Cost-Effectiveness of the Geriatrician-Led Comprehensive Geriatric Assessment in Different Healthcare Settings: An Economic Evaluation.

Eric Kai-Chung Wong, Wanrudee Isaranuwatchai, Joanna E M Sale, Andrea C Tricco, Sharon E Straus, David M J Naimark
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Abstract

Background: With a shortage of geriatricians, the appropriate distribution of geriatricians across healthcare settings (e.g., acute care, rehabilitation, or community clinics) is unknown. Our objective was to determine which setting(s) geriatricians should preferentially staff to be most economically attractive for the Canadian healthcare system.

Methods: We conducted a cost-effectiveness analysis using a two-dimensional microsimulation model. The model simulated a population of frail adults aged ≥ 65 years. The simulation was done over a lifetime horizon from the Ontario public payer perspective. Strategies included (1) usual care (baseline proportions of geriatrician CGAs in each setting), (2) acute care only (100% receive CGA in acute care), (3) community care only, (4) rehabilitation only, (5) acute care and community combined, (6) acute care and rehabilitation combined, (7) community and rehabilitation combined, and (8) acute care, community, and rehabilitation combined. Primary model outputs included quality-adjusted life months (QALMs), lifetime costs, and incremental cost-effectiveness ratios (ICERs).

Results: The acute care and rehabilitation combined strategy was undominated at a lifetime cost of C$139,987 and with an effectiveness of 42.09 QALM. At an ICER of C$1203 per QALM, the combination strategy of acute care, rehabilitation, and community clinics was cost-effective relative to acute care and rehabilitation, assuming a cost-effectiveness threshold of C$4167 per QALM (equivalent to C$50,000 per quality-adjusted life year). The other six strategies were dominated. When individually compared to usual care, all of the strategies were dominant or cost-effective.

Conclusions: An undominated strategy of staffing geriatricians was in the acute care and rehabilitation settings, with the option of adding community clinics if cost and resources permit.

在不同的医疗环境中,老年医生主导的综合老年评估的成本效益:一项经济评估。
背景:由于老年医生短缺,老年医生在医疗机构(如急症护理、康复或社区诊所)的适当分布尚不清楚。我们的目标是确定哪些设置(s)老年医生应该优先工作,以最具经济吸引力的加拿大医疗保健系统。方法:采用二维微观模拟模型进行成本-效果分析。该模型模拟了年龄≥65岁的体弱成年人群体。从安大略省公共支付者的角度来看,模拟是在一生的范围内完成的。策略包括:(1)常规护理(每种情况下老年专家CGA的基线比例),(2)仅急性护理(100%在急性护理中接受CGA),(3)仅社区护理,(4)仅康复,(5)急性护理和社区结合,(6)急性护理和康复结合,(7)社区和康复结合,(8)急性护理、社区和康复结合。主要模型输出包括质量调整寿命月(QALMs)、生命周期成本和增量成本-效果比(ICERs)。结果:急性护理和康复联合策略的终身成本为139,987加元,有效性为42.09 QALM。假设每个QALM的成本效益阈值为4167加元(相当于每个质量调整生命年50,000加元),在每个QALM的ICER为1203加元时,相对于急性护理和康复,急性护理、康复和社区诊所的组合策略具有成本效益。其他六种策略均为劣势策略。当单独与常规护理相比较时,所有策略都占主导地位或具有成本效益。结论:在急症护理和康复机构配备老年医学专家是一种不占主导地位的策略,如果成本和资源允许,可以选择增加社区诊所。
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