Willingness of families caring for victims of dementia to pay for nursing home care: results of a pilot study in Taiwan

A longitudinal evaluation of family caregivers' willingness to pay for an in-home nonpharmacologic intervention for people living with dementia: results from a randomized trial

OBJECTIVE

To determine the willingness-to-pay (WTP) of family caregivers to learn care strategies for persons living with dementia (PLwD).

DESIGN

Randomized clinical trial.

SETTING

Community-dwelling PLwD and their caregivers (dyads) in Maryland and Washington, DC.

PARTICIPANTS

250 dyads.

INTERVENTION

Tailored Activity Program (TAP) compared to attention control. TAP provides activities tailored to the PLwD and instructs caregivers in their use.

MEASUREMENT

At baseline, 3 and 6 months, caregivers were asked their WTP per session for an 8-session 3-month in-home nonpharmacologic intervention to address behavioral symptoms and functional dependence.

RESULTS

At baseline, 3 and 6 months, caregivers assigned to TAP were willing to pay $26.10/session (95%CI:$20.42, $33.00), $28.70 (95%CI:$19.73, $39.30), and $22.79 (95%CI: $16.64, $30.09), respectively; attention control caregivers were willing to pay $37.90/session (95%CI: $27.10, $52.02), $30.92 (95%CI: $23.44, $40.94), $27.44 (95%CI: $20.82, $35.34), respectively. The difference in baseline to 3 and 6 months change in WTP between TAP and the attention control was $9.58 (95%CI: -$5.00, $25.47) and $7.15 (95%CI: -$5.72, $21.81). The difference between TAP and attention control in change in the proportion of caregivers willing to pay something from baseline to 3 and 6 months was -12% (95%CI: -28%, -5%) and -7% (95%CI:-25%, -11%), respectively. The difference in change in WTP, among caregivers willing to pay something, between TAP and attention control from baseline to 3 and 6 months was $17.93 (95%CI: $0.22, $38.30) and $11.81 (95%CI: -$2.57, $28.17).

CONCLUSIONS

Family caregivers are willing to pay more for an intervention immediately following participation in a program similar to which they were asked to value.

Family Caregivers’ Willingness to Pay for Drugs Indicated for the Treatment of Alzheimer’s Disease

The aim of the present study was to examine the willingness of family members caring for patients with probable Alzheimer’s Disease (AD) to pay for drug treatment, using the contingent valuation technique and the theory of planned behavior. A sample of 220 family members (68.2% F, mean age = 62.3; 59.8% spouses and the rest children) were interviewed regarding their willingness to pay (WTP) for drug treatment, their attitudes, normative expectations of significant others and perceived behavioral control. The mean WTP for drug treatment was estimated at about 60–80% of the retail price of the drug at the time of the study. Participants were willing to pay a significantly higher price when provided with information regarding side effects. Including psychological determinants (especially regarding affordability and normative expectations of significant others) improved an economic model. The understanding of decision-making processes in the framework of dementia should be expanded to include economic and psychological determinants.

Direct medical costs in patients with Alzheimer's disease in Taiwan: A population-based study

BACKGROUND

Alzheimer's disease (AD) has the potential to become a major health concern and associated health care costs may become a significant economic burden on society.

OBJECTIVE

The aim of this study was to estimate the direct medical costs attributable to AD in patients aged ≥60 years in Taiwan from 2000 through 2002 and to explore the correlation of these costs with patients' age and sex.

METHODS

This study was based on the National Health Insurance Research Database of Taiwan's National Health Insurance (NHI) program. The NHI program insures >98% of the 23 million inhabitants of Taiwan. Detailed data were extracted from a random sample of 0.2% of inpatient and 5% of outpatient recipients with AD (International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code 331.0) who were aged ≥60 years and who received inpatient or outpatient services with claims from January 1, 2000, to December 31, 2002. Duplicate charges for a specific patient and diagnoses of other types of dementia were excluded from this study.

RESULTS

A total of 69,780 patients were found to have a diagnosis of AD. The direct medical costs for outpatients were estimated at US $1.2 million in 2000, US $1.9 million in 2001, and US $2.3 million in 2002; the costs for inpatient care were estimated at US $670,000 in 2000, US $2.4 million in 2001, and US $3.2 million in 2002. The total direct medical costs were estimated at US $1.86 million in 2000, US $4.24 million in 2001, and US $5.48 million in 2002. The increase of total direct medical costs was not significantly correlated with patients' age or sex.

CONCLUSIONS

From 2000 through 2002, the direct medical costs of AD increased annually in Taiwan among patients with AD aged ≥60 years. No significant correlation was found between increased total direct medical costs and sex or age. The cost estimate presented here has implications for future decision making about reallocating medical resources for treating AD in Taiwan.

Caregiver characteristics and economic cost of home-based care: a case study of Maun and Gumare villages in North West District, Botswana

The home-based care programme in Botswana was initiated partly to augment hospital or clinical care by reducing the healthcare costs associated with chronic illnesses such as HIV/AIDS. A number of studies have pointed to the psyco-social impacts of home based care, however there has been few attempts to quantify the direct and indirect costs associated with home based care. This study was carried out in the North West District of Botswana, which is noted for a relatively larger proportion of households with critically ill persons. The objectives of the study were to identify the characteristics of the caregivers and their patients; to estimate the direct and indirect costs of home-based care; and to estimate caregivers' willingness to pay for care services. Data was collected using a structured questionnaire addressed to 120 primary caregivers and analyzed using SPSS. The economic cost of caregiving was estimated using the replacement cost method. The annual value per caregiver was estimated at P31 320 (US$4818.46). The study also revealed that more often than not, women are involved in caregiving activities.

The general public's willingness to pay for tax increases to support unrestricted access to an Alzheimer's disease medication

BACKGROUND

Alzheimer's disease (AD) is a neurodegenerative disorder highlighted by progressive declines in cognitive and functional abilities.

OBJECTIVE

Our objective was to assess the general public's maximum willingness to pay ((M)WTP) for an increase in annual personal income taxes to fund unrestricted access to AD medications.

METHODS

We randomly recruited 500 Canadians nationally and used computer-assisted telephone interviewing to administer a questionnaire. The questionnaire contained four 'efficacy' scenarios describing an AD medication as capable of symptomatically treating cognitive decline or modifying disease progression. The scenarios also described the medication as having no adverse effects or a 30% chance of adverse effects. We randomized participants to order of scenarios and willingness-to-pay bid values; (M)WTP for each scenario was the highest accepted bid for that scenario. We conducted linear regression and bootstrap sensitivity analyses to investigate potential determinants of (M)WTP.

RESULTS

Mean (M)WTP was highest for the 'disease modification/no adverse effects' scenario ($Can130.26) and lowest for the 'symptomatic treatment/30% chance of adverse effects' scenario ($Can99.16). Bootstrap analyses indicated none of our potential determinants (e.g. age, sex) were associated with participants' (M)WTP.

CONCLUSIONS

The general public is willing to pay higher income taxes to fund unrestricted access to AD (especially disease-modifying) medications. Consequently, the public should favour placing new AD medications on public drug plans. As far as we are aware, no other study has elicited the general public's willingness to pay for AD medications.

Measuring the value of older people's production: a diary study

BACKGROUND

The productive capacity of retired people is usually not valued. However, some retirees produce much more than we might expect. This diary-based study identifies the activities of older people, and suggests some value mechanisms. One question raised is whether it is possible to scale up this diary study into a larger representative study.

METHODS

Diaries kept for one week were collected among 23 older people in the north of Sweden. The texts were analysed with a grounded theory approach; an interplay between ideas and empirical data.

RESULTS

Some productive activities of older people must be valued as the opportunity cost of time or according to the market value, and others must be valued with the replacement cost. In order to make the choice between these methods, it is important to consider the societal entitlement. When there is no societal entitlement, the first or second method must be used; and when it exists, the third must be used.

CONCLUSIONS

An explicit investigation of the content of the entitlement is needed to justify the choice of valuation method for each activity. In a questionnaire addressing older people's production, each question must be adjusted to the type of production. In order to fully understand this production, it is important to consider the degree of free choice to conduct an activity, as well as health-related quality of life.

Evaluating willingness-to-pay thresholds for dementia caregiving interventions: application to the tailored activity program

OBJECTIVES

The study aims to apply willingness-to-pay (WTP) values derived from the literature to inform decision-makers of the cost-effectiveness of the Tailored Activity Program (TAP), an intervention proven to reduce caregiver burden.

METHODS

TAP and other caregiver interventions employ an individual perspective and non-quality-adjusted life-year (QALY) outcome measure where the primary objective is to determine caregiver burden from an individual perspective. Therefore, standard cost/QALY thresholds are not appropriate. To identify relevant WTP values, we searched for studies that: 1) were published in the past 5 years and used contingent valuation methodology to identify WTP; 2) assessed WTP for a dementia-related intervention requiring out-of-pocket expenditure; and 3) asked caregivers their WTP for an outcome related to reducing caregiver burden. Three studies were identified utilizing four WTP values. We also assessed potential financial savings that caregivers could achieve from purchasing TAP. To assess the probability of TAP being cost-effective, we built a Monte Carlo simulation to test the four WTP values applied to two TAP outcome measures: reduction in caregiver hours "on duty;" and "doing things."

RESULTS

  For outcome measure "on duty," WTP varied between $1.06/hour and $4.58/hour. For outcome measure "doing things," WTP varied between $2.21/hour and $9.57/hour. Applying the four identified WTP values from the literature to TAP outcomes resulted in TAP cost-effectiveness varying between 50% and 80% for both outcome measures.

CONCLUSIONS

When WTP data are not collected prospectively or conventional metrics cannot be applied, retrospectively assessing literature-derived WTP may be acceptable for informing decision-makers of potential cost-effectiveness of a proven program. Application of WTP to TAP shows potential cost-effectiveness that can be expected under the tested WTP scenarios.

Caring for relatives with dementia: willingness-to-pay for a reduction in caregiver's burden

Informal care constitutes a large percentage of total care for patients with dementia. Providing care for cognitively impaired individuals is stressful and demanding. This study applies the contingent valuation method to estimate the willingness-to-pay of informal caregivers for a reduction of their burden. In 109 face-to-face interviews, caregivers with demented relatives stated their willingness-to-pay for three hypothetical treatments of the patient. Results suggest that caregiver's disutility from burden is considerable. On average, caregivers are willing to pay 2200 Swiss Francs (US$1500) per year for a reduction of their burden level from moderate to low. Therefore, interventions which combat the negative consequences of caregiving have great potential to yield a social net benefit.

Willingness-to-pay for reductions in care need: estimating the value of informal care in Alzheimer's disease

OBJECTIVE

To estimate the value of informal care in Alzheimer's disease using contingent valuation.

METHODS

A questionnaire was administered to 517 primary carers in four countries (UK, Spain, Sweden, and US). Dichotomous choice and bidding game methods were used to elicit their willingness to pay for a reduction in care burden by 1 h per day, or a total elimination of care needs. Further, the relationship between carer willingness to pay and carer and patient characteristics including disease severity and income was examined.

RESULTS

Carers spend on average about 7-9 h per day on giving care to their patient, of which 4-5 h constituted basic and instrumental ADL tasks. For a 1 h reduction in need for care per day, carers in the UK, Spain, Sweden, and US said that they were willing to pay pound105, pound121, pound59, and pound144 per month respectively. The willingness to pay was higher for carers with higher disposable income while the influence of other determinants varied across countries. About one-third of carers were not willing to pay anything for a reduction in care.

CONCLUSIONS

Carers' stated willingness to pay for reductions in care giving time is substantial and comparable to the prices currently paid for treatments that achieve this benefit. Its determinants seem more directly related to carer status than directly to patient status and may vary by region and by cultural and sociologic factors.

"If you have the flu symptoms, your asymptomatic spouse may better answer the willingness-to-pay question". Evidence from a double-bounded dichotomous choice model with heterogeneous anchoring

The small sample size of contingent valuation (CV) surveys conducted in patients may have limited the use of the single-bounded (SB) dichotomous choice format which is recommended in environmental economics. In this paper, we explore two ways to increase the statistical efficiency of the SB format: (1) by the inclusion of proxies in addition to patients; (2) by the addition of a follow-up dichotomous question, i.e. the double-bounded (DB) dichotomous choice format. We found that patients (n=223) and spouses (n=64) answering on behalf of the patient had on average a similar willingness-to-pay for earlier alleviation of flu symptoms. However, a patient was significantly more likely to anchor his/her answer on the first bid as compared to a spouse. Finally, our original DB model with shift effect and heterogeneous anchoring reconciled the discrepancies found in willingness-to-pay statistics between SB and DB models in keeping with increased statistical efficiency.

A systematic review of the use of contingent valuation in Alzheimer's disease research

This systematic review was conducted to examine the use of an economic evaluation strategy called `contingent valuation' in Alzheimer's disease (AD). Several scholarly and internet databases were searched for relevant citations. Articles were included in the review if they contained an original report of the use of contingent valuation in AD. Six articles — all of which assessed contingent valuation defined as willingness-to-pay (WTP) — met this criterion. Overall, caregivers' and patients' WTP for medications was higher when outcomes were better (e.g. cure versus stability). Cost-benefit analyses in two articles indicated that cholinesterase inhibitors, caregiver training, diagnostic testing, and publicly funded AD research would have net benefits for society. The articles were difficult to compare because of differences in methodology and setting. The articles also had a mix of methodological problems pertaining to study population, survey design, and elicitation of WTP. WTP is a useful means of conducting socioeconomic and policy research in AD, provided researchers are careful to address potential problems with comparability and methodology.

Demand for private health insurance in Chinese urban areas

Between 1993 and 2003, the proportion of urban residents without health insurance rose from 27 to 50%. The probability of outpatient visits in the previous 2 weeks dropped from 19.9 to 11.8% in urban areas between 1993 and 2003, and from 16.0 to 13.9% in rural areas. To improve risk-pooling and risk-sharing, private health insurance should play an important role in China's health insurance system. This paper estimates the demand for private health insurance in urban areas using contingent valuation methods. Individuals were asked about their willingness-to-pay (WTP) for major catastrophic disease insurance (MCDI), inpatient expenses insurance (IEI), and outpatient expenses insurance (OEI). The study was based on a household survey conducted in four small cities in China in 2004 and included 2671 respondents. More people would like to buy IEI and MCDI (48.5 and 43.0%, respectively) than OEI (24.5%). In addition, individuals would pay a higher premium for MCDI and IEI than for OEI. The price elasticities of demand for MCDI, IEI, and OEI were -0.27, -0.34, and -0.42, respectively. The determinants of enrollment in the three private health insurance programs were similar with employment status, age, education, and income.

Feasibility and construct validity of the parent willingness-to-pay technique for children with juvenile idiopathic arthritis

OBJECTIVE

To assess the feasibility and construct validity of the willingness-to-pay (WTP) technique for measuring health care preferences in families of children with juvenile idiopathic arthritis (JIA).

METHODS

Parents were asked to estimate the monthly US dollar amount they would be willing to pay to obtain for their child the following hypothetical drugs: ARTHRO, which guarantees complete clinical response; and NO-STOM-ACHE, a drug that eliminates gastrointestinal (GI) symptoms. A yes/no question was used with random assignment of the starting bids. Parents who agreed to pay the starting bid were then asked whether they would be willing to pay 200% and then 400% of this initial bid. Socioeconomic data and information on medications, disease activity, patient physical function, wellbeing, and health-related quality of life (HRQOL) were obtained.

RESULTS

Sixty-two families of children with JIA were interviewed. GI symptoms were present in 54%, and 53% of the children had joints with active arthritis or limited range of motion. Four parents (7%) were unwilling to pay anything for any of the studied medications. The mean amount (median; mean percentage of available family income) families were willing to pay was $395 ($300; 15%) for ARTHRO and $109 ($80; 4%) for NO-STOM-ACHE. Correlation and regression analysis supported that, adjusted for the available family income, the WTP for ARTHRO was associated with disease activity, pain, and the HRQOL of the patients. After correction for the starting bids and the available family income, the WTP for NO-STOM-ACHE was associated with the patient's HRQOL, pain, and the amount of GI discomfort.

CONCLUSION

The WTP technique is feasible and has construct validity for measuring health care preferences for children with JIA. Relatively large WTP estimates support a possible important negative impact of the disease on families of children with JIA.

Willingness-to-pay for community-based insurance in Burkina Faso

PURPOSE

To study the willingness-to-pay (WTP) for a proposed community-based health insurance (CBI) scheme in order to provide information about the relationship between the premium that is required to cover the costs of the scheme and expected insurance enrollment levels. In addition, factors that influence WTP were to be identified.

METHODS

Data were collected from a household survey using a two-stage cluster sampling approach, with each household having the same probability of being selected. Interviews were conducted with 2414 individuals and 705 household heads. The take-it-or-leave-it (TIOLI) and the bidding game were used to elicit WTP.

RESULTS

The average individual was willing to pay 2384 (elicited by the TIOLI) or 3191 (elicited by the bidding game) CFA (3.17 US dollars or 4.25 US dollars) to join CBI for him/herself. The head of household agreed to pay from 6448 (elicited by the TIOLI) or 9769 (elicited by the bidding game) CFA (8.6 US dollars or 13.03 US dollars) to join the health insurance scheme for his/her household. These results were influenced by household and individual ability-to-pay, household and individual characteristics, such as age, sex and education. The two methods yielded similar patterns of estimated WTP, in that higher WTP was obtained for higher income level, higher previous medical expenditure, higher education, younger people and males. A starting point bias was found in the case of the bidding game.

CONCLUSIONS

Both TIOLI and bidding game methods can elicit a value of WTP for CBI. The value elicited by the bidding game is higher than by the TIOLI, but the two approaches yielded similar patterns of estimated WTP. WTP information can be used for setting insurance premium. When setting the premiums, it is important to consider differences between the real market and the theoretical one, and between the WTP and the cost of benefits package. The beneficiaries of CBI should be enrolled at the level of households or villages in order to protect vulnerable groups such as women, elders and the poor.

Gender's effect on willingness-to-pay for community-based insurance in Burkina Faso

The purpose was to study gender's effect on willingness-to-pay (WTP) for community-based insurance (CBI) in order to provide information for deciding enrolment unit and setting premium in Burkina Faso. A two-stage cluster sampling was used in the household survey, with each household having the same probability of being selected. One thousand one hundred and seventy-eight men and 1236 women in the 800 households were interviewed. The bidding game approach was used to elicit WTP. We found that compared to male, female had less education, lower income and expenditure, less episodes of diseases and lower ratio of becoming household head, but higher marriage rate. These characteristics influenced the WTP difference between men and women. Men were willing to pay 3666 CFA ($4.89) to join CBI, 928 CFA higher than women were. Education and economic status positively influenced WTP, implying higher years of schooling and economic status and higher WTP. Age and distance to health facility negatively influenced WTP, thus higher age and longer distance and less WTP. Based on the results from this study, we suggest that CBI should be enrolled on the basis of households or villages in order to protect vulnerable persons, such as the aged, women and the poor. In setting premium a policy-maker needs to take into account costs of the CBI benefits package, possible subsidies from government and other agencies and WTP information. WTP should never be taken as a premium because it only provides some information for the respondents' financial acceptability for a certain benefits package.

Predictors of institutionalization in patients with dementia in Korea

BACKGROUND

Many studies have sought to determine the predictors of institutionalization of patients with dementia. Such studies, performed in developed western societies, have come to various conclusions which may not be supported in an East Asian culture such as that found in Korea.

OBJECTIVES

This study aimed to determine the factors that predict institutionalization of patients in Korea diagnosed with dementia.

METHODS

Seventy-nine cases (37 institutionalized, 42 community-dwelling) in the Kwangju area were evaluated for patient characteristics, severity of dementia symptoms, caregiver characteristics, burden and distress. Logistic regression was performed to determine predictors of actual institutionalization.

RESULTS

Six predictors of institutionalization were identified. Of these, three were patient-related factors: higher score on the Clinical Dementia Rating, higher score on the Brief Psychiatric Rating Scale, and shorter duration of dementia. The other three were caregiver-related factors: younger age, higher education (formal schooling), and higher cost of home care.

CONCLUSIONS

As seen in previous western studies, institutionalization of dementia sufferers was influenced by both patient and caregiver factors. But, the specific predictors and their relative influences might be explained best by the particular social, cultural and economic situation in Korea. This study was the first of its kind in Korea and, as such, could serve as a reference for future intra-cultural and cross-cultural comparisons.