Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention

Steven R Counsell, Christopher M Callahan, Wanzhu Tu, Timothy E Stump, Gregory W Arling, Steven R Counsell, Christopher M Callahan, Wanzhu Tu, Timothy E Stump, Gregory W Arling

Abstract

Objectives: To provide, from the healthcare delivery system perspective, a cost analysis of the Geriatric Resources for Assessment and Care of Elders (GRACE) intervention, which is effective in improving quality of care and outcomes.

Design: Randomized controlled trial with physicians as the unit of randomization.

Setting: Community-based primary care health centers.

Participants: Nine hundred fifty-one low-income seniors aged 65 and older; 474 participated in the intervention and 477 in usual care.

Intervention: Home-based care management for 2 years by a nurse practitioner and social worker who collaborated with the primary care physician and a geriatrics interdisciplinary team and were guided by 12 care protocols for common geriatric conditions.

Measurements: Chronic and preventive care costs, acute care costs, and total costs in the full sample (n5951) and predefined high-risk (n5226) and low-risk (n5725) groups.

Results: Mean 2-year total costs for intervention patients were not significantly different from those for usual care patients in the full sample ($14,348 vs $11,834; P=.20) and high-risk group ($17,713 vs $18,776; P=.38). In the high-risk group, increases in chronic and preventive care costs were offset by reductions in acute care costs, and the intervention was cost saving during the postintervention, or third, year ($5,088 vs $6,575; P<.001). Mean 2- year total costs were higher in the low-risk group ($13,307 vs $9,654; P=.01).

Conclusion: In patients at high risk of hospitalization, the GRACE intervention is cost neutral from the healthcare delivery system perspective. A cost-effectiveness analysis is needed to guide decisions about implementation in low-risk patients.

Trial registration: ClinicalTrials.gov NCT00182962.

References

    1. Institute of Medicine (IOM) Retooling for an Aging America. Washington, DC: The National Academies Press; 2008.
    1. Wenger NS, Solomon DS, Roth CP, et al. The quality of medical care provided to vulnerable community-dwelling older patients. Ann Intern Med. 2003;139:740–747.
    1. A Data Book: Healthcare Spending and the Medicare Program, June 2005. Washington DC: MedPAC; 2005.
    1. Mongan JJ, Ferris TG, Lee TH. Options for slowing the growth of health care costs. N Engl J Med. 2008;358:1509–1514.
    1. Reuben DB. Organizational interventions to improve health outcomes of older persons. Med Care. 2002;40:416–428.
    1. Reuben DB. Better care for older people with chronic diseases: An emerging vision. JAMA. 2007;298:2673–2674.
    1. Counsell SR, Callahan CM, Clark DO, et al. Geriatric care management for low-income seniors: A randomized controlled trial. JAMA. 2007;298:2623–2633.
    1. Luck J, Parkerton P, Hagigi F. What is the business case for improving care for patients with complex conditions? J Gen Intern Med. 2007;22(suppl 3):396–402.
    1. Callahan CM, Counsell SR. Measuring and communicating the value of geriatrics. J Am Geriatr Soc. 2002;50:1741–1743.
    1. Pacala JT, Boult C, Boult L. Predictive validity of a questionnaire that identifies older persons at risk for hospital admission. J Am Geriatr Soc. 1995;43:3714–3717.
    1. Vojta CL, Vojta DD, TenHave TR, et al. Risk screening in a Medicare/Medicaid population: Administrative data versus self report. J Gen Intern Med. 2001;16:525–530.
    1. Counsell SR, Callahan CM, Buttar AB, et al. Geriatric Resources for Assessment and Care of Elders (GRACE): A new model of primary care for low-income seniors. J Am Geriatr Soc. 2006;54:1136–1141.
    1. McDonald CJ, Overhage JM, Tierney WM, et al. The Regenstrief Medical Record System: A quarter century experience. Int J Med Inform. 1999;54:225–253.
    1. McDonald CJ, Overhage JM, Barnes M, et al. The Indiana Network for Patient Care: A working local health information infrastructure. Health Aff (Milwood) 2005;24:1214–1220.
    1. Tu W, Zhou XH. A Wald test comparing medical costs based on log-normal distributions with zero valued costs. Statist Med. 1999;18:2749–2761.
    1. Bodenheimer T, Fernandez A. High and rising health care costs. Part 4: Can costs be controlled while preserving quality? Ann Intern Med. 2005;143:26–31.
    1. Fireman B, Bartlett J, Selby J. Can disease management reduce health care costs by improving quality? Health Aff (Millwood) 2004;23:63–75.
    1. Hotz-Eakin D. An analysis of literature on disease management programs. Congressional Budget Office report to Congress; October 2004; Washington, DC: Congressional Budget Office; [Accessed May 17, 2008]. [on-line]. Available at .
    1. Rich MW, Nease RF. Cost-effectiveness analysis in clinical practice: The case of heart failure. Arch Intern Med. 1999;159:1690–1700.
    1. Unutzer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manage Care. 2008;14:95–100.
    1. Cohen HJ, Feussner JR, Weinberger M, et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med. 2002;346:905–912.
    1. Boult C, Boult LB, Morishita L, et al. A randomized clinical trial of outpatient geriatric evaluation and management. J Am Geriatr Soc. 2001;49:351–359.
    1. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: A randomized multicenter trial. JAMA. 2000;284:2877–2885.
    1. Reuben DB, Frank JC, Hirsch SH, et al. A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations. J Am Geriatr Soc. 1999;47:269–276.
    1. Bernabei R, Landi F, Gambassi G, et al. Randomised trial of impact of model of integrated care and case management for older people living in community. BMJ. 1998;316:1348–1351.
    1. Leveille SG, Wagner EH, Davis C, et al. Preventing disability and managing chronic illness in frail older adults: A randomized trial of a community-based partnership with primary care. J Am Geriatr Soc. 1998;46:1191–1198.
    1. Stuck AE, Aronow HU, Steiner A, et al. A trial of annual in-home comprehensive geriatric assessments for elderly people living in the community. N Engl J Med. 1995;333:1184–1189.
    1. Keeler EB, Robalino DA, Frank JC, et al. Cost-effectiveness of outpatient geriatric assessment with an intervention to increase adherence. Med Care. 1999;37:1199–1206.
    1. The Dartmouth Atlas of Health Care. [Accessed May 13, 2008];The Dartmouth Institute for Health Policy and Clinical Practice. [on-line]. Available at .
    1. Dorr DA, Wilcox A, McConnell KJ, et al. Productivity enhancement for primary care providers using multicondition care management. Am J Manage Care. 2007;13:22–28.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi