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Gungabissoon U, Broadbent M, Perera G, Ashworth M, Galwey N, Stewart R. The Impact of Dementia on Diabetes Control: An Evaluation of HbA 1c Trajectories and Care Outcomes in Linked Primary and Specialist Care Data. J Am Med Dir Assoc 2022; 23:1555-1563.e4. [PMID: 35661655 DOI: 10.1016/j.jamda.2022.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 04/25/2022] [Accepted: 04/30/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Diabetes self-care may become increasingly challenging as cognition declines. We sought to characterize glycated hemoglobin A1c (HbA1c) trajectories, markers of diabetes-related management, health care utilization, and mortality in people with preexisting type 2 diabetes (T2D) with and without dementia and based on the extent of cognitive impairment at the time of dementia diagnosis. DESIGN Retrospective matched cohort study. SETTING AND PARTICIPANTS Using a linkage between a primary care (Lambeth DataNet) and a secondary mental healthcare database, up to 5 individuals aged ≥65 y with preexisting T2D without dementia were matched to each individual with dementia based on age, sex, and general practice. METHODS Comparisons were made for HbA1c trajectories (linear mixed effects models), markers of diabetes-related management and severity at dementia diagnosis (logistic regression), mortality (Cox regression), and health care utilization (multilevel mixed effects binomial regression). RESULTS In 725 incident dementia and 3154 matched comparators, HbA1c trajectories differed by dementia status; HbA1c increased over time for mild dementia and non-dementia, but the increase was greater in the mild dementia group; for those with moderate-severe dementia, HbA1c decreased over time. Despite individuals with dementia having increased health care utilization around the time of dementia diagnosis, they were less likely to have had routine diabetes-related management. Patients with dementia had a higher prevalence of macrovascular complications and diabetes foot morbidity at dementia diagnosis and a higher mortality risk than those without dementia; these relationships were most marked in those with moderate-severe dementia. CONCLUSIONS AND IMPLICATIONS Our study has highlighted important differences in the monitoring, management, and control of diabetes in people with dementia. The effects of frailty and the extent of cognitive impairment on the ability to self-manage diabetes and on glycemic control may need to be considered in treatment guidelines and by primary care.
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Affiliation(s)
- Usha Gungabissoon
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom; Epidemiology, Value, Evidence and Outcomes, Global Medical, GlaxoSmithKline (GSK) R&D, London, United Kingdom.
| | - Matthew Broadbent
- South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Gayan Perera
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom
| | | | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom
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Gungabissoon U, Perera G, Galwey NW, Stewart R. Potentially avoidable causes of hospitalisation in people with dementia: contemporaneous associations by stage of dementia in a South London clinical cohort. BMJ Open 2022; 12:e055447. [PMID: 35383067 PMCID: PMC8984034 DOI: 10.1136/bmjopen-2021-055447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To estimate the frequency of all-cause and ambulatory care sensitive condition (ACSCs)-related hospitalisations among individuals with dementia. In addition, to investigate differences by stage of dementia based on recorded cognitive function. SETTING Data from a large London dementia care clinical case register, linked to a national hospitalisation database. PARTICIPANTS Individuals aged ≥65 years with a confirmed dementia diagnosis with recorded cognitive function. OUTCOME MEASURES Acute general hospital admissions were evaluated within 6 months of a randomly selected cognitive function score in patients with a clinical diagnosis of dementia. To evaluate associations between ACSC-related hospital admissions (overall and individual ACSCs) and stage of dementia, an ordinal regression was performed, modelling stage of dementia as the dependant variable (to facilitate efficient model selection, with no implication concerning the direction of causality). RESULTS Of the 5294 people with dementia, 2993 (56.5%) had at least one hospitalisation during a 12-month period of evaluation, and 1192 (22.5%) had an ACSC-related admission. Proportions with an all-cause or ACSC-related hospitalisation were greater in the groups with more advanced dementia (all-cause 53.9%, 57.1% and 60.9%, p 0.002; ACSC-related 19.5%, 24.0% and 25.3%, p<0.0001 in the mild, moderate and severe groups, respectively). An ACSC-related admission was associated with 1.3-fold (95% CI 1.1 to 1.5) increased odds of more severe dementia after adjusting for demographic factors. Concerning admissions for individual ACSCs, the most common ACSC was urinary tract infection /pyelonephritis (9.8% of hospitalised patients) followed by pneumonia (7.1%); in an adjusted model, these were each associated with 1.4-fold increased odds of more severe dementia (95% CI 1.2 to 1.7 and 1.1 to 1.7, respectively). CONCLUSIONS Potentially avoidable hospitalisations were common in people with dementia, particularly in those with greater cognitive impairment. Our results call for greater attention to the extent of cognitive status impairment, and not just dementia diagnosis, when evaluating measures to reduce the risk of potentially avoidable hospitalisations.
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Affiliation(s)
- Usha Gungabissoon
- Epidemiology (Value Evidence and Outcomes), GSK, Brentford, London, UK
- Psychological Medicine, King's College London, Institute of Psychiatry Psychology and Neuroscience, London, UK
| | - Gayan Perera
- Psychological Medicine, King's College London, Institute of Psychiatry Psychology and Neuroscience, London, UK
| | | | - Robert Stewart
- Psychological Medicine, King's College London, Institute of Psychiatry Psychology and Neuroscience, London, UK
- Mental Health of Older Adults, South London and Maudsley NHS Foundation Trust, London, UK
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Gilmore-Bykovskyi A, Cotton Q, Morgan J, Block L. Diverse perspectives on hospitalisation events among people with dementia: protocol for a multisite qualitative study. BMJ Open 2021; 11:e043016. [PMID: 33550256 PMCID: PMC7925923 DOI: 10.1136/bmjopen-2020-043016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION People living with dementia (PLWD) are more likely to experience hospitalisation events (hospitalisation, rehospitalisation) than those without dementia. Many hospitalisation events, particularly rehospitalisation within 30 days of discharge, are thought to be avoidable. Yet our understanding of dementia-specific risk and protective factors surrounding avoidable hospitalisation is limited to specific intersetting transitions and predominantly clinician perspectives. Broader insights are needed to design accessible and effective solutions for reducing avoidable hospitalisations. We have designed the Stakeholders Understanding of Prevention Protection and Opportunities to Reduce HospiTalizations (SUPPORT) Study to address these gaps. The objectives of the SUPPORT Study are to elicit and examine family caregiver, community and hospital providers' perspectives on avoidable hospitalisation events among PLWD, and to identify opportunities for effective prevention. METHODS AND ANALYSIS We will conduct a multisite, descriptive qualitative study to interview around 100 family caregivers, community and hospital providers. We will identify and sample from regions and communities with higher socio-contextual disadvantage and hospital utilisation, and will aim to recruit individuals representing diverse racial/ethnic backgrounds. Interviews will follow a descriptive qualitative design in conjunction with constant comparison techniques to sample divergent situations and events. We will employ a range of analytical approaches to address specific research questions including thematic (inductive and deductive), comparative and dimensional analysis. Interviews will be conducted individually or in focus groups and follow a semistructured interview guide. ETHICS AND DISSEMINATION The study is approved by the University of Wisconsin-Madison Institutional Review Board. Informed consent procedures will incorporate steps to evaluate capacity to provide informed consent in the event that participants express concerns with thinking or memory or demonstrate challenges recalling study details during the consent process to ensure capacity to consent to participation. A series of publicly available reports, seminars and symposia will be undertaken in collaboration with collaborating organisation partners.
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Affiliation(s)
- Andrea Gilmore-Bykovskyi
- Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Division of Geriatrics, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Quinton Cotton
- Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Jennifer Morgan
- Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Laura Block
- Nursing, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Testa L, Hardy JE, Jepson T, Braithwaite J, Mitchell RJ. Comparison of health service use trajectories of residential aged care residents reviewed by a hospital avoidance program versus usual care. Arch Gerontol Geriatr 2020; 93:104293. [PMID: 33220568 DOI: 10.1016/j.archger.2020.104293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/15/2020] [Accepted: 11/01/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare health service use trajectories of residential aged care facility (RACF) residents reviewed by the Aged Care Rapid Response Team (ARRT) to RACF residents who received usual care. METHODS A retrospective group-based trajectory analysis of RACF residents aged ≥65 years who were reviewed by ARRT during 1 July 2015 to 30 June 2016 was conducted. Health service use trajectories were followed for two years to 30 June 2018 and compared to RACF residents aged ≥65 years who lived in the same Local Health District and received usual care. RESULTS There were 2,245 ARRT-reviewed resident hospitalisations and 11,892 usual care resident hospital admissions during 2015-16. Trajectory analysis categorised ARRT-reviewed residents into four groups and usual care residents into three groups. Age, comorbid health conditions and dementia were predictors of group membership in both ARRT-reviewed RACF residents and usual care RACF residents. Additionally, gender predicted group membership in ARRT-reviewed RACF residents and fall-related injuries predicted group membership in usual care RACF residents. CONCLUSION The identification of health service use trajectories assists in understanding hospital use by older RACF residents and may offer guidance in the design of prevention measures, including hospital avoidance programs.
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Affiliation(s)
- Luke Testa
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia.
| | - James E Hardy
- Royal North Shore Hospital, Reserve Road, St Leonards, NSW, 2065, Australia; The University of Sydney, Sydney, NSW, 2006, Australia
| | - Therese Jepson
- Royal North Shore Hospital, Reserve Road, St Leonards, NSW, 2065, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Rebecca J Mitchell
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
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Gnanamanickam ES, Dyer SM, Harrison SL, Liu E, Whitehead C, Crotty M. Associations between Cognitive Function, Hospitalizations and Costs in Nursing Homes: A Cross-sectional Study. J Aging Soc Policy 2020; 34:552-567. [PMID: 32600162 DOI: 10.1080/08959420.2020.1777824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In an Australian nursing home population, associations between cognitive function and 12-month hospitalizations and costs were examined. Participants with dementia had 57% fewer hospitalizations compared to those without dementia, with 41% lower mean hospitalization costs; poorer cognition scores were also associated with fewer hospitalizations. The cost per admission for those with dementia was 33% greater due to longer hospital stays (5.5 days versus 3.1 days for no dementia, p = .05). People with dementia were most frequently hospitalized for fractures. These findings have policy implications for increasing investment in accurate and timely diagnosis of dementia and fall and fracture prevention strategies to further reduce associated hospitalization costs.
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Affiliation(s)
- Emmanuel Sumithran Gnanamanickam
- Rehabilitation, Aged and Extended Care, College of Medicine and Public Health, Flinders University, Adelaide, Australia.,NHMRC Cognitive Decline Partnership Centre, The University of Sydney, Sydney, Australia.,Health Economics and Social Policy, Australian Centre for Precision Health, University of South Australia, Adelaide, Australia.,Health Data Science and Clinical Trials, Flinders University, Adelaide, Australia
| | - Suzanne Marie Dyer
- Rehabilitation, Aged and Extended Care, College of Medicine and Public Health, Flinders University, Adelaide, Australia.,NHMRC Cognitive Decline Partnership Centre, The University of Sydney, Sydney, Australia
| | - Stephanie Lucy Harrison
- Rehabilitation, Aged and Extended Care, College of Medicine and Public Health, Flinders University, Adelaide, Australia.,NHMRC Cognitive Decline Partnership Centre, The University of Sydney, Sydney, Australia.,Registry of Older South Australians, Health Ageing Research Consortium, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Enwu Liu
- Rehabilitation, Aged and Extended Care, College of Medicine and Public Health, Flinders University, Adelaide, Australia.,NHMRC Cognitive Decline Partnership Centre, The University of Sydney, Sydney, Australia.,Bone Health and Fractures Research Program, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Craig Whitehead
- Rehabilitation, Aged and Extended Care, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Maria Crotty
- Rehabilitation, Aged and Extended Care, College of Medicine and Public Health, Flinders University, Adelaide, Australia.,NHMRC Cognitive Decline Partnership Centre, The University of Sydney, Sydney, Australia
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Gungabissoon U, Perera G, Galwey NW, Stewart R. The association between dementia severity and hospitalisation profile in a newly assessed clinical cohort: the South London and Maudsley case register. BMJ Open 2020; 10:e035779. [PMID: 32284392 PMCID: PMC7200045 DOI: 10.1136/bmjopen-2019-035779] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/07/2020] [Accepted: 03/20/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To evaluate the risk and common causes of hospitalisation in patients with newly diagnosed dementia and variation by severity of cognitive impairment. SETTING We used data from a large London mental healthcare case register linked to a national hospitalisation database. PARTICIPANTS Individuals aged ≥65 years with newly diagnosed dementia with recorded cognitive function and the catchment population within the same geography. OUTCOME MEASURES We evaluated the risk and duration of hospitalisation in the year following a dementia diagnosis. In addition we identified the most common causes of hospitalisation and calculated age-standardised and gender-standardised admission ratios by dementia severity (mild/moderate/severe) relative to the catchment population. RESULTS Of the 5218 patients with dementia, 2596 (49.8%) were hospitalised in the year following diagnosis. The proportion of individuals with mild, moderate and severe dementia who had a hospital admission was 47.9%, 50.8% and 51.7%, respectively (p= 0.097). Duration of hospital stay increased with dementia severity (median 2 days in mild to 4 days in severe dementia, p 0.0001). After excluding readmissions for the same cause, the most common primary hospitalisation discharge diagnoses among patients with dementia were urinary system disorders, pneumonia and fracture of femur, accounting for 15%, 10% and 6% of admissions, respectively. Overall, patients with dementia were hospitalised 30% more than the catchment population, and this trend was observed for most of the discharge diagnoses evaluated. Standardised admission ratios for urinary and respiratory disorders were higher in those with more severe dementia at diagnosis. CONCLUSIONS Individuals with a dementia diagnosis were more likely to be hospitalised than individuals in the catchment population. The length of hospital stay increased with dementia severity. Most of the common causes of hospitalisation were more common than expected relative to the catchment population, but standardised admission ratios only varied by dementia stage for certain groups of conditions.
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Affiliation(s)
- Usha Gungabissoon
- Epidemiology (Value Evidence and Outcomes), GSK, Brentford, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Gayan Perera
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | | | - Robert Stewart
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, UK
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8
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Fishman P, Coe NB, White L, Crane PK, Park S, Ingraham B, Larson EB. Cost of dementia in Medicare managed care: a systematic literature review. THE AMERICAN JOURNAL OF MANAGED CARE 2019; 25:e247-e253. [PMID: 31419102 PMCID: PMC7441813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- Paul Fishman
- Department of Health Services, University of Washington, 1959 NE Pacific St, Seattle, WA 98185.
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Bouza C, Martínez-Alés G, López-Cuadrado T. The impact of dementia on hospital outcomes for elderly patients with sepsis: A population-based study. PLoS One 2019; 14:e0212196. [PMID: 30779777 PMCID: PMC6380589 DOI: 10.1371/journal.pone.0212196] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 01/29/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Prior studies have suggested that dementia adversely influences clinical outcomes and increases resource utilization in patients hospitalized for acute diseases. However, there is limited population-data information on the impact of dementia among elderly hospitalized patients with sepsis. METHODS From the 2009-2011 National Hospital Discharge Database we identified hospitalizations in adults aged ≥65 years. Using ICD9-CM codes, we selected sepsis cases, divided them into two cohorts (with and without dementia) and compared both groups with respect to organ dysfunction, in-hospital mortality and the use of hospital resources. We estimated the impact of dementia on these primary endpoints through multivariate regression models. RESULTS Of the 148 293 episodes of sepsis identified, 16 829 (11.3%) had diagnoses of dementia. Compared to their dementia-free counterparts, they were more predominantly female and older, had a lower burden of comorbidities and were more frequently admitted due to a principal diagnosis of sepsis. The dementia cohort showed a lower risk of organ dysfunction (adjusted OR: 0.84, 95% Confidence Interval [CI]: 0.81, 0.87) but higher in-hospital mortality (adjusted OR: 1.32, 95% [CI]: 1.27, 1.37). The impact of dementia on mortality was higher in the cases of younger age, without comorbidities and without organ dysfunction. The cases with dementia also had a lower length of stay (-3.87 days, 95% [CI]: -4.21, -3.54) and lower mean hospital costs (-3040€, 95% [CI]: -3279, -2800). CONCLUSIONS This nationwide population-based study shows that dementia is present in a substantial proportion of adults ≥65s hospitalized with sepsis, and while the condition does seem to come with a lower risk of organ dysfunction, it exerts a negative influence on in-hospital mortality and acts as an independent mortality predictor. Furthermore, it is significantly associated with shorter length of stay and lower hospital costs.
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Affiliation(s)
- Carmen Bouza
- Health Technology Assessment Agency, Carlos III Health Institute, Madrid, Spain
- * E-mail:
| | - Gonzalo Martínez-Alés
- Department of Psychiatry, La Paz University Hospital, Madrid, Spain
- School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - Teresa López-Cuadrado
- School of Medicine, Autonomous University of Madrid, Madrid, Spain
- National Epidemiology Centre, Carlos III Health Institute, Madrid, Spain
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Niu H, Alvarez-Alvarez I, Aguinaga-Ontoso I, Guillen-Grima F. Trends in Hospital Morbidity From Alzheimer's Disease in the European Union, 2000 to 2014. Am J Alzheimers Dis Other Demen 2018; 33:440-449. [PMID: 30068226 PMCID: PMC10852452 DOI: 10.1177/1533317518787270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Alzheimer's disease (AD) has become a concerning public health issue. We aimed to analyze the trends of hospital morbidity from AD in the European Union (EU) in the period 2000 to 2014. METHODS Data from hospital discharges of men and women over 50 years old hospitalized due to AD in the EU were extracted from Eurostat database. We tested for secular trends computing anual percent change, and identified significant changes in the linear slope of the trend. RESULTS Hospital morbidity from AD showed a 0.8% (95% confidence intervals -2.2 to 0.6) slight declining trend in the EU. In men and women, we recorded a -0.5% and -1.0% decrease in hospital morbidity rates, respectively. Several countries showed changing trends during the study period. CONCLUSION Alzheimer's disease hospital morbidity has slightly declined in the entire EU in the past years. Eastern European countries showed steadily increasing trends, whereas in western and Mediterranean countries the rates decreased or leveled off.
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Affiliation(s)
- Hao Niu
- Department of Health Sciences, Public University of Navarra, Pamplona, Navarra, Spain
| | | | - Ines Aguinaga-Ontoso
- Department of Health Sciences, Public University of Navarra, Pamplona, Navarra, Spain
| | - Francisco Guillen-Grima
- Department of Health Sciences, Public University of Navarra, Pamplona, Navarra, Spain
- Navarra’s Institute for Health Research (IDISNA), Pamplona, Navarra, Spain
- Preventive Medicine, University of Navarra Clinic, Pamplona, Navarra, Spain
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Pohontsch NJ, Scherer M, Eisele M. (In-)formal caregivers' and general practitioners' views on hospitalizations of people with dementia - an exploratory qualitative interview study. BMC Health Serv Res 2017; 17:530. [PMID: 28778160 PMCID: PMC5545047 DOI: 10.1186/s12913-017-2484-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 07/31/2017] [Indexed: 11/13/2022] Open
Abstract
Background Dementia is an irreversible chronic disease with wide-ranging effects on patients’, caregivers’ and families’ lives. Hospitalizations are significant events for people with dementia. They tend to have poorer outcomes compared to those without dementia. Most of the previous studies focused on diagnoses leading to hospitalizations using claims data. Further factors (e.g. context factors) for hospitalizations are not reproduced in this data. Therefore, we investigated the factors leading to hospitalization with an explorative, qualitative study design. Methods We interviewed informal caregivers (N = 12), general practitioners (GPs, N = 12) and formal caregivers (N = 5) of 12 persons with dementia using a semi-structured interview guideline. The persons with dementia were sampled using criteria regarding their living situation (home care vs. nursing home care) and gender. The transcripts were analyzed using the method of structuring content analysis. Results Almost none of the hospitalizations, discussed with the (in-)formal caregivers and GPs, seemed to have been preventable or seemed unjustifiable from the interviewees’ points of view. We identified several dementia-specific factors promoting hospitalizations (e.g. the neglect of constricted mobility, the declining ability to communicate about symptoms/accidents and the shift of responsibility from person with dementia to informal or formal caregivers) and context-specific factors promoting hospitalizations (e.g. qualification of nursing home personal, the non-availability of the GP and hospitalizations for examinations/treatments also available in ambulatory settings). Hospitalizations were always the result of the interrelation of two factors: illnesses/accidents and context factors. The impact of both seems to be stronger in presence of dementia. Conclusions Points for action in terms of reducing hospitalization rates were: better qualified nurses, a 24-h-GP-emergency service and better compensation for ambulatory monitoring/treatments and house calls. Many hospitalizations of people with dementia cannot be prevented. Therefore, hospital staffs need to be better prepared to handle patients with dementia in order to reduce the negative effects of hospitalizations. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2484-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nadine Janis Pohontsch
- Department of General Practice/Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Martin Scherer
- Department of General Practice/Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Marion Eisele
- Department of General Practice/Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Are Hospital/ED Transfers Less Likely Among Nursing Home Residents With Do-Not-Hospitalize Orders? J Am Med Dir Assoc 2017; 18:438-441. [DOI: 10.1016/j.jamda.2016.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/02/2016] [Accepted: 12/02/2016] [Indexed: 11/21/2022]
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Porell FW, Carter M. Discretionary Hospitalization of Nursing Home Residents With and Without Alzheimer’s Disease. J Aging Health 2016; 17:207-38. [PMID: 15750052 DOI: 10.1177/0898264304274302] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study analyzes facility variations in hospital admission rates of nursing home (NH) residents with and without Alzheimer’s disease (AD) or related dementia with the aim of better understanding how facility-level contextual factors differentially affect hospitalization risks. Method: The sample population consists of 19,217 and 18,399 Medicaid residents with and without AD, respectively, from 546 NHs in Massachusetts between 1991 and 1993. Hospital use is measured as annual nonpsychiatric discretionary hospital admissions to short-term general hospitals. Multilevel estimation methods are used to obtain facility and market area parameter estimates. Results: There was greater interfacility variation in discretionary hospital admission rates of AD residents than residents without AD, particularly among more vulnerable subgroups of AD residents. Discussion: The findings underscore the importance of licensed nursing personnel in reducing discretionary hospitalizations among NH residents with AD.
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Affiliation(s)
- Frank W Porell
- Gerontology Center, University of Massachusetts at Boston, Boston, MA 02125-3393 USA
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Darbà J, Kaskens L, Lacey L. Relationship between global severity of patients with Alzheimer's disease and costs of care in Spain; results from the co-dependence study in Spain. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2015; 16:895-905. [PMID: 25348897 DOI: 10.1007/s10198-014-0642-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 10/10/2014] [Indexed: 05/18/2023]
Abstract
OBJECTIVE The objectives of this analysis were to examine how patients' global severity with Alzheimer's disease (AD) relates to costs of care and explore the incremental effects of global severity measured by the clinical dementia rating (CDR) scale on these costs for patients in Spain. METHODS The Codep-EA study is an 18-multicenter, cross-sectional, observational study among patients (343) with AD according to the CDR score and their caregivers in Spain. The data obtained included (in addition to clinical measures) also socio-demographic data concerning the patient and its caregiver. Cost analyses were based on resource use for medical care, social care, caregiver productivity losses, and informal caregiver time reported in the resource utilization in dementia (RUD). Lite instrument and a complementary questionnaire. Multivariate regression analysis was used to model the effects of global severity and other socio-demographic and clinical variables on cost of care. RESULTS The mean (standard deviation) costs per patient over 6 months for direct medical, social care, indirect and informal care costs, were estimated at €1,028.1 (1,655.0), €843.8 (2,684.8), €464.2 (1,639.0) and €33,232.2 (30,898.9), respectively. Dementia severity, as having a CDR score 0.5, 2, or 3 with CDR score 1 being the reference group were all independently and significantly associated with informal care costs. Whereas having a CDR score of 2 was also significantly related with social care costs, a CDR score of 3 was associated with most cost components including direct medical, social care, and total costs, all compared to the reference group. CONCLUSIONS The costs of care for patients with AD in Spain are substantial, with informal care accounting for the greatest part. Dementia severity, measured by CDR score, showed that with increasing severity of the disease, direct medical, social care, informal care and total costs augmented.
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Affiliation(s)
- J Darbà
- Department of Economics, Universitat de Barcelona, Diagonal 690, 08034, Barcelona, Spain.
| | - L Kaskens
- BCN Health Economics & Outcomes Research SL, Barcelona, Spain
| | - L Lacey
- Janssen Alzheimer Immunotherapy Research and Development, LLC and Pfizer Inc, Dublin, Ireland
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Zhu CW, Cosentino S, Ornstein K, Gu Y, Andrews H, Stern Y. Use and cost of hospitalization in dementia: longitudinal results from a community-based study. Int J Geriatr Psychiatry 2015; 30:833-41. [PMID: 25351909 PMCID: PMC4414886 DOI: 10.1002/gps.4222] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 09/04/2014] [Accepted: 09/09/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The aim of this study is to examine the relative contribution of functional impairment and cognitive deficits on risk of hospitalization and costs. METHODS A prospective cohort of Medicare beneficiaries aged 65 and older who participated in the Washington Heights-Inwood Columbia Aging Project (WHICAP) were followed approximately every 18 months for over 10 years (1805 never diagnosed with dementia during study period, 221 diagnosed with dementia at enrollment). Hospitalization and Medicare expenditures data (1999-2010) were obtained from Medicare claims. Multivariate analyses were conducted to examine (1) risk of all-cause hospitalizations, (2) hospitalizations from ambulatory care sensitive (ACSs) conditions, (3) hospital length of stay (LOS), and (4) Medicare expenditures. Propensity score matching methods were used to reduce observed differences between demented and non-demented groups at study enrollment. Analyses took into account repeated observations within each individual. RESULTS Compared to propensity-matched individuals without dementia, individuals with dementia had significantly higher risk for all-cause hospitalization, longer LOS, and higher Medicare expenditures. Functional and cognitive deficits were significantly associated with higher risks for hospitalizations, hospital LOS, and Medicare expenditures. Functional and cognitive deficits were associated with higher risks of for some ACS but not all admissions. CONCLUSIONS These results allow us to differentiate the impact of functional and cognitive deficits on hospitalizations. To develop strategies to reduce hospitalizations and expenditures, better understanding of which types of hospitalizations and which disease characteristics impact these outcomes will be critical.
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Affiliation(s)
- Carolyn W. Zhu
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- James J Peters VA Medical Center, Bronx, NY, USA
| | - Stephanie Cosentino
- Cognitive Neuroscience Division of the Gertrude H. Sergievsky Center, Taub Institute for Research on Alzheimer's Disease and the Aging Brain, and Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Katherine Ornstein
- The Samuel Bronfman Department of Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yian Gu
- Cognitive Neuroscience Division of the Gertrude H. Sergievsky Center, Taub Institute for Research on Alzheimer's Disease and the Aging Brain, and Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Howard Andrews
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Yaakov Stern
- Cognitive Neuroscience Division of the Gertrude H. Sergievsky Center, Taub Institute for Research on Alzheimer's Disease and the Aging Brain, and Department of Neurology, Columbia University Medical Center, New York, NY, USA
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Ramos–Estebanez C, Moral–Arce I, Rojo F, Gonzalez–Macias J, Hernandez JL. Vascular Cognitive Impairment and Dementia Expenditures: 7–Year Inpatient Cost Description in Community Dwellers. Postgrad Med 2015; 124:91-100. [DOI: 10.3810/pgm.2012.09.2597] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Maxwell CJ, Amuah JE, Hogan DB, Cepoiu-Martin M, Gruneir A, Patten SB, Soo A, Le Clair K, Wilson K, Hagen B, Strain LA. Elevated Hospitalization Risk of Assisted Living Residents With Dementia in Alberta, Canada. J Am Med Dir Assoc 2015; 16:568-77. [PMID: 25717011 DOI: 10.1016/j.jamda.2015.01.079] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 12/10/2014] [Accepted: 01/07/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Assisted living (AL) is an increasingly used residential option for older adults with dementia; however, lower staffing rates and service availability raise concerns that such residents may be at increased risk for adverse outcomes. Our objectives were to determine the incidence of hospitalization over 1 year for dementia residents of designated AL (DAL) facilities, compared with long-term care (LTC) facilities, and identify resident- and facility-level predictors of hospitalization among DAL residents. METHODS Participants were 609 DAL (mean age 85.7 ± 6.6 years) and 691 LTC (86.4 ± 6.9 years) residents with dementia enrolled in the Alberta Continuing Care Epidemiological Studies. Research nurses completed a standardized comprehensive assessment of residents and interviewed family caregivers at baseline (2006-2008) and 1 year later. Standardized administrator interviews provided facility level data. Hospitalization was determined via linkage with the provincial Inpatient Discharge Abstract Database. Multivariable Cox proportional hazards models were used to identify predictors of hospitalization. RESULTS The cumulative annual incidence of hospitalization was 38.6% (34.5%-42.7%) for DAL and 10.3% (8.0%-12.6%) for LTC residents with dementia. A significantly increased risk for hospitalization was observed for DAL residents aged 90+ years, with poor social relationships, less severe cognitive impairment, greater health instability, fatigue, high medication use (11+ medications), and 2+ hospitalizations in the preceding year. Residents from DAL facilities with a smaller number of spaces, no chain affiliation, and from specific health regions showed a higher risk of hospitalization. CONCLUSIONS DAL residents with dementia had a hospitalization rate almost 4-fold higher than LTC residents with dementia. Our findings raise questions about the ability of some AL facilities to adequately address the needs of cognitively impaired residents and highlight potential clinical, social, and policy areas for targeted interventions to reduce hospitalization risk.
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Affiliation(s)
- Colleen J Maxwell
- Schools of Pharmacy and Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
| | - Joseph E Amuah
- Health System Performance Branch, Canadian Institute for Health Information, Ottawa, Ontario, Canada
| | - David B Hogan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Division of Geriatric Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Monica Cepoiu-Martin
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Andrea Gruneir
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Scott B Patten
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Andrea Soo
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kenneth Le Clair
- Division of Geriatric Psychiatry, Queen's University and Center for Studies in Aging and Health, Providence Care, Kingston, Ontario, Canada
| | - Kimberley Wilson
- Department of Family Relations and Applied Nutrition, University of Guelph, Macdonald Institute, Guelph, Ontario, Canada
| | - Brad Hagen
- Faculty of Health Sciences, University of Lethbridge, Lethbridge, Alberta, Canada
| | - Laurel A Strain
- Department of Sociology, University of Alberta, Edmonton, Alberta, Canada
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Pinkert C, Holle B. [People with dementia in acute hospitals. Literature review of prevalence and reasons for hospital admission]. Z Gerontol Geriatr 2013; 45:728-34. [PMID: 22538786 DOI: 10.1007/s00391-012-0319-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
People with dementia who are hospitalized depend on hospital care that is tailored to their particular needs. However, the current structural conditions and standardized care plans are often opposed to the needs for familiarity and orientation that people with dementia have. For the development of dementia-specific care concepts, it is important to know the proportion of persons with dementia who are hospitalized as well as the diagnosis that leads to hospital admission. The results of the literature review show prevalence estimates of 3.4-43.3%. The probability or risk of hospitalization for persons with dementia is between 1.4-3.6 times greater than it is for non-dementia persons. In addition, the reasons for admission are different. People with dementia are more frequently hospitalized due to infectious diseases, fractures, or nutritional disorders than non-dementia persons. Based on these results, one can hypothesize that there is a need for cross-sectoral care approaches, since these indicate the necessity for further research in order to establish a reliable database.
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Affiliation(s)
- C Pinkert
- Arbeitsgruppe Versorgungsstrukturen, Deutsches Zentrum für Neurodegenerative Erkrankungen e. V. (DZNE), Standort Witten, Stockumer Str. 12, 58453, Witten.
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Affiliation(s)
- Robert L. Kane
- Division of Health Policy and Management, School of Public Health; University of Minnesota; Minneapolis; Minnesota
| | - Joseph G. Ouslander
- Charles E. Schmidt College of Medicine; Florida Atlantic University; Boca Raton; Florida
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Givens JL, Selby K, Goldfeld KS, Mitchell SL. Hospital transfers of nursing home residents with advanced dementia. J Am Geriatr Soc 2012; 60:905-9. [PMID: 22428661 DOI: 10.1111/j.1532-5415.2012.03919.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe diagnoses and factors associated with hospital transfer in nursing home (NH) residents with advanced dementia. DESIGN Prospective cohort study. SETTING Twenty-two Boston, Massachusetts-area NHs. PARTICIPANTS Three hundred twenty-three NH residents with advanced dementia. MEASUREMENTS Data were collected quarterly for up to 18 months. Data regarding transfers were collected with regard to hospitalization or emergency department (ED) visit, diagnosis, and duration of inpatient admission. Information on the occurrence of any acute medical event (pneumonia, febrile episode, or other acute illness) in the prior 90 days was obtained quarterly. Logistic regression conducted at the level of the acute medical event identified characteristics associated with hospital transfer. RESULTS The entire cohort experienced 74 hospitalizations and 60 ED visits. Suspected infections were the most common reason for hospitalization (44, 59%), most frequently attributable to a respiratory source (30, 41%). Feeding tube-related complications accounted for 47% of ED visits. In adjusted analysis conducted on acute medical events, younger resident age, event type (pneumonia or other event vs febrile episode), chronic obstructive pulmonary disease, and the lack of a do-not-hospitalize (DNH) order (adjusted odds ratio = 5.22, 95% confidence interval = 2.31-11.79) were associated with hospital transfer. CONCLUSION The majority of hospitalizations of NH residents with advanced dementia were due to infections and thus were potentially avoidable, because infections are often treatable in the NH. Feeding tube-related complications accounted for almost half of all ED visits, representing a common but underrecognized burden of this intervention. Advance care planning in the form of a DNH order was the only identified modifiable factor associated with avoiding hospitalization.
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Affiliation(s)
- Jane L Givens
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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Bentkover J, Cai S, Makineni R, Mucha L, Treglia M, Mor V. Road to the nursing home: costs and disease progression among medicare beneficiaries with ADRD. Am J Alzheimers Dis Other Demen 2012; 27:90-9. [PMID: 22495336 PMCID: PMC10697347 DOI: 10.1177/1533317512440494] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To estimate long-term care costs and disease progression among Medicare beneficiaries aged 65+ with ADRD. METHODS Retrospective analysis of Medicare Part A claims and nursing home (NH) Minimum Data Set (MDS) records among beneficiaries 1999-2007. Expenditures were grouped into 3 periods; PRE, events occurring between date of ADRD diagnosis, before first NH admission; PERI, from first NH admission to at least 100 days; and, PERM, after 120 days. Utilization and reimbursements were computed for each period. RESULTS Demographics of the3,681,702 ADRD beneficiaries showed average age of 83 (+/-7), female (67.7%) and white (87.4%). Medicare reimbursements per person increased by 58% from the PRE ($47,912) to PERM period ($75,654). Age, ethnicity, gender (male), and comorbidities were significantly related to total reimbursements in each phase. CONCLUSIONS Applying a taxonomy of NH phases, Medicare expenditures per person year are higher among patients in their terminal phase and higher still with comorbidities.
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Affiliation(s)
- Judith Bentkover
- Center for Gerontology & Healthcare, Health Services Policy & Practice, Brown University, Providence, RI, USA
| | - Shubing Cai
- Center for Gerontology & Healthcare, Health Services Policy & Practice, Brown University, Providence, RI, USA
| | - Rajesh Makineni
- Center for Gerontology & Healthcare, Health Services Policy & Practice, Brown University, Providence, RI, USA
| | - Lisa Mucha
- Global Health Economics and Outcomes Research, Pfizer, Inc, Collegeville, PA, USA
| | | | - Vincent Mor
- Center for Gerontology & Healthcare, Health Services Policy & Practice, Brown University, Providence, RI, USA
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Mauskopf J, Mucha L. A review of the methods used to estimate the cost of Alzheimer's disease in the United States. Am J Alzheimers Dis Other Demen 2011; 26:298-309. [PMID: 21561991 PMCID: PMC10845619 DOI: 10.1177/1533317511407481] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2024]
Abstract
UNLABELLED BACKGROUN/RATIONALE: To determine the suitability of published estimates of the US cost of Alzheimer's disease (AD) for use in cost-effectiveness models for new AD treatments. METHODS A systematic literature review of published information on direct medical, direct nonmedical, indirect, and informal care costs for different levels of disease severity. RESULTS Nineteen studies were included in the review. In studies presenting mean costs by disease severity, the change in different types of costs with increasing disease severity varied, depending on the data sources and characteristics of patients with AD. In studies presenting the results of regression analyses, costs were shown to be independently associated with cognition, functional status, behavioral symptoms, and dependence. CONCLUSIONS Published US studies (1) did not include all the types of costs and AD populations, and (2) generally did not include all the measures of disease severity that are needed for cost-effectiveness models.
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Affiliation(s)
- Josephine Mauskopf
- Health Economics, RTI Health Solutions, Research Triangle Park, NC, USA.
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Oremus M, Aguilar SC. A systematic review to assess the policy-making relevance of dementia cost-of-illness studies in the US and Canada. PHARMACOECONOMICS 2011; 29:141-156. [PMID: 21090840 DOI: 10.2165/11539450-000000000-00000] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
A systematic review of dementia cost-of-illness (COI) studies in the US and Canada was conducted to explore the policy-making relevance of these studies. MEDLINE, CINAHL, EconLit, AMED and the Cochrane Library were searched from inception to March 2010 for English-language COI articles. Content analysis was used to extract common themes about dementia cost from the conclusions of articles that passed title, abstract and full-text screening. These themes informed our exploration of the policy-making relevance of COI studies in dementia. The literature search retrieved 961 articles and data were extracted from 46 articles. All except three articles reported data from the US; 27 articles included Alzheimer's dementia only. Common themes pertained to general observations about dementia cost, cost drivers in dementia, caregiver cost, items that may lower dementia cost, social service cost, Medicare and Medicaid cost, and cost comparisons with other diseases. The common themes suggest policy-oriented research for the future. However, the extracted COI studies were typically not conducted for policy-making purposes and they did not commonly provide prescriptive policy options. Researchers and policy makers need to consider whether the optimal research focus in dementia should be on programme evaluations instead of more COI studies.
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Affiliation(s)
- Mark Oremus
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 50 Main Street East, Hamilton, Ontario, Canada.
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Fillit H, Cummings J, Neumann P, McLaughlin T, Salavtore P, Leibman C. Novel approaches to incorporating pharmacoeconomic studies into phase III clinical trials for Alzheimer's disease. J Nutr Health Aging 2010; 14:640-7. [PMID: 20922340 DOI: 10.1007/s12603-010-0310-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The societal and individual costs of Alzheimer's disease are significant, worldwide. As the world ages, these costs are increasing rapidly, while health systems face finite budgets. As a result, many regulators and payers will require or at least consider phase III cost-effectiveness data (in addition to safety and efficacy data) for drug approval and reimbursement, increasing the risks and costs of drug development. Incorporating pharmacoeconomic studies in phase III clinical trials for Alzheimer's disease presents a number of challenges. We propose several specific suggestions to improve the design of pharmacoeconomic studies in phase III clinical trials. We propose that acute episodes of care are key outcome measures for pharmacoeconomic studies. To improve the possibility of detecting a pharmacoeconomic impact in phase III, we suggest several strategies including; study designs for enrichment of pharmacoeconomic outcomes that include co-morbidity of patients; reducing variability of care that can affect pharmacoeconomic outcomes through standardized care management; employing administrative claims data to better capture meaningful pharmacoeconomic data; and extending clinical trials in open label follow-up periods in which pharmacoeconomic data are captured electronically by administrative claims. Specific aspects of power analysis for pharmacoeconomic studies are presented. The particular pharmacoeconomic challenges caused by the use of biomarkers in clinical trials, the increasing use of multinational studies, and the pharmacoeconomic challenges presented by biologicals in development for Alzheimer's disease are discussed. In summary, since we are entering an era in which pharmacoeconomic studies will be essential in drug development for supporting regulatory approval, payor reimbursement and integration of new therapies into clinical care, we must consider the design and incorporation of pharmacoeconomic studies in phase III clinical trials more seriously and more creatively.
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Affiliation(s)
- H Fillit
- The Alzheimer's Drug Discovery Foundation, NY, NY, USA
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Lang PO, Zekry D, Michel JP, Drame M, Novella JL, Jolly D, Blanchard F. Early markers of prolonged hospital stay in demented inpatients: a multicentre and prospective study. J Nutr Health Aging 2010; 14:141-7. [PMID: 20126963 DOI: 10.1007/s12603-009-0182-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Dementia is a serious, chronic, and costly public health problem. Prior studies have described dementia as increasing length of hospital stay, but so far no explanations have been proposed. METHODS To identify early markers for prolonged hospital stay in demented elderly inpatients, 178 community-dwelling or institutionalized subjects aged 75+, hospitalized through an emergency department in 9 teaching hospitals in France, were analyzed. Prolonged hospital stays were defined according a limit adjusted for Diagnosis Related Group. All patients underwent a comprehensive geriatric assessment at admission. Logistic regression multifactorial mixed model was performed. Center effect was considered as a random effect. RESULTS Of the 178 stays, 52 were prolonged. Most concerned community-dwelling patients (86%). Multifactor analysis demonstrated that demographic variables had no influence on the length of stay, while diagnosis of delirium (OR 2.31; 95% CI 1.77 - 2.91), walking difficulties (OR 1.94; 95% CI 1.62 - 2.43) and report by the informal caregiver of moderate or severe burden (OR 1.52; 95% CI 1.19 - 1.86) or low social quality-of-life score (OR 1.25; 95% CI 1.03 - 1.40), according to the Zarit's Burden Inventory short scale (12 items) and the Duke's Health Profile respectively, were identified as early markers for prolonged hospital stays. CONCLUSION At the time of the rising incidence of cognitive disorders, these results suggest that preventive approaches might be possible. In a hospital setting as well as in a community-dwelling population, more specific, specialized and coordinated care, using the expertise of multiple disciplines appears as a probable effective measure to limit prolonged hospital stay. Such approaches require (i) clear patient-oriented goal definition, (ii) understanding and appreciation of roles among various health care and social disciplines and, (iii) cooperation between partners in patient's management. However, the cost- and health-effectiveness of such approaches should be evaluated.
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Affiliation(s)
- P-O Lang
- Department of rehabilitation and geriatrics, Medical school and University Hospitals of Geneva, Geneva, Switzerland.
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Cohen JT, Neumann PJ. Decision analytic models for Alzheimer's disease: state of the art and future directions. Alzheimers Dement 2008; 4:212-22. [PMID: 18631970 DOI: 10.1016/j.jalz.2008.02.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Revised: 02/01/2008] [Accepted: 02/04/2008] [Indexed: 10/22/2022]
Abstract
Decision analytic policy models for Alzheimer's disease (AD) enable researchers and policy makers to investigate questions about the costs and benefits of a wide range of existing and potential screening, testing, and treatment strategies. Such models permit analysts to compare existing alternatives, explore hypothetical scenarios, and test the strength of underlying assumptions in an explicit, quantitative, and systematic way. Decision analytic models can best be viewed as complementing clinical trials both by filling knowledge gaps not readily addressed by empirical research and by extrapolating beyond the surrogate markers recorded in a trial. We identified and critiqued 13 distinct AD decision analytic policy models published since 1997. Although existing models provide useful insights, they also have a variety of limitations. (1) They generally characterize disease progression in terms of cognitive function and do not account for other distinguishing features, such as behavioral symptoms, functional performance, and the emotional well-being of AD patients and caregivers. (2) Many describe disease progression in terms of a limited number of discrete states, thus constraining the level of detail that can be used to characterize both changes in patient status and the relationships between disease progression and other factors, such as residential status, that influence outcomes of interest. (3) They have focused almost exclusively on evaluating drug treatments, thus neglecting other disease management strategies and combinations of pharmacologic and nonpharmacologic interventions. Future AD models should facilitate more realistic and compelling evaluations of various interventions to address the disease. An improved model will allow decision makers to better characterize the disease, to better assess the costs and benefits of a wide range of potential interventions, and to better evaluate the incremental costs and benefits of specific interventions used in conjunction with other disease management strategies.
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Affiliation(s)
- Joshua T Cohen
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center, Boston, MA, USA.
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Mitchell SL, Teno JM, Intrator O, Feng Z, Mor V. Decisions to forgo hospitalization in advanced dementia: a nationwide study. J Am Geriatr Soc 2007; 55:432-8. [PMID: 17341248 DOI: 10.1111/j.1532-5415.2007.01086.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine the prevalence and factors associated with decisions to forgo hospitalization in nursing home (NH) residents with advanced dementia. DESIGN Cross-sectional study. SETTING All Medicare- and Medicaid-certified NHs within the 48 contiguous U.S. states. PARTICIPANTS NH residents with advanced dementia were identified using Minimum Data Set (MDS) assessments completed close to April 1, 2000 (N=91,521). MEASUREMENTS Multilevel, multivariate logistic regression identified factors independently associated with having a do-not-hospitalize (DNH) directive. Independent variables included subject characteristics (MDS), facility factors (On-line Survey of Certification of Automated Records), and hospital referral region (HRR) features (Dartmouth Atlas). RESULTS Nationwide, 7.1% (n=6,518) residents with advanced dementia had DNH orders (range 0.7% in Oklahoma to 25.9% in Rhode Island). Resident characteristics associated with having a DNH order were older age, white, living will, durable power of attorney for health care, and total functional dependence. Controlling for these factors, DNH orders were more likely in residents of facilities with the following features: not part of a chain, urban location, special care dementia unit, fewer black residents, nurse practitioner or physician assistant on staff, higher staffing ratios, and location in HRRs with fewer intensive care unit admissions during terminal hospitalizations. CONCLUSION Directives to forgo hospitalization for U.S. NH residents with advanced dementia are uncommon and are associated with the organizational features of the facilities caring for them and the intensity of end-of-life care practiced in the region, as well as individual resident characteristics.
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Affiliation(s)
- Susan L Mitchell
- Hebrew SeniorLife, Institute for Aging Research and Beth Israel Deaconess Medical Center, Boston, Massachusetts 02131, USA.
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Jönsson L, Eriksdotter Jönhagen M, Kilander L, Soininen H, Hallikainen M, Waldemar G, Nygaard H, Andreasen N, Winblad B, Wimo A. Determinants of costs of care for patients with Alzheimer's disease. Int J Geriatr Psychiatry 2006; 21:449-59. [PMID: 16676288 DOI: 10.1002/gps.1489] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Alzheimer's disease (AD), the most common cause of dementia, is a major cause of disability and care burden in the elderly. This study aims to estimate the costs of formal and informal care and identity determinants of care costs. MATERIALS AND METHODS Two hundred and seventy-two (AD) patients and their caregivers were recruited among patients attending regular visits at six memory clinic in Sweden, Denmark, Norway and Finland. Patients with a diagnosis of AD and with an identifiable primary caregiver were eligible for inclusion. Data was collected by questionnaires at baseline, and at scheduled follow-up visits after 6 months and again after 12 months. Cognitive function was assessed with the Mini Mental State Examination (MMSE) and behavioural disturbances were measured using a brief version of the neuropsychiatric inventory (NPI). RESULTS Total annual costs were on average 172,000 SEK, ranging from 60,700 SEK in mild dementia to 375,000 SEK in severe dementia. Costs for community care (special accommodation, home help, etc.) constituted about half of total costs of care and increase sharply with increasing cognitive impairment. Informal care costs, valued at the opportunity cost of the caregiver's time, make up about a third of total costs and also increased significantly with disease severity. Medical care costs (inpatient care, outpatient care, pharmaceuticals), on the other hand, were not significantly related to disease severity. Regression analysis confirmed a strong association between costs and cognitive function, between patients as well as within patients over time. There was also a significant influence on costs from behavioural disturbances. Sensitivity analysis showed that the method chosen to value informal care can have considerable impact on results. CONCLUSIONS Costs of care in patient with AD are high and related to dementia severity as well as presence of behavioural disturbances. The cost estimates presented have implications for future economic evaluation of treatments for Alzheimer's disease.
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Affiliation(s)
- Linus Jönsson
- Division of Geriatric Epidemiology, the Neurotec Department, Karolinska Institutet, Stockholm, Sweden.
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Lamberg JL, Person CJ, Kiely DK, Mitchell SL. Decisions to Hospitalize Nursing Home Residents Dying with Advanced Dementia. J Am Geriatr Soc 2005; 53:1396-401. [PMID: 16078968 DOI: 10.1111/j.1532-5415.2005.53426.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe the prevalence of, timing of, and factors associated with decisions not to hospitalize nursing home residents with advanced dementia who were dying. DESIGN Retrospective cohort study. SETTING Six hundred seventy five-bed nursing facility in Boston. PARTICIPANTS Two hundred forty residents in a teaching nursing home who died between January 2001 and December 2003 with advanced dementia. MEASUREMENTS The prevalence and timing of do-not-hospitalize (DNH) orders were determined from the medical record. Data describing demographic characteristics, health conditions, advance care planning, sentinel events, and health services usage during the last 6 months of life were examined. Factors associated with having a DNH order were identified. RESULTS At the time of death, 83.8% of subjects had a DNH order. The prevalence of DNH orders was 50.0% and 34.4%, 30 and 180 days before death, respectively. Hospital transfers were common during the last 6 months of life (24.6%). Factors independently associated with having a DNH order before death included surrogate decision-maker was not the subject's child (adjusted odds ratio (AOR)=4.39, 95% confidence interval (CI)=1.52-12.66), eating problems (AOR=4.17, 95% CI=1.52-11.47), aged 92 and older (AOR=2.78, 95% CI=1.29-5.96), and length of stay 2 years or longer (AOR=2.34, 95% CI=1.11-4.93). CONCLUSION For most institutionalized persons with advanced dementia, a decision to forgo hospitalization is not made until death is imminent. Thus, hospital transfers are common near the end of life. The finding that DNH orders are associated with patient and surrogate factors can help clinicians identify cases in which decisions to forgo hospitalizations may be facilitated.
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Affiliation(s)
- Jennifer L Lamberg
- Hebrew SeniorLife, Research and Training Institute, Boston, Massachusetts 02131, USA
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Gupta SK, Lamont EB. Patterns of Presentation, Diagnosis, and Treatment in Older Patients with Colon Cancer and Comorbid Dementia. J Am Geriatr Soc 2004; 52:1681-7. [PMID: 15450045 DOI: 10.1111/j.1532-5415.2004.52461.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To estimate patterns of colon cancer presentation, diagnosis, and treatment according to history of dementia using National Cancer Institute (NCI) Surveillance, Epidemiology, and End-Result (SEER) Medicare data. DESIGN Population-level cohort study. SETTING NCI's SEER-Medicare database. PARTICIPANTS A total of 17,507 individuals aged 67 and older with invasive colon cancer (Stage I-IV) were identified from the 1993-1996 SEER file. Medicare files were evaluated to determine which patients had an antecedent diagnosis of dementia. MEASUREMENTS Parameters relating to the cohort's patterns of presentation and care were estimated using logistic regressions. RESULTS The prevalence of dementia in the cohort of newly diagnosed colon cancer patients was 6.8% (1,184/17,507). Adjusting for possible confounders, dementia patients were twice as likely to have colon cancer reported after death (i.e., autopsy or death certificate) (adjusted odds ratio (AOR)=2.31, 95% confidence interval (CI)=1.79-3.00). Of those diagnosed before death (n=17,049), dementia patients were twice as likely to be diagnosed noninvasively than with tissue evaluation (i.e., positive histology) (AOR=2.02 95% CI=1.63-2.51). Of patients with Stage I -III disease (n=12,728), patients with dementia were half as likely to receive surgical resection (AOR=0.48, 95% CI=0.33-0.70). Furthermore, of those with resected Stage III colon cancer (n=3,386), dementia patients were 78% less likely to receive adjuvant 5-fluorouracil (AOR=0.22, 95% CI=0.13-0.36). CONCLUSION Although the incidences of dementia and cancer rise with age, little is known about the effect of dementia on cancer presentation and treatment. Elderly colon cancer patients are less likely to receive invasive diagnostic methods or curative-intent therapies. The utility of anticancer therapies in patients with dementia merits further study.
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Affiliation(s)
- Supriya K Gupta
- Section of Hematology-Oncology, University of Chicago, Chicago, Illinois 60637, USA.
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Jönsson L. Pharmacoeconomics of cholinesterase inhibitors in the treatment of Alzheimer's disease. PHARMACOECONOMICS 2003; 21:1025-1037. [PMID: 13129415 DOI: 10.2165/00019053-200321140-00003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
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.
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Affiliation(s)
- Linus Jönsson
- Department of Neuroscience, Occupational Therapy and Elderly Care Research (NEUROTEC), Karolinska Institutet, Stockholm, Sweden.
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Bromberg MB, Harati Y. Neuromuscular highlights from the american academy of neurology annual meeting. J Clin Neuromuscul Dis 2001; 3:39-44. [PMID: 19078653 DOI: 10.1097/00131402-200109000-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- M B Bromberg
- From the *Department of Neurology, University of Utah, Salt Lake City, Utah; and daggerBaylor College of Medicine, Houston, Texas
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