Table 8. Main characteristics of studies evaluating the cost-effectiveness of multicomponent interventions.
| 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 | Ballard et al. 2018 [77] | WHELD intervention (person-centred care, management of agitation, physical exercise and psychosocial approaches) vs Usual Care alone (Nursing Home) |
UK | RCT CCA (9 months) |
553 / 0 (257 /296) |
Health and social care system |
|
— | In the base-case analysis, incremental cost per unit of effectiveness < 0 | High | The intervention was dominant (better outcomes and lower costs than the comparator). WHELD intervention confers benefits in terms of QoL (DEMQOL Proxy), agitation (CMAI score), and neuropsychiatric symptoms (NPI score), albeit with relatively small effect sizes in terms of clinically significant benefits (on CMAI and NPI). However, the benefits to the broader population of people with dementia in care homes make this a meaningful benefit in the quality of care. No significant reduction in antipsychotic use was achieved, and antipsychotic use was stable in both study groups. | Medium |
| 1.2 | Romeo et al. 2018 [78] | WHELD intervention (person-centred care, management of agitation, physical exercise and psychosocial approaches) + Usual care vs Usual Care alone (Nursing Home) |
UK | RCT CEA+CUA (9 months) |
549 / 0 (267 / 282) |
Health and social care system |
|
— | Mean ICERs in the base case analysis: -£137,978 per QALY gained -£348 per point improvement in agitation (CMAI score) |
High | The intervention was dominant (better outcomes and lower costs than the comparator) for a wide range of societal WTP thresholds. The assessment of cost-effectiveness and parameter uncertainty confirmed that the intervention would have a high probability of being cost effective. If decision makers were willing to pay £30,000 for QALY gained (£200 for each point improvement in CMAI score), the probability that the intervention is cost effective is as high as 90% (100%). | Medium |
| 2 | Steinbeisser et al. 2020 [83] | MAKS intervention vs Usual Care (Community setting: day care centers) |
Germany | RCT CEA (6 months) |
453 / 0 (263 / 190) |
Societal |
|
— | In the base-case analysis, incremental cost per unit of effectiveness < 0 | High | The intervention has a high probability to be dominant (better outcomes and lower costs than the comparator). It has: 78% (95%) probability of cost-effectiveness for a WTP of €0 (€939.66) for 1 MMSE point; 77.4% (95%) probability of cost-effectiveness for a WTP of €0 (€ 937.73) for 1 ETAM point. For outcome measures such as MMSE and ETAM scores, no societal WTP thresholds have been defined. | High |
| 3 | Wolfs et al. 2011 [79] | Integrated approach (map of the patient and caregiver needs to develop a personalised treatment course) Vs Usual Care (Community-based: Diagnostic research centre for psycho-geriatrics) |
Netherlands | RCT CUA (1 year) |
219 / 0 (131 / 88) |
Societal |
|
— | Mean ICER: €1,267 per QALY gained | Moderate | Partial cost-effectiveness: the intervention was cost-effective in terms of QALYs for ambulatory PwDs but not in terms of improvements in clinical measures such as cognitive impairment or behavioural and psychological symptoms (due to relevant statistical uncertainty). | Low |
| 4 | El Alili et al. 2020 [84] | Namaste Care Family Program vs Usual Care (Nursing home) |
Netherlands | RCT CEA+CUA (12 months) |
231 / 116 (116 / 115) |
Health care system Societal |
|
|
Mean ICERs in the main analysis (societal perspective): -€8,919 for 1 point improvement/reduction in QUALID score; -€7,310 for 1 point improvement in GAIN score; -€315,671 per QALY gained | Moderate | The intervention was potentially dominant (better outcomes and lower costs than the comparator) but there is statistical uncertainty surrounding the results: the probability of cost-effectiveness did not exceed 70% for any threshold value of WTP for one additional QALY. Moreover, for outcome measures such as the QUALID and GAIN, no societal WTP thresholds have been defined. | Medium |
| 5 | Søgaard et al. 2014 [80] | Psychosocial intervention (DAISY) vs Usual Care (Community-based: Primary care and memory clinics) |
Denmark | RCT CUA (36 months) |
330 / 330 (163 / 167) |
Health and social care system Societal |
|
|
Mean Incremental cost per QALY <0 (additional average cost of €3,401; difference in mean QALYs: -0.09) | Low/Absent | The intervention was more costly and less effective even though the authors found no significant difference in both the measured costs and QALYs between the intervention and control groups. The probability of cost-effectiveness from a societal perspective did not exceed 36% for any threshold value of WTP for one additional QALY. The alternative scenario analysis showed that the probability of cost-effectiveness could increase if the cost perspective were restricted to formal health care and if the programme were focused only on patients and caregivers with special needs. | High |
| 6 | Eloniemi-Sulkava et al. 2009 [81] | Multicomponent support intervention for couples vs Usual Care (Community-based) |
Finland | RCT CCA (2 years) |
125 / 125 (63 / 62) |
Health and social care system |
|
|
A decrease in healthcare costs for the intervention group (the mean difference was €7,985 per capita per year) due to a reduction in the use of community services and expenditures (difference not considering the intervention costs) | Low/Absent | The authors found a substantial equivalence in the institutionalisation risk between the control and the treated groups and lower healthcare costs for the intervention group. However, when the intervention costs were included, the differences between the groups were not significant. | Low |
CCA: Cost-consequence analysis; CCI: Charlson Comorbidity Index; CDR: Clinical Dementia Rating; CMAI = Cohen- Mansfield Agitation Inventory; CSDD: Cornell Scale for Depression in Dementia; 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; ETAM: Erlangen Test of Activities of Daily Living in Persons with Mild Dementia or Mild Cognitive Impairment; FAST: Functional Assessment Staging Test; GAIN: Gain in Alzheimer Care Instrument for family caregivers; IADLs: Instrumental Activities of Daily Living; MMSE: Mini-Mental State Examination; NPI: Neuropsychiatric Inventory; QUALID: Quality of Life in Late-Stage Dementia; QALYs: Quality Adjusted Life Years; QUIS: Quality of Interactions Scale; RCT: Randomised controlled trial; RUD: Resource utilization in dementia-instrument; ZBI: Zarit Burden Interview (self-reported questionnaire used to assess carer burden).