Clinical characteristics and six-month outcomes of nursing home residents with low activities of daily living dependency.

BACKGROUND: Up to 30% of nursing home residents have very little dependency in activities of daily living (ADLs). We compared the characteristics and six-month outcomes of a sample of low-ADL--dependent nursing home residents (LDR) with other residents. METHODS: This is a cross-sectional, six-month follow-up study using secondary data analysis. We combined the separate 1990 and 1993 cohorts in the Resident Assessment Instrument evaluation study. In each case these data were collected in the same 254 nursing homes in 10 states. We studied residents with a length of stay greater than 60 days and age 65 years and older (N = 3955). We compared the baseline characteristics of LDR (n = 985) with all other residents. We then compared six-month outcomes of LDR with other residents and characteristics of LDR with poor outcomes (death or worsened ADL disability) with LDR who remained stable. RESULTS: The LDR had a significantly decreased frequency of geriatric syndromes (i.e., cognitive impairment, urinary incontinence, under-nutrition, vision problems, poor balance, and pressure ulcers) and neurological disease but had the same frequency of non-neurological chronic diseases and were on more medications. Thirty-one percent had poor six-month outcomes associated with baseline poor cognition, incontinence, poor appetite, and presence of vascular disease, daily pain, shortness of breath, and multiple medications. CONCLUSION: Our research identified 29% of nursing home residents with higher physical function (LDR) who had fewer geriatric syndromes and neurological disease diagnoses; 69% of these remained stable at 6 months. Those LDR with a higher risk of poor outcomes could be prospectively identified. LDR who remained stable for 6 months may represent a group who could potentially be maintained in the community.

The cost-utility of screening for depression in primary care.

BACKGROUND: Depressive disorders are common in primary care and cause substantial disability, but they often remain undiagnosed. Screening is a frequently proposed strategy for increasing detection of depression. OBJECTIVE: To examine the cost-utility of screening for depression compared with no screening. DESIGN: Nonstationary Markov model. DATA SOURCES: The published literature. TARGET POPULATION: Hypothetical cohort of 40-year-old primary care patients. TIME HORIZON: Lifetime. PERSPECTIVE: Health care payer and societal. INTERVENTIONS: Self-administered questionnaire followed by provider assessment. OUTCOME MEASURES: Costs and quality-adjusted life-years (QALYs). RESULTS OF BASE-CASE ANALYSIS: Compared with no screening, the cost to society of annual screening for depression in primary care patients is $192 444/QALY. Screening every 5 years and one-time screening cost $50 988/QALY and $32 053/QALY, respectively, compared with no screening. From the payer perspective, the cost of annual screening is $225 467. RESULTS OF SENSITIVITY ANALYSES: Cost-utility ratios are most sensitive to the prevalence of major depression, the costs of screening, rates of treatment initiation, and remission rates with treatment. In Monte Carlo sensitivity analyses, the cost-utility of annual screening is less than $50 000/QALY only 2.2% of the time. In multiway analyses, four model variables must be changed to extreme values for the cost-utility of annual screening to fall below $50 000/QALY, but a change in only one variable increases the cost-utility of one-time screening to more than $50 000/QALY. One-time screening is more robustly cost-effective if screening costs are low and effective treatments are being given. CONCLUSIONS: Annual and periodic screening for depression cost more than $50 000/QALY, but one-time screening is cost-effective. The cost-effectiveness of screening is likely to improve if treatment becomes more effective.