The economic burden of Alzheimer's disease care

Assessing the health and economic impact of galantamine treatment in patients with Alzheimer's disease in the health care systems of different countries

INTRODUCTION

Cholinesterase inhibitors have been shown to improve cognitive function and improve or maintain global function.

OBJECTIVE

To estimate the long-term economic impact of treating patients with Alzheimer's disease with galantamine in seven healthcare systems: Australia, Canada, Finland, New Zealand, Sweden, the Netherlands and the UK.

METHODS

The time until patients require full-time care (FTC), defined as the consistent requirement for a significant amount of care giving and supervision each day, and the associated costs were evaluated using the 'Assessment of Health Economics in Alzheimer's Disease (AHEAD)' model. Efficacy data were obtained from three clinical trials comparing galantamine with placebo and local cost and resource use data were determined for each country. Forecast costs reported in Euros (2001 value), were made for up to 10 years in each healthcare system. All costs were determined from a perspective somewhat broader than that of a comprehensive payer, including social services. Both benefits and costs were discounted at 3%.

RESULTS

Galantamine (16 mg/day) is predicted to delay the need for FTC by 6.8%, thus the cumulative cost of care over 10 years is expected to be reduced, and this offsets much or all of the cost of galantamine. Approximately five patients need to be treated to avoid 1 year of FTC. In each healthcare system, FTC was estimated to account for 61-92% of the cost. Savings were estimated for most of the countries. For those countries with an expected expense, there were reasonable costs per FTC month avoided (euro553, discounted) and costs per quality-adjusted life year gained (euro25,000).

CONCLUSION

In addition to the clinical benefits associated with galantamine treatment, the savings predicted from delaying FTC may offset the treatment costs.

Family involvement in residential long-term care: a synthesis and critical review

The objective of this review is to critically synthesize the existing literature on family involvement in residential long-term care. Studies that examined family involvement in various long-term care venues were identified through extensive searches of the literature. Future research and practice must consider the complexity of family structure, adopt longitudinal designs, provide direct empirical links between family involvement and resident outcomes, and offer rigorous evaluation of interventions in order to refine the literature.

The Price of Palliative Care: Toward a Complete Accounting of Costs and Benefits

In this article, currently accepted standards for cost-benefit analysis of health care interventions are outlined, and a framework to evaluate palliative care within these standards is provided. Recent publications on the economic implications of palliative care are reviewed, which are only the "tip of the iceberg" of the potential costs and benefits. Using this framework, the authors offer guidelines for performing comprehensive cost-benefit analyses of palliative care and conclude that many of the issues beneath the surface may be substantial and deserving of closer scrutiny. Methods for gathering relevant cost-benefit information are detailed, along with potential obstacles to implementation. This approach is applicable to palliative care in general, including palliative care for elders.

Variation in cost of informal caregiving and formal-service use for people with Alzheimer's disease

This study used a geographically diverse sample to estimate the total cost of informal care and formal services for community-residing Alzheimer's disease (AD) care recipients. Baseline data were used for 1200 family caregivers from the Resources for Enhancing Alzheimer's Caregiver Health (REACH) study, a multisite intervention trial. The replacement-wage-rate approach estimated informal cost. Formal services were assigned a cost based on secondary sources. Annual cost per care recipient amounted to 23,436 dollars for informal care and 8064 dollars for formal services. Variation in informal cost was almost entirely due to instrumental activities of daily living (IADLs) assistance. Cross-site differences in cost persisted after controlling for caregiver and care-recipient characteristics. Geographic variation may suggest regional preferences or ethnic/cultural values. Further study is needed to determine whether this reflects differences in access or availability or how including a control group for care recipients with nondementia diagnoses might have affected these findings.

Cost effects of a specialized care center for people with Alzheimer's disease

A retrospective cohort control study of three populations, 65 years of age or older, at the same institution estimated the incremental cost of Alzheimer's disease (AD). The AD population of the ambulatory Alzheimer's Disease Center (ADC) (n = 640) was matched by age, gender, ethnicity, and address to one with AD from the general internal medicine practice (AD-GM) (n = 419) and to a control group without AD (n = 5331)from the same general medicine practice. Medicare costs of all care for all diagnoses were obtained for 1998 and 1999. Mean per person annual Medicare costs were $19,418 for ADC, $18, 753 for AD-GM, and $12,085 for the control group. Incremental cost for ADC population was $7,333 and $6,668 for AD-GM population compared with the control group. Incremental cost was $665 (9.1 percent) higher for ADC than AD-GM. Higher non-AD hospitalizations and length of stay (LOS) by AD populations were the main cost drivers.

The Relationship Between a Dementia Diagnosis, Chronic Illness, Medicare Expenditures, and Hospital Use

OBJECTIVES

To determine whether dementia increases medical expenditures, the probability of hospitalization, and potentially preventable hospitalization, controlling for variables including age and comorbidity.

DESIGN

Cross-sectional analysis of 1 year of claims data comparing usage by patients with claims for dementia with usage by those without dementia.

SETTING

A nationally representative 5% random sample of Medicare beneficiaries in 1999.

PARTICIPANTS

Medicare beneficiaries aged 65 and older with fee-for-service Medicare Parts A and B coverage for 1999 (N=1,238,895; dementia patients n=103,512).

MEASUREMENTS

Per capita expenditures, rate of all-cause hospitalization, rate of preventable hospitalization as defined using ambulatory-care sensitive condition (ACSC) admissions, and dementia identified using International Classification of Diseases, 9th Edition, codes 290, 294, and 331.

RESULTS

Prevalence of dementia was 8.3%. In a model of expenditures in those who survived the year adjusting for age, sex, race, and comorbidity, dementia was associated with an incremental cost of 6,927 US dollars, or 3.3 times greater total expenditures than in nondementia patients (P<.001), with higher expenditures for each specific type of Medicare service. Hospitalization accounted for 54% of adjusted costs. The adjusted odds of hospitalization associated with dementia were 3.68 (95% confidence interval (CI)=3.62-3.73) and adjusted odds of ACSC hospitalization were 2.40 (95% CI=2.35-2.46). In those who died, the associations were positive but of smaller magnitude.

CONCLUSION

In a nationally representative sample, higher Medicare expenditures associated with a diagnosis of dementia are in large part due to increased hospitalization. Further study is needed into the factors associated with high rates of hospitalization in dementia patients including aspects of ambulatory management that may be improved.

The Needs of the Caregiver in the Long-Term Treatment of Alzheimer Disease

The long-term well-being of caregivers should be included as part of the treatment of patients with Alzheimer disease (AD). Throughout the process of caring for patients with AD, caregivers frequently experience social, emotional, physical, and financial losses, which become more significant as the disease progresses. Minimizing these losses is a goal in the overall management of AD. Successful treatment of the patient has been shown to positively impact quality of life for the caregiver. Randomized, controlled studies of acetylcholinesterase inhibitors (AChEIs) have demonstrated the effectiveness of these agents in stabilizing cognitive function and delaying behavioral symptoms. Moreover, a decrease in the incidence of nursing home placement has been associated with this therapy. The growing burden of AD on families and society as a whole warrants the investigation of ways to minimize the impact of AD. AChEIs play an important role in this effort. Further studies are needed to more closely examine the impact of specific AChEIs on caregiver burden.

Family involvement in nursing homes: effects on stress and well-being

While it is clear that families remain involved in the lives of loved ones following placement in a nursing home, little research has examined whether visiting and the provision of care has effects on the emotional stress and psychological well-being of family members. Utilizing pre-placement and post-placement data from the Caregiver Stress and Coping Study (n = 185) as well as a theoretical framework to delineate the manifestation of caregiver stress (i.e., the stress process model), the goal of this analysis was to determine whether frequency of visits and provision of personal and instrumental activities of daily living assistance following institutionalization were related to post-placement emotional distress, family conflict, and psychological well-being among family members. Following control of a wide array of pre-placement and post-placement covariates, multiple regression models found that visiting was negatively associated with post-placement role overload; moreover, the provision of instrumental activities of daily living help was negatively related to loss of intimate exchange at post-placement. The results suggest that family involvement following institutionalization may operate differently than when in the community, and add to the literature emphasizing the positive implications of family involvement in residential long-term care.

Impact of rivastigmine on costs and on time spent in caregiving for families of patients with Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD) places a significant burden on health care systems worldwide. As new treatments are developed, their cost-effectiveness is often assessed to help health care professionals make informed decisions. In addition to the more common practice of assessing direct medical costs, indirect costs, including time spent in caregiving, should be evaluated.

METHODS

This study examined the potential effects of the dual cholinesterase inhibitor rivastigmine (Exelon) on caregivers of patients with AD. Results from two 26-week, placebo-controlled trials have demonstrated the clinically relevant and statistically significant efficacy of rivastigmine (6-12 mg/day) compared to placebo, on cognition, activities of daily living, and global functioning. By delaying progression of AD, significant savings in caregiver burden are anticipated, as measured by time spent caregiving and its related costs. Data collected in a prospective, observational study of AD patients and their caregivers were used to establish the relationship between disease severity (based on Mini-Mental State Examination [MMSE] score) and time spent caregiving (according to the 5-item Caregivers Activity Survey score). A significant correlation was observed between the two scores (N = 43, r = -.56, p < .0001), demonstrating that more time for supervision from caregivers is required as the disease progresses. This finding was used to estimate the reduced caregiver burden resulting from the delay in disease progression that was demonstrated with use of rivastigmine.

RESULTS

Over a 2-year period, the reduction in time spent in caregiving reached 691 hours for caregivers of patients with mild AD (MMSE score 21-30), resulting in a total savings of approximately 11,253 dollars. Treatment of patients with moderately severe AD was also evaluated. The trend was similar but the impact was less, suggesting an economic benefit to early therapy.

CONCLUSION

Early diagnosis and a pharmacologic intervention that allows the patients to remain at home longer by delaying disease progression would have a beneficial impact on patients, caregivers, and payers, and should therefore be encouraged through initiatives designed to identify and treat patients early in the course of disease.

Population aging and the need for long term care: a comparison of the United States and the People's Republic of China

Both developing and major developed countries of the world are facing the global aging of their citizenry. The United States and the People's Republic of China each share in this phenomenon. The rapid growth of their aging populations comes as both countries are experiencing a sustained period of economic stability with an accompanying drop in fertility rates (Coale & Watkins 1986; Dyson & Murphy 1985). Together with longer expected life spans in both countries, these factors have caused a shift in the population structure which will result in increasingly large portions of the population who will potentially require assistance with ADL's and/or long term care (Olson 1990; Kennedy, LaPlante & Kaye 1997). The careful assessment and interpretation of available data to define the actual extent of need should be part of a process to help guide each country as they prepare for the future.

Cost-effectiveness of PET in the diagnosis of Alzheimer disease

PURPOSE

To evaluate the cost-effectiveness of positron emission tomography (PET) in the diagnosis of Alzheimer disease (AD) in community-dwelling patients with mild or moderate dementia who present to specialized AD centers.

MATERIALS AND METHODS

A decision-analytic model was used to compare costs and quality-adjusted life years (QALYs) associated with strategies involving single photon emission computed tomography (SPECT), dynamic susceptibility-weighted contrast material-enhanced magnetic resonance (MR) imaging, and PET as functional imaging adjuncts to the standard clinical work-up. Sensitivity analyses were performed to examine changes in test characteristics, health-related quality-of-life survey instruments, therapeutic effectiveness, and treatment rules.

RESULTS

The use of PET to confirm the results of the standard clinical work-up cost more but yielded fewer benefits than a strategy in which dynamic susceptibility-weighted contrast-enhanced MR imaging was substituted for the typically performed structural computed tomography. This relationship remained stable in scenarios in which standard diagnostic work-up accuracy, drug treatment effectiveness, and version of the Health Utilities Index were altered. Dynamic susceptibility-weighted contrast-enhanced MR imaging cost US dollars 598800 per QALY gained (range, US dollars 74400 to US dollars 1.9 million per QALY), compared with the cost of the standard diagnostic work-up. Treating all patients with dementia was the dominant imaging strategy, except when side effects in patients with non-AD-related dementia were modeled. In all scenarios, SPECT yielded fewer benefits than other strategies at a higher cost.

CONCLUSION

PET may have high diagnostic accuracy, but adding it to the standard diagnostic regimen at AD clinics would yield limited, if any, benefits at very high costs.

Assessment of health economics in Alzheimer's disease (AHEAD): treatment with galantamine in the UK

OBJECTIVE

To assess the long-term health and economic impact of treating mild to moderate Alzheimer's disease (AD) with galantamine (16 mg or 24 mg per day) compared to no cholinesterase therapy in the UK.

METHODS

The long-term costs and outcomes were assessed using a model developed from longitudinal data on a cohort of AD patients. The model predicts the time until patients require full-time care, defined as the consistent requirement for a significant amount of care and supervision each day. Efficacy data were obtained from three clinical trials comparing galantamine with placebo, forecasts were made for ten years. Costs were determined in 2001 British pounds and discounted at 6% per annum, while outcomes such as time to full-time care were discounted at 1.5%.

RESULTS

Without pharmacological treatment, patients are expected to incur costs of 28,134 British pounds over ten years, 70% of costs accrue from providing full-time care. Galantamine (16 mg per day) is predicted to reduce the duration of the full-time care state by 12%; approximately five patients need to be treated to avoid one year of full-time care. The ten-year incremental costs per month of full-time care avoided average pound 192 British pounds per patient and 8,693 British pounds per QALY. Savings (1380 British pounds) are predicted for patients who continue treatment beyond six months and whose cognitive function is maintained or improved. Comparable results were estimated for the 24 mg dose.

CONCLUSION

In addition to the clinical benefits associated with galantamine treatment, the savings predicted from delaying when full-time care is needed may offset the treatment costs.

Cognitive impairment and resource use of nursing home residents: a structural equation model

BACKGROUND

Only a few studies have examined relationships between cognitive impairment and resource use of nursing home residents, and these studies have yielded mixed results.

METHODS

To develop and test structural equation models for relationships between cognitive impairment, covariates, and resource use of nursing home residents on Alzheimer special care units (SCUs) and conventional units.

RESEARCH DESIGN

Analysis of data obtained in 1999 from an Indiana nursing facility time study that measured resident-specific direct care minutes per day, and assessment data from the Minimum Data Set (version 2.0).

PARTICIPANTS

Participants were 1290 residents without specialized nursing requirements or licensed therapies: 447 drawn from 22 SCUs in 16 facilities, 485 from 16 conventional units in the same facilities, and 358 from units in 13 facilities without SCUs.

MEASURES

Direct care resource use (weighed minutes/d), Cognitive Performance Scale, activities of daily living (ADLs), clinically complex conditions, daily behavioral problems, physical restraints, psychotropic medication, and Alzheimer or dementia diagnosis.

RESULTS

Cognitive impairment had a substantial indirect effect on resource use in facilities with and without SCUs. This effect was mediated largely through ADL dependency and SCU placement. Severity of cognitive impairment was strongly related to ADL dependency, and ADL, in turn, was a strongly related to resource use. Also, residents on SCUs used significantly more direct care resources than residents on conventional units.

CONCLUSIONS

This study demonstrates relationships between cognitive impairment, covariates, and resource use for nursing home residents on SCUs and conventional units. It also raises issues about reimbursement for care of dementia residents.

Economic evaluation of galantamine in the treatment of mild to moderate Alzheimer's disease in the United States

BACKGROUND

Alzheimer's disease (AD) is estimated to affect up to 11% of those aged > or =65 years in the United States, and the number of patients with AD is predicted to increase over the next few decades as the population ages. The substantial social and economic burden associated with AD is well established, with the cost of management increasing as the disease progresses.

OBJECTIVE

The aim of this study was to evaluate the economic impact of galantamine 16 and 24 mg/d relative to no pharmacologic treatment in the management of mild to moderate AD in the United States based on the concept of need for full-time care (FTC).

METHODS

Calculations were made using the Assessment of Health Economics in Alzheimer's Disease model, which applies predictive equations to estimate the need for FTC and the associated costs. The predictive equations were developed from longitudinal data on patients with AD. Inputs to the equations were derived by analyzing the data from 2 randomized, placebo-controlled, galantamine clinical trials. Resource use (from a payer perspective) was estimated from US clinical trial data, and costs were estimated from several US databases. Analyses were carried out over 10 years, and costs and benefits were discounted at 3%.

RESULTS

In the base case, 3.9 to 4.6 patients need to start treatment with galantamine to avoid 1 year of FTC, depending on dose. Treated patients spent 7% to 8% more time pre-FTC and 12% to 14% less time requiring FTC, resulting in savings of 2408 to 3601 US dollars. Time horizons below 3 years, very high discontinuation rates, or increased survival with galantamine reversed the savings. Conversely, limiting treatment to responders delayed FTC by 6 to 7 months, with savings of approximately 9097 to 11,578 US dollars.

CONCLUSIONS

These results suggest that use of galantamine in patients with AD in the United States could reduce the use of costly resources such as formal home care and nursing homes, leading to cost savings over time.

The magnitude of dementia occurrence in the world

In this study, the worldwide occurrence of dementia in 2000 and during the period 1950-2050 was estimated. The calculations were based on worldwide demographics of the elderly and age-specific prevalence and incidence values of dementia, estimated from a meta-analysis. In a sensitivity analysis, different prevalence sources were used. The worldwide number of persons with dementia in 2000 was estimated at about 25 million persons. Almost half of the demented persons (46%) lived in Asia, 30% in Europe, and 12% in North America. Fifty-two percent lived in less developed regions. About 6.1% of the population 65 years of age and older suffered from dementia (about 0.5% of the worldwide population) and 59% were female. The number of new cases of dementia in 2000 was estimated to be 4.6 million. The forecast indicated a considerable increase in the number of demented elderly from 25 million in the year 2000 to 63 million in 2030 (41 million in less developed regions) and to 114 million in 2050 (84 million in less developed regions). In conclusion, the majority of demented elders live in less developed regions, and this proportion will increase considerably in the future.

Cost of illness of Alzheimer's disease: how useful are current estimates?

PURPOSE

The goal of this literature review was to determine the validity and policy relevance of recent estimates from many countries of Alzheimer's disease (AD) costs.

DESIGN AND METHODS

We searched Medline and other databases for English-language peer-reviewed journals on total, direct, indirect, and per case cost of AD that used 1985-2000 data. We adjusted costs of U.S. studies for inflation. We adjusted non-U.S. studies by that country's medical cost inflation rate and purchasing power parity (PPP).

RESULTS

Of 71 studies identified, 21 met all criteria for inclusion. Annual inflation adjusted U.S. total costs of AD varied from $5.6 billion to $88.3 billion. AD total per case (direct and indirect) costs varied from $1,500 to $91,000; indirect/family costs varied from $3,700 to $21,000. Among non-U.S. studies, AD annual adjusted per case costs varied from PPP $2,300 to PPP $30,000. Cost variation was due to diverse study methods, data sources, services included, and lack of clear differentiation between cost of AD and cost of caring for people with AD.

IMPLICATIONS

The cost of AD is high, although reliable estimates are not available. Costs are likely to rise given expected demographic shifts in all countries. The widely variable cost estimates call into question the real costs of Alzheimer's disease and their applicability to policy initiatives.

Full-spectrum proxy consent for research participation when persons with Alzheimer disease lose decisional capacities: research ethics and the common good

This article focuses on riskier forms of research in Alzheimer disease (AD). It asks two fundamental questions. First, what is the upper threshold of potential risk that should be allowable in AD Research ("maximal potential risk")? Second, should proxy consent be permitted in higher-risk research even when there is no clear potential therapeutic value to the subject? There has been little discussion of maximal potential risk at a time when studies may be becoming increasingly invasive and risky. Proxy consent under such circumstances merits more thorough defense. This article discusses these questions on the basis of a "common good" ethic and calls for more input from researchers and the AD-affected constituency in resolving them.

Pharmacoeconomics of cholinesterase inhibitors in the treatment of Alzheimer's disease

Cholinesterase inhibitors constitute one of few treatment options available for Alzheimer's disease, the most common cause of dementia. The modest effects and relatively high acquisition costs of these drugs make the health economics of dementia an important subject of study. Simulation models can be used to bring together existing data and make predictions of the long-term cost effectiveness of treatment. Most models have been built around cognitive function as a key parameter based on the observed relationship between cognitive function and costs of care. Patients with more severe disease attain higher total costs of care. Also, these patients have a higher share of formal care costs than do patients with mild disease, who are usually looked after by informal caregivers. The valuation of unpaid care is controversial, and the choice of method may affect results considerably. Another important issue is the measurement of health-related QOL in patients with Alzheimer's disease. The few existing studies have used proxy respondents to elicit utility weights in different disease states; however, this methodology has not been validated. It is likely that the increased drug costs incurred by the use of cholinesterase inhibitors will be offset (at least partly) by savings in other healthcare costs. However, these results should be viewed as preliminary, since we are still awaiting data from long-term follow-up studies. Also, the value of treatment for patients and caregivers in terms of QOL improvements has yet to be established.

Cognitive function and acute care utilization

OBJECTIVES

Little is known about variation in cognitive function across the aged population, or how use and costs of health care vary with cognitive impairment. This study was designed to create a typology of cognitive function in a nationally representative sample, and evaluate acute care use in relation to cognitive function, holding constant confounding factors. By including proxy assessments of cognitive function, this is the first study to include individuals unable to respond themselves.

METHODS

We analyzed the baseline year of the Asset and Health Dynamics Among the Oldest Old (AHEAD) survey, sponsored by the National Institute on Aging, to create three levels of cognitive function, using direct measures for self-respondents (n = 6,651) and proxy evaluations for the others (n = 792). We used a two-part model to predict the likelihood of using various health services and to evaluate intensity of care among users.

RESULTS

Sixteen percent, 64%, and 20% of the sample fell into the low, moderate, and high cognitive function groups, respectively, that differed significantly on almost all demographic and health status measures, and some utilization measures. Controlling for other health and functional status measures, lower cognitive function had a significant and negative effect on outpatient services, but did not affect hospital use directly.

DISCUSSION

Lower cognitive function may be a barrier to outpatient care, but these analyses should be repeated using administrative use and cost data.

Resource utilisation and cost analysis of memantine in patients with moderate to severe Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD) is a devastating illness that causes enormous emotional stress to affected families and is associated with substantial medical and nonmedical costs.

OBJECTIVE

To determine the effects of 28 weeks of memantine treatment for patients with AD on resource utilisation and costs.

STUDY DESIGN AND METHODS

Multicentre, prospective, double-blind, randomised, placebo-controlled clinical trial performed in the US. The Wilcoxon-Mann-Whitney test was used to examine the resource utilisation variables and logistic regression models were used for multivariate resource utilisation analyses. Analysis of covariance (ANCOVA) models (log and non-log) were computed to examine costs from a societal perspective. All costs were calculated in 1999 US dollars.

STUDY POPULATION

Outpatients with moderate to severe AD. Overall, 252 patients received randomised treatment, and 166 patients (placebo n = 76, memantine n = 90) formed the treated-per-protocol (TPP) subset for the health economic analyses, on which the main cost analysis was based.

MAIN OUTCOME MEASURE

Resource Utilisation in Dementia (RUD) scale, measuring patient and caregiver resource utilisation, and various sources for cost calculations.

RESULTS

Controlling for baseline differences between the groups, significantly less caregiver time was needed for patients receiving memantine than for those receiving placebo (difference 51.5 hours per month; 95% CI -95.27, -7.17; p = 0.02). Analysis of residential status also favoured memantine: time to institutionalisation (p = 0.052) and institutionalisation at week 28 (p = 0.04 with the chi-square test). Total costs from a societal perspective were lower in the memantine group (difference dollars US 1089.74/month [non-overlapping 95% CI for treatment difference -1954.90, -224.58]; p = 0.01). The main differences between the groups were total caregiver costs (dollars US-823.77/month; p = 0.03) and direct nonmedical costs (dollars US-430.84/month; p = 0.07) favouring memantine treatment. Patient direct medical costs were higher in the memantine group (p < 0.01), mainly due to the cost of memantine.

CONCLUSION

Resource utilisation and total health costs were lower in the memantine group than the placebo group. The results suggest that memantine treatment of patients with moderate to severe AD is cost saving from a societal perspective.

Informal caregiving for chronic lung disease among older Americans

STUDY OBJECTIVE

To obtain nationally representative estimates of the additional time, and related cost, of unpaid family caregiving (informal caregiving) associated with chronic lung disease among older Americans.

DESIGN

Multivariable regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people > or = 70 years old (n = 7,443).

PARTICIPANTS

National population-based sample of the community-dwelling elderly.

MEASUREMENTS

Weekly hours of informal caregiving, and imputed cost of caregiver time, for community-dwelling elderly who reported the following: (1) no lung disease, (2) lung disease without associated activity limitations, or (3) lung disease with associated activity limitations.

RESULTS

After adjusting for sociodemographic variables, potential caregiver network, and comorbid conditions, individuals with chronic lung disease and associated activity limitations (n = 403) received an additional 5.1 h/wk of informal care when compared to those with no lung disease (n = 6,593; p < 0.001). The associated additional yearly cost of informal care per case was $2,200 USD. This represents a national annual cost of informal caregiving for chronic lung disease of > $2 billion USD.

CONCLUSIONS

The quantity and associated economic cost of informal caregiving for elderly individuals with chronic lung disease are substantial. These costs to families and society must be accounted for if the full societal costs of chronic lung disease are to be calculated. Pulmonary physicians caring for elderly individuals with chronic lung disease should be mindful of the importance of informal care for the well-being of their patients, as well as the potential for significant burden on those (often elderly) individuals providing the care.

Managing end-of-life care: comparing the experiences of terminally Ill patients in managed care and fee for service

There have been no published empirical studies comparing the experiences of terminally ill patients in managed care organizations (MCOs) and those in fee for service (FFS). This investigation represents the first empirical study to systematically compare substantive outcomes between populations of terminally ill patients enrolled in MCO and FFS healthcare delivery systems. The investigators interviewed 988 patients whose physicians judged them to be terminally ill and 893 of their caregivers. Outcomes assessments were made in six domains: patient-physician relationship; access to care and use of health care; prevalence of symptoms; and planning for end-of-life care, care needs, and economic burdens. Overall, the two populations of terminally ill patients were found to have comparable outcomes, but several significant differences were present. MCO patients were more likely than their FFS counterparts to use an inconvenient hospital (P =.02), spend more than 10% of their income on medical care (P =.02), and have been bedridden more than 50% of the time during the last 4 weeks of life (P =.03). Caregivers of MCO patients were as likely as the caregivers of FFS patients to report a substantial caregiving burden (P =.59). Despite concerns about the threats of MCOs to the physician-patient relationship, few differences in the quality of the relationship between the two cohorts were found. Finally, terminally ill patients in MCOs did not show better experiences than those in FFS on any outcome measure. Additional research is required to explore how MCOs may improve upon the care available to dying patients.

The public health impact of Alzheimer's disease, 2000-2050: potential implication of treatment advances

Recent developments in basic research suggest that therapeutic breakthroughs may occur in Alzheimer's disease treatment over the coming decades. To model the potential magnitude and nature of the effect of these advances, historical data from congestive heart failure and Parkinson's disease were used. Projections indicate that therapies which delay disease onset will markedly reduce overall disease prevalence, whereas therapies to treat existing disease will alter the proportion of cases that are mild as opposed to moderate/severe. The public health impact of such changes would likely involve both the amount and type of health services needed. Particularly likely to arise are new forms of outpatient services, such as disease-specific clinics and centers. None of our models predicts less than a threefold rise in the total number of persons with Alzheimer's disease between 2000 and 2050. Therefore, Alzheimer's care is likely to remain a major public health problem during the coming decades.

The costs of vascular dementia: a comparison with Alzheimer's disease

OBJECTIVES

To estimate the costs of Medicare patients with vascular dementia (VaD). To compare the costs of VaD to Alzheimer's disease (AD) and controls without dementia.

METHODS

The study samples were drawn from community-dwelling patients in a large Medicare managed care organization (MCO) operating in the Northeast region of the USA. Costs for three study groups were contrasted in the study: 240 cases with vascular dementia (VaD), 1,366 cases with Alzheimer's disease (AD), and 19,300 controls without dementia. Costs were estimated from medical and pharmacy claims data. Estimated cost differences are controlled for age, gender, and comorbid conditions using regression analysis.

RESULTS

VaD patients accounted for 6% of all dementia patients identified in the health plan. VaD patients had substantially higher prevalence rates for 10 cardiovascular conditions compared with AD patients and controls. Annual costs for VaD patients were US$6,797 greater than AD patients. Compared with controls, costs were US$10,545 higher for VaD patients and US$3,748 higher for AD patients. Higher costs for VaD and AD patients relative to controls were largely attributable to higher inpatient costs.

CONCLUSIONS

Annual medical costs for VaD patients were substantially higher than costs for patients with AD and control patients without dementia. The high cost of VaD patients suggests a need to improve medical management and treatment of these patients to optimize patient outcomes and medical costs.

Family care for older adults with disabilities: toward more targeted and interpretable research

Family care of the elderly is key to the long-term care system, and its importance has led to an abundance of research over the past two decades. Several methodological and substantive issues, if addressed, could create even more targeted and interpretable research. The present review critically examines methodological topics (i.e., definitions of family caregiving, measurement of caregiving inputs) and conceptual issues (i.e., family involvement in long-term residential settings, and the care receiver's perspective on care) that have received insufficient attention in the caregiving literature. Throughout this review recommendations are offered to improve these areas and advance the state of the art.

Time spent on informal and formal care giving for persons with dementia in Sweden

The purpose of this paper was to explore the time spent on caring by families of persons with dementia in Sweden. As part of a European Commission project, interviews were carried out on a sample of 92 carers, caring for persons with dementia. The interviews focused on time spent on caring, IADL, ADL and surveillance, as well as formal support received and used. Informal care, measured as hours spent caring, was about 8.5 times greater than formal services (299 and 35 h per month, respectively). Approximately 50% of the total informal care consisted of time spent on surveillance (day and night). Formal care input and informal support, in terms of ADL increased with dementia severity. A regression analysis showed that dementia severity, behavioural disturbances and coping were associated with the amount of informal care. This study gives some new perspectives on informal care giving for persons with dementia and support strategies in general. Some carers do carry a very heavy 24 h responsibility. This aspect of caring must be addressed by the development of well-targeted respite and relief support programmes.

Assessment, measures and approaches to easing caregiver burden in Alzheimer's disease

The reduction of caregiver burden for those caring for patients with Alzheimer's disease (AD) is especially important given the prevalence of AD as populations age. This paper reviews the complex nature of caregiver burden, how it is measured, and possible interventions that may affect caregiver burden. Caregiver characteristics as well as symptoms exhibited by patients contribute to burden. A number of specific quantitative measures which have been developed to better evaluate caregiver burden are discussed. Such measures are also useful in measuring the impact of interventions on caregiver burden. Pharmacological treatment of patients with AD through the use of acetylcholinesterase inhibitors has positively affected cognition, activities of daily living, and behavioural problems. These benefits significantly reduce caregiver burden. The same is true for psychosocial interventions for the caregiver. It has been suggested that combining both approaches should be utilised for optimal management. Our knowledge of caregiver burden has greatly increased over the past two decades with clear benefits for both patients and caregivers. However, many aspects still clearly require further research. Given the significance of caregiver burden, various aspects have been extensively studied including contributing and protective factors, quantitative assessment, and pharmacological and psychosocial intervention. It is important for clinicians to be aware of this knowledge so that they can effectively incorporate it into their treatment plans for those affected by AD.

The diagnosis and differential diagnosis of dementia

The initial approach to the patient with memory complaints should consist of a focused history, mental status examination, and functional assessment. Patients with MCI should be monitored every 6 to 12 months for conversion to dementia. Delirium, depression, amnestic disorders, and aphasias should be considered in the differential diagnosis of memory impairment. Once a diagnosis of dementia is made, patients should have a brain CT or MRI scan and laboratory tests to assist with determining the cause. It is crucial that dementia be recognized and evaluated at the earliest stage so as to begin appropriate therapy and allow the patient to have a role in management decisions. In the future, therapies for MCI may prevent conversion to dementia. The need for early recognition makes the development of diagnostic tools, such as quantitative or functional neuroimaging, and genetic or clinical biologic markers essential.

The costs of caring: medical costs of Alzheimer's disease and the managed care environment

This review summarizes the medical costs associated with Alzheimer's disease (AD) and related dementias, as well as the payers responsible for these medical costs in the US health care system. It is clear from this review that AD and related dementias are associated with substantial medical costs. The payers responsible for a majority of these costs are families of patients with AD and the US government through the Medicare and Medicaid programs. In an attempt to control expenditures, Medicare and Medicaid have turned to managed care principles and managed care organizations. The increase in "managed" dementia care gives rise to several potential problems for patients with AD, along with many opportunities for systematic improvement in the quality of dementia care. Evidence-based disease management programs provide the greatest opportunities for improving managed dementia care but will require the development of dementia-specific quality of care measures to evaluate and continually improve them.

The impact of symptom severity on the cost of Alzheimer's disease

OBJECTIVES

ITo examine the economic impact of Alzheimer's disease (AD) as the disease progresses on patients' medical costs and caregivers' productivity.

DESIGN

A 12-page, self-administered mail survey, fielded in November 1999.

SETTING

Households with AD caregivers, selected from a nationwide (U.S.) consumer database.

PARTICIPANTS

One thousand seven hundred fifteen caregivers of noninstitutionalized AD patients.

MEASUREMENTS

Disease progression was measured using a scale of symptom frequency and measures of instrumental and physical functioning. Cost components included hospital days, physician visits, and emergency room visits. Lost productivity was assessed using hours per week that caregivers provided care and the number of days that they missed from work because of caregiving.

RESULTS

The direct costs of caring for AD patients for 6 months totaled $3,129, whereas the indirect costs were $26,080. Patients with more-frequent symptoms used all healthcare resources, including the hospital, emergency room, and physicians, more often than those with less-frequent symptoms. Those with lower levels of physical and instrumental functioning also used the hospital and physicians more often than those with higher levels of physical and instrumental functioning. Caregivers of these more severely impaired patients spent more hours providing care and reported missing more work than those caring for higher-functioning patients. These relationships remained after controlling for potentially confounding factors.

CONCLUSIONS

This large study of patients at all stages of AD shows that the direct and indirect costs of AD are considerably lower for patients with fewer symptoms. Longitudinal studies will determine the impact on the overall cost of care of interventions that reduce symptoms and maintain patients at earlier stages of the disease.

National estimates of the quantity and cost of informal caregiving for the elderly with dementia

OBJECTIVE

Caring for the elderly with dementia imposes a substantial burden on family members and likely accounts for more than half of the total cost of dementia for those living in the community. However, most past estimates of this cost were derived from small, nonrepresentative samples. We sought to obtain nationally representative estimates of the time and associated cost of informal caregiving for the elderly with mild, moderate, and severe dementia.

DESIGN

Multivariable regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people age 70 years or older (N = 7,443).

SETTING

National population-based sample of the community-dwelling elderly.

MAIN OUTCOME MEASURES

Incremental weekly hours of informal caregiving and incremental cost of caregiver time for those with mild dementia, moderate dementia, and severe dementia, as compared to elderly individuals with normal cognition. Dementia severity was defined using the Telephone Interview for Cognitive Status.

RESULTS

After adjusting for sociodemographics, comorbidities, and potential caregiving network, those with normal cognition received an average of 4.6 hours per week of informal care. Those with mild dementia received an additional 8.5 hours per week of informal care compared to those with normal cognition (P < .001), while those with moderate and severe dementia received an additional 17.4 and 41.5 hours (P < .001), respectively. The associated additional yearly cost of informal care per case was 3,630 dollars for mild dementia, 7,420 dollars for moderate dementia, and 17,700 dollars for severe dementia. This represents a national annual cost of more than 18 billion dollars.

CONCLUSION

The quantity and associated economic cost of informal caregiving for the elderly with dementia are substantial and increase sharply as cognitive impairment worsens. Physicians caring for elderly individuals with dementia should be mindful of the importance of informal care for the well-being of their patients, as well as the potential for significant burden on those (often elderly) individuals providing the care.

Reduced employment in caregivers of frail elders: impact of ethnicity, patient clinical characteristics, and caregiver characteristics

BACKGROUND

Without family caregivers, many frail elders who live at home would require nursing home care. However, providing care to frail elders requires a large time commitment that may interfere with the caregiver's ability to work. Our goal was to determine the patient and caregiver characteristics associated with the reduction of employment hours in caregivers of frail elders.

METHODS

This was a cross-sectional study of 2806 patients (mean age 78, 73% women, 29% African American, 12% Hispanic, 54% with dementia) with at least one potentially working caregiver (defined as one who is either currently employed or who would have been employed if they had not been providing care) and their 4592 potentially working caregivers. Patients were enrollees at 11 sites of the Program of All-Inclusive Care for the Elderly (PACE). Social workers interviewed patients and caregivers at the time of PACE enrollment. Caregivers were asked if they had reduced the hours they worked or had stopped working to care for the patient. Nurses interviewed patients and caregivers to assess independence in activities of daily living (ADLs) and the presence of behavioral disturbances. Comorbid conditions were assessed by physicians during enrollment examinations.

RESULTS

A total of 604 (22%) of the 2806 patients had at least one caregiver who either reduced the number of hours they worked or quit working to care for the patient. Patient characteristics independently associated with a caregiver reducing hours or quitting work were ethnicity, 95% confidence interval [CI] 1.14-1.78 for African American;, 95% CI 1.43-2.52 for Hispanic), ADL function below the median (, 95% CI 1.44-2.15), a diagnosis of dementia (, 95% -2.17 if associated with a behavioral disturbance;, 95% CI 1.06-1.63 if not associated with a behavioral disturbance), or a history of stroke (OR = 1.42, 95% CI 1.16-1.73). After controlling for these patient characteristics, caregiver characteristics associated with reducing work hours included being the daughter or daughter-in-law of the patient (OR = 1.69, 95% CI 1.37-2.08) and living with the patient (OR = 4.66, 95% CI 3.65-5.95 if no other caregiver lived at home, OR = 2.53, 95% CI 2.03-3.14 if another caregiver lived at home).

CONCLUSIONS

Many caregivers reduce the number of hours they work to care for frail elderly relatives. The burden of reduced employment is more likely to be incurred by the families of ethnic minorities and of patients with specific clinical characteristics. Daughters and caregivers who live with the patient are more likely to reduce work hours than other caregivers. Future research should examine the impact of lost caregiver employment on patients' families and the ways in which the societal responsibility of caring for frail elders can be equitably shared.

Factors influencing long-term home care utilization by the older population: implications for targeting

This research was designed to explore factors that affect the choice of long-term care modalities in the older population and to discuss the appropriate target population of home health care services within the entire long-term care system. The study subjects' activities of daily living limitations, cognitive status, and sociodemograhic data at the time of admission were obtained from retrospective chart reviews. The sample included 134 older subjects who were receiving long-term care from a Long-Term Home Health Care Program or a nursing home in New York City. The results indicated that Long-Term Home Health Care Program use by older persons was characterized by a higher rate of being admitted from private homes, less cognitive impairments, less limitations in activities of daily living, and younger age than older patients who were nursing home residents. Consequently, in the choice of different care modalities, health-related factors of the older population were found to be more important predictors than sociodemographic characteristics or support system. The implication to both nurses and researchers is the development of eligibility criteria that captures the unique characteristics of disabled older persons in each of the different long-term care programs to serve them better in a cost-effective manner.

Public attitudes about genetic testing for Alzheimer's disease

In a general population survey (N = 314), 79 percent of respondents stated that they would take a hypothetical genetic test to predict whether they will eventually develop Alzheimer's disease. The proportion fell to 45 percent for a "partially predictive" test (which had a one in ten chance of being incorrect). Inclination to obtain testing was similar across age groups. Respondents were willing to pay $324 for the completely predictive test. Respondents stated that if they tested positive, they would sign advance directives (84 percent), get their finances in order (74 percent), and purchase long-term care insurance (69 percent). Only a third of respondents expressed concern about confidentiality. The results suggest that people value genetic testingfor personal and financial reasons, but they also underscore the need to counsel potential recipients carefully about the accuracy and implications of test information.

Alzheimer's disease and other dementia in nursing homes: levels of management and cost

OBJECTIVE

To estimate comparative management levels and the annual cost of caring for a nursing home resident with and without dementia.

METHOD

Data from the 1995 Massachusetts Medicaid nursing home database were used to examine residents with Alzheimer's disease, other types of dementia, and no dementia to determine care and dependency levels. Massachusetts Medicaid 1997 per-diem rates for each of 10 designated management levels were applied accordingly to residents in each level to estimate annual care costs. Costs from this analysis are reported in 1997 U.S. dollars.

RESULTS

Of the 49,724 nursing home residents identified, 26.4% had a documented diagnosis of dementia. On average, a resident with dementia requires 229 more hours of care annually than one without dementia, resulting in a mean additional cost of $3,865 per patient with dementia per year.

CONCLUSIONS

Dementia increases the care needs and cost of caring for a nursing home resident.

Cognitive impairment and mortality in older primary care patients

OBJECTIVE

To assess the impact of cognitive impairment on mortality in older primary care patients after controlling for confounding effects of demographic and comorbid chronic conditions.

DESIGN

Prospective cohort study.

SETTING

Academic primary care group practice.

PARTICIPANTS

Three thousand nine hundred and fifty-seven patients age 60 and older who completed the Short Portable Mental Status Questionnaire (SPMSQ) during routine office visits.

MEASUREMENTS

Cognitive impairment measured at baseline using the SPMSQ, demographics, problem drinking, history of smoking, clinical data (including weight, cholesterol level, and serum albumin), and comorbid chronic conditions collected at baseline; survival time measured during the 5 to 7 years after baseline.

RESULTS

Eight hundred and eighty-six patients (22.4%) died during the 5 to 7 years of follow-up. Cognitive impairment was categorized as having no impairment (84.3%), mild impairment (10.5%), and moderate-to-severe impairment (5.2%) based on SPMSQ score. Chi-square tests revealed that patients with moderate-to-severe impairment were significantly more likely to die compared with patients with mild impairment (40.8% vs 21.5%) and those with no impairment (40.8% vs 21.4%). No significant difference in crude mortality was found between patients with no impairment and those with mild impairment. After analyzing time to death using the Kaplan-Meier method, patients with moderate-to-severe cognitive impairment were at increased risk of death compared with those with no or mild impairment (Log-rank chi(2) = 55.5; P <.0001). Even in multivariable analyses using Cox proportional hazards to control for confounding factors, compared with those with no impairment, moderately-to-severely impaired patients had an increased risk of death, with a hazard ratio (HR) of 1.70. Increased risk of death was also associated with older age (HR = 1.03 for each year), a history of smoking (HR = 1.48), having a serum albumin level <3.5 g/L (HR = 1.29), and weighing less than 90% of the ideal body weight (HR = 1.98). Outpatient diagnoses associated with increased mortality risk were diabetes mellitus, coronary artery disease, congestive heart failure, cerebrovascular disease, cancer, anemia, and chronic obstructive pulmonary disease (HR range 1.36-1.67). Factors protective of mortality risk included female gender (HR = 0.67) and black race (HR = 0.73).

CONCLUSIONS

Moderate-to-severe cognitive impairment is associated with an increased risk of mortality, even after controlling for confounding effects of demographic and clinical characteristics. Mild cognitive impairment is not associated with mortality risk, but a longer follow-up period may be necessary to identify this risk if it exists.

Dementia family caregiver training: affecting beliefs about caregiving and caregiver outcomes

OBJECTIVES

Family caregiving is an integral part of the care system for persons with dementing disorders, such as Alzheimer's disease. This study tested role-training intervention as a way to help family caregivers appreciate and assume a more clinical belief set about caregiving and thereby ameliorate the adverse outcomes associated with caregiving.

DESIGN

Training effectiveness was tested in a trial in which family care receiver dyads were randomly assigned to training beginning immediately or were placed in a wait-list control group and assigned to receive training in 5 to 6 months, following completion of data collection.

SETTING

A community-based 14-hour training program provided in seven weekly 2-hour sessions. The training program curriculum was built on a stress and coping theory base. Recruitment and randomization were ongoing. Programs were begun every 2 months over a two and one half-year period for a total of 16 programs.

PARTICIPANTS

Community health and social service agencies referred primary caregivers and at least one other family member of community-dwelling persons with dementia to participate.

MEASUREMENTS

Data reported in this paper were gathered from each participating family at entry to the study and 5 months later. Standard measures of beliefs about caregiving, burden, depression, and reaction to care receiver behavior were administered to caregivers. A standard measure of mental status was administered to the person with dementia and standardized instruments were used to gather information from caregivers concerning care receivers' behavior and abilities to perform activities of daily living (ADLs).

RESULTS

Data were analyzed from 94 caregiver/care receiver dyads with complete sets of data. Treatment and control caregivers and care receivers were similar at baseline, and care receivers in both groups declined similarly over the 5-month period. Significant within-group improvements occurred with treatment group caregivers on measures of beliefs about caregiving (P = .044) and reaction to behavior (P = .001). When outcomes were compared, treatment group caregivers were significantly different (in the expected direction) from those in the control group on measures of the stress mediator, beliefs (P = .025), and key outcomes, response to behavior (P = .019), depression (P = .040), and burden (P = .051). There was a significant positive association between the strengthened mediator, the caregivers' having less-emotionally enmeshed beliefs about caregiving roles and responsibilities, and the outcome, namely improvements in burden (P = .019) and depression (P = .007).

CONCLUSION

A caregiver training intervention focused on the work of caregiving and targeted at knowledge, skills, and beliefs benefits caregivers in important outcome dimensions. The results suggest the benefits of providing information, linkage, and role coaching to dementia family caregivers.

Estimating the costs of informal care for people with Alzheimer's disease: methodological and practical challenges

Although Alzheimer's disease and related disorders may have a heavy impact on informal caregivers, estimates of informal care costs have been neglected and when included in cost of illness studies, valuations have been highly variable. Although these variations are in part due to differences in samples and the difficulty in measuring caregiving time, this illustrates the need to standardise the methodology not only for valuing formal, but also informal care costs. Methods used for valuing informal care are identified, together with theoretical and practical challenges in measurement. In particular the measurement of time and it's associated satisfaction or utility is complex and valuations of time need to consider aspects of the caregiving experience which influence the marginal valuation of the time spent caring. More empirical work is required to elicit information on both the positive and negative satisfaction associated with caregiving and to incorporate this into valuations of the costs related to informal care.

What Terminally Ill Patients Care About: Toward a Validated Construct of Patients' Perspectives

BACKGROUND

Citizens have conveyed to professionals that care at the end of life is less than optimal. Efforts to improve matters have tended to work in piecemeal fashion, on tangible more than personal aspects of care, and without the benefit of documented perspectives of those who face dying. Policy initiatives and clinical interventions need guidance from a broad framework that is validated by patients' perspectives.

PURPOSE

Our goals were to: (1) assess the construct validity and stability over time of the portions of a conceptual framework that concern patients' subjective experiences; (2) develop a foundation for measurement of these personally meaningful factors; and (3) examine these factors' associations for potential clinical or policy significance.

POPULATION

Patients were from six diverse geographical areas whose physicians judged their survival prognosis to be 6 months or less. Physicians who referred the patients were randomly selected from state and specialty association lists.

METHODS

We used in-person survey methodology and multivariate analysis of patient responses. The analysis fell into two parts. Using exploratory factor analysis, we looked for evidence of discrete dimensions of experiences. Using regression analysis, we examined associations among them.

RESULTS

Of 1,131 eligible patients, 988 were interviewed (87.4% response rate). Of 682 patients who survived to follow-up interview 4-6 months later, 650 were interviewed (95.3% response rate). Exploratory factor analysis identified 12 discrete factors (accounting for 55% of variance; maximum Spearman's p = 0.24), 8 of which met criteria for representing measurable dimensions (accounting for 46% of variance). These 8 were: patient-clinician relationship; social connectedness; caregiving needs; psychological distress; spirituality/religiousness; personal acceptance; sense of purpose; and clinician communication. Eigenvalues ranged from 1.45 to 6.30 and Cronbach's alpha from 0.63 to 0.85. The concordance between these dimensions and those in the proposed framework indicated that two dimensions required minor modifications and six were confirmed, providing evidence of good construct validity for this portion of the framework. The same dimensions were also evident at follow-up except that the first two above-listed loaded on one combined factor, clinician interaction (eigenvalues 1.83-7.92; Cronbach's alpha from 0.64 to 0.86). This provides evidence of the construct's stability over time. Clinical communication and patient-clinician relationship were associated (odds ratio [OR] 2.79, 2.31-3.36). Better clinician communication correlated with somewhat better personal acceptance (OR 1.10,1.02-1.19), and a better patient-clinician relationship correlated with less psychological distress (OR 0.84, 0.75-0.95).

CONCLUSIONS

We conclude that: (1) Personally meaningful aspects of patients' experience of terminal illness can be represented in valid, multidimensional constructs that are stable over time; (2) They are measurable; and (3) Aspects of the therapeutic relationship appear to correlate with patients' experience of the dying process.

Dementia: the cost of care for behaviourally disturbed patients living in the community

OBJECTIVE

To determine the cost of care of people with dementia and behavioural disturbances living in the community, which is currently unknown.

DESIGN, SETTING & PATIENTS

This is a study of 12 randomly selected subjects attending a continuing care dementia day facility for people with behavioural disturbances.

MEASURES

Hours of care received from different sources were recorded and costed.

RESULTS

The total mean direct costs to the public services was pound400 per person per week. Caregiver's time costed at professional rates were pound1208 per person per week.

CONCLUSIONS

Unpaid caregivers supported by publicly funded agencies provide a less expensive service compared to specialised institutional care.

How much do persons with Alzheimer's disease cost Medicare?

BACKGROUND

Medicare claims are increasingly being used to identify persons with chronic diseases such as Alzheimer's disease (AD) for the purpose of determining the cost to Medicare of caring for such persons. Past work has been limited by the use of only 1 or 2 years of claims data to identify cases, leading to worries that this might lead to an undercount of prevalent cases and bias cost findings.

OBJECTIVES

To analyze the average total cost to the Medicare program in 1994 of persons with a claims-based diagnosis of AD, using a 12-year period of claims history to identify prevalent cases, and to investigate the effect on cost of time since diagnosis.

DESIGN

A cross-sectional design with a 12-year retrospective period to identify persons with AD.

SETTING

Medical care practices, hospitals, and other providers of services to Medicare beneficiaries in the US in 1994.

SUBJECTS

Respondents to the screener (n = 10,858) and community (5429) and institutional (n = 1341) questionnaire of the 1994 National Long Term Care Survey, with and without a claims-based diagnosis of AD.

MEASUREMENTS

Average total cost to Medicare in 1994, measured as the actual amount Medicare paid for inpatient, outpatient, home health, skilled nursing facility, hospice, and Part B services, including payments to physicians, and other items such as durable medical equipment. We also measured disability in a variety of ways, including cognition, activity limitations, and residence in a nursing home.

RESULTS

The average total cost to Medicare of persons with a claims-based diagnosis of AD was $6021 versus $2310 (P < .001) for persons without a diagnosis. When adjusting for patient characteristics, the ratio of cost between persons with AD and those without was reduced to about 1.6 to 1. Time since diagnosis was an important predictor of average total cost in 1994, with each additional year since diagnosis resulting in a $248 (P = .04) decrease in total cost (about 10% of the total sample mean cost of $2426). There was mixed evidence that persons with a diagnosis of AD incurred less cost than otherwise similarly disabled Medicare beneficiaries.

CONCLUSIONS

Time since diagnosis with AD is an important predictor of cost and one that should be explicitly included in any rate-setting formula. Expanding the period used to identify cases resulted in an increase in the unadjusted ratio of cost of a Medicare beneficiary with AD relative to one without primarily because our control group costs are lower compared with those of past work.

Medical services utilization and charge comparisons between elderly patients with and without Alzheimer's disease in a managed care organization

OBJECTIVES

The purposes of this study were to describe the health service utilization patterns and the associated charges for elderly patients (aged > or = 65 years) diagnosed with Alzheimer's disease (AD) enrolled in a managed care organization (MCO), and to compare these patterns and charges with those of elderly enrollees not diagnosed with AD (non-AD).

METHODS

We analyzed medical claims data over a 12-month period for the population of elderly patients with a diagnosis of AD or AD-related dementia, and for all other elderly patients enrolled in an integrated MCO. Comparisons were made at the level of service location (eg, inpatient hospital, outpatient hospital, physician's office).

RESULTS

For a total of 250 patients diagnosed with AD (66.0% female, 34.0% male; mean age. 80.5 years), health care charges were 1.6 times higher per patient per year than the corresponding charges for 13,553 non-AD patients (58.6% female, 41.4% male; mean age, 73.3 years). AD patients received 1.7 times more health care services per patient per year than their non-AD counterparts.

CONCLUSIONS

Despite the lack of nursing home and prescription drug data, our results show that AD patients in this MCO used more health care services and had higher annual medical care charges than non-AD patients. If MCOs conduct similar analyses of elderly AD patients' patterns of care and compare these with the patterns of elderly non-AD patients, they may be able to pinpoint areas of disparity in medical care and improve service delivery for AD patients.

Predicting 10-year care requirements for older people with suspected Alzheimer's disease

OBJECTIVE

To describe the types and costs of care received for 10 years after the identification of an older person with suspected Alzheimer's disease (AD) by using data from 3254 patients with suspected AD who participated in the National Long Term Care Survey (NLTCS).

METHODS

By using a Markov model derived using grade of membership techniques, the following were determined: survival probabilities at 10 years; years of survival during the 10 years; years in institutions; years with two or more impairments in basic activities of daily living; hours of paid and informal care while the older person lived in the community; and costs of paid community, institutional, and medical care.

RESULTS

Greater degrees of cognitive impairment present when AD was identified were associated with reduced predicted probability of surviving 10 years, increased predicted number of years spent in institutions, increased hours of care required while affected individuals remained in the community, and increased costs of paid community, institutional, and medical care. Substantial differences between men and women were seen: severity-adjusted 10-year costs were almost two times higher for women with AD than for men ($75,000 compared with $44,000); according to sensitivity analysis, average 10-year costs might be as high as $109,000 for women and $67,000 for men.

CONCLUSIONS

AD imposes a substantial burden on older persons. Interventions that slow the progression of the disease may therefore affect community survival as well as healthcare costs.

Understanding economic and other burdens of terminal illness: the experience of patients and their caregivers

BACKGROUND

Terminal illness imposes substantial burdens--economic and otherwise--on patients and caregivers. The cause of these burdens is not understood.

OBJECTIVE

To determine the mechanism for economic and noneconomic burdens of terminal illness and to identify potential ameliorating interventions.

DESIGN

In-person interviews of terminally ill patients and their caregivers.

SETTING

Six randomly selected U.S. sites: Worcester, Massachusetts; St. Louis, Missouri; Tucson, Arizona; Birmingham, Alabama; Brooklyn, New York; and Mesa County, Colorado.

PARTICIPANTS

988 terminally ill patients and 893 caregivers.

MEASUREMENTS

Needs for transportation, nursing care, homemaking, and personal care; subjective perception of economic burden; expenditure of more than 10% of household income on health care costs; caregiver depression and sense of interference with his or her life; and patient consideration of euthanasia or physician-assisted suicide.

RESULTS

Of all patients, 34.7% had substantial care needs. Patients who had substantial care needs were more likely to report that they had a subjective sense of economic burden (44.9% compared with 35.3%; difference, 9.6 percentage points [95% CI, 3.1 to 16.1]; P = 0.005); that 10% of their household income was spent on health care (28.0% compared with 17.0%; difference, 11.0 percentage points [CI, 4.8 to 17.1]; P < or = 0.001); and that they or their families had to take out a loan or mortgage, spend their savings, or obtain an additional job (16.3% compared with 10.2%; difference, 6.1 percentage points [CI, 1.4 to 10.6]; P = 0.004). Patients with substantial care needs were more likely to consider euthanasia or physician-assisted suicide (P = 0.001). Caregivers of these patients were more likely to have depressive symptoms (31.4% compared with 24.8%; difference, 6.6 percentage points [CI, 0.4 to 12.8]; P = 0.01) and to report that caring for the patients interfered with their lives (35.6% compared with 24.3%; difference, 11.3 percentage points [CI, 5.0 to 17.7]; P = 0.001). Caregivers of patients whose physicians listened to patients' and caregivers' needs had fewer burdens.

CONCLUSIONS

Substantial care needs are an important cause of the economic and other burdens imposed by terminal illness. Through empathy, physicians may be able to ameliorate some of these burdens.