Cost-effectiveness of an in-home respite care program to support informal caregivers of persons with dementia: A model-based analysis

Study Aim/Purpose:  This study sought to determine the cost-effectiveness of an in-home respite care program administered by a nonprofit organization in Belgium.

Summary of Methods:  To determine cost-effectiveness, the study compared costs of care and quality of life years (QALYs) for an in-home respite care program plus standard community-based dementia care to a standard community-based dementia care alone. The authors used a five-year time horizon to estimate costs and benefits, assuming a repetition of the program every 6 months. Cost-effectiveness was analyzed by dividing the incremental costs for the group receiving in-home respite by the difference in QALYs between the two groups. Additionally, to address uncertainty and to assess the robustness of the model scenario, one-way and probabilistic sensitivity analyses were conducted.

Estimates of costs and cost-effectiveness were based on six-month increments over the five-year period, applying the age-dependent decision analytic Markov model applied from two perspectives: 1) third-party payer (the Belgian government) costs and 2) broader societal costs. The third-party payer approach estimated the costs of community-based dementia health care and institutionalization, while the broader societal approach also included costs of informal care, non-health-care costs, and patient and caregiver co-payments. The estimates of the costs of care for community-based dementia care were calculated using the Resource Use in Dementia questionnaire and the costs of institutionalization were obtained from literature on nursing home care in Belgium. Cost of the informal care provided by caregivers was determined based on the value of benefits lost due to time spent providing informal care. For caregivers under age 65, these values were calculated at the national hourly gross wage rate. For older caregivers they were calculated at 35% of that rate.

For QALY measures, the authors used three straightforward dementia-specific “utilities of state”: living at home, institutionalization, and death. They also used QALY measures from the international literature. The model considered age-related relative risk reduction (RRR) using caregiver survey responses based on the Desire to Institutionalize Scale, which the authors in previous research found to be a valid proxy for actual placement. Age-specific mortality rates were derived from Belgian mortality rates adjusted to dementia-specific mortality rates from the first year of the study.

Summary of Results:  Implementing the program resulted in a QALY gain of 0.14 in favor of the intervention group compared with the comparison group. From the third-party perspective, the authors estimated an incremental cost of 1270 Euros of the intervention and an incremental cost-effectiveness ratio of 9042 Euros/QALY. From the societal perspective, they found an estimated incremental cost of 1220 Euros and the incremental cost-effectiveness ratio of 8690 Euros/QALY. The authors ran the model with different cost and benefit assumptions and obtained similar results.

Study Limitations (as cited by authors):  The authors noted several study limitations that cause some uncertainty in their findings. For example, they note that they used responses on the Desire to Institutionalize Scale (DIS) to assess relative risk reduction (RRR), based on past research showing the association between DIS responses and decreased risk after one year. However, for this study the authors used the DIS to estimate RRR over five years, despite the fact that there are no data demonstrating these longer-term effects on participants’ institutionalization rates. The authors also pointed out that their results are specific to the program in the trial and effects could vary for respite programs of different duration or costs.

Authors’ Discussion/Conclusions:  The authors concluded that their findings of the cost-effectiveness of  an in-home respite program, when provided in addition to standard community-based dementia care, reveal the value of such services for the person with dementia, their caregivers and society. The authors also suggested that the cost-effectiveness of an in-home respite program embedded in a larger health care organization should be greater than that found for a small program administered by a nonprofit agency with large overhead costs. With regard to future research , the authors recommended that cost-effectiveness analyses should become standard practice when evaluating dementia programs.