Wong Eric Kai-Chung, Isaranuwatchai Wanrudee, Sale Joanna E M, Tricco Andrea C, Straus Sharon E, Naimark David M J
Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
J Am Geriatr Soc. 2025 Mar 26. doi: 10.1111/jgs.19448.
With a shortage of geriatricians, the appropriate distribution of geriatricians across healthcare settings (e.g., acute care, rehabilitation, or community clinics) is unknown. Our objective was to determine which setting(s) geriatricians should preferentially staff to be most economically attractive for the Canadian healthcare system.
We conducted a cost-effectiveness analysis using a two-dimensional microsimulation model. The model simulated a population of frail adults aged ≥ 65 years. The simulation was done over a lifetime horizon from the Ontario public payer perspective. Strategies included (1) usual care (baseline proportions of geriatrician CGAs in each setting), (2) acute care only (100% receive CGA in acute care), (3) community care only, (4) rehabilitation only, (5) acute care and community combined, (6) acute care and rehabilitation combined, (7) community and rehabilitation combined, and (8) acute care, community, and rehabilitation combined. Primary model outputs included quality-adjusted life months (QALMs), lifetime costs, and incremental cost-effectiveness ratios (ICERs).
The acute care and rehabilitation combined strategy was undominated at a lifetime cost of C$139,987 and with an effectiveness of 42.09 QALM. At an ICER of C$1203 per QALM, the combination strategy of acute care, rehabilitation, and community clinics was cost-effective relative to acute care and rehabilitation, assuming a cost-effectiveness threshold of C$4167 per QALM (equivalent to C$50,000 per quality-adjusted life year). The other six strategies were dominated. When individually compared to usual care, all of the strategies were dominant or cost-effective.
An undominated strategy of staffing geriatricians was in the acute care and rehabilitation settings, with the option of adding community clinics if cost and resources permit.
由于老年医学专家短缺，目前尚不清楚老年医学专家在不同医疗环境（如急症护理、康复或社区诊所）中的合理分配情况。我们的目标是确定老年医学专家应优先在哪些环境中工作，以使加拿大医疗系统在经济上最具吸引力。
我们使用二维微观模拟模型进行了成本效益分析。该模型模拟了年龄≥65岁的体弱成年人。模拟从安大略省公共支付方的角度在整个生命周期内进行。策略包括：（1）常规护理（各环境中老年医学专家综合老年评估的基线比例），（2）仅急症护理（100%在急症护理中接受综合老年评估），（3）仅社区护理，（4）仅康复护理，（5）急症护理和社区护理相结合，（6）急症护理和康复护理相结合，（7）社区护理和康复护理相结合，以及（8）急症护理、社区护理和康复护理相结合。主要模型输出包括质量调整生命月（QALMs）、终身成本和增量成本效益比（ICERs）。
急症护理和康复护理相结合的策略在终身成本为139,987加元且有效性为42.09 QALM的情况下未被其他策略主导。在每QALM为1203加元的ICER下，假设每QALM的成本效益阈值为4167加元（相当于每质量调整生命年50,000加元），急症护理、康复护理和社区诊所相结合的策略相对于急症护理和康复护理而言具有成本效益。其他六种策略被主导。与常规护理单独比较时，所有策略均占主导地位或具有成本效益。
老年医学专家人员配置的一个未被其他策略主导的方案是配置在急症护理和康复环境中，如果成本和资源允许，可选择增加社区诊所。
