A systematic review to assess the policy-making relevance of dementia cost-of-illness studies in the US and Canada

The Financial Risks of Unpaid Caregiving During the COVID-19 Pandemic: Results From a Self-reported Survey in a Canadian Jurisdiction

As health service delivery shifts from institutions to the home, greater care responsibilities are being imposed on unpaid caregivers. However, gaps remain concerning how these responsibilities are contributing to caregivers' financial risk. This study describes results from an online survey conducted in late-2020 in Ontario, Canada, about the financial risks of unpaid, homebased caregiving throughout the first year of the COVID-19 pandemic. Among 190 caregivers, salient findings include difficulties paying for care expenses after the pandemic was declared than before (P = .002); more caregivers retiring or becoming unemployed during the pandemic than before (P = .013); and a significant relationship between paying out-of-pocket for a home care worker and experiencing a decrease in the availability of such support during the pandemic (P = .029). Overall, the financial stressors of caregiving during the pandemic contributed negatively to caregivers' mental health, with 64.2% noting could be partly offset by greater government and employment-based assistance in managing care expenses and productivity losses. Findings from this study will better inform policies that aim to protect unpaid caregivers from financial risk in pandemic recovery efforts and beyond. Results may also be useful in other welfare states where unpaid caregivers provide the majority of home care services.

Assistive technology and telecare to maintain independent living at home for people with dementia: the ATTILA RCT

BACKGROUND

Assistive technology and telecare have been promoted to manage the risks associated with independent living for people with dementia, but there is limited evidence of their effectiveness.

OBJECTIVES

This trial aimed to establish whether or not assistive technology and telecare assessments and interventions extend the time that people with dementia can continue to live independently at home and whether or not they are cost-effective. Caregiver burden, the quality of life of caregivers and of people with dementia and whether or not assistive technology and telecare reduce safety risks were also investigated.

DESIGN

This was a pragmatic, randomised controlled trial. Blinding was not undertaken as it was not feasible to do so. All consenting participants were included in an intention-to-treat analysis.

SETTING

This trial was set in 12 councils in England with adult social services responsibilities.

PARTICIPANTS

Participants were people with dementia living in the community who had an identified need that might benefit from assistive technology and telecare.

INTERVENTIONS

Participants were randomly assigned to receive either assistive technology and telecare recommended by a health or social care professional to meet their assessed needs (a full assistive technology and telecare package) or a pendant alarm, non-monitored smoke and carbon monoxide detectors and a key safe (a basic assistive technology and telecare package).

MAIN OUTCOME MEASURES

The primary outcomes were time to admission to care and cost-effectiveness. Secondary outcomes assessed caregivers using the 10-item Center for Epidemiological Studies Depression Scale, the State-Trait Anxiety Inventory 6-item scale and the Zarit Burden Interview.

RESULTS

Of 495 participants, 248 were randomised to receive full assistive technology and telecare and 247 received the limited control. Comparing the assistive technology and telecare group with the control group, the hazard ratio for institutionalisation was 0.76 (95% confidence interval 0.58 to 1.01; p = 0.054). After adjusting for an imbalance in the baseline activities of daily living score between trial arms, the hazard ratio was 0.84 (95% confidence interval 0.63 to 1.12; p = 0.20). At 104 weeks, there were no significant differences between groups in health and social care resource use costs (intervention group - control group difference: mean -£909, 95% confidence interval -£5336 to £3345) or in societal costs (intervention group - control group difference: mean -£3545; 95% confidence interval -£13,914 to £6581). At 104 weeks, based on quality-adjusted life-years derived from the participant-rated EuroQol-5 Dimensions questionnaire, the intervention group had 0.105 (95% confidence interval -0.204 to -0.007) fewer quality-adjusted life-years than the control group. The number of quality-adjusted life-years derived from the proxy-rated EuroQol-5 Dimensions questionnaire did not differ between groups. Caregiver outcomes did not differ between groups over 24 weeks.

LIMITATIONS

Compliance with the assigned trial arm was variable, as was the quality of assistive technology and telecare needs assessments. Attrition from assessments led to data loss additional to that attributable to care home admission and censoring events.

CONCLUSIONS

A full package of assistive technology and telecare did not increase the length of time that participants with dementia remained in the community, and nor did it decrease caregiver burden, depression or anxiety, relative to a basic package of assistive technology and telecare. Use of the full assistive technology and telecare package did not increase participants' health and social care or societal costs. Quality-adjusted life-years based on participants' EuroQol-5 Dimensions questionnaire responses were reduced in the intervention group compared with the control group; groups did not differ in the number of quality-adjusted life-years based on the proxy-rated EuroQol-5 Dimensions questionnaire.

FUTURE WORK

Future work could examine whether or not improved assessment that is more personalised to an individual is beneficial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN86537017.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 19. See the NIHR Journals Library website for further project information.

Medicaid Contributes Substantial Costs to Dementia Care in an Ethnically Diverse Community

OBJECTIVES

The main objective of this study was to estimate effects of dementia on Medicaid expenditures in an ethnically diverse community.

METHODS

The sample included 1,211 Medicare beneficiaries who did not have any Medicaid coverage and 568 who additionally had full Medicaid coverage enrolled in the Washington Heights-Inwood Columbia Aging Project (WHICAP), a multiethnic, population-based, prospective study of cognitive aging in northern Manhattan (1999-2010). Individuals' dementia status was determined using a rigorous clinical protocol. Relationship between dementia and Medicaid coverage and expenditures were estimated using a two-part model.

RESULTS

In participants who had full Medicaid coverage, average annual Medicaid expenditures were substantially higher for those with dementia than those without dementia ($50,270 vs. $21,966, p < .001), but Medicare expenditures did not differ by dementia status ($8,458 vs. $9,324, p = .19). In participants who did not have any Medicaid coverage, average annual Medicare expenditures were substantially higher for those with dementia than those without dementia ($12,408 vs. $8,113, p = .02). In adjusted models, dementia was associated with a $6,278 increase in annual Medicaid spending per person after controlling for other characteristics.

DISCUSSION

Results highlight Medicaid's contribution to covering the cost of dementia care in addition to Medicare. Studies that do not include Medicaid are unlikely to accurately reflect the true cost of dementia.

Economics of dementia: A review of methods

Given the expected increase in the number of people with dementia in the coming years, it is anticipated that the resources necessary to support those with dementia will significantly increase. There will therefore likely be increased emphasis on how best to use limited resources across a number of domains including prevention, diagnosis, treatment and supporting informal caregivers. There has been increasing use of economic methods in dementia in the past number of years, in particular, cost-of-illness analysis and economic evaluation. This paper reviews the aforementioned methods and identities a number of methodological issues that require development. Addressing these methodological issues will enhance the quality of economic analysis in dementia and provide some useful insights about the best use of limited resources for dementia.

Utilization of healthcare services among elderly with cognitive impairment no dementia and influence of depression and anxiety: a longitudinal study

OBJECTIVES

Little objective and nationally representative data are available concerning the influence of cognitive impairment no dementia (CIND) on utilization of healthcare services. The main objective was to compare the use of healthcare services over three years, between elders with current or incident CIND and those without CIND. A second objective was to evaluate the effect of depression and anxiety.

METHODS

Cross-sectional and longitudinal data from a population-based survey of 2265 older adults living in Quebec (Canada) were used. CIND was identified using normative data for the Mini-Mental State Examination and was linked with medical records from public health insurance plan. Multinomial logistic regressions adjusted for relevant socio-demographic, social network and health-related confounders were conducted for each service. Interaction between CIND and depression/anxiety was also examined.

MAIN RESULTS

Current CIND was a predictor of longer anxiolytic/sedative/hypnotic medication use. Incident CIND led to longer hospital stay. Depression raised the likelihood of frequenting geriatricians, psychiatrists or neurologists and emergency department, but lessened the likelihood of visiting general practitioners. The addition of the psychiatric conditions to the incident CIND did not increase the likelihood of consuming antidepressants, while the incident CIND cases without psychiatric conditions increased this likelihood.

DISCUSSION

Compared to older adults without CIND, older adults with CIND have a distinct utilization of healthcare services. Multiple evaluations over many years may help to better understand the utilization of healthcare services in individuals with CIND. In the meantime, evaluations of these conditions at key moments could allow a more efficient use of health resources.

The economic burden of dementia in China, 1990-2030: implications for health policy

Objective

To quantify and predict the economic burden of dementia in China for the periods 1990–2010 and 2020–2030, respectively, and discuss the potential implications for national public health policy.

Methods

Using a societal, prevalence-based, gross cost-of-illness approach and data from multiple sources, we estimated or predicted total annual economic costs of dementia in China. We included direct medical costs in outpatient and inpatient settings, direct non-medical costs – e.g. the costs of transportation – and indirect costs due to loss of productivity. We excluded comorbidity-related costs.

Findings

The estimated total annual costs of dementia in China increased from 0.9 billion United States dollars (US$) in 1990 to US$ 47.2 billion in 2010 and were predicted to reach US$ 69.0 billion in 2020 and US$ 114.2 billion in 2030. The costs of informal care accounted for 94.4%, 92.9% and 81.3% of the total estimated costs in 1990, 2000 and 2010, respectively. In China, population ageing and the increasing prevalence of dementia were the main drivers for the increasing predicted costs of dementia between 2010 and 2020, and population ageing was the major factor contributing to the growth of dementia costs between 2020 and 2030.

Conclusion

In China, demographic and epidemiological transitions have driven the growth observed in the economic costs of dementia since the 1990s. If the future costs of dementia are to be reduced, China needs a nationwide dementia action plan to develop an integrated health and social care system and to promote primary and secondary prevention.

The association between caregiver well-being and care provided to persons with Alzheimer's disease and related disorders

BACKGROUND

Alzheimer's disease and related disorders (ADRD) are some of the leading causes of morbidity in developed nations. Unpaid family caregivers are primarily responsible for providing the care and support needed by persons with ADRD. In the process of caring for their loved ones with ADRD, caregivers often have to deal with multiple challenges, including their own deteriorating well-being and overall quality-of-life (QoL). A recent systematic review showed that very little research has been undertaken to study the relationship between AD caregiver QoL and the level or quality of care that caregivers provide to their loved ones. In this study, we investigate the relationships between caregiver well-being and the care provided to persons with ADRD.

METHODS

We used 12-month follow-up data from the Philadelphia site (n = 125) of the National Institutes of Health (NIH) multi-site study, Resources for Enhancing Alzheimer's Caregiver Health (REACH I) to examine the relationship between caregiver well-being and the level or quality of care provided while adjusting for important covariates (e.g., age, income, and years since caregiving). Caregivers who participated in REACH I had to be at least 21 years of age and they had to be providing at least 4 h of care per day for 6 months or more to a live-in loved one with ADRD. Linear regression analysis was used to examine the relationships between well-being and the level or quality of care provided to persons with ADRD.

RESULTS

Of the 255 caregivers who participated in the REACH I study, 125 (49.0 %) remained after 12 months of follow-up. Comparisons of participants at the 12-month follow-up and participants who were lost to follow-up showed that these two sets of participants were not statistically significantly different on any of the variables examined in this study. Linear regression analysis showed that there was no statistically significant association between caregiver well-being and level or quality of care provided.

CONCLUSIONS

Further research is required to investigate the factors associated with level and quality of care provided to persons with ADRD, and whether caregiver well-being (or QoL in general) is a contributor.

Errors in self-reports of health services use: impact on alzheimer disease clinical trial designs

BACKGROUND

Most Alzheimer disease clinical trials that compare the use of health services rely on reports of caregivers. The goal of this study was to assess the accuracy of self-reports among older adults with Alzheimer disease and their caregiver proxy respondents. This issue is particularly relevant to Alzheimer disease clinical trials because inaccuracy can lead both to loss of power and increased bias in study outcomes.

METHODS

We compared respondent accuracy in reporting any use and in reporting the frequency of use with actual utilization data as documented in a comprehensive database. We next simulated the impact of underreporting and overreporting on sample size estimates and treatment effect bias for clinical trials comparing utilization between experimental groups.

RESULTS

Respondents self-reports have a poor level of accuracy with κ-values often below 0.5. Respondents tend to underreport use even for rare events such as hospitalizations and nursing home stays. In analyses simulating underreporting and overreporting of varying magnitude, we found that errors in self-reports can increase the required sample size by 15% to 30%. In addition, bias in the reported treatment effect ranged from 3% to 18% due to both underreporting and overreporting errors.

CONCLUSIONS

Use of self-report data in clinical trials of Alzheimer disease treatments may inflate sample size needs. Even when adequate power is achieved by increasing sample size, reporting errors can result in a biased estimate of the true effect size of the intervention.

Cost-of-illness studies of diabetes mellitus: a systematic review

BACKGROUND

Diabetes mellitus (DM) is recognised as a major health problem.

OBJECTIVES

The aims of this study are two-fold: (1) to describe the methods used in the identified cost-of-illness (COI) studies of DM and (2) to summarise their study findings regarding the economic impact of DM.

METHODS

This is a systematic review of MEDLINE and Scopus journal articles reporting the cost of type 1 and/or 2 DM that were published in English from 2007 to 2011. Costs reported in the included studies were converted to US dollars.

RESULTS

The systematic search yielded 30 articles. The studies varied considerably in their study design, perspective and included cost categories. Estimates for the total annual costs of DM ranged from US$141.6 million to US$174 billion; direct costs ranged from US$150 to US$14,060 per patient per year (pppy) whereas indirect costs ranged from US$39.6 to US$7,164 pppy. Inpatient cost was the major contributor to direct cost in half of the studies that included inpatient costs, physician services and medications.

CONCLUSION

There is a considerable economic burden associated with DM. Future research should focus on improving methods of estimating costs, enhancing the interpretation of study findings and facilitating comparisons between studies.

Using U.S. Medicare records to evaluate the indirect health effects on spouses: a case study in Alzheimer's disease patients

BACKGROUND

The burden experienced by spouses of patients with Alzheimer's disease (AD) may have negative consequences for their physical health. We describe here a method for analyzing United States Medicare records to determine the changes in health service use and costs experienced by spouses after their marital partner receives an AD diagnosis.

METHODS

We initially identified all beneficiaries in the 2001-2005 Medicare 5% sample who had multiple claims listing the ICD-9 diagnostic code for AD, 331.0. The 5% sample includes spouses who share a Medicare account with their marital partners because they lack a sufficient work history for full eligibility on their own. A matched cohort study assessed incremental health costs in the spouses of AD patients versus a control group of spouses of non-AD patients. Longitudinal and cross-sectional analyses tracked the impact of a patient's AD diagnosis on his or her spouse's healthcare costs.

RESULTS

Our method located 54,593 AD patients of whom 11.5% had spouses identifiable via a shared Medicare account. AD diagnosis in one member of a couple was associated with significantly higher monthly Medicare payments for the other member's healthcare. The spouses' elevated costs commenced 2 to 3 months before their partners' AD diagnosis and persisted over the follow-up period. After 31 months, the cumulative additional Medicare reimbursements totaled a mean $4,600 in the spouses of AD patients. This excess was significant even after accounting for differences in baseline health status between the cohorts.

CONCLUSION

The study methodology provides a framework for comprehensively evaluating medical costs of both chronically ill patients and their spouses. This method also provides monthly data, which makes possible a longitudinal evaluation of the cost effects of specific health events. The observed correlations provide a coherent demonstration of the interdependence between AD patients' and spouses' health. Future research should examine caregiving burden and other possible factors contributing to the AD spouses' health outcomes. It should also extend the method presented here to evaluations of other chronic diseases of the elderly.

Impact of dementia on payments for long-term and acute care in an elderly cohort

BACKGROUND

Older people with dementia have increased risk of nursing home (NH) use and higher Medicaid payments. Dementia's impact on acute care use and Medicare payments is less well understood.

OBJECTIVES

Identify trajectories of incident dementia and NH use, and compare Medicare and Medicaid payments for persons having different trajectories.

RESEARCH DESIGN

Retrospective cohort of older patients who were screened for dementia in 2000-2004 and were tracked for 5 years. Trajectories were identified with latent class growth analysis.

SUBJECTS

A total of 3673 low-income persons aged 65 or older without dementia at baseline.

MEASURES

Incident dementia diagnosis, comorbid conditions, dual eligibility, acute and long-term care use and payments based on Medicare and Medicaid claims, medical record systems, and administrative data.

RESULTS

Three trajectories were identified based on dementia incidence and short-term and long-term NH use: (1) high incidence of dementia with heavy NH use (5% of the cohort) averaging $56,111/year ($36,361 Medicare, $19,749 Medicaid); (2) high incidence of dementia with little or no NH use (16% of the cohort) averaging $16,206/year ($14,644 Medicare, $1562 Medicaid); and (3) low incidence of dementia and little or no NH use (79% of the cohort) averaging $8475/year ($7558 Medicare, $917 Medicaid).

CONCLUSIONS

Dementia and its interaction with NH utilization are major drivers of publicly financed acute and long-term care payments. Medical providers in Accountable Care Organizations and other health care reform efforts must effectively manage dementia care across the care continuum if they are to be financially viable.

Economic evaluation of treatment options in patients with Alzheimer's disease: a systematic review of cost-effectiveness analyses

INTRODUCTION

Alzheimer's disease (AD) is common among the elderly; it is responsible for 60-80% of all dementia cases. AD is characterized by cognitive decline, behavioural and psychological symptoms, and reductions in functioning and independence. Because of its progressive neurodegenerative nature and unknown aetiology, the burden of AD becomes increasingly significant in an aging population. Estimates indicate that 35.6 million people worldwide suffered from AD in 2010. By 2030 and 2050, this figure is predicted to increase to 65.7 million and 115.4 million, respectively. Costs will also rise along with the increase in the number of people diagnosed with AD. In 2010, the worldwide costs associated with dementia were estimated to be $US604 billion.

OBJECTIVE

The objective of this study was to conduct a systematic review of current publications dealing with the pharmacoeconomic factors associated with AD medications and to describe the decision-analytic models used to evaluate long-term outcomes.

METHODS

A systematic literature search was performed to identify articles published between 1 January 2007 and 15 July 2010. The search was also based on a previous systematic review, which included literature up to 2007. Articles were included if they were complete and original economic evaluations of AD and if they were comparative in nature. A quality assessment of the included publications was conducted and relevant information was extracted into tables.

RESULTS

Seven out of 2067 identified articles were included in this systematic review. Four articles evaluated treatment with donepezil, one with galantamine and two with memantine. The studies were conducted in America, Europe and Asia. Five different groups of medications were compared. The incremental cost-effectiveness ratios (ICERs) for the group of patients treated with donepezil versus no drug treatment ranged from a dominant value to 281, 416.13 euros per quality-adjusted life-year (QALY). Patients treated with donepezil versus placebo showed ICERs with a range from a dominant value (not specified) up to 20, 866.77 euros per QALY. Treatment with memantine in addition to donepezil versus treatment with donepezil alone showed an ICER range from a dominant value to 6818.33 euros per QALY. In comparison with the memantine treatment as an add-on therapy, the ICER of memantine monotherapy versus standard care (without cholinesterase inhibitors [CEIs]) ranged from a dominant value to 63, 087.20 euros per QALY. Finally, the economic evaluation of galantamine in comparison with usual care without any AD drugs showed ICERs ranging from 1894.70 euros to 6953 euros per QALY.

CONCLUSION

The seven identified publications included in this review indicate that treatment with CEIs or memantine seems to be reasonable in terms of clinical effects and costs for patients with AD. Depending on different hypotheses, assumptions and variables (e.g. time horizon, discount rates, initial number of patients in different states, etc.) in the sensitivity analyses, treatment with these drugs seems to be primarily a cost-effective strategy or even a cost-saving strategy. Nevertheless, the results generally are associated with a degree of uncertainty. The comparability of the results from the different economic evaluations is limited because of the different assumptions made.

A review of the methods used to estimate the cost of Alzheimer's disease in the United States

BACKGROUN/RATIONALE: To determine the suitability of published estimates of the US cost of Alzheimer's disease (AD) for use in cost-effectiveness models for new AD treatments.

METHODS

A systematic literature review of published information on direct medical, direct nonmedical, indirect, and informal care costs for different levels of disease severity.

RESULTS

Nineteen studies were included in the review. In studies presenting mean costs by disease severity, the change in different types of costs with increasing disease severity varied, depending on the data sources and characteristics of patients with AD. In studies presenting the results of regression analyses, costs were shown to be independently associated with cognition, functional status, behavioral symptoms, and dependence.

CONCLUSIONS

Published US studies (1) did not include all the types of costs and AD populations, and (2) generally did not include all the measures of disease severity that are needed for cost-effectiveness models.