Data from: Economic evaluation of a general hospital unit for older people with delirium and dementia (TEAM randomised controlled trial)

Background: 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 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. Objective: To examine the cost-effectiveness of the MMHU for older people with delirium and dementia in general hospitals, compared with standard care. Methods: Six 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%). Results: The 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. Conclusions: The 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.研究背景：每3例医院急性内科收治患者中，就有1例为伴有认知障碍的老年患者。此类患者的临床结局欠佳，住院期间的照护质量亦饱受诟病。针对谵妄与痴呆老年患者开发的专科照护单元——医学与心理健康单元（Medical and Mental Health Unit, MMHU），已通过随机对照试验开展验证。结果显示，该单元可显著提升照护质量与患者满意度，但在3个月随访的健康状态结局方面未体现出显著优势。 研究目的：评估综合医院内针对谵妄与痴呆老年患者的MMHU照护模式相较于标准照护的成本效益。 研究方法：共纳入600名年龄≥65岁、因急性内科疾病入院且入院时被判定存在认知障碍的受试者，将其随机分配至MMHU组，或急性老年科/普通内科病房的标准照护组。本研究通过基于试验的经济学评估，以3个月随访期内每获得1个质量调整生命年（quality adjusted life year, QALY）所需成本作为核心评价指标，最终纳入599名受试者（干预组309名）进行分析。针对占比55%的QALY数据缺失问题，研究采用多重插补法与完整病例样本分析两种方式进行处理。 研究结果：MMHU组与标准照护组在3个月时的调整后卫生与社会照护总成本（含干预直接成本）分别为7714英镑与7862英镑，组间差值为-149英镑（95%置信区间[CI]：-298, 4）。两组获得的质量调整生命年（QALY）差值为0.001（95%CI：-0.006, 0.008）。干预方案具备绝对成本效益优势（即成本更低且健康产出更高）的概率为58%，且在产生QALY损失的同时实现成本节约的概率为39%。在20000英镑/QALY的通用成本效益阈值下，该干预方案具备成本效益的概率为94%；若排除存在QALY损失且成本节约的病例场景，该概率降至59%。 研究结论：按照通用的卫生经济学评价标准，MMHU照护模式具备显著的成本效益，但倘若排除QALY损失且成本节约这类认可度较低的临床场景，其成本效益优势则大幅削弱。尽管如此，该照护模式仍值得开展进一步的评估与验证。