Table 6. Main characteristics of studies evaluating the cost-effectiveness of indirect strategies.
| No. | Study | Intervention description and comparator (Setting) | Country | Type of study and economic evaluation (Time horizon) | Sample size No. PwDs/No. Caregivers (Intervention Group/Control Group) |
Perspective | PwD outcome measures | Caregiver outcome measures | Incremental Cost-Effectiveness Ratio (ICER) and other cost-effectiveness measures | Cost-effective. Assess. | Cost-effectiveness rationale | Quality of the study |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1.1 | Michalowsky et al. 2019 [63] | Dementia Care Management (Delphi-MV trial) vs Usual Care (Community-based: home) |
Germany | RCT CUA (24 months) |
444 / 0 (315 / 129) |
Health and social care system Societal |
|
— | In the base-case analysis, Incremental cost per QALY < 0 | High | In the base-case analysis, DCM dominated the usual care in PwDs living alone while the ICER of the DCM for those living with a caregiver valued €26,851 per QALY (below the NICE’s threshold of £30,000 per QALY). The probability of the DCM being cost-effective is 56% at €0 WTP and increases to 88% at a WTP of € 40,000 per QALY (close to the NICE’s threshold). | High |
| 1.2 | Rädke et al. 2020 [116] | Dementia Care Management (Delphi-MV trial) vs Usual Care (Community-based: home) |
Germany | RCT CUA (24 months) |
444 / 0 (315 / 129) |
Health and social care system |
|
— | In the base-case analysis, Incremental cost per QALY < 0 | High | DCM dominated usual care in PwDs >80, female, living alone, with functional impairment (B-ADL), with cognitive deficit (MMSE). The probability of the DCM being cost-effective at a WTP of € 40,000 per QALY (close to the NICE’s threshold of £30,000 per QALY) was higher in females (96% versus 16% for males), in those living alone (96% versus 26% for those living not alone), in those being moderately to severely cognitively (100% versus 3% for patients without cognitive impairment) and functionally impaired (97% versus 16% for patients without functional impairment), and in PwDs having a high comorbidity (96% versus 26% for patients with a low comorbidity). | High |
| 2 | Wimo et al. 1995 [67] | Group living for dementia patients vs Home living and Institutional living (Group living) |
Sweden | Prospective study with Markov model CUA (Expected life-length of 8 years) |
108 / 0 (46 / 39 home; 23 instit.) |
Health and social care system Societal |
|
— | Incremental cost per QALY gained < 0 (compared to both institutionalisation and living at home) | High | Dominant (better outcomes and lower costs) even at a low WTP. Additional evidence needed since the study was not a RCT. | Medium |
| 3 | MacNeil Vroomen et al. 2016 [62] | Case management (Intensive Case Management Model; Linkage Model) vs Usual Care (Community-based: home) |
Netherlands | Prospective study CEA+CUA (24 months) |
521 / 521 (234 ICMM; 214 LM / 73 control) |
Societal |
|
|
Mean ICERs: €9,581,433 per QALY (ICMM vs control); €2,236,139 per QALY (LM vs control) (combined QALYs for patient and caregiver). The loss of one combined QALY is associated with cost-saving. |
Moderate | For all outcomes (NPI, GHQ, QALYs), the probability that the ICMM was cost-effective in comparison with LM and the control group is larger than 97% at a WTP of 0 €/incremental unit of effect. However, cost savings were accompanied by a small (non-significant) negative effect on QALYs for the PwDs in both ICMM and LM groups compared to the control group. Additional evidence needed since the study was not a RCT. | Medium |
| 4 | Wimo et al. 1994 [70] | Adult Day Care vs Wait-list (Community-based: Day Care) |
Sweden | Prospective study CEA (12 months) |
100 /0 (55 / 45) |
Health and social care system |
|
— | Incremental cost per unit of effectiveness < 0 | Moderate | Day Care was both cost-saving and had better outcomes. Since the changes between the groups were not significant regarding the cost-effectiveness quotient, the authors could not conclude that day care was cost-effective. However, for a subgroup of patients with the most distressed psychosocial situations, day care has shown to be cost-effective (it provides the same QoL indices of the comparator but at a lower cost). | Medium |
| 5 | Melis et al. 2008 [120] | Dutch Geriatric Intervention Programme (preventive nurse visits) vs Usual Care (Community-based: home) |
Netherlands | RCT CEA (6 months) |
151 / 0 (85 / 66) |
Health and social care system |
|
— | Mean ICER of €3,418 per successful treatment (prevented functional decline accompanied by improved well-being) (point estimate) | Moderate | Partial cost-effectiveness. Dominant intervention with a probability of 34.6%. Cost-effectiveness with a probability of 95% for a WTP of €34,000 for a successful treatment (no established WTP thresholds for unit of effectiveness). | Medium |
| 6 | Livingston et al. 2019 [65] | MARQUE intervention (mandatory training sessions for staff and implement new procedures to reduce agitation) vs Usual Care (Nursing Home) |
UK | RCT CUA (8 months) |
318 / 354 (PwD: 155/163) (Staff: 175/179) |
Health and social care system |
|
|
Mean ICER of £14,064 per QALY gained (patient) | Low/ Absent |
The MARQUE intervention was not found to be significantly less costly than usual care while it was not effective for reducing agitation and antipsychotic drug consumption or increasing QALYs. Very low probability of cost-effectiveness: the mean incremental cost per QALY gained (£14,064) is less than the NICE threshold of £20,000 per QALY, but with a relatively low probability (62%). | Medium |
| 7 | Meeuwsen et al. 2013 [66] | Memory clinics (providing drugs and non-pharmacological interventions) vs Care by GP (Community-based: Memory clinics) |
Netherlands | RCT CUA (12 months) |
160 / 160 (83 / 77) |
Societal |
|
|
Mean ICER of €41,442 per QALY (patient + caregiver). The loss of one combined QALY is associated with cost-savings | Low/ Absent |
Compared to GPs’ care, treatment provided by the memory clinics was on average €1,024 cheaper and showed a non-significant decrease of 0.025 QALYs. There was no evidence that memory clinics were more cost-effective compared to GPs with regard to post-diagnosis treatment and coordination of care of patients with dementia in the first year after diagnosis. | High |
| 8 | Howard et al. 2021 [68] | Assistive technology and telecare for independent living vs limited control technology (Community-based: home) |
UK | RCT CEA+CUA (3-6-12-24 months) |
495 / 495 (248 / 247) |
Health and social care system Societal |
|
|
Mean ICER assessed after 24 months under the societal perspective: £ 33,672 per QALY (participant) | Low/ Absent |
Time living independently outside a care home was not significantly longer in participants. Participants attained fewer QALYs at non-significantly lower costs than controls | High |
| 9 | Van de Ven et al. 2014 [130] | Dementia Care Mapping Vs Usual care (Nursing Home) |
Netherlands | RCT CCA (18 months) |
318 / 319 (PwD: 154/164) (Staff: 141/178) |
Health and social care system |
|
|
Intervention is cost-neutral compared to usual care without significant positive effects on outcomes | Low/ Absent |
Cost-neutral intervention without significant improvements in outcomes. The intervention group showed lower costs associated with outpatient hospital appointments over time than the control group but these costs are negligible compared to the costs associated with daily care. Besides, the average number of falls and the use of psychotropic drugs were not significantly different between the intervention group and the control group. | Low |
| 10 | Meads et al. 2019 [133] | Dementia Care Mapping Vs Usual care (Nursing Home) |
UK | RCT CEA+CUA (16 months) |
726/ 0 (418/308) |
Health and social care system |
|
— | In the base-case analysis: £64,380 per QALY; £272 per CMAI unit improvement. | Low/ Absent |
Costs higher in the intervention arm than in the control arm, and small QALY gains. The base-case estimate of the cost of CMAI unit improvement (£272) is higher than previous estimates. | High |
ADLs: Activities of Daily living; BADLS: Bristol Activities of Daily Living Scale; B-ADL: Bayer-Activities of Daily Living Scale; CCA: Cost-consequence analysis; CCI: Charlson Comorbidity Index; CDR: Clinical Dementia Rating; CES-D: Center for Epidemiologic Studies Depression Scale; CMAI = Cohen- Mansfield Agitation Inventory; CSRI: Client Service Receipt Inventory; CUA: Cost-utility analysis; DEMQOL Proxy: Dementia Quality of Life score reported by a carer; EQ-5D: EuroQol-5 Dimensions; FAST: Functional Assessment Staging Test; GARS-3: Groningen Activity Restriction Scale-3; GDS: Global Deterioration Scale; GHQ: General Health Questionnaire; IADLs: Instrumental Activities of Daily Living; IWB: Index of well-being; MBI: Maslach Burnout Inventory; MDDAS: Multi-Dimensional Dementia Assessment Scale; MMSE: Mini-Mental State Examination; MOS-20MH: mental health subscale of the Medical Outcomes Study Short Form; NPI: Neuropsychiatric Inventory; QALYs: Quality Adjusted Life Years; QUIS: Quality of Interactions Scale; RCT: Randomised controlled trial; SCD: Sense of Competence in Dementia; SF-12: Short Form questionnaire-12 items; STAI: State-Trait Anxiety Inventory; STS: Staff Tactics Scale; ZBI: Zarit Burden Interview (self-reported questionnaire used to assess carer burden).