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Sedative-Hypnotic Medicines and Falls in Community-Dwelling Older Adults: A Cost-Effectiveness (Decision-Tree) Analysis from a US Medicare Perspective

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Abstract

Background

Both the 2012 Beers list and the American Geriatric Society ‘Choosing Wisely’ campaign suggest restraint in the use of sedative-hypnotics for the treatment of insomnia in older people. Sedative hypnotic agents continue to be widely prescribed even though their use in the elderly is associated with an increased risk of falls, fractures, and emergency hospitalizations.

Objective

The aim of this study was to estimate the cost effectiveness of cognitive behavioral therapy (CBT) compared with sedative-hypnotics and no treatment for insomnia in the US Medicare population, adjusting for the risk of falls and related consequences.

Methods

A model-based economic evaluation (decision tree) using the US Medicare perspective and a conservative annual temporal framework was conducted. Simulations were performed in a hypothetical cohort of Medicare beneficiaries suffering from insomnia. The main outcome measure was the incremental cost per quality-adjusted life year (QALY) gained. Sensitivity analyses assessed the robustness of the base-case analysis.

Results

On an annual basis, CBT showed a dominance (cost: US$19,442; QALYs: 0.594) over sedative hypnotics (cost: US$32,452; QALYs: 0.552) and no treatment (cost: US$33,853; QALYs: 0.517). Assuming a willingness to pay of US$50,000, the net monetary benefit was positive for CBT (US$10,287) and negative for sedative hypnotics (−US$4,851) and no treatment (−US$7,993). CBT had a 95 % chance of being the dominant strategy, with results most sensitive to an older adult’s baseline risk of falling.

Conclusion

Failure to consider drug harms such as drug-induced falls and hospitalization represents a growing public health concern, significantly underestimating the cost of sedative-hypnotic therapy and loss in quality of life for the elderly. Public payers should reconsider reimbursement of sedative-hypnotic drugs as first-line treatment for insomnia in older adults.

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Acknowledgments

This research was funded by the Michel Saucier Endowed Chair in Geriatric Pharmacology, Health and Aging, Faculty of Pharmacy, Université de Montréal, Quebec, Canada.

Dr. Cara Tannembaum designed the study and participated in the data analysis and interpretation. She wrote the first draft of the manuscript. Dr. Vakaramoko Diaby participated in the study design (modeling), was responsible for data analysis, interpretation of the findings and review of the manuscript. Mr. Dharmender Singh participated in the study design and data analysis. Dr. Sylvie Perreault was responsible for the study design, interpretation of the findings and review of the manuscript. Ms. Mireille Luc helped with the data collection and review of the manuscript. Dr. Helen-Maria Vasiliadis participated in the study design, the data analysis and interpretation and critically reviewed the manuscript. Drs. Tannenbaum and Diaby are guarantors. All authors declare no conflicts of interest.

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Correspondence to Cara Tannenbaum or Vakaramoko Diaby.

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Cara Tannenbaum and Vakaramoko Diaby are co-first authors.

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Tannenbaum, C., Diaby, V., Singh, D. et al. Sedative-Hypnotic Medicines and Falls in Community-Dwelling Older Adults: A Cost-Effectiveness (Decision-Tree) Analysis from a US Medicare Perspective. Drugs Aging 32, 305–314 (2015). https://doi.org/10.1007/s40266-015-0251-3

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