Donepezil use in managed Medicare: effect on health care costs and utilization

Cost of Alzheimer's disease

The progressive deterioration associated with Alzheimer's disease (AD) results in high economic cost to the patients, caregivers, and the society as a whole. Cost-of-AD studies conducted over the last decade have produced discrepant results, mainly as a consequence of the different methodologies employed. The present review is an attempt to present the methodology of the cost studies in AD and provide the reader with the tools necessary for a critical assessment of the results.

The pharmacoeconomics of cognitive enhancers in moderate to severe Alzheimer's disease

Alzheimer's disease is associated with a substantial economic impact on patients, their caregivers and society. Due to the current rise in the aging population, the prevalence and impact of Alzheimer's disease are expected to increase greatly. The cost of caring for someone with Alzheimer's disease is magnified in the more severe stages of the disease. There are four cognitive enhancers commonly used for the treatment of Alzheimer's disease: three cholinesterase inhibitors (donepezil, rivastigmine and galantamine) and one NMDA receptor antagonist (memantine). Of these, donepezil and memantine have been approved in many countries as pharmacological treatments for moderate to severe Alzheimer's disease, while donepezil, rivastigmine and galantamine are approved treatments for mild to moderate Alzheimer's disease. While cost effectiveness has been well studied in mild to moderate Alzheimer's disease, the cost-benefit information for drug therapy in moderate to severe Alzheimer's disease is less clear. This article reviews the pharmacoeconomic data available on these four drugs, with a specific focus on moderate to severe Alzheimer's disease, including economic burden, cost drivers, clinical outcomes and pharmacoeconomic studies. A key driver of the cost of Alzheimer's disease is the severity of the disease, indicating that the ability to stabilize the disease state is a potential source of cost savings. Drug therapies that can limit increases in behavioural problems and cognitive and functional impairment, and postpone institutionalization without an increase in longevity may serve to reduce the economic burden on Alzheimer's disease patients. The data suggest that, while the available, approved agents offer only modest improvements in clinical outcomes, they could be cost-effective treatments for moderate to severe Alzheimer's disease when viewed from the societal perspective. For memantine and donepezil, data are available that suggest that the cost of these drugs is offset by the clinical and societal benefits provided by slowing the progression of Alzheimer's disease. While there are few head-to-head comparison trials, the similarity in costs of the treatments and efficacy against placebo suggest that cost effectiveness will not be substantially different among treatments. More studies that examine longitudinal resource utilization and its relationship to drug treatment in the moderate to severe stages are needed to clarify cost benefit in this population and possibly differentiate between individual medications.

Savings from sub-groups?: Policy guidance and Alzheimer's disease treatments

BACKGROUND

A range of new therapeutic agents are now available for the management of Alzheimer's disease. With limited resources available however, policy-makers and other health care professionals have to prioritise and judge competing treatments on criteria such as the magnitude of clinical effectiveness and cost-effectiveness. Policy guidance that restricts treatments to defined patient sub-groups can improve the cost-effectiveness of treatments, and can help limit rises in health care expenditures. Budget impact models that estimate the amount of additional costs and potential savings are being increasingly used by policy-makers. However, the amount of savings estimated in such models depends on the effectiveness of treatment in changing morbidity, and the association between morbidity and costs.

AIM

To examine the magnitude of cost savings arising from provision of treatment to different patient sub-groups, using policy guidance decisions made by the National Institute for Health and Clinical Excellence (NICE) for cholinesterase inhibitor therapies in Alzheimer's Disease (AD) in the United Kingdom National Health Service (NHS).

METHOD

Cohort simulation modelling.

RESULTS

Policy guidance decisions that restricted treatment to smaller patient sub-groups were associated with lower overall care costs, but did not reduce drug costs.

CONCLUSIONS

Given increasing recognition by health policy-makers of the importance of affordability of new treatments, greater attention should be paid to measurement of cost impacts by sub-groups within health economic modelling.

Should older adults be screened for dementia?

The question of whether to screen for dementia and Alzheimer's disease (AD) has been discussed in many forums throughout the world. Generally, medical advisory groups and policy-making groups have recognized the importance of early diagnosis but have uniformly avoided making recommendations to screen at-risk populations. This presentation reflects the support for reconsidering the importance of screening individuals at risk or above a certain age. In this statement, the majority of the authors support the consideration of dementia risk factors in individuals at age 50, with routine yearly screening after 75. Other authors remain concerned that the benefits of treatments of early disease do not yet support a general screening recommendation. These statements are made to encourage progress toward the development of a consensus regarding the widespread institution of screening policy. Accordingly, members of the worldwide scientific community are invited to add their perspective by contributing short commentaries (1500 words) on this subject.

Economic considerations in the management of Alzheimer's disease

Alzheimer’s disease is a devastating chronic disease that significantly increases healthcare costs and affects the quality of life (QoL) of the afflicted patients and their caregivers. Population aging and other demographic changes may further increase the already staggering costs of this devastating disease. While few pharmacoeconomic studies have used a prospective health economics design to assess resource utilization, most studies showed beneficial treatment effects and suggested potential savings in healthcare costs and reductions in caregiver burden. Various degrees of cost savings have been reported depending on the type of economic model, treatment evaluated, and region used in the studies. Direct comparisons of the results are difficult because different methods have been used in these evaluations. The preference of patients and families for home care for as long as possible suggests that promoting noninstitutional care for these patients should become a priority. Continued home care for patients under pharmacological treatment may reduce caregiver burden, healthcare costs, and ultimately improve patients’ and caregivers’ QoL.

Impact of donepezil use in routine clinical practice on health care costs in patients with Alzheimer's disease and related dementias enrolled in a large medicare managed care plan: A case-control study

BACKGROUND

Clinical studies have shown efficacy of cholinesterase inhibitors (eg, donepezil) in mild to moderate Alzheimer's disease (AD). However, there are limited studies examining the impact on health care costs of cholinesterase inhibitors prescribed in routine clinical practice.

OBJECTIVE

The purpose of this study was to estimate the impact of donepezil use on health care costs and utilization in patients with mild to moderate AD and related dementias.

METHODS

This case-control study was conducted using data from the Health Insurance Plan of Greater New York (New York, New York). Data from patients with predominantly mild to moderate AD and related dementias who were enrolled in this Medicare managed care plan from January 1, 1999, to December 31, 2002, were included. The health care costs and utilization of patients who had received donepezil prescribed in routine clinical practice were compared with those of patients who had never received donepezil or other cholinesterase inhibitors (control group). The 2 study groups were matched for age, sex, number of comorbid conditions, and presence of complications of late-stage dementia. Regression analysis was used to estimate the impact of donepezil use on health care costs and utilization during a 12-month follow-up period, controlling for characteristics associated with the outcomes. The analyses did not use a direct measure of disease severity but instead used proxy measures of severity based on medical conditions associated with late-stage dementia.

RESULTS

Data from 687 patients were included in the study. The donepezil group comprised 229 patients (140 women, 89 men; mean age, 79.6 years); the control group, 458 patients (280 women, 178 men; mean age, 80.0 years). The mean costs of medical services per year in the donepezil group were US $2500 (95% CI, $300-$4671) less than those in the control group (P = 0.024). Lower medical costs in the donepezil group ($3325; 95% CI, $1163-$5486; P < 0.003 vs controls) were largely attributable to the lower costs of services performed in the hospital ($2594; 95% CI, $846-$4341; P < 0.004 vs controls) and postacute skilled nursing facility (SNF) ($1012; 95% CI, $444-$1579; P < 0.001 vs controls), which were partially offset by $1241 in higher prescription, physician's office, and outpatient hospital costs. Patients receiving donepezil had shorter mean lengths of stay in the hospital (3.00 vs 5.43 days; 95% CI, 0.66-4.19; P < 0.008) and postacute SNF (0.42 vs 3.40 days; 95% CI, 1.28-4.69; P < 0.001) but a higher mean number of physician's office visits (10.91 vs 7.91 visits; 95% CI, 1.63-4.36; P < 0.001) compared with controls.

CONCLUSIONS

In this case-control study in patients with predominantly mild to moderate AD and related dementias, donepezil therapy prescribed in routine clinical practice was associated with reduced health care costs to the Medicare managed care plan studied. The findings support previous pharmacoeconomic studies with larger sample sizes obtained over a longer period of time, and with improved case-matching criteria.

The economic benefits of acetylcholinesterase inhibitors for patients with Alzheimer disease and associated dementias

Most cost-effectiveness studies using simulation modeling have demonstrated that donepezil, rivastigmine, and galantamine are cost effective for the treatment of mild-to-moderate Alzheimer disease (AD). These conclusions are in large part based on the assumption that improvement in cognitive status, or prevention of cognitive and functional decline, reduces the amount of time patients spend institutionalized or receiving other full-time care. However, as discussed in this article, outcomes besides delay to institutionalization affect the costs of AD. In reviews of utilization data from Medicare and managed care organizations, it was noted that hospitalization and post acute care in skilled nursing facilities accounted for the largest amount of excess direct costs, even among patients with mild or moderate AD. These utilization reviews also suggest that many patients with AD and related dementias require inpatient care because they are not able to self-manage comorbid conditions. The improvements in cognitive status and daily functioning associated with acetylcholinesterase inhibitor (AChEI) therapy are expected to translate into improved management of comorbidities and reduced caregiver burden, thus reducing the total cost of care. To confirm these and other economic benefits of AChEIs, pharmacoeconomic outcomes should be evaluated routinely as part of randomized, controlled trials and through well-controlled observational studies of AD patients in community and institutional settings.

Identification and characterization of potential impurities of donepezil

Five unknown impurities ranging from 0.05 to 0.2% in donepezil were detected by a simple isocratic reversed-phase high performance liquid chromatography (HPLC). These impurities were isolated from crude sample of donepezil using isocratic reversed-phase preparative high performance liquid chromatography. Based on the spectral data (IR, NMR and MS), the structures of these impurities were characterised as 5,6-dimethoxy-2-(4-pyridylmethyl)-1-indanone (impurity I), 4-(5,6-dimethoxy-2,3-dihydro-1H-2-indenylmethyl) piperidine (impurity II), 2-(1-benzyl-4-piperdylmethyl)-5,6-dimethoxy-1-indanol (impurity III) 1-benzyl-4(5,6-dimethoxy-2,3-dihydro-1H-2-indenylmethyl) piperidine (impurity IV) and 1,1-dibenzyl-4(5,6-dimethoxy-1-oxo-2,3-dihydro-2H-2-indenylmethyl)hexahydropyridinium bromide (impurity V). The synthesis of these impurities and their formation was discussed.

Cost effectiveness of cholinesterase inhibitors in the treatment of Alzheimer's disease: a review with methodological considerations

Cholinesterase inhibitors have been available for the treatment of Alzheimer's disease since 1993. They have significantly positive effects on cognitive functioning and other domains of functional capacity, such as activities of daily life in terms of efficacy, but the clinical value of these effects are under discussion. Cholinesterase inhibitors may also influence behavioural and psychological symptoms in Alzheimer's disease. Cholinesterase inhibitors are also regarded as rather expensive and, therefore, the question of cost effectiveness is essential. Pharmacoeconomic evaluations of cholinesterase inhibitors have so far been conducted in retrospect on efficacy data from prospective randomised clinical trials combined with economic data from other sources. There are no published specific cost-effectiveness studies of cholinesterase inhibitors which prospectively collected empirical data on costs and outcomes. There is only one published randomised clinical trial with such empirical data with a cost consequence analysis design, indicating cost neutrality. Several types of models to describe the long-term effects have been published, indicating cost effectiveness. However, due to methodological considerations, the validity of these models is difficult to judge. A research agenda for the cost effectiveness of cholinesterase inhibitors is proposed, including long-term studies with empirical data on resource use, costs and outcomes, studies on quality of life, informal care and behavioural and psychological symptoms, combination and comparative studies on mild cognitive impairment.

The cost-benefit of cholinesterase inhibitors in mild to moderate dementia: a willingness-to-pay approach

OBJECTIVE

This study aimed to measure the economic value of cholinesterase inhibitors when used to treat Alzheimer's disease using the willingness-to-pay (WTP) approach and the framework of cost-benefit analysis.

METHODS AND STUDY DESIGN

A cost-benefit analysis using the WTP approach was employed. The study sample consisted of 28 nonprofessional caregivers of outpatients with mild to moderate dementia from Toronto, ON, Canada. The caregivers were presented with four scenarios. In the first scenario, scenario A, a hypothetical patient with mild dementia was stabilised with a cholinesterase inhibitor. In the second scenario, scenario A with adverse effects, the above patient (A) experienced adverse effects caused by the drug. In the third scenario, scenario B, the patient exhibited behavioural symptoms in addition to mild dementia, and both were stabilised with the drug. In the fourth scenario, scenario B with adverse effects, the above patient (B) experienced adverse effects caused by the drug. The caregivers were then asked what amount they would pay, in Canadian dollars, each year to buy the medication, assuming that they were the caregivers of the patient described. A multivariate regression analysis was performed to assess the relationship between the demographic data (including the caregiver's yearly income) and the WTP. The average WTP was also predicted for the general population and the elderly population of Canada using data from Statistics Canada, and these values were compared with the cost of the medication.

STUDY PERSPECTIVE

Nonprofessional caregiver perspective. All monetary values are 1999 values unless otherwise specified.

RESULTS

The mean yearly WTP was $Can4540 (95% CI 2334-6746) for scenario A, $Can3686 (95% CI 1530-5842) for scenario A with adverse effects, $Can5003 (95% CI 2661-7345) for scenario B and $Can4486 (95% CI 2222-6750) for scenario B with adverse effects. The WTP decreased when drug adverse effects were present (significantly in scenario A; p = 0.04), but did not significantly increase when behavioural symptoms were present and stabilised. In all scenarios, caregiver yearly income was the only significant predictor of WTP, in the direction expected. For all scenarios, the calculated WTPs from the regression analysis using our sample mean, the average Canadian population data and the elderly population data were all higher than the yearly cost of the cholinesterase inhibitors, with the net benefit ranging from $Can1723 to $Can4508.

CONCLUSIONS

The results of the study, from a small sample of nonprofessional caregivers, revealed that the caregivers are willing to pay more for cholinesterase inhibitors than the drugs cost, even when the adverse effects of the drugs are taken into consideration. This indicates a net benefit for cholinesterase inhibitors in the treatment of mild to moderate dementia from a consumer's point of view.

Economic evaluation of galantamine in the treatment of mild to moderate Alzheimer's disease in the United States

BACKGROUND

Alzheimer's disease (AD) is estimated to affect up to 11% of those aged > or =65 years in the United States, and the number of patients with AD is predicted to increase over the next few decades as the population ages. The substantial social and economic burden associated with AD is well established, with the cost of management increasing as the disease progresses.

OBJECTIVE

The aim of this study was to evaluate the economic impact of galantamine 16 and 24 mg/d relative to no pharmacologic treatment in the management of mild to moderate AD in the United States based on the concept of need for full-time care (FTC).

METHODS

Calculations were made using the Assessment of Health Economics in Alzheimer's Disease model, which applies predictive equations to estimate the need for FTC and the associated costs. The predictive equations were developed from longitudinal data on patients with AD. Inputs to the equations were derived by analyzing the data from 2 randomized, placebo-controlled, galantamine clinical trials. Resource use (from a payer perspective) was estimated from US clinical trial data, and costs were estimated from several US databases. Analyses were carried out over 10 years, and costs and benefits were discounted at 3%.

RESULTS

In the base case, 3.9 to 4.6 patients need to start treatment with galantamine to avoid 1 year of FTC, depending on dose. Treated patients spent 7% to 8% more time pre-FTC and 12% to 14% less time requiring FTC, resulting in savings of 2408 to 3601 US dollars. Time horizons below 3 years, very high discontinuation rates, or increased survival with galantamine reversed the savings. Conversely, limiting treatment to responders delayed FTC by 6 to 7 months, with savings of approximately 9097 to 11,578 US dollars.

CONCLUSIONS

These results suggest that use of galantamine in patients with AD in the United States could reduce the use of costly resources such as formal home care and nursing homes, leading to cost savings over time.

An economic evaluation of donepezil in mild to moderate Alzheimer's disease: results of a 1-year, double-blind, randomized trial

The costs and consequences of donepezil versus placebo treatment in patients with mild to moderate Alzheimer's disease (AD) were evaluated as part of a 1-year prospective, double-blind, randomized, multinational clinical trial. Patients received either donepezil (n = 142; 5 mg/day for 28 days followed by 10 mg/day according to the clinician's judgement) or placebo (n = 144). Unit costs were assessed in 1999 Swedish kronas (SEK) and converted to US dollars (USD). Donepezil-treated patients gained functional benefits relative to placebo on the Progressive Deterioration Scale (p = 0.042) and Instrumental Activities of Daily Living scale (p = 0.025) at week 52. Caregivers of donepezil-treated patients spent an average of 400 h less annually providing care than caregivers of placebo-treated patients. Mean annual healthcare costs were SEK 137,752 (USD 16,438) per patient for the donepezil group and SEK 135,314 (USD 16,147) in the placebo group. With the average annual cost of donepezil at SEK 10,723 (USD 1,280) per patient, the SEK 2,438 (USD 291) cost difference represented a 77% cost offset. When caregiver time and healthcare costs were included, mean annual costs were SEK 209,244 (USD 24,969) per patient in the donepezil group and SEK 218,434 (USD 26,066) in the placebo group, a total saving associated with donepezil treatment of SEK 9,190 (USD 1,097) per patient [95% CI of SEK -43,959 (USD -5,246), SEK 25,581 (USD 3,053); p = 0.6]. The positive effects on the efficacy outcome measures combined with no additional costs from a societal perspective indicate that donepezil is a cost-effective treatment, representing an improved strategy for the management of patients with AD.

Pharmacoeconomics of cholinesterase inhibitors in the treatment of Alzheimer's disease

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.

Optimizing coding and reimbursement to improve management of Alzheimer's disease and related dementias

The objectives of this study were to review the diagnostic, International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM), diagnosis related groups (DRGs), and common procedural terminology (CPT) coding and reimbursement issues (including Medicare Part B reimbursement for physicians) encountered in caring for patients with Alzheimer's disease and related dementias (ADRD); to review the implications of these policies for the long-term clinical management of the patient with ADRD; and to provide recommendations for promoting appropriate recognition and reimbursement for clinical services provided to ADRD patients. Relevant English-language articles identified from MEDLINE about ADRD prevalence estimates; disease morbidity and mortality; diagnostic coding practices for ADRD; and Medicare, Medicaid, and managed care organization data on diagnostic coding and reimbursement were reviewed. Alzheimer's disease (AD) is grossly undercoded. Few AD cases are recognized at an early stage. Only 13% of a group of patients receiving the AD therapy donepezil had AD as the primary diagnosis, and AD is rarely included as a primary or secondary DRG diagnosis when the condition precipitating admission to the hospital is caused by AD. In addition, AD is often not mentioned on death certificates, although it may be the proximate cause of death. There is only one ICD-9-CM code for AD-331.0-and no clinical modification codes, despite numerous complications that can be directly attributed to AD. Medicare carriers consider ICD-9 codes for senile dementia (290 series) to be mental health codes and pay them at a lower rate than medical codes. DRG coding is biased against recognition of ADRD as an acute, admitting diagnosis. The CPT code system is an impediment to quality of care for ADRD patients because the complex, time-intensive services ADRD patients require are not adequately, if at all, reimbursed. Also, physicians treating significant numbers of AD patients are at greater risk of audit if they submit a high frequency of complex codes. AD is grossly undercoded in acute hospital and outpatient care settings because of failure to diagnose, limitations of the coding system, and reimbursement issues. Such undercoding leads to a lack of recognition of the effect of AD and its complications on clinical care and impedes the development of better care management. We recommend continuing physician education on the importance of early diagnosis and care management of AD and its documentation through appropriate coding, expansion of the current ICD-9-CM codes for AD, more appropriate use of DRG coding for ADRD, recognition of the need for time-intensive services by ADRD patients that result in a higher frequency of use of complex CPT codes, and reimbursement for CPT codes that cover ADRD care management services.

Barriers to drug discovery and development for Alzheimer disease

Alzheimer disease (AD) is a neurodegenerative condition leading to progressive, irreversible loss of cognitive and behavioral function. Despite considerable investments in neuroscience research, only four drugs, all cholinesterase inhibitors, have been approved for the symptomatic management of AD in the United States. Although basically safe and modestly effective, these drugs are far from ideal, being neither universally efficacious nor disease modifying. AD exacts a considerable toll in direct medical costs, quality of life, and caregiver burden for persons and society. In addition to the obvious clinical benefit, therapeutic agents for AD and related dementias represent a considerable market opportunity for the pharmaceutical and biotechnology industries. There are currently 8-10 million AD sufferers in the seven major pharmaceutical markets. The market will grow rapidly in coming decades, as the developed world experiences an enormous increase in its elderly population. Given the great need for new therapeutic agents to manage and prevent AD, the Institute for the Study of Aging and the Fidelity Foundation organized a workshop, "Barriers to the Discovery and Development of Drugs for Alzheimer's Disease," to examine ways to expedite drug discovery and development. The identified barriers and potential solutions will be discussed here and in the accompanying articles in more detail.

Donepezil and rivastigmine in the treatment of Alzheimer's disease: a best-evidence synthesis of the published data on their efficacy and cost-effectiveness

BACKGROUND

Various drugs have been approved for the treatment of Alzheimer's disease (AD) in the United States and Canada, including donepezil and rivastigmine, although questions remain as to their efficacy, effectiveness, and long-term benefits.

OBJECTIVE

The goal of this study was to conduct a best-evidence synthesis of data on the efficacy and cost-effectiveness of donepezil and rivastigmine in the treatment of AD.

METHODS

Relevant published randomized controlled trials (RCTs) and Phase IV open-label extension studies (excluding abstracts) were identified through searches of MEDLINE, HealthSTAR, and PsycINFO for the period January 1984 to October 2001. The bibliographies of retrieved articles were searched for additional publications. For inclusion in the best-evidence synthesis, clinical trials had to pass a blinded quality assessment (score > or =5 on the Jadad scale) and use National Institute of Neurological and Communicative Disease and Stroke-Alzheimer's Disease and Related Disorders Association diagnostic criteria. Economic studies were selected using National Health Service Centre for Reviews and Dissemination criteria for reporting critical summaries of economic evaluations.

RESULTS

Nine RCTs of donepezil and 2 of rivastigmine were identified and met inclusion criteria for the best-evidence synthesis. Eight donepezil trials and both rivastigmine trials included patients with mild AD (Mini-Mental State Examination [MMSE] score, 15-27) or moderate AD (MMSE score, 8-14); 1 donepezil trial included patients with moderate or severe AD (MMSE score, 0-7). In the RCTs of donepezil, the mean decrease in scores on the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog) was greater with active treatment than with placebo (lower scores indicate less cognitive deterioration). In the RCTs of rivastigmine, ADAS-cog scores decreased over the follow-up period with both active treatment and placebo; however, scores decreased more with active treatment. Three Phase IV studies of donepezil and I Phase IV study of rivastigmine were identified. Their results were consistent with those of the RCTs. Ten economic studies (7 donepezil, 3 rivastigmine) were identified and reviewed. In 4 of the donepezil studies and all 3 rivastigmine studies, use of the drug cost less than a no-drug strategy.

CONCLUSIONS

The efficacy data indicate that both donepezil and rivastigmine can delay cognitive impairment and deterioration in global health for at least 6 months in patients with mild to moderate AD. Patients receiving active treatment will have more favorable ADAS-cog scores for at least 6 months, after which their scores will begin to converge with those of patients receiving placebo. Differences in methodology, types of direct or indirect costs included, and sources of cost data made it difficult to compare and synthesize findings of the economic studies; therefore, the cost-effectiveness data are inconclusive.

The costs of caring: medical costs of Alzheimer's disease and the managed care environment

This review summarizes the medical costs associated with Alzheimer's disease (AD) and related dementias, as well as the payers responsible for these medical costs in the US health care system. It is clear from this review that AD and related dementias are associated with substantial medical costs. The payers responsible for a majority of these costs are families of patients with AD and the US government through the Medicare and Medicaid programs. In an attempt to control expenditures, Medicare and Medicaid have turned to managed care principles and managed care organizations. The increase in "managed" dementia care gives rise to several potential problems for patients with AD, along with many opportunities for systematic improvement in the quality of dementia care. Evidence-based disease management programs provide the greatest opportunities for improving managed dementia care but will require the development of dementia-specific quality of care measures to evaluate and continually improve them.

Economic cost of Alzheimer disease in Israel

The objective of this prospective study was to evaluate the cost of Alzheimer disease (AD) in Israel. Seventy-one AD patients who lived in the community, 50 institutionalized AD patients, both AD groups' respective primary caregivers, and 50 healthy elderly subjects were interviewed. The interviews covered information about the number of caregivers' hours invested in caring for the patient and amount of expenditures such as in house paid help and payments for day care. The annual social cost of caring for a person with AD in Israel was approximately $17,000, whether the patient lived at home or in a nursing home, but the cost components differed in the two groups. For community-dwelling patients, 60% of the cost represented an imputed value of unpaid indirect care compared with 12% for institutionalized patients. Also, in both residences, the private cost was significantly higher than the public cost, i.e., more 75% of the services provided to patients were paid out of pocket. Cost of institutionalization was the major component of the social cost. The cost of the disease increased with functional and cognitive deterioration for the community-dwelling group only. With projected increases in the number of persons at risk for developing AD, the economic impact of the disease on future costs will be significant. Efforts to delay deterioration and, as a result, delay institutionalization seem crucial for cost containment.