Dementia and Medicare at life's end

Incremental Healthcare Costs of Dementia and Cognitive Impairment in Community-Dwelling Older Adults: A Prospective Cohort Study

BACKGROUND

Cognitive impairment and dementia are associated with higher healthcare costs; whether these increased costs are attributable to a greater comorbidity burden is unknown. We sought to determine associations of cognitive impairment and dementia with subsequent total and sector-specific healthcare costs after accounting for comorbidities and to compare costs by method of case ascertainment.

METHODS

Index examinations (2002-2011) of 4 prospective cohort studies linked with Medicare claims. 8 165 community-dwelling Medicare fee-for-service beneficiaries (4 318 women; 3 847 men). Cognitive impairment identified by self-or-proxy report of dementia and/or abnormal cognitive testing. Claims-based dementia and comorbidities derived from claims using Chronic Condition Warehouse algorithms. Annualized healthcare costs (2023 dollars) were ascertained for 36 months following index examinations.

RESULTS

521 women (12.1%) and 418 men (10.9%) met the criteria for cognitive impairment; 388 women (9%) and 234 men (6.1%) met the criteria for claims-based dementia. After accounting for age, race, geographic region, and comorbidities, mean incremental costs of cognitive impairment versus no cognitive impairment in women (men) were $6 883 ($7 276) for total healthcare costs, $4 160 ($4 047) for inpatient costs, $1 206 ($1 587) for skilled nursing facility (SNF) costs, and $689 ($668) for home healthcare (HHC) costs. Mean adjusted incremental total and inpatient costs associated with claims-based dementia were smaller in magnitude and not statistically significant. Mean adjusted incremental costs of claims-based dementia versus no claims-based dementia in women (men) were $759 ($1 251) for SNF costs and $582 ($535) for HHC costs.

CONCLUSIONS

Cognitive impairment is independently associated with substantial incremental total and sector-specific healthcare expenditures not fully captured by claims-based dementia or comorbidity burden.

Hospitalizations of the older adults with and without dementia during the last two years of life: the impact of comorbidity and changes from 2002 to 2017

BACKGROUND

Multimorbidity creates challenges for care and increases health care utilization and costs. People with dementia often have multiple comorbidities, but little is known about the role of these comorbidities in hospitalizations.

AIMS

This study examines the frequency of hospitalizations during the last two years of life in older adults with and without dementia, the impact of comorbidities on hospitalizations, and their time trends.

METHODS

The data came from national registers and covered all persons 70 and above who died in Finland in 2002-2017. The effect of dementia and comorbidities on hospitalizations in the last two years of life was determined using binary logistic regression and negative binomial regression.

RESULTS

At all levels of comorbidity, people with dementia were less likely to be hospitalized and had a lower number of hospitalizations than people at the same level of comorbidity but no dementia. Hospitalizations were strongly associated with multimorbidity. During the study period, the overall hospitalization rates from home and LTC have declined.

DISCUSSION

The declining trend of hospitalization during the 15-year study period should be interpreted in the context of the health and long-term care system.

CONCLUSION

Among people with dementia, comorbidities were the main driver for hospitalizations. Regardless of the number of comorbidities, people with dementia were hospitalized less often than people without dementia in last two years of life. It remains unclear whether the lower hospitalization rate is due to the improved ability to care for people with dementia outside the hospital or to the lack of sufficient medical care for them.

Public spending on acute and long-term care for Alzheimer's disease and related dementias

INTRODUCTION

We estimate the spending attributable to Alzheimer's disease and related dementias (ADRD) to the United States government for the first 5 years post-diagnosis.

METHODS

Using data from the Health and Retirement Study matched to Medicare and Medicaid claims, we identify a retrospective cohort of adults with a claims-based ADRD diagnosis along with matched controls.

RESULTS

The costs attributable to ADRD are $15,632 for traditional Medicare and $8833 for Medicaid per dementia case over the first 5 years after diagnosis. Seventy percent of Medicare costs occur in the first 2 years; Medicaid costs are concentrated among the longer-lived beneficiaries who are more likely to need long-term care and become Medicaid eligible.

DISCUSSION

Because the distribution of the incremental costs varies over time and between insurance programs, when interventions occur and the effect on the disease course will have implications for how much and which program reaps the benefits.

Caring for Patients With Dementia at End of Life

Care of the dementia patient continues to be challenging. It is a terminal condition that many times goes undiagnosed leading to improper evidence-based interventions. Healthcare professionals (HCPs) should initiate goals of care conversations early with patients and their families in order to align treatment preferences. Early integration of palliative medicine is an important intervention that can lead to better manage symptoms and lessen the strain on loved ones. Additionally, early enrollment into hospice should be encouraged with loved ones to promote quality of life as defined by the patient.

Exploring costs, cost components, and associated factors among people with dementia approaching the end of life: A systematic review

INTRODUCTION

Understanding costs of care for people dying with dementia is essential to guide service development, but information has not been systematically reviewed. We aimed to understand (1) which cost components have been measured in studies reporting the costs of care in people with dementia approaching the end of life, (2) what the costs are and how they change closer to death, and (3) which factors are associated with these costs.

METHODS

We searched the electronic databases CINAHL, Medline, Cochrane, Web of Science, EconLit, and Embase and reference lists of included studies. We included any type of study published between 1999 and 2019, in any language, reporting primary data on costs of health care in individuals with dementia approaching the end of life. Two independent reviewers screened all full-text articles. We used the Evers' Consensus on Health Economic Criteria checklist to appraise the risk of bias of included studies.

RESULTS

We identified 2843 articles after removing duplicates; 19 studies fulfilled the inclusion criteria, 16 were from the United States. Only two studies measured informal costs including out-of-pocket expenses and informal caregiving. The monthly total direct cost of care rose toward death, from $1787 to $2999 USD in the last 12 months, to $4570 to $11921 USD in the last month of life. Female sex, Black ethnicity, higher educational background, more comorbidities, and greater cognitive impairment were associated with higher costs.

DISCUSSION

Costs of dementia care rise closer to death. Informal costs of care are high but infrequently included in analyses. Research exploring the costs of care for people with dementia by proximity to death, including informal care costs and from outside the United States, is urgently needed.

Medicare expenditures attributable to dementia

OBJECTIVE

To estimate dementia's incremental cost to the traditional Medicare program.

DATA SOURCES

Health and Retirement Study (HRS) survey-linked Medicare part A and B claims from 1991 to 2012.

STUDY DESIGN

We compared Medicare expenditures for 60 months following a claims-based dementia diagnosis to those for a randomly selected, matched comparison group.

DATA COLLECTION/EXTRACTION METHODS

We used a cost estimator that accounts for differential survival between individuals with and without dementia and decomposes incremental costs into survival and cost intensity components.

PRINCIPAL FINDINGS

Dementia's five-year incremental cost to the traditional Medicare program is approximately $15 700 per patient, nearly half of which is incurred in the first year after diagnosis. Shorter survival with dementia mitigates the incremental cost by about $2650. Increased costs for individuals with dementia were driven by more intensive use of Medicare part A covered services. The incremental cost of dementia was about $7850 higher for females than for males because of sex-specific differential mortality associated with dementia.

CONCLUSIONS

Dementia's cost to the traditional Medicare program is significant. Interventions that target early identification of dementia and preventable inpatient and post-acute care services could produce substantial savings.

Direct medical costs and source of cost differences across the spectrum of cognitive decline: a population-based study

BACKGROUND

Objective cost estimates and source of cost differences are needed across the spectrum of cognition, including cognitively normal (CN), mild cognitive impairment (MCI), newly discovered dementia, and prevalent dementia.

METHODS

Subjects were a subset of the Mayo Clinic Study of Aging stratified-random sampling of Olmsted County, MN, residents aged 70 to 89 years. A neurologist reviewed provider-linked medical records to identify prevalent dementia (review date = index). Remaining subjects were invited to participate in prospective clinical/neuropsychological assessments; participants were categorized as CN, MCI, or newly discovered dementia (assessment date = index). Costs for medical services/procedures 1-year pre-index (excluding indirect and long-term care costs) were estimated using line-item provider-linked administrative data. We estimated contributions of care-delivery site and comorbid conditions (including and excluding neuropsychiatric diagnoses) to between-category cost differences.

RESULTS

Annual mean medical costs for CN, MCI, newly discovered dementia, and prevalent dementia were $6042, $6784, $9431, $11,678, respectively. Hospital inpatient costs contributed 70% of total costs for prevalent dementia and accounted for differences between CN and both prevalent and newly discovered dementia. Ambulatory costs accounted for differences between CN and MCI. Age-, sex-, education-adjusted differences reached significance for CN versus newly discovered and prevalent dementia and for MCI versus prevalent dementia. After considering all comorbid diagnoses, between-category differences were reduced (e.g., prevalent dementia minus MCI (from $4842 to $3575); newly discovered dementia minus CN (from $3578 to $711)). Following the exclusion of neuropsychiatric diagnoses from comorbidity adjustment, between-category differences tended to revert to greater differences.

CONCLUSIONS

Cost estimates did not differ significantly between CN and MCI. Substantial differences between MCI and prevalent dementia reflected high inpatient costs for dementia and appear partly related to co-occurring mental disorders. Such comparisons can help inform models aimed at identifying where, when, and for which individuals proposed interventions might be cost-effective.

Rate of use and determinants of withdrawal of care among patients with subarachnoid hemorrhage in the United States

BACKGROUND

The use of "withdrawal of care" and impact upon outcomes among patients with subarachnoid hemorrhage (SAH) is not well studied.

OBJECTIVE

To identify the rate and determinants of "withdrawal of care" among SAH patients.

METHODS

We determined the frequency of "withdrawal of care" and compared the demographic, clinical characteristics, and in-hospital outcomes among patients with SAH stratified by use of "withdrawal of care."

RESULTS

"Withdrawal of care" during hospitalization was instituted in 8912 (3.4%) of the 266,067 patients with SAH. In the stepwise logistic regression, age >65 (odds ratio [OR] 4.5, 95% confidence interval [95% CI] 3.3-6.1), women (OR 1.2, 95% CI 1.0-1.3), African American (OR 0.7, 95% CI 0.5-0.8), Hispanic ethnicity (OR 0.4, 95% CI 0.3-0.6), renal failure (OR 1.6, 95% CI 1.2-1.9), intracerebral hemorrhage (OR 2.0, 95% CI 1.7-2.4, All Patient Refined Diagnosis-Related Groups severity score of extreme loss of function (OR 40.1, 95% CI 6.0-270.7), All Patient Refined Diagnosis-Related Groups severity score of severe loss of function (OR 15.0, 95% CI 2.1-103.8), insurance status of private health maintenance organization (OR 0.7, 95% CI 0.5-0.9), and hospital region south United States (OR 0.7, 95% CI 0.5-0.8), were significant predictors of "withdrawal of care" among patients with SAH. In-hospital mortality was significantly greater, but mean hospitalization charges and length of stay were significantly lower among those with "withdrawal of care."

CONCLUSIONS

Although "withdrawal of care" was effective in limiting hospital charges and resource use, caution is needed to avoid disproportionately high mortality. The prominent relationship between race/ethnicity, insurance status, and hospital location with "withdrawal of care" raises concerns that factors other than severity of disease influence decision making.

A longitudinal analysis of the lifetime cost of dementia

OBJECTIVE

Estimate the lifetime cost of dementia to Medicare and Medicaid.

DATA SOURCE

1997-2005 Medicare Current Beneficiary Survey.

STUDY DESIGN

A multistage analysis was conducted to first predict the probability of developing dementia by age and then predict the annual Medicare/Medicaid expenditures conditional on dementia status. A cohort-based simulation was conducted to estimate the lifetime cost of dementia.

PRINCIPAL FINDINGS

The average lifetime cost of dementia per patient for Medicare is approximately $12,000 (2005 dollars) and for Medicaid about $11,000. Dementia onset at older age leads to shorter duration and lower lifetime cost. Increased educational level leads to longer longevity, more dementia cases per cohort, but shorter duration, and lower lifetime cost per patient, which could offset the cost increase induced by more dementia cases. Increased body mass index leads to more dementia cases per cohort and higher lifetime cost per patient.

CONCLUSION

Net cost of dementia is lower than the estimates from cross-sectional studies. Promoting healthy lifestyle to reverse the obesity epidemic is a short-term priority to confront the epidemic of dementia in the near future. Promoting higher education among the younger generation is a long-term priority to mitigate the effect of population aging on the dementia epidemic in the distant future.

Dementia as a determinant of social and health service use in the last two years of life 1996-2003

BACKGROUND

Dementia is one of the most common causes of death among old people in Finland and other countries with high life expectancies. Dementing illnesses are the most important disease group behind the need for long-term care and therefore place a considerable burden on the health and social care system. The aim of this study was to assess the effects of dementia and year of death (1998-2003) on health and social service use in the last two years of life among old people.

METHODS

The data were derived from multiple national registers in Finland and comprise all those who died in 1998, 2002 or 2003 and 40% of those who died in 1999-2001 at the age of 70 or over (n = 145 944). We studied the use of hospitals, long-term care and home care in the last two years of life. Statistics were performed using binary logistic regression analyses and negative binomial regression analyses, adjusting for age, gender and comorbidity.

RESULTS

The proportion of study participants with a dementia diagnosis was 23.5%. People with dementia diagnosis used long-term care more often (OR 9.30, 95% CI 8.60, 10.06) but hospital (OR 0.33, 95% CI 0.31, 0.35) and home care (OR 0.50, 95% CI 0.46, 0.54) less often than people without dementia. The likelihood of using university hospital and long-term care increased during the eight-year study period, while the number of days spent in university and general hospital among the users decreased. Differences in service use between people with and without dementia decreased during the study period.

CONCLUSIONS

Old people with dementia used long-term care to a much greater extent and hospital and home care to a lesser extent than those without dementia. This difference persisted even when controlling for age, gender and comorbidity. It is important that greater attention is paid to ensuring that old people with dementia have equitable access to care.

Comorbidity in aging and dementia: scales differ, and the difference matters

BACKGROUND

Accurate assessment of the effect of dementia on healthcare utilization and costs requires separation of the effects of comorbid conditions, often poorly accounted for in existing claims-based studies.

OBJECTIVE

To determine whether two different types of comorbidity and risk adjustment scales, the Chronic Disease Score (CDS) and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G), perform similarly in older persons with and without dementia.

METHODS

All subjects in the community-outreach diagnostic program of the University of Washington Alzheimer's Disease Research Center Satellite were included (N = 619). Subjects' mean age was 75 ± 9 years; 40% were cognitively normal, 17% were cognitively impaired but not demented, and 43% were demented. CDS and CIRS-G scores (neuropsychiatric disorders excluded to reduce colinearity with group) were examined across strata of age, education, and cognitive classification by using analysis of variance, analysis of covariance, and linear regression.

RESULTS

CIRS-G scores were sensitive to factors known to be associated with chronic disease burden, including age (F = 21.3 [df = 2, 616], p <0.001), education (F = 6.6 [df = 3, 614], p <0.001), and cognitive status (F = 40.5 [df = 2, 616], p <0.001), whereas the CDS was not. In the subset of persons with CDS scores of 0 (40% of the total sample), CIRS-G scores ranged from very low to high burden of disease and remained significantly different across age, education, and cognitive status groups. In regression analyses predicting CIRS-G score, CDS score and cognitive status interacted (β = -0.10, t = 1.9 [df = 1, 609], p = 0.06). After controlling for age, the amount of variance shared by the CIRS-G-13 and CDS differed by cognitive group (>32% for normal and mildly impaired groups combined, 17% for dementia).

CONCLUSION

Different methods of measuring and adjusting for comorbidity are not equivalent, and dementia amplifies the discrepancies. The CDS, if used to control for comorbidity in comparative studies of healthcare utilization and costs for persons with and without dementia, will underestimate burden of comorbid disease and artificially inflate the costs attributed to dementia.