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

Health Care Costs of Alzheimer's and Related Dementias Within a Medicare Managed Care Provider

BACKGROUND

Although one third of Medicare beneficiaries are enrolled in Medicare Advantage (MA) plans, there is limited information about the cost of treating Alzheimer disease and related dementias (ADRD) in these settings.

OBJECTIVE

The objective of this study was to estimate direct health care costs attributable to ADRD among older adults within a large MA plan.

RESEARCH DESIGN

A retrospective cohort design was used to estimate direct total, outpatient, inpatient, ambulatory pharmacy, and nursing home costs for 3 years before and after an incident ADRD diagnosis for 927 individuals diagnosed with ADRD relative to a sex-matched and birth year-matched set of 2945 controls.

SUBJECT

Adults 65 years of age and older enrolled in the Kaiser Permanente Washington MA plan and the Adult Changes in Thought (ACT) Study, a prospective longitudinal cohort study of ADRD and brain aging.

MEASURES

Data on monthly health service use obtained from health system electronic medical records for the period 1992-2012.

RESULTS

Total monthly health care costs for individuals with ADRD are statistically greater (P<0.05) than controls beginning in the third month before diagnosis and remain significantly greater through the eighth month following diagnosis. Greater total health costs are driven by significantly (P<0.05) greater nursing home costs among individuals diagnosed with ADRD beginning in the third month prediagnosis. Although total costs were no longer significantly greater at 8 months following diagnosis, nursing home costs remained higher for the people with dementia through the 3 years postdiagnosis we analyzed.

CONCLUSION

Greater total health care costs among individuals with ADRD are primarily driven by nursing home costs.

Cost of dementia in Medicare managed care: a systematic literature review

OBJECTIVES

We conducted a systematic review of studies reporting the direct healthcare costs of treating older adults with diagnosed Alzheimer disease and related dementias (ADRD) within private Medicare managed care plans.

STUDY DESIGN

A systematic review of all studies published in English reporting original empirical analyses of direct costs for older adults with ADRD in Medicare managed care.

METHODS

All papers indexed in PubMed or Web of Science reporting ADRD costs within Medicare managed care plans from 1983 through 2018 were identified and reviewed.

RESULTS

Despite the growth in Medicare managed care enrollment, only 9 papers report the costs of care for individuals with ADRD within these plans, and only 1 study reports data less than 10 years old. This limited literature reports wide ranges for ADRD-attributable costs, with estimates varying from $3738 to $8726 in annual prevalent costs and $8938 to $38,794 in 1-year immediate postdiagnosis incident costs. Reviewed studies also used varied study populations, case and cost ascertainment methods, and analytic methods, making cross-study comparisons difficult.

CONCLUSIONS

The expected continued growth in Medicare managed care enrollment, coupled with the large and growing impact of ADRD on America's healthcare delivery and finance systems, requires more research on the cost of ADRD within managed care. This research should use more consistent approaches to identify ADRD prevalence and provide more detail regarding which components of care are included in analyses and how the costs of care are captured and measured.

Emergency Department Use by Community-Dwelling Individuals With Dementia in the United States: An Integrative Review

As part of the National Plan to Address Alzheimer's Disease, reducing potentially avoidable emergency department (ED) use by individuals with dementia has been identified as a component of enhancing the quality and efficiency of care for this population. To help inform the development of interventions to achieve this goal, an integrative review was conducted to: (a) compare rates and reasons for ED visits by community-dwelling individuals with and without dementia, considering also the effect of dementia subtype and severity; and (b) identify other risk factors for increased ED use among community-dwelling individuals with dementia. Nineteen articles met inclusion criteria. Individuals with dementia had higher rates of ED visits compared to those without dementia, although differences were attenuated in the last year of life. Increased symptoms and disability were associated with increased rates of ED visits, whereas resources that enabled effective management of increased need decreased rates. Gerontological nurses across settings are on the frontlines of preventing potentially avoidable ED visits by community-dwelling individuals with dementia through patient and family education and leadership in the development of new models of care. [Journal of Gerontological Nursing, 44(3), 23-30.].

Care needs and clinical outcomes of older people with dementia: a population-based propensity score-matched cohort study

Objective

To explore the healthcare resource utilization, psychotropic drug use and mortality of older people with dementia.

Design

A nationwide propensity score-matched cohort study.

Setting

National Health Insurance Research database.

Participants

A total of 32,649 elderly people with dementia and their propensity-score matched controls (n=32,649).

Measurements

Outpatient visits, inpatient care, psychotropic drug use, in-hospital mortality and all-cause mortality at 90 and 365 days.

Results

Compared to the non-dementia group, a higher proportion of patients with dementia used inpatient services (1 year after index date: 20.91% vs. 9.55%), and the dementia group had more outpatient visits (median [standard deviation]: 7.00 [8.87] vs. 3.00 [8.30]). Furthermore, dementia cases with acute admission had the highest psychotropic drug utilization both at baseline and at the post-index dates (difference-in-differences: all <0.001). Dementia was associated with an increased risk of all-cause mortality (90 days, Odds ratio (OR)=1.85 [95%CI 1.67-2.05], p<0.001; 365 days, OR=1.59 [1.50-1.69], p<0.001) and in-hospital mortality (90 days, OR=1.97 [1.71-2.27], p<0.001; 365 days, OR=1.82 [1.61-2.05], p<0.001) compared to matched controls.

Conclusions

When older people with dementia are admitted for acute illnesses, they may increase their use of psychotropic agents and their risk of death, particularly in-hospital mortality.

The clinical and economic burden of newly diagnosed Alzheimer's disease in a medicare advantage population

BACKGROUND/RATIONALE

Alzheimer's disease (AD) represents a serious public health issue affecting approximately 5.4 million individuals in the United States and is projected to affect up to 16 million by 2050. This study examined health care resource utilization (HCRU), costs, and comorbidity burden immediately preceding new diagnosis of AD and 2 years after diagnosis.

METHODS

This study utilized a claims-based, retrospective cohort design. Medicare Advantage members newly diagnosed with AD (n = 3374) were compared to matched non-AD controls (n = 6748). All patients with AD were required to have 12 months of continuous enrollment prior to AD diagnosis (International Classification of Diseases, Clinical Modification [ICD-9] 331.0), during which time no diagnosis of AD, a related dementia, or an AD medication was observed. Non-AD controls demonstrated no diagnosis of AD, a related dementia, or a prescription claim for an AD medication treatment during their health plan enrollment. Medical and pharmacy claims data were used to measure HCRU, costs, and comorbidity burden over a period of 36 months (12 months pre-diagnosis and 24 months post-diagnosis).

RESULTS

The HCRU and costs were greater for AD members during the year prior to diagnosis and during postdiagnosis years 1 and 2 compared to controls. The AD members also displayed greater comorbidity than their non-AD counterparts during postdiagnosis years 1 and 2, as measured by 2 different comorbidity indices.

CONCLUSIONS

Members newly diagnosed with AD demonstrated greater HCRU, health care costs, and comorbidity burden compared to matched non-AD controls.

Association between Cognitive Decline in Older Adults and Use of Primary Care Physician Services in Pennsylvania

OBJECTIVE

To assess the relationship between cognitive decline of older patients (≥ 65 y) and use of primary care physician (PCP) services over 24 months.

DESIGN

Retrospective analysis of prospectively collected data from a cluster randomized trial that took place from 2006-2010 and investigated the relationship between formal neuropsychological evaluation and patient outcomes in primary care.

SETTING

Twenty-four PCPs in 11 practices in southwestern Pennsylvania. Most practices were suburban and included more than 5 PCPs.

PARTICIPANTS

A sample of 423 primary care patients 65 years old or older.

MEASUREMENTS

The association between the number of PCP visits and a decline in cognitive status, as determined by multivariable analyses that controlled for patient-level, physician-level, and practice-level factors (eg, patient age, comorbidities, and symptoms of depression; practice location and size; PCP age and sex) and used a linear mixed model with a random intercept to adjust for clustering.

RESULTS

Over a 2-year follow-up, 199 patients (47.0%) experienced a decline in cognitive status. Patients with a cognitive decline had a mean of 0.69 more PCP visits than did patients without a cognitive decline (P < .05).

CONCLUSIONS

Early signs of cognitive decline may be an indicator of greater use of primary care. Given the demographic trends, more PCPs are likely to be needed to meet the increasing needs of the older population.

Use of services by community-dwelling patients with dementia: a systematic review

Dementia is a complicated disease requiring medical, psychological, and social services. Services to address these needs include medical care (outpatient physician/specialist, inpatient, emergency) and community care (home health, day care, meal preparation, transportation, counseling, support groups, respite care, physical therapy). This systematic review of articles published in English from 1991 to the present examines studies of ambulatory, community-dwelling dementia patients with established dementia diagnoses. Searches of the Medline database using 13 combinations of search terms, plus searches of Embase and PsycINFO databases using 3 combinations of terms and examination of reference lists of related articles, resulted in identification of 15 studies dealing with healthcare utilization among community-dwelling dementia patients in both medical and community care settings. Patients with dementia frequently use the full spectrum of medical services. Community resources are used less frequently. Community healthcare services may be a valuable resource in alleviating some burden of dementia care for physicians.

Dementia and Medicare at life's end

OBJECTIVE

To determine the effect of a diagnosis of Alzheimer's disease or related dementias (ADRD), and the timing of first ADRD diagnosis, on Medicare expenditures at end of life.

DATA SOURCES

Monthly Medicare payment data for the 5 years before death linked to the National Long-Term Care Survey (NLTCS) for decedents between 1996 and 2000 (N=4,899).

DATA EXTRACTION METHODS

Medicare payment data for the 5 years before death were used to compare 5-year and 6-month intervals of expenditures (total and six subcategories of services) for persons with and without a diagnosis of ADRD during the last 5 years of life, controlling for age, gender, race, education, comorbidities, and nursing home status. Covariate matching was used.

PRINCIPAL FINDINGS

On average, ADRD diagnosis was not significantly associated with excess Medicare payments over the last 5 years of life. Regarding the timing of ADRD diagnosis, there were no significant 5-year total expenditure differences for persons diagnosed with dementia more than 1 year before death. Payment differences by 6-month intervals were highly sensitive to timing of ADRD diagnosis, with the highest differences occurring around the time of diagnosis. There were reduced, non-significant, or negative total payment differences after the initial diagnosis for those diagnosed at least 1 year before death. Only those diagnosed with ADRD in the last year of life had significantly higher Medicare payments during the last 12 months of life, primarily for acute care services.

CONCLUSIONS

ADRD has a smaller impact on total Medicare expenditures than previously reported in controlled studies. The significant differences occur primarily around the time of diagnosis. Although rates of dementia are increasing per se, our results suggest that long-term (1+ year) ADRD diagnoses do not contribute to greater total Medicare costs at the end of life.

Healthcare costs and utilization for Medicare beneficiaries with Alzheimer's

Background

Alzheimer's disease (AD) is a neurodegenerative disorder incurring significant social and economic costs. This study uses a US administrative claims database to evaluate the effect of AD on direct healthcare costs and utilization, and to identify the most common reasons for AD patients' emergency room (ER) visits and inpatient admissions.

Methods

Demographically matched cohorts age 65 and over with comprehensive medical and pharmacy claims from the 2003–2004 MEDSTAT MarketScan^® Medicare Supplemental and Coordination of Benefits (COB) Database were examined: 1) 25,109 individuals with an AD diagnosis or a filled prescription for an exclusively AD treatment; and 2) 75,327 matched controls. Illness burden for each person was measured using Diagnostic Cost Groups (DCGs), a comprehensive morbidity assessment system. Cost distributions and reasons for ER visits and inpatient admissions in 2004 were compared for both cohorts. Regression was used to quantify the marginal contribution of AD to health care costs and utilization, and the most common reasons for ER and inpatient admissions, using DCGs to control for overall illness burden.

Results

Compared with controls, the AD cohort had more co-morbid medical conditions, higher overall illness burden, and higher but less variable costs ($13,936 s. $10,369; Coefficient of variation = 181 vs. 324). Significant excess utilization was attributed to AD for inpatient services, pharmacy, ER visits, and home health care (all p < 0.05). In particular, AD patients were far more likely to be hospitalized for infections, pneumonia and falls (hip fracture, syncope, collapse).

Conclusion

Patients with AD have significantly more co-morbid medical conditions and higher healthcare costs and utilization than demographically-matched Medicare beneficiaries. Even after adjusting for differences in co-morbidity, AD patients incur excess ER visits and inpatient admissions.

Impact of patient selection criteria on prevalence estimates and prevalence of diagnosed dementia in a Medicaid population

OBJECTIVES

This study estimated the prevalence of diagnosed dementia among Indiana Medicaid beneficiaries in 2004. The dependence of prevalence estimates upon use of several patient selection criteria to identify patients with dementia also was evaluated.

METHODS

Indiana Medicaid claims data were analyzed for the period July 1, 2002 to December 31, 2004. An expert panel survey was conducted to assess perceived specificity of ICD codes used in previous studies to define dementia. Prevalence estimates were calculated with varying levels of each selection criteria, that is, ICD code set, interval of data examined, and number of occurrences of dementia-related claims. To assess specificity and sensitivity of the dementia patient selection criteria, Minimum Data Set data for a subset of beneficiaries that resided in a nursing home any time in 2004 were examined.

RESULTS

Depending on the patient selection criteria used, estimates of prevalence of diagnosed dementia for individuals 40 years old or older varied from 7.7% to 15.3%, whereas prevalence estimates for individuals 60 years old or older varied from 14.5% to 26.6%. When the following selection criteria were used: (1) occurrence of one or more dementia-related claims, (2) the expert panel ICD set, and (3) up to 30 months of data for defining dementia, the prevalence estimates in the Indiana Medicaid population were 10.9% for individuals 40 years old or older and 20.3% for individuals 60 years old or older.

CONCLUSIONS

Careful selection of claims-based criteria for identifying patients with dementia is important because the criteria may affect estimates by 100%. Prevalence of diagnosed dementia among Indiana Medicaid beneficiaries was 3 to 4 times higher than the reported prevalence from a decade ago in Medicaid populations of other states, even when the same patient selection criteria were used. A number of factors beyond increased occurrence of the disease including increased screening, greater likelihood of recording dementia codes in claims, or other factors may be responsible. The combination of patient selection criteria used in this study had good sensitivity, specificity, and accuracy when compared with Minimum Data Set data.

Medicare cost differences between nursing home patients admitted with and without dementia

PURPOSE

Our objective in this study was to compare Medicare costs of treating older adults with and without dementia in nursing home settings.

DESIGN AND METHODS

An expert panel established the dementia status of a stratified random sample of newly admitted residents in 59 Maryland nursing homes between 1992 and 1995. Medicare expenditures per-person month (PPM) were compared for 640 residents diagnosed with dementia and 636 with no dementia for 1 year preadmission and 2 years postadmission. Multivariate analysis with generalized estimating equations was used to identify the source of Medicare cost differentials between the two groups.

RESULTS

Medicare expenditures peaked in the month immediately preceding admission and dropped to preadmission levels by the third month in a nursing home. Adjusted PPM costs postadmission for the dementia group as a whole were 79% (p < .001) of the Medicare costs of treating residents without dementia. For the subgroup of residents admitted without a Medicare qualified stay (MQS), those with dementia had Medicare costs of just 63% (p < .001) of those without dementia. Overall Medicare costs PPM were insignificantly different between the two groups admitted with a MQS.

IMPLICATIONS

Whether nursing home residents are admitted with a MQS is the single most important factor in assessing treatment cost differentials between residents admitted with and without dementia. Failure to consider this factor may lead researchers and policy makers to misdirect their attention from the true source of the differential-dementia patients admitted without a qualifying stay.

Validation of a Brief Screen for Cognitive Impairment (BSCI) Administered by Telephone for Use in the Medicare Population

The aim of this research was to examine the validity of a brief screen for cognitive impairment (BSCI) consisting of three questions administered by telephone (delayed recall, frequency of help with planning trips for errands, and frequency of help remembering to take medications). The study design was an age and gender matched case-control study. Seventy managed care members, 35 with dementia (cases) and 35 without dementia (controls), were assessed using BSCI embedded within a longer health assessment questionnaire commonly used in Medicare-managed care. A number of measures were used to examine validity of BSCI, including comparisons of the differences between cases and controls in BSCI scores, comparisons of the correlations between patient scores on BSCI and the Mini Mental Status Exam (MMSE, a common screening test for dementia) and the Alzheimer's Disease Assessment Scale (ADAS, a common dementia assessment test), and comparisons of the areas under the receiver operating characteristic (ROC) curves for the three instruments. BSCI scores for cases and controls were significantly different, as were their scores for the MMSE and ADAS. Scores on BSCI were significantly correlated with scores for the MMSE and ADAS using both the Kendall's tau-b and Spearman rank-order correlation; correlations ranged from 0.654 between BSCI and ADAS to -0.83 for the correlation between BSCI and the MMSE (p < 0.001 for both). The areas under the ROC curves ranged from 0.94 to 0.96 for the three tests, meaning that they were equally accurate in discriminating between demented and nondemented patients. BSCI, a brief telephone screen for cognitive impairment due to dementia, discriminates between demented patients and normal controls as well as two standard tests of dementia, and may be considered a valid screen for dementia. Compared to existing screening tests, it has the additional advantages of extreme brevity, and ease of administration and scoring by lay interviewers via telephone. The use of brief screening instruments for dementia, such as the one validated here, will be increasingly important for the effective management of dementia and other chronic diseases where dementia is a coexisting condition.

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.

Health care utilization in dementia patients with psychiatric comorbidity

PURPOSE

The purpose of this research was to determine if differences in service use exist between dementia patients with and without psychiatric comorbidity.

DESIGN AND METHODS

A retrospective cohort study was conducted on all Veterans Affairs (VA) beneficiaries seen at the Houston Veterans Affairs Medical Center with a VA Outpatient Clinic File diagnosis of dementia in 1997. The primary dependent measure was amount of Houston VA health service use from study entry until the end of fiscal year 1999 or until death.

RESULTS

Of the 864 dementia patients in the identified cohort, two thirds had a comorbid psychiatric diagnosis. Examination of 2-year health service use revealed that, after adjusting for demographic and medical comorbidity differences, dementia patients with psychiatric comorbidity had increased medical and psychiatric inpatient days of care and more psychiatric outpatient visits compared with patients without psychiatric comorbidity.

IMPLICATIONS

Further understanding of the current health service use of dementia patients with psychiatric comorbidity may help to establish a framework for considering change in the current system of care. A coordinated system of care with interdisciplinary teamwork may provide both cost-effective and optimal treatment for dementia patients.