Table A3:

Goldfeld et al, 2013

Goldfeld KS, Hamel MB, Mitchell S. Cost-effectiveness of the decision to hospitalize nursing home residents with advanced dementia. J Pain Symptom Manage 2013;46:640–51
Methods
Study details	Population	Interventions
Type of economic analysis: CUA Study design: CUA using individual patient data Perspective: Not stated, but inferred Medicare expenditures Time horizon: 18 months	Nursing home residents with advanced dementia (323 residents of 22 nursing homes in the Boston area were followed in the prospective cohort study of Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study, conducted between February 2003 and February 2009) Mean age: ∼ 85 years Male: 14%	CUA 1: No DNH order CUA 2: Hospitalization for suspected pneumonia in nursing home residents with advanced dementia Advance directives to avoid future hospital transfers in the event of an acute illness and decisions not to hospitalize when an acute illness (i.e., pneumonia) occurred
Approach to analysis
Residents with and without DNH orders, or those who were and were not hospitalized for pneumonia, may have differed in ways that also could explain differences in expenditures, survival, and quality-adjusted survival. MSM was used to adjust for possible confounding. MSM provided estimates of mean Medicare expenditures, survival, and quality-adjusted survival. These were used to calculate the INBs of treatment vs. nontreatment. The INB was the primary measure. Bootstrap methods were used to estimate the standard error of the incremental expenditure and quality-adjusted survival estimates
Results
Costs	Health outcomes	Cost effectiveness
Currency and cost year: 2007 US dollars CUA 1: Incremental (no DNH – DNH) $5,972 (SD $1,569) CUA 2: Incremental (hospitalization –no hospitalization): $3,697 (SD $5,981) Discount rate: 0%	Primary outcome: QALY CUA 1: Incremental (no DNH–DNH): 0.01 (SD 0.01) CUA 2: Incremental (hospitalization – no hospitalization): −0.03 (SD 0.02) Discount rate: 0	Primary ICER CUA 1: ICER $589,000/year CUA 2: Hospitalization was dominated
Interpretation
Sensitivity analyses	Limitations and applicability
CUA 1: Not having a DNH order was not cost-effective at lower levels of WTP, assuming low to moderate levels of unmeasured confounding CUA 2: Hospitalization for pneumonia was not cost-effective for all WTP levels, and for all levels of unmeasured confounding related to expenditures and quality-adjusted survival (i.e., < 90% of INBs were positive) Treatment effectiveness CUA 1: 124 (46%) and 144 (54%) residents did and did not have DNH orders, respectively. Resident characteristics independently associated with not having a DNH order were: male, adjusted OR 2.3 95% CI 1.1–5.0; nonwhite, adjusted OR 5.6 95% CI 1.9–17.0; PEG tube adjusted OR 4.0 95% CI 1.1–14.5 CUA 2: Among residents with pneumonia, 113 (86%) were not hospitalized and 18 (14%) were hospitalized. Resident characteristics independently associated with a greater likelihood of hospitalization included: age 85 years or less, adjusted OR 3.8 (95% CI 1.1–13.0); male, adjusted OR 3.4 (95% CI 1.0–11.8); no DNH order, adjusted OR 13.2 (95% CI 1.6–111.4); COPD, adjusted OR 4.4)95% CI 1.0–19.0)	Few limitations. This was a prospective cohort study. The methods were robust and transparent. QALY weights were estimated by mapping to health status using validated mapping methods. The conclusion is likely to be applicable to long-term care residents in Ontario
Data Sources
Clinical effectiveness: Prospective cohort study Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life
Costs: Use of Medicare services was abstracted from the chart at each assessment: hospital admissions, ED visits, physician and other professional visits in the nursing home, hospice enrollment, and skilled nursing facility admission after hospitalization. Medicare expenditures attributable to these services were determined using publicly available sources and based on nationally representative rates from 2007 in US dollars
Quality of life: Data from 2 validated health status measures were collected from nurse interviews. The Symptom Management at the End-of-Life in Dementia Scale, ascertained quarterly, quantified the frequency with which residents experienced distressing symptoms (e.g., pain, depression, fear, anxiety, and agitation) over the preceding 90 days. The Comfort Assessment in Dying with Dementia Scale, ascertained within 14 days of death, quantified the frequency with which residents experienced distressing symptoms during the last week of life. We developed and validated a method that mapped the 2 scales to the HUI2. Possible HUI2 scores range from −0.025 to 1.00; perfect health is scored 1.00, death is scored 0.00, and a negative score implies a state worse than death. In the CASCADE study, the residents’ mean (SD) HUI2 score was 0.165 (0.060) (range −0.005 to 0.215)
Funding
This study was supported in part by grants R01AG024091 and K24AG033640 (Dr. Mitchell) from the National Institute on Aging

Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; CUA, cost-utility analysis; DNH, do-not-hospitalize; ED, emergency department; HUI2, Health Utility Index Mark 2; ICER, incremental cost-effectiveness ratio; INBs, incremental net benefits; MSM, marginal structured modelling; PEG, percutaneous endoscopic gastrostomy; QALY, quality-adjusted life-year; SD, standard deviation; WTP, willingness to pay.