities, then it is realistic to assume a cost would be incurred. Thus one can argue that from the university perspective, this space had no opportunity cost, as there was no next best alternative use for this space for the university. Thus, a sensitivity analysis (1a) was conducted without this additional cost to the university. Conversely, if wanting to extrapolate this analysis to other locations where available of suitable facilities is scarce and a higher market rate is required to hire (e.g. in a inner-city location), a sensitivity analysis (1b) that used an amount four times higher than the market rate identified in the base case was also used. The second sensitivity analysis reduced the cost of hiring a health professional to recruit participants for the student clinic. This cost was anticipated to be higher for the pilot program which these models were based upon due to it being a new pilot program that did not have existing links to clinical services. However, with the subsequent establishment of a more permanent clinic it is anticipated that clinical health professionals would make clinic referrals directly with less need for support such that this cost would be reduced to two thirds of what it was in the pilot. The third sensitivity analysis sought to investigate the impact of the general practitioner who supervises the clinic billing the Commonwealth Government through the Medicare Benefits Scheme for a short health assessment, with these funds transferring to the university. The fourth sensitivity analysis was a series of analyses (4a–4e) that varied the number of patients seen at each clinic (from the base-case of 6). The number of patients seen was varied between 3, 4, 5, 7 and 8. The fifth sensitivity analysis was a series of analyses (5a–5d) that varied the proportion of patients (from the base-case of 20%) who would have gone on to seek similar services to the ones they received from the student clinic from the publicly funded primary health care system. The proportion seeking these services was varied across 5%, 10%, 30% and 40%. Finally, two-way sensitivity analyses were conducted (6a–6e) that combined sensitivity analyses 3 and 4 so that the effect of varying the number of patients seen combined with the general practitioner who supervises the clinic billing the commonwealth government through the Medicare Benefits Scheme for a short health assessment could be examined.
Results The results of the base-case analyses and of the sensitivity analyses are presented in Table I. The base case revealed that the student clinic cost the university an additional $289 per student day of clinical education, whereas the state government saved $49 and the Commonwealth Government saved $66. Overall, society paid an additional $175 per student day of clinical education indicating that this is a more expensive means for
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providing clinical education placements compared to conventional clinical immersion in a hospital. However, these findings were particularly sensitive to whether the general practitioner who supervised the student clinic bills the Commonwealth Government through the Medicare Benefits Schedule for a short health assessment for each patient (sensitivity analysis 3). In this circumstance, the university paid $212 per student day of education, the state government perspective was unchanged, while the Commonwealth Government paid $11 per student-day of education more than they did under the conventional clinical immersion in a hospital model. This finding was itself sensitive somewhat to the number of patients seen, as increasing the numbers reduced the cost to the university ($251 per student-day of education with three patients per clinic down to $186 per student-day of education with eight patients per clinic) and improved the societal cost per student-day of education ($208 per student-day of education with three patients per clinic down to $152 per student-day of education with 8 patients per clinic). The results of the base-case analyses for the societal and Commonwealth Government perspectives were also sensitive to the proportion of patients seen who would otherwise have gone on to receive equivalent services through the publicly-funded primary health care system. Increasing this proportion increased the savings and reduced the costs for the Commonwealth Government and society, respectively.
Discussion The stress on finding sufficient numbers of traditional clinical education placements to meet demand is apparent across health professionals (Barnett et al., 2008; Dahlenburg, 2006; Devey, 2005; Leners et al., 2006; Prideaux, 2009; Thistlethwaite et al., 2007). Interprofessional student clinics offer a promising opportunity to meet some of these demands, however the economic implications to a range of stakeholders in using this approach have previously been unknown. The present economic evaluation, based on a pilot study in Victoria, Australia, has demonstrated that this model yields substantially higher costs per day of student clinical education than the conventional immersion in a hospital setting model. Given the developing evidence for the benefits of interprofessional education (Reeves, Perrier, Goldman, Freeth, & Zwarenstein 2013) consideration needs to be given to approaches that might improve the economic efficiency of interprofessional education initiatives. Modifications to the pilot study approach examined in our sensitivity analyses were shown to make the student clinic more economically viable from the university perspective in some scenarios. This largely involved transfer payments where general practitioner services were charged to the Commonwealth Government via the Medicare Benefits Schedule. However, transfer payments between stakeholder groups do not represent a net gain or loss from the societal perspective. The key factors that drove down net costs from the societal perspective were increasing the number of patients seen in each clinic and increasing the proportion of patients who would have gone on to use publicly funded primary health care services had they not accessed the student clinic. This latter finding indicates that targeting patients who are particularly likely to need to access these services should be a strong consideration when setting patient selection criteria for future clinics. Interprofessional education initiatives have reported superior health care outcomes to profession-specific initiatives for patients with chronic health conditions such as diabetes (Barcelo et al., 2010; Janson et al., 2009; Taylor, Hepworth, Buerhaus, Dittus, & Speroff, 2007) so chronic disease patients might be an appropriate target group for similar clinic initiatives.
153 240 178 112 56 51 0 298
0
281 48 66 166
153 240 178 112 56 51 38 298
0
289 48 66 175
200
314 48 66
0
150 298
51
56
112
153 240 178
525 525
6 9 0.2
1b
136
250 48 66
0
38 298
51
56
112
153 240 178
525 350
6 9 0.2
2
175
212 48 11
349
38 298
51
56
112
153 240 178
525 525
6 9 0.2
3
208
289 48 33
0
38 149
51
56
112
153 240 178
525 525
3 9 0.2
4a
197
289 48 44
0
38 199
51
56
112
153 240 178
525 525
4 9 0.2
4b
186
289 48 55
0
38 249
51
56
112
153 240 178
525 525
5 9 0.2
4c
Positive values indicate that student clinic costs more for this stakeholder than conventional clinical education.
525 525
6 9 0.2
1a
525 525
6 9 0.2
Base case
164
289 48 77
0
38 348
51
56
112
153 240 178
525 525
7 9 0.2
4d
152
289 48 88
0
38 398
51
56
112
153 240 178
525 525
8 9 0.2
4e
224
289 48 17
0
38 75
51
56
112
153 240 178
525 525
6 9 0.05
5a
Sensitivity analyses
208
289 48 33
0
38 149
51
56
112
153 240 178
525 525
6 9 0.1
5b
141
289 48 99
0
38 448
51
56
112
153 240 178
525 525
6 9 0.3
5c
108
289 48 133
0
38 597
51
56
112
153 240 178
525 525
6 9 0.4
5d
208
251 48 6
175
38 149
51
56
112
153 240 178
525 525
3 9 0.2
6a
197
238 48 8
233
38 199
51
56
112
153 240 178
525 525
4 9 0.2
6b
186
225 48 9
291
38 249
51
56
112
153 240 178
525 525
5 9 0.2
6c
164
199 48 13
407
38 348
51
56
112
153 240 178
525 525
7 9 0.2
6d
152
186 48 15
466
38 398
51
56
112
153 240 178
525 525
8 9 0.2
6e
T. P. Haines et al.
a
Number of patients per clinic Number of students per clinic Probability patients would go on and access similar services if not for the student clinic Cost ($AUD 2011 value) General practitioner per clinic Patient and student recruitment per clinic Clinic educator per clinic Clinic administrator per clinic University to hospital transfer payments per student day State government to hospital transfer payment per clinic for medical students State government to hospital transfer payment per clinic for allied health students State government to hospital transfer payment per clinic for nursing students Venue opportunity costs per clinic Commonwealth government savings through MBS for services patients would otherwise have accessed if not for student clinic per clinic Commonwealth government costs through MBS for general practitioner services provided through student clinic per clinic Net-cost per student-day of educationa University perspective State government perspective Commonwealth government perspective Societal perspective
Analysis
Table I. Cost inputs and outcomes of the base-case analysis and sensitivity analyses.
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In no scenario modelled did the interprofessional student clinic reduce the costs of providing clinical education from a societal perspective. However, this finding is based on the assumption that the student clinic and conventional clinical education provide equivalent learning outcomes for students. It is possible that interprofessional education elements specifically incorporated into the student clinic may have improved collaborative team behaviours and professional practices (Reeves et al., 2013). There are also potential advantages to interprofessional education in terms of improved patient care, communication and outcomes (Barcelo et al., 2010; Helitzer et al., 2011; Janson et al., 2009; Taylor et al., 2007). In order to economically justify use of the student clinic on this basis from the societal perspective, the value of this educational advantage would need to exceed $175 per student education day going by the base-case analysis. Economics remain only one factor of many in the consideration of the effectiveness of an educational intervention. The present analysis was limited by the paucity of information available relating to student and patient outcomes from involvement in a student clinic. We used multiple one and two-way sensitivity analyses to examine uncertainty and gauge the impact of varying clinic parameters, including the likelihood that some patients would otherwise go on and seek equivalent health services elsewhere. We did not model the impact the student clinic might have on preventing future hospital admissions or utilisation of other health services or resources. For this analysis, we assumed that future hospitalisations would not be affected by attendance at the student clinic however the World Health Organisation (2010) have reported that collaborative practice may both reduce hospital admissions and reduce patient complications. Hospitalisations can account for very high costs, and their prevention would therefore have the potential to create large savings for multiple stakeholder groups. Such an outcome could swing our current cost-minimization analyses in favour of the student clinics, thus further research on this subject is critical if student clinics are to be shown to be economically justifiable from a societal perspective. Our study was also restricted as the data used and assumptions employed were based upon work conducted in one state in Australia. Other states and countries are likely to have different funding arrangements between the different stakeholder groups. Other cost drivers are also likely to be heavily influenced by variations in health and education policy settings. For example, a key cost of our clinic was that of a health professional to identify, recruit and refer suitable patients though to the student clinic. This task was complicated by the wide array of publicly funded postdischarge and primary healthcare services that many patients were already referred to as a part of usual care in Australia. This task may be easier and less costly in other countries that do not have comparable levels of publicly funded health care services available. There are a large number of medical student clinics in operation in America supporting the health care needs of the uninsured and disadvantaged (Simpson & Long, 2007). For comparison, the medical student clinic in Massachusetts, America reports the employment of one educator to oversee three medical student team consultations, with 12 patients attending per clinic session (Berman et al., 2012). To ensure interprofessional teaching, our model employed two educators from different professions for our three student teams, with up to six patients attending per session. Both the supervision ratio and slower patient throughput contribute to the greater cost of the interprofessional model, although the nature of the consultation is not comparable. Our analysis did not examine the perspective of hospitals, hospital staff or patients in the analyses undertaken. In the current Victorian health care context, transfer payments from state
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government to hospitals, and universities to hospitals are made to compensate hospitals for the resources consumed in provision of this education in proportion to the volume of clinical education provided and the professional groups involved. Our analysis assumed that removal of clinical education time would be accompanied by removal of these payments, resulting in no net gain or loss for hospitals. In summary, conducting a student clinic to provide clinical education opportunities for health professional students creates additional costs on universities and society compared to conventional clinical immersion within the hospital setting. Transfer payments can be made, particularly through the Medicare Benefits Schedule, to help ‘‘even-out’’ the costs of conducting a student clinic between stakeholder groups. It is possible that improved patient outcomes and hospitalisations prevented could make this system economically viable from a societal perspective, however trial data is needed before this could be satisfactorily factored in to this equation. Further research is required to determine if these higher education costs are justified by the short-term benefits of a better-educated workforce, and longer term benefits of better-coordinated, comprehensive patient care.
Acknowledgements The authors thank Peninsula Health and Mornington Peninsula Clinical Placement Network for facilitating this project.
Declaration of interest The authors declare no conflicts of interest. This project was possible due to funding made available by Health Workforce Australia and the Department of Health, Victoria. The authors were responsible for the writing and content of this article.
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