Economic and ethical implications of improving access to health care for older people with intellectual disabilities in England: a cost-effectiveness modelling study of health checks
The Lancet 390 S4
An increasing number of people with intellectual disabilities are reaching old age. Knowledge has emerged internationally about the complex and largely unmet health needs of this specific ageing population, and associated costs. Annual health checks, incentivised but not mandatory for primary care in England, seek to reduce health inequities for this population. However, their cost-effectiveness is unknown. Our study aimed to address this evidence gap.
We developed a decision analytical Markov model to compare a strategy in which older people with intellectual disabilities received annual health checks with standard care. The model, developed to inform a guideline for the National Institute for Health and Care Excellence (NICE), followed hypothetical cohorts of 1000 people in England from when they were 40 years old until they died. Outcome measure was cost per quality-adjusted life-year (QALY) gained. We calculated incremental cost-effectiveness ratios (ICER). Costs were assessed from a health provider perspective and expressed in 2016 British pounds. Costs and QALYs were discounted at 3·5%. We carried out probabilistic sensitivity analysis. Data from published studies as well as expert opinions informed parameters.
Annual health checks led to a mean QALY gain of 0·072 (95% CI 0·069–0·113) and mean incremental costs of £4911 (4897–5133). For a threshold of £30?000, annual health checks were not cost effective (mean ICER £89?200, 95% CI 86?252 to 136?769). Costs of intervention needed to reduce from £258 to under £100 per year for annual health checks to be cost effective.
Although our findings need to be considered with caution since the model was based on assumptions to overcome evidence gaps, they suggest that providing cost-effective annual health checks is difficult. This immediately raises ethical questions about equitable access to health checks and health itself. Additional resources are needed if health systems are to contribute to a fairer society.