부산대학교 도서관

Keywords: cognitive behavioral therapy; cost-effectiveness analysis; insomnia; osteoarthritis; sleep initiation and maintenance disorders Abstract Background Osteoarthritis-related insomnia is the most common form of comorbid insomnia among older Americans. A randomized clinical trial found that six sessions of telephone-delivered cognitive behavioral therapy for insomnia (CBT-I) improved sleep outcomes in this population. Using these data, we evaluated the incremental cost-effectiveness of CBT-I from a healthcare sector perspective. Methods The study was based on 325 community-dwelling older adults with insomnia and osteoarthritis pain enrolled with Kaiser Permanente of Washington State. We measured quality-adjusted life years (QALYs) using the EuroQol 5-dimension scale. Arthritis-specific quality of life was measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Insomnia-specific quality of life was measured using the Insomnia Severity Index (ISI) and nights without clinical insomnia (i.e., 'insomnia-free nights'). Total healthcare costs included intervention and healthcare utilization costs. Results Over the 12months after randomization, CBT-I improved ISI and WOMAC by -2.6 points (95% CI: -2.9 to -2.4) and -2.6 points (95% CI: -3.4 to -1.8), respectively. The ISI improvement translated into 89 additional insomnia-free nights (95% CI: 79 to 98) over the 12months. CBT-I did not significantly reduce total healthcare costs (-$1072 [95% CI: -$1968 to $92]). Improvements in condition-specific measures were not reflected in QALYs gained (-0.01 [95% CI: -0.01 to 0.01]); at a willingness-to-pay of $150,000 per QALY, CBT-I resulted in a positive net monetary benefit of $369 with substantial uncertainty (95% CI: -$1737 to $2270). Conclusion CBT-I improved sleep and arthritis function without increasing costs. These findings support the consideration of telephone CBT-I for treating insomnia among older adults with comorbid OA. Our findings also suggest potential limitations of the general quality of life measures in assessing interventions designed to improve sleep and arthritis outcomes. Article Note: Funding information National Institute on Aging, Grant/Award Number: R01AG053221 CAPTION(S): Appendix S1. Supporting Information. Supplementary Methods S1. Multiple imputation details. Supplementary Methods S2. Definition, calculation, and interpretation of three terms: incremental cost-effectiveness ratios, willingness to pay, and net monetary benefit. Supplementary Table S1. Number and percentage of individuals who had responded to patient-reported health outcome surveys at a given time point or disenrolled from health plan. Supplementary Table S2. Percent of estimates from the 1000 bootstrap resamples that fall into each quadrant of the incremental cost-effectiveness plane shown in Figure 1 of the manuscript. Supplemental Table S3. Observed effectiveness outcomes by treatment arm and period (baseline and over the 12months after randomization) in the complete case sample (n = 236). Supplemental Table S4. Observed mean healthcare utilization costs over the 12months after randomization. Supplemental Figure S1. Cost-effectiveness acceptability curve of CBT-I for quality-adjusted life years (derived from the as measured by the EuroQol five dimension) in the 12months after randomization. Byline: Weiwei Zhu, Susan M. McCurry, Michael Von Korff, Robert Wellman, Charles M. Morin, Michael V. Vitiello