Using Cost-Effectiveness Analysis in Mixed Methods Research: An Evaluation of an Integrated Care Program for Frequently Hospitalized Older Adults in Singapore

Abstract

Traditional evaluation techniques are often not suitable for studying health interventions operating in real-world settings, particularly when interventions operate through complex causal pathways. We describe a mixed methods design for evaluating an integrated home care and social support service targeting mature and older adults (55+ years) in Singapore. Here, nurses and community health workers visit patients’ homes to address health and social needs while facilitating linkages to community-based services and providing caregiver support. Our mixed methods evaluation plan is composed of three components: quantitative comparison of hospital-based service utilization, cost-effectiveness analysis, and qualitative investigation into the experiences of patients, caregivers, and individuals who declined services. This article contributes a description of how cost-effectiveness analysis adds value when incorporated into mixed methods studies.

A Mixed-Methods Approach for Embedding Cost Analysis Within Fidelity Assessment in School-Based Programs

“…Together, we believe this mixed-methods approach is informative with regard to PBIS cost estimation, and lends itself well to potential application to other school-based programs and frameworks commonly used in the special education and behavioral disorders fields. It is important to acknowledge, however, that mixed-methods approaches have been previously used in cost studies, largely in the field of medicine (e.g., Penkunas et al, 2020); however, there has been a greater emphasis on and expansion of the use of mixed-methods approaches in education as well (e.g., Pas et al, 2020). Toward that end, we hope that the current study serves to motivate and inform further use of mixed-methods approaches for documenting costs in educational studies.…”

“…After describing this process and the multiple sources of data collected from a set of 77 U.S. PBIS schools at different levels of implementation, we provide a case illustration of PBIS implementation (Dopp et al, 2019; Onwuegbuzie, 2012). Specifically, we used a convergent parallel research design in which raw qualitative data from the PBIS fidelity assessment were used to create a case illustration, whereas quantitative data from the PBIS fidelity assessment were used to identify the costs associated with PBIS implementation (Leech & Onwuegbuzie, 2009; Penkunas et al, 2020).…”

“…Although there have been some prior efforts to apply cost-benefit analysis to PBIS and various activities within the framework (e.g., Blonigen et al, 2008; Swain-Bradway et al, 2017), this study was novel in that it used a mixed-methods design in which a case illustration of a single school’s cost data in relation to the multi-informant fidelity data is used (Creswell & Clark, 2011; Tashakkori & Teddlie, 2010). This also serves as one of only a few examples of such an approach in the field of education, whereas there is a longer history of such approaches in other fields, such as medicine (e.g., Penkunas et al, 2020). Although this article focused on PBIS, we anticipate a similar approach could be leveraged to track the costs associated with other school-based programs.…”

“…Leveraging a sample of 77 schools implementing Positive Behavioral Interventions and Supports (PBIS), we summarize the average cost data collected, contrasting high and low fidelity implementation. We then provide a case illustration of PBIS implementation and the related costs (Penkunas et al, 2020), so that readers can see how these data were collected in practice and have utility at the school level. We collected data from multiple sources, including multi-informant interviews, document review, and observations.…”

Towards a More Comprehensive Understanding of Fostering Connections: The Trauma-Informed Foster Care Programme: A Mixed Methods Approach With Data Integration

“…The Medical Research Council (MRC) framework for the development and evaluation of complex interventions recommends taking both quantitative and qualitative approaches in the evaluation stage (Craig et al, 2008): a quantitative approach to assess intervention effectiveness, and a qualitative approach to evaluate the intervention process. The MRC framework recognises the limitations of experimental studies when considering the development and evaluation of complex interventions (Penkunas et al, 2020). Whilst randomised controlled trials (RCT) are considered to be the gold standard of intervention evaluation, as a singular approach they limit the evaluation of complex interventions.…”