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.
Similar content being viewed by others
References
Hampton LM, Daubresse M, Chang HY, Alexander GC, Budnitz DS. Emergency department visits by adults for psychiatric medication adverse events. JAMA Psychiatry. 2014. doi:10.1001/jamapsychiatry.2014.436 (Epub ahead of print).
Weich S, Pearce HL, Croft P, et al. Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study. BMJ. 2014;19(348):g1996.
Kannus P, Sievanen H, Palvanen M, Jarvinen T, Parkkari J. Prevention of falls and consequent injuries in elderly people. Lancet. 2005;366:1885–93.
World Health Organization (2007) WHO global report on falls prevention in older age. Available: http://www.who.int/ageing/publications/Falls_prevention7March.pdf?ua=1. Accessed 26 Mar 2014.
American Geriatrics Society in partnership with the American Board of Internal Medicine Foundation Choosing Wisely initiative Five Things Physicians and Patients Should Question. http://www.americangeriatrics.org/files/documents/Five_Things_Physicians_and_Patients_Should_Question.pdf. Accessed 29 Sept 2013.
Agency for Healthcare Research and Quality National Guidelines Clearinghouse. Clinical practice guidelines for the management of patients with insomnia in primary care. Madrid (Spain): Health Technology Assessment Unit, Laín Entralgo Agency, Ministry of Health, Social Services and Equality (Spain). 2009. http://www.guideline.gov/content.aspx?id=38982&search=sleep+elderly+patients. Accessed 17 June 2014.
Buysse DJ. Insomnia. JAMA. 2013;309(7):706–16.
Morin CM, Benca R. Chronic insomnia. Lancet. 2012;379:1129–41.
Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009;169:1952–60.
Zint K, Haefeli WE, Glynn RJ, et al. Impact of drug interactions, dosage, and duration of therapy on the risk of hip fracture associated with benzodiazepine use in older adults. Pharmacoepidemiol Drug Saf. 2010;19:1248–55.
Chong Y, Fryar CD, Gu Q. Prescription sleep aid use among adults: United States, 2005–2010. NCHS data brief, no 127. Hyattsville, MD: National Center for Health Statistics. 2013. http://www.cdc.gov/nchs/data/databriefs/db127.htm. Accessed 17 June 2014.
Moloney ME, Konrad TR, Zimmer CR. The medicalization of sleeplessness: a public health concern. Am J Public Health. 2011;101:1429–33.
Schubert I, Küpper-Nybelen J, Ihle P, Thürmann P. Prescribing potentially inappropriate medication (PIM) in Germany’s elderly as indicated by the PRISCUS list. An analysis based on regional claims data. Pharmacoepidemiol Drug Saf. 2013;22:719–27.
Halme AS, Beland SG, Preville M, Tannenbaum C. Uncovering the source of new benzodiazepine prescriptions in community-dwelling older adults. Int J Geriatr Psychiatry. 2013;28:248–55.
Daley M, Morin CM, LeBlanc M, Grégoire JP, Savard J. The economic burden of insomnia: direct and indirect costs for individuals with insomnia syndrome, insomnia symptoms, and good sleepers. Sleep. 2009;32:55–64.
Schwartz JA, Pearson SD. Cost consideration in the clinical guidance documents of physician specialty societies in the United States. JAMA Intern Med. 2013;173:1091–7.
Shumway-Cook A, Ciol MA, Hoffman J, et al. Falls in the Medicare population: incidence, associated factors, and impact on health care. Phys Ther. 2009;89:324–32.
Graafmans WC, Ooms ME, Hofstee HM, et al. Falls in the elderly: a prospective study of risk factors and risk profiles. Am J Epidemiol. 1996;143:1129–36.
Gray AM, Clarke PM, Wolstenholme JL, Wordsworth S. Applied methods of cost-effectiveness analysis in healthcare. Oxford University Press; 2010.
Stone KL, Ancoli-Israel S, Blackwell T, et al. Actigraphy-measured sleep characteristics and risk of falls in older women. Arch Intern Med. 2008;168:1768–75.
Rothman KJ, Greenland S, Lash TL. Modern epidemiology. 3rd ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2008.
National Center for Injury Prevention and Control, Centers for Disease Control and Prevention Centers for Disease Control and Prevention Web-based Injury Statistics Query and Reporting System (WISQARS). http://www.cdc.gov/ncipc/wisqars. Accessed 4 Oct 2013.
Roudsari BS, Ebel BE, Corso PS, Molinari NA, Koepsell TD. The acute medical care costs of fall-related injuries among the US older adults. Injury. 2005;36:1316–22.
Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and non-fatal falls among older adults. Inj Prev. 2006;12:290–5.
McIntyre A, Mehta S, Aubut J, Dijkers M, Teasell RW. Mortality among older adults after a traumatic brain injury: a meta-analysis. Brain Inj. 2013: 31–40.
Leibson CL, Tosteson AN, Gabriel SE, Ransom JE, Melton LJ. Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. J Am Geriatr Soc. 2002;50:1644–50.
National Government Services medicare physician fee schedule pricing 2013. http://www.ngsmedicare.com/ngs/portal/ngsmedicare/home. Accessed 23 May 2013.
Centers for Medicare and Medicaid Services (October 2013) national average retail price. Draft NARP file. http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Prescription-Drugs/Survey-of-Retail-Prices.html. Accessed 23 May 2013.
The Alabama Medicaid Agency Cost of dispensing prescription drugs in Alabama. http://www.medicaid.state.al.us/documents/program-RX/AAC/COD_FINAL_REPORT_1.06.10.pdf. Accessed 4 Oct 2013.
Findorff MJ, Wyman JF, Nyman JA, Croghan CF. Measuring the direct healthcare costs of a fall injury event. Nurs Res. 2007;56:283–7.
Rizzo JA, Friedkin R, Williams CS, Nabors J, Acampora D, et al. Health care utilization and costs in a Medicare population by fall status. Med Care. 1998;36:1174–88.
Finkelstein EA, Chen H, Miller TR, Corso PS, Stevens JA. A comparison of the case-control and case-crossover designs for estimating medical costs of nonfatal fall-related injuries among older Americans. Med Care. 2005;43:1087–91.
Davis JC, Robertson MC, Ashe MC, et al. International comparison of cost of falls in older adults living in the community: a systematic review. Osteoporos Int. 2010;21:1295–306.
Health Quality Ontario. The Falls/fractures economic model in ontario residents aged 65 years and over (FEMOR). Ont Health Technol Assess Ser. 2008;8:1–54.
Leger D, Morin CM, Uchiyama M, et al. Chronic insomnia, quality-of-life, and utility scores: comparison with good sleepers in a cross-sectional international survey. Sleep Med. 2012;13:43–51.
Iglesias CP, Manca A, Torgerson DJ. The health-related quality of life and cost implications of falls in elderly women. Osteoporos Int. 2009;20:869–78.
Borgstrom F, Sobocki P, Strom O, Jonsson B. The societal burden of osteoporosis in Sweden. Bone. 2007;40:1602–9.
Mitchell MD, Gehrman P, Perlis M, Umscheid CA. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Fam Pract. 2012;2012(13):13–40.
Stevens JA, Ballesteros MF, Mack KA, et al. Gender differences in seeking care for falls in the aged Medicare population. Am J Prev Med. 2012;43:59–62.
Tinetti ME, Han L, Lee DS, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med. 2014;174:588–95.
Hartholt KA, Polinder S, Van der Cammen TJ, Panneman MJ, Van der Velde N, Van Lieshout EM, Patka P, Van Beeck EF. Costs of falls in an ageing population: a nationwide study from the Netherlands (2007–2009). Injury. 2012;43(7):1199–203.
Tannenbaum C, Paquette A, Hilmer S, Holroyd-Leduc J, Carnahan R. A systematic review of amnestic and non-amnestic mild cognitive impairment induced by anticholinergic, antihistamine. GABAergic and opioid drugs. Drugs Aging. 2012;29:639–58.
Dassanayake T, Michie P, Carter G, Jones A. Effects of benzodiazepines, antidepressants and opioids on driving: a systematic review and meta-analysis of epidemiological and experimental evidence. Drug Saf. 2011;34(2):125–56.
Billioti de Gage S, Moride Y, Ducruet T, Kurth T, Verdoux H, Tournier M, Pariente A, et al. Benzodiazepine use and risk of Alzheimer’s disease: case–control study. BMJ. 2014;9(349):g5205.
Alexander GC, Gallagher SA, Mascola A, Moloney RM, Stafford RS. Increasing off-label use of antipsychotic medications in the United States, 1995–2008. Pharmacoepidemiol Drug Saf. 2011;20(2):177–84.
Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014;174:890–8.
Cook JM, Biyanova T, Masci C, Coyne JC. Older patient perspectives on long-term anxiolytic benzodiazepine use and discontinuation: a qualitative study. J Gen Intern Med. 2007;22:1094–100.
Vicens C, Bejarano F, Sempere E, Mateu C, Fiol F, Socias I, et al. Comparative efficacy of two interventions to discontinue long-term benzodiazepine use: cluster randomised controlled trial in primary care. Br J Psychiatry. 2014;204(6):471–9.
Drozda JP. Physician specialty society clinical guidelines and bending the cost curve. JAMA Intern Med. 2013;173:1097–9.
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.
Author information
Authors and Affiliations
Corresponding authors
Additional information
Cara Tannenbaum and Vakaramoko Diaby are co-first authors.
Rights and permissions
About this article
Cite this article
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
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40266-015-0251-3