A Cost-Benefit Analysis of Music Therapy in a Home Hospice

Rafael Romo, MSN, RN; Lisa Gifford, MSN, RN

Disclosures

Nurs Econ. 2007;25(6):353-358. 

In This Article

Methods

This retrospective study was performed in a medium-sized, for-profit home hospice in the San Francisco Bay area. The hospice has an "always say yes" policy on admitting patients with only one limitation: the patient can not be receiving cure-focused chemotherapy. Otherwise, the hospice admits pa tients on antibiotics, receiving fluids and TPN, and who are expected to die within days of admission. Palliative interventions may be performed, including chemotherapy, radiation, thoracentesis, paracentesis, and blood transfusions. The hospice promises admission within 24 hours of referral, and offers music and message therapy to its patients. Neither of these alternative therapies is billed to patients, as allowed under Medicare rules. Historical data were captured on September 19, 2006, and extended back to the time of admission for each subject. At that time, the hospice had a census of 129 patients, and 23 were receiving MT.

The MT program has been well-established for 2 years. The hospice contracts with a board-certified music therapist (MT-BC) who is an integral part of the patient care team and attends all interdisciplinary meetings. Any staff member involved in direct patient care can recommend MT for a patient. After the hospice medical director writes an order, the MT-BC performs an initial evaluation. If the patient is deemed appropriate for MT, a plan of care is developed that includes one-on-one sessions and prerecorded music to be used at specific times and for specific situations.

Table 1 shows the demographic breakdown of the study subjects. A convenience sample (n=9) was taken from the list of patients receiving MT and residing in a private home. One MT patient was ultimately excluded as an outlier. Nursing costs for this patient were 180% above the mean and medication costs were 600% above, skewing the final results. Limiting subjects to those residing in their homes was done for the ease of record review, which could be done entirely from the hospice offices. The MT patients were then matched with patients (n=8) receiving standard care (SC) and residing in private homes. Patients were matched for age, length of stay, and gender. Matching for diagnosis was not feasible because of the small sample size. Patients in skilled nursing facilities were not included because these patients were spread across a large number of different facilities. Given the time constraints of this study, coordinating visits to the facilities was not feasible.

A cost-benefit analysis (CBA) was performed comparing patients receiving MT to patients not receiving MT (SC). CBA compares two alternatives by quantifying the benefits of each alternative and comparing it to the cost of the interventions. CBA requires that there be a common unit of measurement for the benefits, generally dollars, and calculates the total value of the benefits (cost savings). The savings are then divided by the cost of the intervention, resulting in the cost-benefit ratio. If the ratio is greater than 1.0, the intervention is cost beneficial (Watkins, n.d.). In this study, MT was an alternative for SC, and the benefits were the cost savings between MT over SC. The costs of the intervention were only the additional cost of the MT program, as the cost of SC is included in the costs for the patients in MT.

When performing a CBA, care must be taken to account for contingent valuation, a patient's perception of the intervention's value. If a patient is to be charged for a session of MT and is not willing to pay for the session, the contingent valuation becomes zero because the patient has decided MT is not valuable (Watkins, n.d.). Since the hospice does not require the patient to pay for MT, contingent valuation was not an important issue in this study. In a CBA, data must also be adjusted so that past and future dollars can be compared to today's dollars; however, this study spans only a 9-month period, making aging unnecessary. The requirement to have a common unit of comparison means that CBA can only be used to compare tangible results. The literature identified a number of areas of potential savings that can be quantified easily: the use of medication for pain, anxiety, sleep, and depression, the number and length of nursing visits (both RN and LVN), and the number and length of home health aide (HHA) visits. The benefits can be measured in total cost savings.

Nursing and HHA hours were gathered from a computer database. For each subject, charge creation reports were generated from the revenue gathering data. The total number of hours for RNs, LVNs, and HHAs was calculated from the data. Using budgetary data, the total cost of the hours was calculated. The cost of the MT program was calculated by examining billing records. Each visit to a subject patient was included in the cost figures. The MT-BC also attends interdisciplinary team (IDT) meetings and is paid for attendance. Since the MT-BC attends IDT meetings regardless of caseload, every IDT meeting that the MT-BC attended was also included in the costs.

Calculating the cost of medications could not be done as directly as staffing costs. The hospice utilizes a contract pharmacy that charges a fixed per diem rate for each patient; consequently, no variation in medication costs could be expected between subject groups. However, each patient's initial prescription and all refills are captured in the medication ordering system. Utilizing an online drug cost estimator (Prime Therapeutics, n.d.), estimates for the retail cost of the medications were determined that allowed equal comparison. The drug costs were calculated from each prescription and refill, not from the actual patient usage. This was done because the cost of a medication is incurred at the time it is ordered, whether or not the patient actually uses the drug. The total cost of medication was then calculated. The list of medications used in the calculation is shown in Table 2 .

There were a greater number of patient days in the MT group than the SC group that had the effect of weighting the MT group. Consequently, the cost per patient day (PPD) was calculated. This yields an averaged cost for each patient over all the days and is intended to minimize the effect of the additional days for patients in MT. The cost PPD was calculated by dividing the total costs by the total number of patient days for each study group.

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