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Sedative-Hypnotic Medicines and Falls in Community-Dwelling Older Adults: A Cost-Effectiveness (Decision-Tree) Analysis from a US Medicare Perspective

机译:镇静催眠药和社区居住的老年人跌倒:从美国医疗保险的成本效果分析(决策树)

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Background Both the 2012 Beers list and the American Geriatric Society 'Choosing Wisely' campaign suggest restraint in the use of sedative-hypnotics for the treatment of insomnia in older people. Sedative hypnotic agents continue to be widely prescribed even though their use in the elderly is associated with an increased risk of falls, fractures, and emergency hospitalizations. Objective The aim of this study was to estimate the cost effectiveness of cognitive behavioral therapy (CBT) compared with sedative-hypnotics and no treatment for insomnia in the US Medicare population, adjusting for the risk of falls and related consequences. Methods A model-based economic evaluation (decision tree) using the US Medicare perspective and a conservative annual temporal framework was conducted. Simulations were performed in a hypothetical cohort of Medicare beneficiaries suffering from insomnia. The main outcome measure was the incremental cost per quality-adjusted life year (QALY) gained. Sensitivity analyses assessed the robustness of the base-case analysis. Results On an annual basis, CBT showed a dominance (cost: US$19,442; QALYs: 0.594) over sedative hypnotics (cost: US$32,452; QALYs: 0.552) and no treatment (cost: US$33,853; QALYs: 0.517). Assuming a willingness to pay of US$50,000, the net monetary benefit was positive for CBT (US$10,287) and negative for sedative hypnotics (-US$4,851) and no treatment (-US$7,993). CBT had a 95 % chance of being the dominant strategy, with results most sensitive to an older adult's baseline risk of falling. Conclusion Failure to consider drug harms such as drug-induced falls and hospitalization represents a growing public health concern, significantly underestimating the cost of sedative-hypnotic therapy and loss in quality of life for the elderly. Public payers should reconsider reimbursement of sedative-hypnotic drugs as first-line treatment for insomnia in older adults.
机译:背景资料2012年啤酒清单和美国老年医学会的“明智选择”运动都表明,在镇静催眠药治疗老年人失眠症方面存在限制。尽管在老年人中使用镇静催眠药会导致跌倒,骨折和紧急住院的风险增加,但镇静催眠药仍被广泛使用。目的本研究的目的是评估美国医疗保险人群与镇静催眠药和不治疗失眠药相比,认知行为疗法(CBT)的成本效益,并调整跌倒的风险和相关后果。方法采用美国医疗保险的观点和保守的年度时间框架,进行了基于模型的经济评估(决策树)。在患有失眠症的医疗保险受益人的假设队列中进行了模拟。主要结局指标是获得的每质量调整生命年(QALY)的增量成本。敏感性分析评估了基本案例分析的稳健性。结果每年,CBT表现出高于镇静催眠药(成本:32,452美元; QALYs:0.552)的优势(成本:19,442美元; QALYs:0.594),无治疗(成本:33,853美元; QALYs:0.517)。假设愿意支付50,000美元,那么净现金收益对CBT为正(10,287美元),对镇静催眠药为负(-4,851美元),而没有治疗(为7,993美元)。 CBT有95%的机会成为主导策略,其结果对老年人跌倒的基线风险最敏感。结论未能考虑药物危害(例如药物引起的跌倒和住院)代表了日益增长的公共健康问题,这大大低估了镇静催眠治疗的费用和老年人的生活质量损失。公共支付者应重新考虑使用镇静催眠药作为老年人失眠的一线治疗方法。

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