Govert Veldhuijzen

124 Chapter 6 The calculated productivity loss was significantly higher in the nurse counselling group: €35,84 (95% CI: € 26,79 -€48,41) versus CBE: €13,89 (95% CI: €7,64 – €18,84). DISCUSSION CBE creates a significant cost reducing effect for endoscopy units. This was mainly caused by the reduced need of the main cost drivers nursing staff wages and time spend per patient. The costs of patient education were the highest in the academic trial site and lowest in the rural units. One explanation is that the academic site has a more complex caseload of patients, resulting in more time needed for nurses to safeguard the endoscopy workflow. 27 We found that only 3.0% of CBE patients needed a pre-colonoscopy visit which resulted in a 97% drop of patient expenditure on travel costs. From a societal standpoint the introduction of CBE significantly reduces patient productivity loss calculated with the cost-friction method. 26 The main cause of this reduction is the absence of paid work (22.4% versus 4.1%) in contrast to absence of unpaid work or needing replacement for unpaid work. This is most probably due to the ubiquitous availability of the CBE, which allows patient education to be easily transferred outside of office hours. The annual number of colonoscopies is rising and moving from nurse counselling to CBE will have a major impact on a macro-economic scale. The data presented here assumes 100% CBE utilization to educate patients. But implementing CBE in the endoscopy department is not as easy as buying new office furniture. Implementation demands investments and change management. The basic motive to design the original cost model was to have an instrument that could show the substitution of costs in an endoscopy unit. 21 As it turned out, the original business case provided by the sales department of the software developer was too optimistic about the cost reducing effects. Main shortcoming of the business model was not considering the effect of transition of tasks amongst staff. Nursing time saved by CBE resulted in more back office workload. This study showed the importance of fully implementing the CBE in an endoscopy department for every patient that is invited for endoscopy. Parallel tracks with old fashioned letters via mail increased the workload of primarily auxiliary staff, that is already faced with more back office work due to the CBE. The used model was applied to prospectively monitor the actual cost in four endoscopy units during the