The cost-effectiveness of the decision to hospitalize nursing home residents with advanced dementia

Abstract

Context: Nursing home (NH) residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve quality of life. Cost-effectiveness analyses of decisions to hospitalize these residents have not been reported.

Objectives: To estimate the cost-effectiveness of 1) not having a do-not-hospitalize (DNH) order and 2) hospitalization for suspected pneumonia in NH residents with advanced dementia.

Methods: NH residents from 22 NHs in the Boston area were followed in the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study conducted between February 2003 and February 2009. We conducted cost-effectiveness analyses of aggressive treatment strategies for advanced dementia residents living in NHs when they suffer from acute illness. Primary outcome measures included quality-adjusted life days (QALD) and quality-adjusted life years, Medicare expenditures, and incremental net benefits (INBs) over 15 months.

Results: Compared with a less aggressive strategy of avoiding hospital transfer (i.e., having DNH orders), the strategy of hospitalization was associated with an incremental increase in Medicare expenditures of $5972 and an incremental gain in quality-adjusted survival of 3.7 QALD. Hospitalization for pneumonia was associated with an incremental increase in Medicare expenditures of $3697 and an incremental reduction in quality-adjusted survival of 9.7 QALD. At a willingness-to-pay level of $100,000/quality-adjusted life years, the INBs of the more aggressive treatment strategies were negative and, therefore, not cost effective (INB for not having a DNH order, -$4958 and INB for hospital transfer for pneumonia, -$6355).

Conclusion: Treatment strategies favoring hospitalization for NH residents with advanced dementia are not cost effective.

Keywords: Advanced dementia; cost-effectiveness analysis; health care expenditures; nursing home residents; quality of life.

Figure 1. Cost-effectiveness analysis bootstrap and cost-effectiveness analysis curves (CEAC)

Panel A presents the cost-effectiveness results for not having a DNH order. Panel B presents the cost-effectiveness results for the hospitalization for pneumonia. In both panels, the left plot shows the bootstrap estimates of incremental Medicare expenditure ($1000 increments) (Y-axis) against and quality-adjusted survival (days) (X-axis), demonstrating the variance of the joint estimates of expenditure and quality-adjusted survival. Two willingness-to-pay lines are presented: $50,000/quality-adjusted life year (QALY) (dotted line) and $300,000/QALY (dashed line). All points below and to the right of these willingness-to-pay lines are considered cost-effective (i.e., positive INB). The plots on the right of each panel display the proportion of bootstrap estimates with positive incremental net benefits (INBs) (i.e., cost effective) for each level of willingness-to-pay from $25,000 to $300,000. Any point along the CEAC where the proportion of positive INBs is 90% or greater can be considered cost-effective. For example, in Panel A, only 20% of the INBs are positive at a willingness-to-pay of $300,000.

Figure 2. Sensitivity of CEAC estimates to unmeasured confounding

Without unmeasured confounding, the assumption is that average expenditure and quality-adjusted outcomes for the two groups (treated and untreated) would be the same if they received the same treatment. In the sensitivity analysis, the assumption was relaxed, and alternative plots of the CEACs were constructed based on three different sets of hypothetical conditions: (1) less costly residents tend to seek treatment, (2) no unmeasured confounding for expenditures, and (3) more costly residents tend to seek treatment. For each level of unmeasured confounding with respect to expenditures, five alternative CEACs were plotted based on different levels of unmeasured confounding with respect to quality-adjusted survival, ranging from 10% to 50%. For example, Panel A3 presents the hypothetical condition whereby expenditures under treatment for residents without DNH orders would be 30% greater than those with the order. At a WTP level of $75,000, the treatment approach was not cost-effective (i.e. less than 90% of the INBs were positive) if unmeasured confounding related to quality-adjusted survival was 30% or less.