Economic Evaluation of an Intervention to Improve Mouth Care and Reduce Pneumonia Incidence in Nursing Homes: An Exploratory Analysis.

Background/

Objectives

Poor oral health, which is often overlooked in nursing homes (NHs), is associated with aspiration pneumonia. This analysis assesses the cost effectiveness of an oral hygiene intervention, "Mouth Care Without a Battle©" (MCWB), which trains NH staff to provide daily mouth care. The first year of a pragmatic cluster randomized effectiveness trial conducted in 14 NHs demonstrated a significant reduction in pneumonia incidence in intervention NHs.

Methods

Because the two-year primary outcome was not statistically significant, the first-year analysis is post hoc. The incremental cost-effectiveness ratio (ICER) of costs (staff training, time spent providing mouth care, and pneumonia-related hospitalizations) to effects (reductions in pneumonia cases) over one year was estimated using bootstrapping.

Results

Analyses for 1605 residents with clustering by NH show that the likelihood that MCWB is cost-saving ranges from 6.5% to 61.1% depending on whether staff are paid benefits and various levels of estimated hospital costs. Similarly, the likelihood that MCWB results in reduced pneumonia cases but with higher costs ranges from 32.0% to 86.6%. Whether MCWB is cost-effective depends on society's willingness to pay for reduced pneumonia cases and related unmeasured benefits. These estimates may represent a lower bound of potential cost savings because analyses did not include costs of treating pneumonia if not hospitalized, ambulance transport, or the emotional costs of illness. However, other excluded costs (e.g., dental restorations) and resources required to improve fidelity could reduce the likelihood of cost savings.

Conclusions

MCWB and similar interventions that improve oral health care in NHs may yield cost savings or produce benefits from the reduction in pneumonia that justify net increases in costs incurred. It is also important to consider who bears the costs (e.g., the NH) versus who reaps the benefits (e.g., healthier residents and reduced Medicare payments).