Higher Health Care Resource Use, Costs Associated With Falls Among Older Medicare Beneficiaries on Commonly Used Insomnia Medications in the United States

^{By Feride Frech, PhD, MPH, Senior Director, US HEOR & RWE, Eisai Inc, and Timothy Juday, Director, US HEOR & RWE, Eisai Inc.} 

Insomnia, the most common sleep-wake disorder, is prevalent in the general population and is associated with significant human and economic cost. 

The prevalence of insomnia increases with age. The US population age 65 and older numbered 52.4 million in 2018, or about one in every seven Americans. Insomnia-related costs in the US have been estimated to exceed $100 billion per year.

Sleep medications may contribute to the risk of falls in this population. Falls are a main case of morbidity and disability in older adults; more than one in four people 65 or older fall each year and falling once doubles the chances of a recurring fall. In the US, fall-related injuries are among the most expensive medical conditions among adults of all ages and these costs increase with age. In the US, fall-related injuries result in significant medical costs, and the number of falls as well as the resulting expenditures are expected to increase with the aging population. 

This retrospective cohort study sought to compare health care resource utilization (HCRU) and costs between elderly Medicare patients (age 65 years and older) treated with common insomnia medications and a matched control group of elderly Medicare patients (age 65 years and older) with no sleep disorders, and to estimate incremental HCRU and costs associated with falls. 

The retrospective cohort study identified 1,699,913 Medicare beneficiaries from Jan. 2011-Dec. 2017 (mean age of 75 years, 60% female) who received one of the commonly used prescription insomnia medications: zolpidem immediate release (IR,36.2%), zolpidem extended release (ER, 0.5%), trazodone (34.2%), or benzodiazepines (29.1%). A control group with no evidence of sleep-related diagnoses, procedures or treatments was also identified using a 1:1 match on age and sex with the treated cohort. 

After adjustment for age, sex, race, geographic region and comorbidity burden, incidence rates for fall events per 100 person years and adjusted mean per patient per month (PPPM) costs were estimated for the overall insomnia treated group as well as each specific treatment group compared to the control group. 

Fall rates were higher among those with treated insomnia, and the risks of falls varied by treatment  

Overall, more than three times as many patients treated for insomnia had a fall compared to those with no sleep disorders (9.35% vs. 3.09%). Compared to matched controls, the adjusted incidence rate for fall events in the insomnia treated cohort varied by treatment with the biggest difference among patients taking benzodiazepines (11.30% vs. 3.20%) and trazodone (9.51% vs. 3.36%).  

Health care utilization costs were higher among those with treated insomnia compared to those with no sleep disorders 

In this study, older adults treated with commonly used insomnia medications had higher adjusted mean per patient per month (PPPM) costs compared to those with no sleep disorders ($967 vs. $455, p<0.001). The inpatient, emergency department and outpatient costs were also higher for the insomnia treated group than the control group ($1,912 vs. $1,529; $134 vs. $97; and $292 vs. $161, respectively; p<0.001). 

Furthermore, older adults treated with commonly used insomnia medications and a fall event had higher PPPM health care costs compared to those with no fall events ($1,928 vs. $856). 

Falls are a common and serious health problem with potentially devastating consequences among older adults. As the risk of falls varies by insomnia treatment, careful selection for use of insomnia treatment in the elderly population is needed.    

The following limitations were noted by the study authors

Coding errors or omissions may have occurred as claims data are collected for billing and reimbursement, not research purposes. Administrative design precludes determination of causality. Claims data from those covered by Medicare Part C are not available in the claims database used for this study. Results may not be generalizable to other insured populations. This analysis does not include over-the-counter treatments, less frequently used prescription medication and non-pharmacological treatments. 

References:

1. Roth T. Insomnia: definition, prevalence, etiology and consequences. J Clin Sleep Med. 2007;3(5 Suppl):S7–S10.
2. Sleep Foundation, 2020 https://www.sleepfoundation.org/articles/sleep-aids-and-insomnia
3. The Administration for Community Living.
4. Wickwire EM et al. Sleep Med Rev. 2016 Dec;30:72-82.
5. Kathy L. Nguyen, Jonathan H. Watanabe; Association Between Sleep Medications and Falls and Fall-related Worries in Community-Dwelling Older Adults in the United States. Journal of Contemporary Pharmacy Practice 1 June 2019; 66 (3): 23–32.
6. Centers for Disease Control and Prevention, 2017 https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html
7. Florence CS et al. The Medical Costs of Fatal Falls and Fall Injuries among Older Adults. J Am Geriatr Soc. 2018;66(4): 693–698.