This study examined the cost-effectiveness of a multicomponent psychosocial intervention to decrease the stress and burden of caregivers of people with dementia and improve their ability to manage behavioral problems of the care recipient. REACH II was one of the first studies to systematically assess the efficacy of a multicomponent intervention in a racially and ethnically diverse dementia caregiving sample. Moreover, the current study is the first cost-effectiveness analysis comparing an in-home-based family caregiving intervention with a control condition. At the end of 6 months, there was a significant difference between intervention caregivers and control caregivers in hours providing care, such that the caregivers in the intervention group had more time to allocate to noncaregiving activities. For the 6 months, total cost for each intervention caregiver was $1,214, and total cost for each control caregiver was $54.
The ICER showed that, for an additional hour of non-caregiving time per day, intervention costs were $4.96 per day per caregiver ($893 total over 6 months). The intervention would be even more cost-effective if the reduction in hours spent caring extends beyond the 6-month period without additional intervention. The unit cost (hour) investment decreases with increase in length of intervention effect.
A major limitation of the study was the lack of additional follow-up data after the intervention ended. These data would have allowed the sustainability of the intervention effect to be determined, although it is not unreasonable to assume that the intervention effects would last for at least 6 months. Other caregiving studies with similar interventions have shown that intervention effects can last 3 to 8 months,34–37
up to 1 year,38–41
or up to 18 months.42
In one cost-effectiveness study43
of a multicomponent institution-based dementia intervention,17
in addition to significant psychological improvement, cost savings of $5,975 (1990 U.S. dollars) were evident at 39 months. Further study to determine duration of intervention effect would be beneficial.
Another study limitation was the lack of objective healthcare utilization data. Although no significant differences were reported, data were according to caregiver report for use of services by the dyad, the caregiver, and the care recipient and covered only the month preceding baseline and 6-month follow-up data collection. Numbers were small, and examination of Medicare services use is an area for future study.
Because family caregiving accounts for a large proportion of the care of those with AD, providing relief to families is an important goal. At the beginning of the study, caregivers reported an average of approximately 8 hours per day providing care. At the end of the intervention, hours providing care had remained the same for control group caregivers and decreased for intervention caregivers. Although this cost-effectiveness analysis focused on the Memphis site, findings were similar across all REACH II sites, which included the three racial and ethnic groups: whites, blacks, and Hispanics. One intriguing area for future research is to investigate whether spending less time in caregiving activities is related to health outcomes.
Although 68% of the Memphis REACH II caregivers were not working, providing additional time may be even more critical for those who are still working to allow them to provide care without excessive loss of job productivity or having to quit their job. Twenty-five (27.5%) of the 92 caregivers had quit work to care for their care recipient, and 14.3% reported reducing their work hours to provide care. Less time spent in caregiving tasks might make it possible for caregivers to remain employed and reduce work interruptions, although time costs for participating in interventions may affect homemakers and retired or employed caregivers differently, competing not only with caregiving tasks, other familial obligations, and personal needs, but also real wage earnings and may influence who chooses to participate in an intervention.
In addition to the intervention, other factors had the potential to influence the outcome of noncaregiving hours. Recent research has shown that caregivers whose care recipients use cognitive enhancers may gain additional time per day not spent in providing care.44,45
For the REACH study, there was no significant difference between the intervention and control groups in use of cognitive enhancers at baseline. The percentage of control care recipients using cognitive enhancers was 43.2% at baseline and 47.7% at 6-month follow-up, and intervention care recipients' use was 56.8% at baseline and 52.3% at follow-up.
Other factors, including care recipient behaviors, caregiver bother, and depression, could have influenced the amount of time spent providing care, but there was no difference in these factors between the intervention and control groups at baseline. The 6-month change in the REACH II multicomponent outcome, which included caregiver burden, emotional well-being, self-care and healthy behaviors, social support, and care recipient problem behaviors, was significantly different between the intervention and control groups. Further study of the potential contribution of each of these five components to the time saved is warranted.
For the purposes of translating this study to an agency setting, the cost estimates may be biased upward for several reasons. For example, in an agency setting, the caseload typically is larger, suggesting that the costs of the intervention would be less. The two Memphis interventionists continued to work with all 103 caregivers during the course of the study, including those whose care recipient died or was placed in an assisted living or nursing home facility, but these additional caregivers were not included in the cost analysis breakdowns. For example, if all 56 intervention caregivers had been included in the intervention training cost analysis, because they benefited from the training, costs for that component would have been $83 per caregiver, instead of $101, indicating greater cost-effectiveness. At least one of the REACH II sites used interventionists with bachelors degrees (as opposed to masters degrees in Memphis), which would further decrease personnel costs, which were the major component of intervention costs. In addition, although caregiver time for participation is valuable and a cost to them and an important component of the cost-effectiveness analysis, these costs of $167 per caregiver would not be part of an agency's costs. Because the intervention included two distinct components, each with separate costs, future work could investigate whether both are necessary to achieve this intervention effect.
As AD progresses, costs increase, from $9,239 per year in early stages to $19,925 in later stages.46
Costs increase based on cognitive levels and comorbid conditions, although costs are 21% lower for patients who live at home than for those who are institutionalized.47
The REACH II intervention was designed to assist caregivers of people with dementia who were providing care at home to enhance their coping skills and management of care recipient behaviors. The intervention significantly improved caregiver quality of life—caregiver burden, depression and emotional well-being, self-care and healthy behaviors, social support, and care recipient problem behaviors. It also provided that most scarce commodity for caregivers—time—in an additional hour per day not providing direct care. Although most caregivers of people with dementia express a desire to provide care in the home, the emotional and physical costs to caregivers are enormous. This intervention was able to alleviate some of that cost.