Projecting the long-term societal value of a disease-modifying treatment for Alzheimer's disease in the United States

Societal Costs of Dementia: 204 Countries, 2000-2019

Background

Dementia prevalence is expected to increase as populations grow and age. Therefore, additional resources will be needed to meet the global demand for care for Alzheimer's disease and related dementias (ADRD).

Objective

Estimate global and country-level health care spending attributable to ADRD and the cost of informal care for people living with ADRD.

Methods

We gathered data from three systematic literature reviews and the Global Burden of Disease 2019 study. We used spatiotemporal Gaussian process regression to impute estimates for the many countries without underlying data. We projected future costs to 2050 based on past trends in costs, diagnosis rates, and institutionalization rate.

Results

We estimated that in 2019, the direct health care spending attributable to ADRD across 204 countries reached $260.6 billion (95% uncertainty interval [UI] 131.6-420.4) and the cost of informal ADRD care was $354.1 billion (95% UI 190.0-544.1). On average, informal care represents 57% (95% UI 38-75%) of the total cost of care. We estimated that direct health care spending attributable to ADRD will reach $1.6 trillion (95% UI 0.6-3.3) in 2050, or 9.4% (95% UI 3.9-19.6%) of projected health spending worldwide. We estimated the cost of informal care will reach $0.9 trillion (95% UI 0.3-1.7) in 2050.

Conclusions

These cost estimates underscore the magnitude of resources needed to ensure sufficient resources for people living with ADRD and highlight the role that informal care plays in provision of their care. Incorporating informal care cost estimates is critical to capture the social cost of ADRD.

Scenarios for the long-term efficacy of amyloid-targeting therapies in the context of the natural history of Alzheimer's disease

INTRODUCTION

Recent clinical trials of amyloid beta (Aβ)-targeting therapies in Alzheimer's disease (AD) have demonstrated a clinical benefit over 18 months, but their long-term impact on disease trajectory is not yet understood. We propose a framework for evaluating realistic long-term scenarios.

METHODS

Results from recent phase 3 trials of Aβ-targeting antibodies were integrated with an estimate of the long-term patient-level natural history trajectory of the Clinical Dementia Rating-Sum of Boxes (CDR-SB) score to explore realistic long-term efficacy scenarios.

RESULTS

Three distinct long-term efficacy scenarios were examined, ranging from conservative to optimistic. These extrapolations of positive phase 3 trials suggested treatments delayed onset of severe dementia by 0.3 to 0.6 years (conservative), 1.1 to 1.9 years (intermediate), and 2.0 to 4.2 years (optimistic).

DISCUSSION

Our study provides a common language for long-term impact of disease-modifying treatments. Our work calls for studies with longer follow-up and results from early intervention trials to provide a comprehensive assessment of these therapies' true long-term impact.

HIGHLIGHTS

We present long-term scenarios of the efficacy of AD therapies. In this framework, scenarios are defined relative to the natural history of AD. Long-term projections with different levels of optimism can be compared. It provides a common language for expressing beliefs about long-term efficacy.

Implications of treatment duration and frequency for value and cost-effective price of Alzheimer treatments

BACKGROUND

Disease-modifying Alzheimer treatments are becoming available. The value of the treatments will be attenuated by their complexity of delivery and monitoring, creating additional medical cost and caregiver burden.

OBJECTIVE

To estimate net treatment value using different assumptions for treatment duration and intensity.

METHODS

We estimated the lifetime value of hypothetical treatments that reduce disease progression by 30% from a payer perspective, which considers cost offsets, i.e., reduced medical and formal social care costs, and quality-adjusted life-year gains, and a societal perspective, which adds reduction in caregiver burden. Estimates for gross value of the treatment were based on a prior publication, medical cost on Medicare payment rates, and caregiver time use on a survey of 21 clinics. We analyzed 5 hypothetical treatment scenarios: treatment until progression to moderate dementia with (1) biweekly and (2) 4-weekly infusions, and time-limited infusions every 4 weeks for (3) 72, (4) 52, and (5) 24 weeks.

RESULTS

Treatment until progression to moderate dementia would take 5.7 years and generate gross value of $20,734 in direct cost offsets, $83,761 from a payer and $87,749 from a societal perspective, respectively. Added medical cost and caregiver burden for the 5 scenarios would be $44,179, $24,875, $21,632, $20,416, and $14,350, respectively. The maximum value-based price per year would be $7,687, $11,088, $47,708, $67,273, and $158,954.

CONCLUSIONS

Assuming identical efficacy and safety, the net value generation of time-limited treatment is projected to be larger than that of chronic treatment. Such determination of net lifetime value can be useful to determine value-based prices for different treatment types.

U.S. dementia care spending by state: 2010-2019

INTRODUCTION

Dementia is the fourth largest cause of death for individuals 70 years of age and older in the United States, and it is tremendously costly. Existing estimates of the indirect costs of dementia are dated and do not report on differences across the United States.

METHODS

We used data from multiple surveys to create cost estimates and projections for informal dementia caregiving at the U.S. state level from 2010 through 2050.

RESULTS

In 2019, the annual replacement cost of informal caregiving was $42,422 per prevalent case, and the forgone wage cost was $10,677 per prevalent case. In 2019, it would have cost $230 billion to hire home health aides to provide all this care. If past trends persist, this cost is expected to grow to $404 billion per year in 2050.

DISCUSSION

The cost of informal care varied substantially by state and is expected to grow through at least 2050.

HIGHLIGHTS

In the United States in 2019, foregone wages due to informal dementia care was $58 billion. Replacing informal dementia care with health aides would have cost $230 billion. These costs vary dramatically by state, even when assessed per prevalent case. These costs are expected to nearly double by 2050.

The Value of Medicare Coverage on Depressive Symptoms Among Older Immigrants

BACKGROUND AND OBJECTIVES

The immigrant population, the primary driver of U.S. population growth, is aging and many immigrants remain uninsured. Lack of health insurance limits access to care, aggravating the already high level of depression for older immigrants. However, there is scarce evidence on how health insurance, particularly Medicare, affects their mental health. Using the Health and Retirement Study, this study examines the effect of Medicare coverage on depressive symptoms of older immigrants in the United States.

RESEARCH DESIGN AND METHODS

Exploiting the fact that many immigrants are not covered by Medicare after passing age 65, we use a difference-in-difference model with propensity score weighting to compare differences in depressive symptoms pre- and post-age-65. We further stratify the sample by socioeconomic status and by race/ethnicity.

RESULTS

Medicare coverage was significantly associated with a reduction in the probability of reporting depressive symptoms for immigrants with low socioeconomic status, especially for those below median wealth levels. The beneficial effect of Medicare coverage was also statistically significant for non-White immigrants-Black, Hispanic, and Asian/Pacific Islander-even when holding socioeconomic status constant.

DISCUSSION AND IMPLICATIONS

Our findings imply that immigration policies that expand health care protection to older immigrants can lead to further health benefits and reduce existing disparities for the aging population. Policy reforms such as providing limited Medicare access to immigrants who paid sufficient taxes but are still awaiting permanent residency status could increase coverage for the uninsured and improve participation of immigrants in the payroll system.

Estimating prevalence of early symptomatic Alzheimer's disease in the United States

INTRODUCTION

Understanding the prevalence of treatment-eligible Alzheimer's disease (AD) is crucial for policy planning.

METHODS

We used a comprehensive literature review and population cascade approach to estimate the number of amyloid-positive, clinically diagnosed patients with mild cognitive impairment (MCI) or mild dementia due to AD in the United States.

RESULTS

An estimated 666,646 individuals were identified as having MCI due to AD (range: 351,926-1,227,776) and 620,850 individuals as having mild dementia due to AD (range: 445,082-820,339). In a US population of 76 million individuals aged 60 or older in 2021, the estimates of MCI and mild dementia due to AD increased with age.

CONCLUSIONS

As earlier diagnosis of AD and new disease-modifying treatments become available, accurate population estimates are required to reduce uncertainty in the number of clinically diagnosed patients eligible for amyloid-targeting therapies.

Health Care Resource Use and Social Costs in Mild Cognitive Impairment and Mild Alzheimer's Disease

Background

As the number of patients with dementia increases, so do the social costs. In recent years, attempts have been made to reduce risk to be dementia and treat it from the early stages of the disease, making it important to estimate the costs of the early stages.

Objective

To estimate the medical and social costs of the early stages of Alzheimer's disease (AD), which include mild cognitive impairment (MCI) due to AD and mild AD.

Methods

Questionnaires were used to obtain basic information (e.g., age, cognitive function) and medical costs, social care costs, family caregiver medical costs, and family caregiver informal care costs from patients with MCI due to AD or mild AD who were attending a memory clinic. A comparison was then conducted between these two groups.

Results

Patients with mild AD had higher total costs, patient medical costs, patient social care costs, and family caregiver informal care costs than did patients with MCI; however, only patient medical costs were significantly different (p = 0.022). A detailed analysis of patient medical costs revealed that anti-dementia drug treatment costs were significantly higher in patients with mild AD (p <  0.001).

Conclusion

Compared with patients with mild AD, those with MCI may have lower patient and family caregiver costs. As it is important to reduce social costs through risk reduction and therapeutic interventions from the early stages of AD, the present findings could help estimate the social costs and verify the cost-effectiveness of early interventions for AD.

Value elements and methods of value-based pricing for drugs in Japan: a systematic review

INTRODUCTION

Value-based pricing (VBP) can be a promising tool for optimizing drug prices. However, there is no consensus on the specific value elements and pricing method that should be used for VBP.

AREAS COVERED

We performed a systematic review and narrative synthesis to investigate the value elements and pricing method for VBP. The main inclusion criterion was that value elements, VBP method, and estimated prices for actual drugs were reported. We performed a search in MEDLINE and ICHUSHI Web. Eight articles met the selection criteria. Four studies adopted the cost-effectiveness analysis (CEA) approach and the others used different approaches. The CEA approach included the value elements of productivity, value of hope, real option value, disease severity, insurance value in addition to costs and quality-adjusted life years. The other approaches used efficacy, toxicity, novelty, rarity, research and development costs, prognosis, population health burden, unmet needs, and effectiveness. Each study used individual methods to quantify these broader value elements.

EXPERT OPINION

Both conventional and broader value elements are used for VBP. To allow VBP to be widely applied to various diseases, a simple, versatile method is preferable. Further research is needed to establish VBP method which enables to incorporate broader values.

Ethical issues when using digital biomarkers and artificial intelligence for the early detection of dementia

Dementia poses a growing challenge for health services but remains stigmatized and under-recognized. Digital technologies to aid the earlier detection of dementia are approaching market. These include traditional cognitive screening tools presented on mobile devices, smartphone native applications, passive data collection from wearable, in-home and in-car sensors, as well as machine learning techniques applied to clinic and imaging data. It has been suggested that earlier detection and diagnosis may help patients plan for their future, achieve a better quality of life, and access clinical trials and possible future disease modifying treatments. In this review, we explore whether digital tools for the early detection of dementia can or should be deployed, by assessing them against the principles of ethical screening programs. We conclude that while the importance of dementia as a health problem is unquestionable, significant challenges remain. There is no available treatment which improves the prognosis of diagnosed disease. Progression from early-stage disease to dementia is neither given nor currently predictable. Available technologies are generally not both minimally invasive and highly accurate. Digital deployment risks exacerbating health inequalities due to biased training data and inequity in digital access. Finally, the acceptability of early dementia detection is not established, and resources would be needed to ensure follow-up and support for those flagged by any new system. We conclude that early dementia detection deployed at scale via digital technologies does not meet standards for a screening program and we offer recommendations for moving toward an ethical mode of implementation. This article is categorized under:Application Areas > Health CareCommercial, Legal, and Ethical Issues > Ethical ConsiderationsTechnologies > Artificial Intelligence.

A Literature Review on the Burden of Alzheimer's Disease on Care Partners

BACKGROUND

Many individuals with Alzheimer's disease (AD) are dependent on nonprofessional care partners. Providing informal care can result in emotional, physical, and financial burdens; however, there is a need for a better understanding of the impact of AD on care partners to support the clinical and economic assessment of potential new treatments.

OBJECTIVE

We conducted a literature review to evaluate the burden experienced by care partners of individuals with AD.

METHODS

Electronic screening and supplementary searches identified studies published from 2011 to 2022 describing the association between AD and the quality of life (QoL) and physical health of care partners, and the economic or financial burden of AD.

RESULTS

Following electronic screening, 62, 25, and 39 studies were included on care partner burden, cost, and healthcare resource use in AD, respectively. Supplementary searches identified an additional 32 studies, resulting in 149 unique studies. These studies showed that care partners of individuals with AD report moderate to severe burden. Higher burden and lower QoL were observed in those caring for individuals with more severe AD. Care partners of individuals with AD experience higher burden, lower QoL, and higher levels of stress, depression, and anxiety than those without caring responsibilities. Informal care costs increased with AD severity and accounted for the greatest proportion of overall societal cost.

CONCLUSIONS

Care partners of individuals with AD experience emotional and economic burden, which increases with AD severity. These impacts should be quantified comprehensively in future studies and captured in economic evaluations of AD interventions.

The Case for a Novel Therapeutic Approach to Dementia: Small Molecule Hepatocyte Growth Factor (HGF/MET) Positive Modulators

An estimated 6.5 million Americans aged 65 years or older have Alzheimer's disease (AD), which will grow to 13.8 million Americans by 2060. Despite the growing burden of dementia, no fundamental change in drug development for AD has been seen in > 20 years. Currently approved drugs for AD produce only modest symptomatic improvements in cognition with small effect sizes. A growing mismatch exists between the urgent need to develop effective drugs for symptomatic AD and the largely failed search for disease modification. The failure rate of clinical trials in AD is high overall, and in particular for disease-modifying therapies. Research efforts in AD have focused predominantly on amyloid-β and tau pathologies, but limiting clinical research to these "classical hallmarks" of the disease does not address the most urgent patient, caregiver, or societal needs. Rather, clinical research should consider the complex pathophysiology of AD. Innovative approaches are needed that provide outside-the-box thinking, and re-imagine trial design, interventions, and outcomes as well as progress in proteomics and fluid biomarker analytics for both diagnostics and disease monitoring. A new approach offering a highly specific, yet multi-pronged intervention that exerts positive modulation on the HGF/MET neurotrophic system is currently being tested in mid-to-late-stage clinical trials in mild to moderate AD. Findings from such trials may provide data to support novel approaches for development of innovative drugs for treating AD at various disease stages, including among patients already symptomatic, and may offer benefits for other neurodegenerative diseases.

A framework for addressing Alzheimer's disease: Without a frame, the work has no aim

Confronting Alzheimer's disease (AD) involves patients, healthcare professionals, supportive services, caregivers, and government agencies interacting along a continuum from initial awareness to diagnosis, treatment, support, and care. This complex scope presents a challenge for health system transformation supporting individuals at risk for, or diagnosed with, AD. The AD systems preparedness framework was developed to help health systems identify specific opportunities to implement and evaluate focused improvement programs. The framework is purposely flexible to permit local adaptation across different health systems and countries. Health systems can develop solutions tailored to system-specific priorities considered within the context of the overall framework. Example metric concepts and initiatives are provided for each of ten areas of focus. Examples of funded projects focusing on screening and early detection are provided. It is our hope that stakeholders utilize the common framework to generate and share additional implementation evidence to benefit individuals with AD.

Using Alzheimer's disease blood tests to accelerate clinical trial enrollment

INTRODUCTION

Screening potential participants in Alzheimer's disease (AD) clinical trials with amyloid positron emission tomography (PET) is often time consuming and expensive.

METHODS

A web-based application was developed to model the time and financial cost of screening for AD clinical trials. Four screening approaches were compared; three approaches included an AD blood test at different stages of the screening process.

RESULTS

The traditional screening approach using only amyloid PET was the most time consuming and expensive. Incorporating an AD blood test at any point in the screening process decreased both the time and financial cost of trial enrollment. Improvements in AD blood test accuracy over currently available tests only marginally increased savings. Use of a high specificity cut-off may improve the feasibility of screening with only an AD blood test.

DISCUSSION

Incorporating AD blood tests into screening for AD clinical trials may reduce the time and financial cost of enrollment.

HIGHLIGHTS

The time and cost of enrolling participants in Alzheimer's disease (AD) clinical trials were modeled. A web-based application was developed to enable evaluation of key parameters. AD blood tests may decrease the time and financial cost of clinical trial enrollment. Improvements in AD blood test accuracy only marginally increased savings. Use of a high specificity cut-off may enable screening with only an AD blood test.