Costs of formal care for frail older people in England: the resource implications study of the MRC cognitive function and ageing study (RIS MRC CFAS)

International depiction of the cost of functional independence limitations among older adults living in the community: a systematic review and cost-of-impairment study

BACKGROUND

Functional independence limitations restrict older adult self-sufficiency and can reduce quality of life. This systematic review and cost of impairment study examined the costs of functional independence limitations among community dwelling older adults to society, the health care system, and the person.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines this systematic review included community dwelling older adults aged 60 years and older with functional independence limitations. Databases (Cochrane Database of Systematic Reviews, EconLit, NHS EED, Embase, CINAHL, AgeLine, and MEDLINE) were searched between 1990 and June 2020. Two reviewers extracted information on study characteristics and cost outcomes including mean annual costs of functional independence limitations per person for each cost perspective (2020 US prices). Quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

85 studies were included. The mean annual total costs per person (2020 US prices) were: $27,380.74 (95% CI: [$4075.53, $50,685.96]) for societal, $24,195.52 (95% CI: [$9679.77, $38,711.27]) for health care system, and $7455.49 (95% CI: [$2271.45, $12,639.53]) for personal. Individuals with cognitive markers of functional independence limitations accounts for the largest mean costs per person across all perspectives. Variations across studies included: cost perspective, measures quantifying functional independence limitations, cost items reported, and time horizon.

CONCLUSIONS

This study sheds light on the importance of targeting cognitive markers of functional independence limitations as they accounted for the greatest costs across all economic perspectives.

The care types choice in filial culture: A cross-sectional study of disabled elderly in China

For the past few decades, studies of care types choice have been restricted to the scope of individual characteristics and health status. Meanwhile, the historiography of the research largely ignores the role of filial culture within China. This study sets out to examine the influence of the factors in the cultural context of filial piety on the choice of care types for older people with disability in China. According to the characteristics of filial culture, the factors influencing the choice of care type for the older people in China are summarized as family endowment and support. The study concludes that gender, residence, living alone or not, family income, real estate, pension and community service have momentous effects on the choice of care type of older people with disability; informal care has a substitutive effect on formal care. The research was based on cross-sectional data of CLHLS 2018 and utilized binary logistic regression analysis to compare the factors influencing the choice of old disabled people between formal and informal care. The study implies that in the context of filial culture, the older people's choice of care types is affected by family endowment and community service supply for the older people in China. In the background of filial culture, the government should give informal care official support such as cash and services, so as to change its attribute of private domain of it and enhance the quality of long-term care.

Cost-effectiveness of a proportionate universal offer of free exercise: Leeds Let’s Get Active

Background

The purpose of this paper is to assess the cost-effectiveness of a proportionate universal programme to reduce physical inactivity (Leeds Let us Get Active (LLGA)) in adults.

Methods

A continuous-time Markov chain model was developed to assess the cost implications and QALY gains associated with increases in physical activity levels across the adult population. A parametric survival analysis approach was applied to estimate the decay of intervention effect over time. Baseline model data were obtained from previous economic models, population-based surveys and other published literature. A cost-utility analysis was conducted from a health care sector perspective over the programme duration (39 months). Scenario and probabilistic sensitivity analyses were performed to test the robustness of cost-effectiveness results.

Results

In total, 51 874 adult residents registered to the programme and provided baseline data,19.5% of which were living in deprived areas. Under base case assumptions, LLGA was found to be likely to be cost-effective. However, variations in key structural assumptions showed sensitivity of the results.

Conclusions

Results from this study suggest a non-negligible level of uncertainty regarding the effectiveness, and therefore, cost-effectiveness of a universal offer of free leisure centre-based exercise that targets hard to reach groups. Further data collection and a shift towards prospective evaluations are needed.

Can we do better? Economic analysis of human resource investment to improve home care service for the elderly in Serbia

BACKGROUND

Social services aimed at the elderly are facing great challenges caused by progressive aging of the global population but also by the constant pressure to spend funds in a rational manner.

PURPOSE

This paper focuses on analyzing the investments into human resources aimed at enhancing home care for the elderly since many countries have recorded progress in the area over the past years. The goal of this paper is to stress the significance of performing an economic analysis of the investment.

METHODS

This paper combines statistical analysis methods such as correlation and regression analysis, methods of economic analysis, and scenario method.

RESULTS

The economic analysis of investing in human resources for home care service in Serbia showed that the both scenarios of investing in either additional home care hours or more beneficiaries are cost-efficient. However, the optimal solution with the positive (and the highest) value of economic net present value criterion is to invest in human resources to boost the number of home care hours from 6 to 8 hours per week and increase the number of the beneficiaries to 33%.

CONCLUSION

This paper shows how the statistical and economic analysis results can be used to evaluate different scenarios and enable quality decision-making based on exact data in order to improve health and quality of life of the elderly and spend funds in a rational manner.

Economic analysis of social services for the elderly in Serbia: two sides of the same coin

According to demographic trends, the ratio of senior citizens in the overall population of the Republic of Serbia is rising. This generates the need to create socially acceptable and economically sustainable models for the protection of the elderly. The goal of this paper is to stress the necessity of analyzing and evaluating the efficiency of social protection services aimed at senior citizens. The first part of the paper underlines the need for economic analysis of these services; while the second part features the analysis of the two most frequently provided services for the elderly in Serbia: admission to social protection institutions and home care for senior citizens. Based on the research results, the paper also provides a comparative overview of the efficiency of the services mentioned. This overview clearly confirms that both services prove to be economically justifiable from a social perspective; nevertheless, it also indicates that the cost of home care per user is considerably lower than the cost of putting a senior citizen into a nursing home. After presenting and discussing the results of the studies, the paper also offers recommendations aimed at enhancing the development and sustainability of the social protection system for the elderly in Serbia.

The personal and health service impact of falls in 85 year olds: cross-sectional findings from the Newcastle 85+ cohort study

INTRODUCTION

Falls are common in older people and increase in prevalence with advancing old age. There is limited knowledge about their impact in those aged 85 years and older, the fastest growing age group of the population. We investigated the prevalence and impact of falls, and the overlap between falls, dizziness and blackouts, in a population-based sample of 85 year olds.

METHODS

DESIGN

Cross-sectional analysis of baseline data from Newcastle 85+ Cohort Study.

SETTING

Primary care, North-East England.

PARTICIPANTS

816 men and women aged 85 years.

MEASUREMENTS

Structured interview with research nurse. Cost-consequence analysis of fall-related healthcare costs.

RESULTS

Over 38% (313/816) of participants had fallen at least once in the previous 12 months and of these: 10.6% (33/312) sustained a fracture, 30.1% (94/312) attended an emergency department, and 12.8% (40/312) were admitted to hospital. Only 37.2% (115/309) of fallers had specifically discussed their falls problem with their general practitioner and only 12.7% (39/308) had seen a falls specialist. The average annual healthcare cost per faller was estimated at £202 (inter-quartile range £174-£231) or US$329 ($284-$377). 'Worry about falling' was experienced by 42.0% (128/305) of fallers, 'loss of confidence' by 40.0% (122/305), and 'going out less often' by 25.9% (79/305); each was significantly more common in women, odds ratios (95% confidence interval) for women: men of 2.63 (1.45-4.55), 4.00 (2.27-7.14), and 2.86 (1.54-5.56) respectively. Dizziness and blackouts were reported by 40.0% (318/796) and 6.4% (52/808) of participants respectively. There was marked overlap in the report of falls, dizziness and blackouts.

CONCLUSIONS

Falls in 85 year olds are very common, associated with considerable psychological and physical morbidity, and have high impact on healthcare services. Wider use of fall prevention services is needed. Significant expansion in acute and preventative services is required in view of the rapid growth in this age group.

Future costs of dementia-related long-term care: exploring future scenarios

BACKGROUND

This study explores how the views of a panel of experts on dementia would affect projected long-term care expenditure for older people with dementia in England in the year 2031.

METHODS

A Delphi-style approach was used to gather the views of experts. The projections were carried out using a macro-simulation model of future demand and associated expenditure for long-term care by older people with dementia.

RESULTS

The panel chose statements that suggested a small reduction in the prevalence of dementia over the next fifty years, a freeze in the numbers of people in care homes, and an increase in the qualifications and pay of care assistants who look after older people with dementia. Projections of expenditure on long-term care that seek to capture the views of the panel suggest that future expenditure on long-term care for this group will rise from 0.6% of GDP in 2002 to between 0.82% and 0.96% of GDP in 2031. This range is lower than the projected expenditure of 0.99% of GDP in 2031 obtained under a range of base case assumptions.

CONCLUSIONS

This paper attempts to bridge the gap between qualitative forecasting methods and quantitative future expenditure modelling and has raised a number of important methodological issues. Incorporating the panel's views into projections of future expenditure in long-term care for people with dementia would result in projected expenditure growing more slowly than it would otherwise.

Resources and Costs Associated with Disabilities of Elderly People Living at Home and in Institutions

Cette étude a été réalisée auprès d'un échantillon représentatif de sujets âgées vivant à domicile (n = 300), dans des ressources de type familial (RTF) ou des pavilions (n = 271) et dans des institutions d'hébergement (n = 774) de zones métropolitaine, urbaines et rurales du Québec afin de: 1) déterminer le niveau d'incapacité et les ressources consacrés aux soins des personnes âgées vivant à domicile ou en institution; 2) estimer les coûts (publics, privés et bénévoles) de ces ressources; 3) comparer les coûts à autonomie égale; 4) prédire les coûts selon le niveau d'incapacité. Les principaux résultats montrent que les sujets des trois milieux de vie présentent des différences significatives quant au niveau d'incapacité, à l'état cognitif et aux soins requis et fournis, bien que des chevauchements importants étaient notables. Le score d'incapacité explique 85 pour cent de la variance du temps de soins ainsi que, respectivement, 55, 15 et 68 pour cent des coûts à domicile, en RTF et pavilions et en institutions. Les soins infirmiers et d'assistance sont responsables de la majorité des coûts dans tous les milieux de vie. Le coût social total des soins à domicile étaient plus élevé que ceux en RTF et pavilions pour les sujets avec un score d'incapacité de 7,4 et plus et même supérieur à ceux en institutions pour un score au-dessus de 38,7.

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.

Recovery in instrumental activities of daily living (IADLs): findings from the Medical Research Council Cognitive Function and Ageing Study (MRC CFAS)

OBJECTIVE

to provide evidence for predictors of recovery in instrumental activities of daily living (IADLs) among disabled older people living in the community.

DESIGN

MRC CFAS recruited a sample of 13,004 individuals aged 65 years and above from five communities in the UK. Participants underwent a baseline interview between 1990 and 1994 and were re-assessed 2 years later.

PARTICIPANTS

the participants who reported that they were unable to perform any IADL without difficulty or help at baseline ('disabled') were included in the analysis.

METHODS

logistic regression was used to estimate odds ratios (OR) for improvement from disabled to non-disabled state at follow-up ('recovery').

RESULTS

at baseline, 50% reported disability of whom 9% reported independent function at follow-up. Women (OR = 0.4) and participants aged > or =75 years (OR = 0.2) were least likely to recover, followed by those with poor self-rated health (OR = 0.5), using at least one medication (OR = 0.6) and having more than or equal to two co-morbidities (OR = 0.6).

CONCLUSION

a minority of participants reporting disability at baseline then reported independent function at 2 years. It may be important to focus on those who seem least likely to recover once they have become disabled. Several factors that have been shown to increase the risk of disability were inversely associated with recovery, suggesting that intervention programmes could target these same factors.

The effect of dementia trends and treatments on longevity and disability: a simulation model based on the MRC Cognitive Function and Ageing Study (MRC CFAS)

BACKGROUND

the numbers with dementia are projected to double between 2001 and 2040, in line with continued increases in life expectancy. Projections have failed to account for the impact of changing risk factors on future numbers with dementia or disability.

OBJECTIVE

to estimate the size of the disabled population over the next 20 years and explore the impact of treatments that delay onset of cognitive impairment and associated disability.

METHODS

a dynamic macro-simulation projection model was used to calculate the numbers of older people with disability to 2026. Transition rates to disability and death conditional on a range of conditions, calculated from the MRC Cognitive Function and Ageing Study, were applied to the 1992 England and Wales population. Scenarios for trends in dementia incidence, risk factors and treatment were devised from a systematic review and applied.

FINDINGS

population ageing alone resulted in 39% more older people between 2006 and 2026 and 82% more with disability. A combination of reduced incidence of cognitive impairment and disabling consequences alongside improved survival provided the largest reductions in the disabled population (15,000) and the numbers cognitively impaired (302,000) compared with ageing of the population alone.

INTERPRETATION

population ageing alone will increase the disabled older population by over 80% and the numbers cognitively impaired by almost 50% over the next 20 years with serious implications for the provision of care. Research priorities should focus on earlier detection of dementia and its risk factors, thereby allowing earlier and more targeted treatment to alleviate its associated disability.

Modernising social care services for older people: scoping the United Kingdom evidence base

In common with other developed countries at the end of the 20th century, modernising public services was a priority of the United Kingdom (UK) Labour administration after its election in 1997. The modernisation reforms in health and social care exemplified their approach to public policy. The authors were commissioned to examine the evidence base for the modernisation of social care services for older people, and for this purpose conducted a systematic review of the relevant peer-reviewed UK research literature published from 1990 to 2001. Publications that reported descriptive, analytical, evaluative, quantitative and qualitative studies were identified and critically appraised under six key themes of modernisation: integration, independence, consistency, support for carers, meeting individuals' needs, and the workforce. This paper lists the principal features of each study, provides an overview of the literature, and presents substantive findings relating to three of the modernisation themes (integration, independence and individuals' needs). The account provides a systematic portrayal both of the state of social care for older people prior to the modernisation process and of the relative strengths and weaknesses of the evidence base. It suggests that, for evidence-based practice and policy to become a reality in social care for older people, there is a general need for higher quality studies in this area.

Cognitive impairment in older people: future demand for long-term care services and the associated costs

BACKGROUND

Projections are presented of future numbers of older people with cognitive impairment (CI) in England, their demand for long-term care (LTC) services and future costs of their care. The sensitivity of the projections to factors that are likely to affect future LTC expenditure is explored. These factors include future numbers of older people, prevalence rates of CI, trends in household composition, informal care provision, care service patterns and unit costs.

METHODS

A macrosimulation (or cell-based) model was developed to produce the projections, building on an earlier PSSRU model. Base case assumptions are made about trends in key factors expected to impact on future LTC expenditure, and variant assumptions about the key factors are introduced to test for sensitivity.

RESULTS

Expenditure on LTC services for older people with CI is projected to rise from 0.60% of Gross Domestic Product (GDP) ( pound5.4 billion) in 2002 to 0.96% of GDP ( pound16.7 billion) in 2031, under base case assumptions. Under variant assumptions, the projection for 2031 ranges from 0.83% to 1.11% of GDP. These figures do not include the opportunity costs of informal care.

CONCLUSIONS

Sensitivity analysis shows that projected demand for LTC is sensitive to assumptions about the future numbers of older people and future prevalence rates of CI and functional disability. Projected expenditure is also sensitive to assumptions about future rises in the real unit costs of services.

Exercise intervention of 65+-year-old men and women: functional ability and health care costs

BACKGROUND AND AIMS

Physical activity has been demonstrated to prevent physical impairment in elderly people. Physical impairment often leads to dependency and the need for help or health services. Therefore, participation in physical activity programs (PAP) may reduce health care costs. The aim of this study was to evaluate: i) the effect of a PAP on functional ability and the use of health care services; ii) the possible association between level of functional ability and public health care costs.

METHODS

185 participants aged 65+ (mean: 74.7 yrs) were recruited. The intervention consisted of a group-based multicomponent PAP, 1.5 hours, once a week, for 5 months. Functional ability was assessed by questionnaire and physical performance tests before and after the PAP. Economic analyses were based on data collected retrospectively from public registers and questionnaires describing the use of health care services (e.g., public home care, GPs, hospitals).

RESULTS

Participants revealed a high level of functional ability. Only a few significant differences between pre- and posttests were observed. Many participants incurred no or very low public health care costs. The probability of using health care services decreased with better functional ability scores and lower age.

CONCLUSIONS

Participants in this study maintained their level of functional ability in the intervention period with unaltered use of health care resources.

Cognitive Impairment after Stroke – Impact on Activities of Daily Living and Costs of Care for Elderly People

BACKGROUND AND PURPOSE

The economic burden of stroke is substantial and is likely to increase with an increasing number of elderly individuals in the population. There is thus a need for information on the use of health care resources and costs among these elderly stroke patients. We examined the impact of the cognitive impairments on the ability to perform activities of daily living (ADL) and utilization and costs of health care in a cohort of elderly stroke patients.

METHODS

One hundred and forty-nine patients aged >/=70 years with acute stroke were included. The patients were assessed regarding their ability to carry out ADL and health resource utilization and cost during the first year after stroke. Cognitive impairments were assessed 18 months after the index stroke.

RESULTS

Stroke severity in acute stroke and cognitive impairment at 18 months after stroke onset was associated with impairment in ADL and increased costs for utilisation of care during the first year. Patients with cognitive impairment were more dependent on personal assistance in ADL. Costs per patient during the study were three times higher for patients with cognitive impairment. Hospital care, institutional living and different kinds of support from society accounted for the highest costs.

CONCLUSIONS

Costs of care utilisation during the first year after stroke were associated with cognitive impairments, stroke severity and dependence in ADL. The results should be interpreted cautiously as the assessment of cognitive function was made 18 months after stroke onset and costs were estimated for the first year after stroke.

Conceptualizations of frailty in relation to older adults

AIM

The aim of this article is to discuss the concept of frailty and its adequacy in identifying and describing older adults as frail.

BACKGROUND

Despite the dramatic increase in use of the term 'frailty' over the past two decades, there is a lack of consensus in the literature about its meaning and use, and no clear conceptual guidelines for identifying and describing older adults as frail. Differences in theoretical perspectives will influence policy decisions regarding eligibility for, and allocation of, scarce health care resources among older adults.

METHOD

The article presents a literature review and synthesis of definitions and conceptual models of frailty in relation to older adults. The first part of the paper is a summary of the synonyms, antonyms and definitions of the term frailty. The second part is a critical evaluation of conceptual models of frailty. Six conceptual models are analysed on the basis of four main categories of assumptions about: (1) the nature of scientific knowledge; (2) the level of analysis; (3) the ageing process; (4) the stability of frailty. The implications of these are discussed in relation to clinical practice, policy and research.

CONCLUSION

The review gives guidelines for a new theoretical approach to the concept of frailty in older adults: (1) it must be a multidimensional concept that considers the complex interplay of physical, psychological, social and environmental factors; (2) the concept must not be age-related, suggesting a negative and stereotypical view of ageing; (3) the concept must take into account an individual's context and incorporate subjective perceptions; (4) the concept must take into account the contribution of both individual and environmental factors.

Assessment of health economics in Alzheimer's disease (AHEAD): treatment with galantamine in the UK

OBJECTIVE

To assess the long-term health and economic impact of treating mild to moderate Alzheimer's disease (AD) with galantamine (16 mg or 24 mg per day) compared to no cholinesterase therapy in the UK.

METHODS

The long-term costs and outcomes were assessed using a model developed from longitudinal data on a cohort of AD patients. The model predicts the time until patients require full-time care, defined as the consistent requirement for a significant amount of care and supervision each day. Efficacy data were obtained from three clinical trials comparing galantamine with placebo, forecasts were made for ten years. Costs were determined in 2001 British pounds and discounted at 6% per annum, while outcomes such as time to full-time care were discounted at 1.5%.

RESULTS

Without pharmacological treatment, patients are expected to incur costs of 28,134 British pounds over ten years, 70% of costs accrue from providing full-time care. Galantamine (16 mg per day) is predicted to reduce the duration of the full-time care state by 12%; approximately five patients need to be treated to avoid one year of full-time care. The ten-year incremental costs per month of full-time care avoided average pound 192 British pounds per patient and 8,693 British pounds per QALY. Savings (1380 British pounds) are predicted for patients who continue treatment beyond six months and whose cognitive function is maintained or improved. Comparable results were estimated for the 24 mg dose.

CONCLUSION

In addition to the clinical benefits associated with galantamine treatment, the savings predicted from delaying when full-time care is needed may offset the treatment costs.

First among Equals?

Despite various problems associated with the introductionand use of the new generation of drugs for Alzheimer’s disease(cholinesterase inhibitors), expenditure on this aspect of patient care tends to eclipse expenditure on caring and support services. Even though evidence for the effectiveness of many patient-centred approaches is increasingly available, in the UK fixed budgets for various types of service usually means that increased expenditure on medication ensures that support services will inevitably have their funding eroded. Is this the best way to provide effective care for people with dementia? The role of drug companies in this process is examined critically.

What determines the use of home care services by elderly people?

The objective of the present study was to investigate the determinants of use of statutory and private home care services by older people living in the community. A questionnaire was distributed to a stratified random sample of 2,000 elderly people living in the community registered with 11 general practices in a British city (equal numbers of men and women, aged 65-74 years, and 75 years or over). The outcome measures were the use of statutory or private home care services in the previous 3 months. Logistic regression was used to explore potential determinants of the use of these services. The response rate was 79%. Increasing age, not owning a car and being a widow(er) were associated with greater use of both statutory and private home care services, as was worse self-reported overall health. Worse physical functioning, worse emotional health, problems with cognition, foot problems and a greater number of falls were determinants of use of statutory and private services. Older age on leaving full-time education was associated with increased use of private home care services. Problems with eyesight were determinants for both types of home care services for women, but only private services for men. For women, leakage of urine was associated with greater use of private services. Social networks and social support were not generally associated with use of these services after controlling for demographic factors. Understanding the determinants for the use of both statutory and private home care services is important because of the increasing numbers of elderly people in the population and the policy to maintain older people in their own homes. Purchasers and providers should be able to address at least some of the modifiable predictors.

Formal and informal care for people with dementia: factors associated with service receipt

Details of service receipt by 132 people diagnosed with dementia and their carers were collected in South London (boroughs of Lewisham, Camberwell, Southwark and Croydon), a geographical area served by several health and social care providers. The data collected included the Caregiver Activity Survey, which details the informal care given. This paper reports the formal and informal services received by the people with dementia at entry to the study. The amount of time spent on specific caring tasks by all informal carers of people with dementia averaged seven hours per week, but was significantly higher for co-resident carers, even when controlling for the level of dependency of the person cared-for. The odds ratios of receipt of formal services are given, according to where people were living: in the community or residential care, with co-resident carers or alone.

Estimating the relationship between disease progression and cost of care in dementia

BACKGROUND

Previous studies have shown a positive relationship between disease severity and cost.

AIMS

To explore the factors affecting time to institutionalisation and estimate the relationship between the costs of care and disease progression.

METHOD

Retrospective analysis of a longitudinal data-set for a cohort of 100 patients diagnosed with Alzheimer's disease or vascular dementia.

RESULTS

Changes in both Mini-Mental State Examination (MMSE) and Barthel scores have independent and significant marginal effects on costs. Each one-point decline in the MMSE score is associated with a pound sterling 56 increase in the four-monthly costs, whereas each one-point fall in the Barthel index is associated with a pound sterling 586 increase in costs.

CONCLUSIONS

It may be inappropriate for economic models of disease progression in dementia to be based solely on measures of cognitive change. MMSE and the Barthel index are independent significant predictors of time to institutionalisation and cost of care, but changes in the Barthel index are particularly important in predicting costs outside institutional care.

Costs and cognitive disability: modelling the underlying associations

BACKGROUND

The high support needs of elderly people with cognitive disability raise questions about the cost-effectiveness of different treatments. Associations between costs and cognitive disability could be influenced by other factors, particularly comorbidities.

AIMS

To examine the links between costs and cognitive disability in the context of covariates.

METHOD

Secondary analyses of data from the UK Office of Population Censuses and Surveys disability surveys for over 4500 elderly people living in households were used to examine associations between cost and cognitive disability.

RESULTS

Costs varied considerably, and were associated with severity of disability along a number of dimensions. The cost-raising effects of cognitive disability were smaller when the analyses controlled for levels of disability in other domains.

CONCLUSIONS

Cognitive disability is significantly associated with higher costs, but these analyses highlight the need to examine a range of disabilities.

Costs of dementia in England and Wales in the 21st century

BACKGROUND

An important factor determining future health care expenditure is the relationship between ageing, health status and development of age-related disorders such as dementia.

AIMS

To estimate the formal care costs associated with dementia in England and Wales between 1994 and 2031.

METHOD

Epidemiological cost model, applied to individuals aged 65 years or over with dementia, using estimates of life expectancy with dementia and dementia-free life expectancy.

RESULTS

Total costs per year were pound 0.95 billion (men) and pound 5.35 billion (women) using 1994 population estimates. For 2031, costs were pound 2.34 billion and pound 11.20 billion, respectively. Reduced dementia prevalence rates and improvements in mental and physical functioning resulted in lower estimates: pound 1.01 billion (men) and pound 5.77 billion (women), and pound 1.65 billion (men) and pound 7.87 billion (women), respectively.

CONCLUSIONS

Future increases in the population aged 65 years or over lead to rising formal care costs. However, the magnitude of cost changes depends on assumptions over dementia prevalence and levels of mental and physical functioning.

Economic evaluations during early (phase II) drug development: a role for clinical trial simulations?

Faced with increasing demands on demonstrating cost effectiveness, pharmaceutical companies are required to conduct pharmacoeconomic evaluations throughout the drug development programme. At present, there is particular emphasis in the literature on burden-of-illness studies and on economic evaluations conducted alongside phase III clinical trials but not on those conducted during phase II clinical trials. This article describes modelling techniques, namely clinical trial simulations (CTS), which are gaining popularity in the clinical research community, but which might also prove to be beneficial during the conduct of these early pharmacoeconomic evaluations. The basic concepts and structure of CTS are described by using published examples of simulations of antipsychotic and anticancer drugs. With the use of an illustrative example of a hypothetical cholinesterase inhibitor for Alzheimer's disease, an integrated CTS-based pharmacoeconomic evaluation is presented. The results demonstrate how the modelling may be of value in 'go/no-go' decisions during the drug development programme.