title: Cost-effectiveness of a brief two-stage emergency department intervention for high-risk elders: results of a quasi-randomized controlled trial.
abstract: OBJECTIVE
  : We determine the cost-effectiveness of a 2-stage emergency department intervention in addition to usual ED care compared with that of usual care alone.
  
  
  METHODS
  The intervention comprises 2 steps: (1) identification of high-risk patients by using a screening tool and (2) a brief standardized nursing assessment to identify unresolved problems, followed by referral to an appropriate community provider. The patient population was composed of individuals aged 65 years and older to be released from the EDs of 4 Montreal hospitals. Patients were randomized by day of ED visit. The perspective of the study is societal, including patients, caregivers, and the formal health care (government-funded) system. Outcomes, measured from randomization to 4 months after randomization, included (1) functional decline, as measured by an activities of daily living instrument, or death, and (2) changes in depressive symptoms. Costs include post-ED care, including hospitalization, physician services, community care, outpatient drugs, and patient and caregiver costs. Cost items were measured with administrative databases and self-reported questionnaires. Unit costs for these items were either province-wide rates or else were estimated directly by using provider data. Cost-effectiveness is assessed in qualitative terms, such that outcomes and costs are compared separately.
  
  
  RESULTS
  The intervention was associated with a reduced rate of functional decline (including death) at 4 months. There was no effect of the intervention on change in the patient's depressive symptoms at 4 months relative to baseline. The estimated ratio of overall costs per patient in the intervention versus the control group, adjusted for covariates, was 0.94 (95% credible interval 0.75 to 1.17). Among patients who had visited the ED during the 30 days before the index visit, the ratio was 0.66 (95% credible interval 0.44 to 0.97).
  
  
  CONCLUSIONS
  In this study setting, the intervention is preferred over usual care because beneficial functional outcomes were observed, and overall societal costs were no higher than if usual care only was given.
authors.affiliation: Department of Clinical Epidemiology and Community Studies, St Mary's Hospital, Montreal, Quebec, Canada. jane.mccusker@mcgill.ca
authors.forename: Jane
authors.initials: J
authors.lastname: McCusker
authors.forename: Philip
authors.initials: P
authors.lastname: Jacobs
authors.forename: Nandini
authors.initials: N
authors.lastname: Dendukuri
authors.forename: Eric
authors.initials: E
authors.lastname: Latimer
authors.forename: Pierre
authors.initials: P
authors.lastname: Tousignant
authors.forename: Josée
authors.initials: J
authors.lastname: Verdon
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D017028:Caregivers; D003072:Cognition Disorders / Q000175:diagnosis; D003266:Continuity of Patient Care; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D003863:Depression / Q000175:diagnosis; D004636:Emergency Service, Hospital / Q000191:economics; D005190:Family; D005260:Female; D005500:Follow-Up Studies; D015577:Geriatric Assessment; D006801:Humans; D008297:Male; D009730:Nursing Assessment / Q000191:economics; D017063:Outcome Assessment, Health Care; D011792:Quebec; D012017:Referral and Consultation; D012044:Regression Analysis; D018570:Risk Assessment; D011795:Surveys and Questionnaires; D013997:Time Factors