Phibbs CS (HERC)
Holty JE (Palo Alto VA)
Goldstein MK (Palo Alto VA)
Garber AM (Palo Alto VA)
Wang Y (Palo Alto VA)
Feussner JR (Medical University of South Carolina)
Cohen HJ (Durham VA)
The Geriatric Evaluation and Management study was developed to assess the impact of a comprehensive geriatric assessment service on the care of the elderly. The purpose of this secondary analysis was to evaluate the effects of inpatient units and outpatients clinics for geriatric evaluation and management on health care utilization, costs, and cost-effectiveness.
A prospective, randomized, controlled trial using a 2x2 factorial design. 1388 participants hospitalized on either a medical or surgical ward at 11 participating Veterans Affairs medical centers. Subjects were randomized to receive either inpatient geriatric unit (GEMU) or usual inpatient care (UCIP), followed by either outpatient care from a geriatric clinic (GEMC) versus usual outpatient care (UCOP). VA Health care utilization, costs, and utility outcomes were assessed. Costs were estimated by assigning Medicare reimbursements to VA utilization for acute medical-surgical hospitalizations and ambulatory care. VA per diem costs were used for other inpatient and long term care. Patient utilities were obtained using indirect measurement.
The main results, published in the New England Journal of Medicine, found no GEMU or GEMC effect on mortality or other patient outcomes. There were statistically insignificant mean per patient cost savings of $1027 for the GEMU and $1665 for the GEMC. In the current analysis, we found that patients assigned to the GEMU had a significantly decreased rate of nursing home placement (odds ratio=0.65; p=0.001). This reduction in nursing home use yielded a savings of $1,975 (p=0.002). There were no other statistically significant differences in the use of, or costs for, different types of health care services. Neither the GEMU nor GEMC care produced statistically significant improvements in standard gamble utility, and all of the cost-effectiveness regions strongly overlapped zero.
Inpatient or outpatient geriatric evaluation and management units are unlikely to increase the costs of care over the first year and are possibly cost saving. Although neither survival nor mean utility improved, the statistically significant reduction in nursing home admissions for patients treated in the GEMU may have independent value for patients and their families.
These results support the continued VA provision of GEMU and GEMC care.