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

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.