Abstract
BackgroundOne in three hospital acute medical admissions is of an older person with cognitive impairment. Their outcomes are poor and the quality of their care in hospital has been criticised. A specialist unit to care for older people with delirium and dementia (the Medical and Mental Health Unit, MMHU) was developed and then tested in a randomised controlled trial where it delivered significantly higher quality of, and satisfaction with, care, but no significant benefits in terms of health status outcomes at three months.ObjectiveTo examine the cost-effectiveness of the MMHU for older people with delirium and dementia in general hospitals, compared with standard care.MethodsSix hundred participants aged over 65 admitted for acute medical care, identified on admission as cognitively impaired, were randomised to the MMHU or to standard care on acute geriatric or general medical wards. Cost per quality adjusted life year (QALY) gained, at 3-month follow-up, was assessed in trial-based economic evaluation (599/600 participants, intervention: 309). Multiple imputation and complete-case sample analyses were employed to deal with missing QALY data (55%).ResultsThe total adjusted health and social care costs, including direct costs of the intervention, at 3 months was £7714 and £7862 for MMHU and standard care groups, respectively (difference -£149 (95% confidence interval [CI]: -298, 4)). The difference in QALYs gained was 0.001 (95% CI: -0.006, 0.008). The probability that the intervention was dominant was 58%, and the probability that it was cost-saving with QALY loss was 39%. At £20,000/QALY threshold, the probability of cost-effectiveness was 94%, falling to 59% when cost-saving QALY loss cases were excluded.ConclusionsThe MMHU was strongly cost-effective using usual criteria, although considerably less so when the less acceptable situation with QALY loss and cost savings were excluded. Nevertheless, this model of care is worthy of further evaluation.Trial RegistrationClinicalTrials.gov NCT01136148
Highlights
About 50% of people over the age of 65 in general hospitals have delirium, dementia or both, representing one in three hospital acute medical admissions. [1,2,3] Various models have been proposed to provide for their particular needs. [3,4,5] The National Dementia Strategy for England promotes old age liaison psychiatry services, [4] it is unclear of what such services should comprise, how they facilitate high quality care, and there is no firm evidence of their cost-effectiveness
[5] We developed an alternative model—a specialist unit in a general hospital to care for people with delirium and dementia (the Medical and Mental Health Unit (MMHU))
In the full-sample cost-effectiveness analysis (CEA), 599 (MMHU: 309) participants were analysed at 90-day follow-up, at which point 139 (MMHU: 68) were dead
Summary
One in three hospital acute medical admissions is of an older person with cognitive impairment. Their outcomes are poor and the quality of their care in hospital has been criticised. A specialist unit to care for older people with delirium and dementia (the Medical and Mental Health Unit, MMHU) was developed and tested in a randomised controlled trial where it delivered significantly higher quality of, and satisfaction with, care, but no significant benefits in terms of health status outcomes at three months
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