Assessing the Value of Treatment to Address Various Symptoms Associated with Multiple Sclerosis: Results from a Contingent Valuation Study

BACKGROUND

Although it is well recognized that people with multiple sclerosis (MS) may experience impairments in addition to limited mobility, there has been little effort to study their relative importance to patients with the condition. The objective of this study was to assess patient preferences for addressing various MS symptoms.

METHODS

This study was conducted at Tufts Medical Center, Boston, Massachusetts. We developed a national online survey of MS patients and neurologists to estimate the value each group places on treating specific MS symptoms. Each respondent was presented with two randomly selected scenarios with different symptoms and treatments. MS patients were asked about their own preferences, whereas neurologists were asked to consider what a patient of theirs would do or think in each scenario. We used a bidding game approach to elicit respondents' willingness to pay (WTP) for the treatments.

RESULTS

To treat mobility alone, WTP for MS patients averaged US$410-US$520 per month, depending on the scenario. For paired symptoms, MS patients would pay most to treat mobility and upper limb function (US$525/month) or mobility and cognition (US$514/month), somewhat less to treat mobility and eyesight (US$445/month), and least to treat mobility and fatigue (US$371/month). Patient WTP values increased with income and education. Neurologists believed their patients would be willing to pay US$216-US$249 per month to treat mobility alone, depending on the scenario. For paired symptoms, neurologists believed patients would pay most to treat mobility and fatigue (US$263/month) and least to treat mobility and upper limb function (US$177/month).

CONCLUSION

Our findings suggest MS patients may value one outcome (e.g., improved arm and hand coordination) over another (e.g., less fatigue). Further, MS patients and neurologists may rank the importance of treating various symptoms differently. Given this potential mismatch, it is crucial for MS patients and their clinicians to discuss treatment priorities that take into account patient preferences.

Prefrontal Cortex Dysfunction and Income: A Study in Neuroeconomics

In four samples of adults, individual income was negatively associated with a measure of prefrontal cortex dysfunction even after implementing controls for age, sex, and education. The small association was stronger for men than for women. These results provide support for a neuroeconomic approach to the study of micro-economic variables.

An 8 year follow-up of a specialist supported employment service for high-ability adults with autism or Asperger syndrome

Few supported employment programmes have been specifically designed for people with autism, especially those who are more able. This study examines the outcome of a supported employment service (NAS Prospects) for adults with autism or Asperger syndrome (IQ 60+) over an 8 year period. Approximately 68 percent of clients found employment. Of the 192 jobs, the majority were permanent contracts and most involved administrative, technical or computing work. Assessment of current clients indicates that IQ, language skills and educational attainments are high. However, work has also been found for those of lower abilities. Individuals supported by Prospects show a rise in salaries, contribute more tax and claim fewer benefits. Satisfaction with the scheme is high among clients, employers and support workers. Although the programme continues to incur a financial deficit, this has decreased. Moreover, there are many non-financial benefits, which are difficult to quantify. The importance of specialist employment support of this kind is discussed.

Reducing Periconceptional Methylmercury Exposure: Cost-Utility Analysis for a Proposed Screening Program for Women Planning a Pregnancy in Ontario, Canada

BACKGROUND

The assessment of neurodevelopmental effects in children associated with prenatal methylmercury exposure, from contaminated fish and seafood in the maternal diet, has recently been strengthened by adjustment for the negative confounding resulting from co-exposure to beneficial polyunsaturated fatty acids (PUFAs).

OBJECTIVES

We aimed to determine the cost-effectiveness of a periconceptional screening program of blood mercury concentration for women planning to become pregnant in Ontario, Canada. Fish intake recommendations would be provided for those found to have blood mercury levels above the intervention threshold.

METHODS

Analysis was conducted using a combined decision tree/Markov model to compare the proposed screening intervention with standard care from a societal perspective over a lifetime horizon. We used the national blood mercury distributions of women 20-49 years of age reported in the Canadian Health Measures Survey from 2009 through 2011 to determine the cognitive deficits associated with prenatal methylmercury exposure for successful planned pregnancies. Outcomes modeled included the loss in quality of life and the remedial education costs. Value of information analysis was conducted to assess the underlying uncertainty around the model results and to identify which parameters contribute most to this uncertainty.

RESULTS

The incremental cost per quality-adjusted life year (QALY) gained for the proposed screening intervention was estimated to be Can$18,051, and the expected value for a willingness to pay of Can$50,000/QALY to be Can$0.61.

CONCLUSIONS

Our findings suggest that the proposed periconceptional blood mercury screening program for women planning a pregnancy would be highly cost-effective from a societal perspective. The results of a value of information analysis confirm the robustness of the study's conclusions.

Use and cost of hospitalization in dementia: longitudinal results from a community-based study

OBJECTIVES

The aim of this study is to examine the relative contribution of functional impairment and cognitive deficits on risk of hospitalization and costs.

METHODS

A prospective cohort of Medicare beneficiaries aged 65 and older who participated in the Washington Heights-Inwood Columbia Aging Project (WHICAP) were followed approximately every 18 months for over 10 years (1805 never diagnosed with dementia during study period, 221 diagnosed with dementia at enrollment). Hospitalization and Medicare expenditures data (1999-2010) were obtained from Medicare claims. Multivariate analyses were conducted to examine (1) risk of all-cause hospitalizations, (2) hospitalizations from ambulatory care sensitive (ACSs) conditions, (3) hospital length of stay (LOS), and (4) Medicare expenditures. Propensity score matching methods were used to reduce observed differences between demented and non-demented groups at study enrollment. Analyses took into account repeated observations within each individual.

RESULTS

Compared to propensity-matched individuals without dementia, individuals with dementia had significantly higher risk for all-cause hospitalization, longer LOS, and higher Medicare expenditures. Functional and cognitive deficits were significantly associated with higher risks for hospitalizations, hospital LOS, and Medicare expenditures. Functional and cognitive deficits were associated with higher risks of for some ACS but not all admissions.

CONCLUSIONS

These results allow us to differentiate the impact of functional and cognitive deficits on hospitalizations. To develop strategies to reduce hospitalizations and expenditures, better understanding of which types of hospitalizations and which disease characteristics impact these outcomes will be critical.

Direct medical costs and source of cost differences across the spectrum of cognitive decline: a population-based study

BACKGROUND

Objective cost estimates and source of cost differences are needed across the spectrum of cognition, including cognitively normal (CN), mild cognitive impairment (MCI), newly discovered dementia, and prevalent dementia.

METHODS

Subjects were a subset of the Mayo Clinic Study of Aging stratified-random sampling of Olmsted County, MN, residents aged 70 to 89 years. A neurologist reviewed provider-linked medical records to identify prevalent dementia (review date = index). Remaining subjects were invited to participate in prospective clinical/neuropsychological assessments; participants were categorized as CN, MCI, or newly discovered dementia (assessment date = index). Costs for medical services/procedures 1-year pre-index (excluding indirect and long-term care costs) were estimated using line-item provider-linked administrative data. We estimated contributions of care-delivery site and comorbid conditions (including and excluding neuropsychiatric diagnoses) to between-category cost differences.

RESULTS

Annual mean medical costs for CN, MCI, newly discovered dementia, and prevalent dementia were $6042, $6784, $9431, $11,678, respectively. Hospital inpatient costs contributed 70% of total costs for prevalent dementia and accounted for differences between CN and both prevalent and newly discovered dementia. Ambulatory costs accounted for differences between CN and MCI. Age-, sex-, education-adjusted differences reached significance for CN versus newly discovered and prevalent dementia and for MCI versus prevalent dementia. After considering all comorbid diagnoses, between-category differences were reduced (e.g., prevalent dementia minus MCI (from $4842 to $3575); newly discovered dementia minus CN (from $3578 to $711)). Following the exclusion of neuropsychiatric diagnoses from comorbidity adjustment, between-category differences tended to revert to greater differences.

CONCLUSIONS

Cost estimates did not differ significantly between CN and MCI. Substantial differences between MCI and prevalent dementia reflected high inpatient costs for dementia and appear partly related to co-occurring mental disorders. Such comparisons can help inform models aimed at identifying where, when, and for which individuals proposed interventions might be cost-effective.

[Comments on ethical hospital management]

An ethical hospital management will be discussed under the topics (financial) resources, responsibility, quality and focus on patients.

Economic analysis of the intangible impacts of informal care for people with Alzheimer's disease and other mental disorders

OBJECTIVES

Valuation of the intangible impacts of informal care remains a great challenge for economic evaluation, especially in the framework of care recipients with cognitive impairment. Our main objective was to explore the influence of intangible impacts of caring on both informal caregivers' ability to estimate their willingness to pay (WTP) to be replaced and their WTP value.

METHODS

We mapped characteristics that influence ability or inability to estimate WTP by using a multiple correspondence analysis. We ran a bivariate probit model with sample selection to further analyze the caregivers' WTP value conditional on their ability to estimate their WTP.

RESULTS

A distinction exists between the opportunity costs of the caring dimension and those of the intangible costs and benefits of caring. Informal caregivers' ability to estimate WTP is negatively influenced by both intangible benefits from caring (P < 0.001) and negative intangible impacts of caring (P < 0.05). Caregivers' WTP value is negatively associated with positive intangible impacts of informal care (P < 0.01).

CONCLUSIONS

Informal caregivers' WTP and their ability to estimate WTP are both influenced by intangible burden and benefit of caring. These results call into question the relevance of a hypothetical generalized financial compensation system as the optimal way to motivate caregivers to continue providing care.

[Risk assessment of pre-term infants]

Pre-term birth occurs when a baby is born before 37 weeks of gestation are completed. Many recent publications on neurodevelopmental and somatic outcome parameters of premature infants are of interest for insurance medicine. Infants born before the 28th week are called extremely pre-term. When examined at five years, 85% had already received or still needed special treatment or support. The results of examinations in early childhood have quite a low predictive value for the further development of the child. In the very and moderately pre-term stages, long-term risks are continuously declining with the length of gravidity. Even "late pre-term" birth (34 to 36 weeks of gestation) is associated with a nearly doubled rate of developmental impairment and chronic disease in childhood and adolescence. Various studies performed in early adulthood showed that former pre-term infants suffered more often from asthma and psychiatric disorders. On average, they also had higher blood pressure, lower insulin sensitivity, and a reduced exercise capacity. It remains to be evaluated how much these risk factors contribute to cardiovascular or pulmonary morbidity and mortality later in life. At least, general mortality after preterm birth seems to be increased up to the oldest age group statistically evaluated up to now, i.e. 18 to 36 years.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association of postpartum maternal morbidities with children's mental, psychomotor and language development in rural Bangladesh

Little is known from developing countries about the effects of maternal morbidities diagnosed in the postpartum period on children's development. The study aimed to document the relationships of such morbidities with care-giving practices by mothers, children's developmental milestones and their language, mental and psychomotor development. Maternal morbidities were identified through physical examination at 6-9 weeks postpartum (n=488). Maternal care-giving practices and postnatal depression were assessed also at 6-9 weeks postpartum. Children's milestones of development were measured at six months, and their mental (MDI) and psychomotor (PDI) development, language comprehension and expression, and quality of psychosocial stimulation at home were assessed at 12 months. Several approaches were used for identifying the relationships among different maternal morbidities, diagnosed by physicians, with children's development. After controlling for the potential confounders, maternal anaemia diagnosed postpartum showed a small but significantly negative effect on children's language expression while the effects on language comprehension did not reach the significance level (p=0.085). Children's development at 12 months was related to psychosocial stimulation at home, nutritional status, education of parents, socioeconomic status, and care-giving practices of mothers at six weeks of age. Only a few mothers experienced each specific morbidity, and with the exception of anaemia, the sample-size was insufficient to make a conclusion regarding each specific morbidity. Further research with a sufficient sample-size of individual morbidities is required to determine the association of postpartum maternal morbidities with children's development.

Cognitive impairment associated with schizophrenia: a review of the humanistic burden

INTRODUCTION

Nearly every individual with schizophrenia is affected by cognitive decline. The aim of this literature review was to: (a) describe the humanistic burden of cognitive impairment associated with schizophrenia (CIAS); (b) develop a conceptual model that depicts the signs and symptoms of CIAS along with key concepts important to patients; and (c) consider the adequacy of potential patient-reported outcome (PRO) instruments for assessing future treatments.

METHODS

The following electronic databases were searched for articles published between January 1999 and November 2009 related to CIAS and PROs, or cost of illness: Medline; Embase; PsycINFO; the Health Economic Evaluation Database; and the National Health Service Economic Evaluation Database and Health Technology Assessment databases at the Centre for Reviews and Dissemination, University of York.

RESULTS

The literature search revealed 3950 abstracts, of which 101 articles were reviewed in detail. Cognitive functions affected include memory, attention/concentration, problem solving, learning, executive function, processing speed, and social cognition. Cognitive impairment impacts the ability of individuals to carry out activities of daily living, work productively, function socially, and adhere to treatment. These effects have economic ramifications through increased direct and indirect costs associated with the treatment of schizophrenia. The literature revealed 39 PRO instruments that have been used to assess functioning. However, no single instrument captures all key concepts of importance to patients with schizophrenia.

CONCLUSION

The significant burden from CIAS for patients and society has implications for designing future treatments and health strategies to improve functional outcomes.

Diagnostic accuracy, effectiveness and cost for cognitive impairment and dementia screening of three short cognitive tests applicable to illiterates

BACKGROUND

Illiteracy, a universal problem, limits the utilization of the most widely used short cognitive tests. Our objective was to assess and compare the effectiveness and cost for cognitive impairment (CI) and dementia (DEM) screening of three short cognitive tests applicable to illiterates.

METHODS

Phase III diagnostic test evaluation study was performed during one year in four Primary Care centers, prospectively including individuals with suspicion of CI or DEM. All underwent the Eurotest, Memory Alteration Test (M@T), and Phototest, applied in a balanced manner. Clinical, functional, and cognitive studies were independently performed in a blinded fashion in a Cognitive Behavioral Neurology Unit, and the gold standard diagnosis was established by consensus of expert neurologists on the basis of these results. Effectiveness of tests was assessed as the proportion of correct diagnoses (diagnostic accuracy [DA]) and the kappa index of concordance (k) with respect to gold standard diagnoses. Costs were based on public prices at the time and hospital accounts.

RESULTS

The study included 139 individuals: 47 with DEM, 36 with CI, and 56 without CI. No significant differences in effectiveness were found among the tests. For DEM screening: Eurotest (k = 0.71 [0.59-0.83], DA = 0.87 [0.80-0.92]), M@T (k = 0.72 [0.60-0.84], DA = 0.87 [0.80-0.92]), Phototest (k = 0.70 [0.57-0.82], DA = 0.86 [0.79-0.91]). For CI screening: Eurotest (k = 0.67 [0.55-0.79]; DA = 0.83 [0.76-0.89]), M@T (k = 0.52 [0.37-0.67]; DA = 0.80 [0.72-0.86]), Phototest (k = 0.59 [0.46-0.72]; DA = 0.79 [0.71-0.86]). There were no differences in the cost of DEM screening, but the cost of CI screening was significantly higher with M@T (330.7 ± 177.1 €, mean ± sd) than with Eurotest (294.1 ± 195.0 €) or Phototest (296.0 ± 196. 5 €). Application time was shorter with Phototest (2.8 ± 0.8 min) than with Eurotest (7.1 ± 1.8 min) or M@T (6.8 ± 2.2 min).

CONCLUSIONS

Eurotest, M@T, and Phototest are equally effective. Eurotest and Phototest are both less expensive options but Phototest is the most efficient, requiring the shortest application time.

Intensive dietary intervention by a dietitian as a case manager among community dwelling older adults: the EDIT study

BACKGROUND

Clinical trials that have assessed the best approach for treating under-nutrition in old age are scarce.

OBJECTIVE

To determine the impact of an intensive nutritional intervention program led by a dietitian on the health and nutritional status of malnourished community dwelling older adults.

METHODS

Sixty-eight eligible participants (age<75) were randomly assigned to a Dietetic Intervention Treatment (DIT), an intensive nutritional intervention led by a dietitian, or a Medical Treatment (MT), a physician-led standard care group, with an educational booklet regarding dietary requirements and recommendations for older adults. An additional 59 eligible participants who were unable to participate in the randomization were included as a non-randomized "untreated nutrition" group (UNG).

RESULTS

Over the 6-month follow-up, the DIT group showed significant improvement in cognitive function (from 25.8±4.5 to 26.8±4, p=0.04), and depression score (from 7.3±3.9 to 5.4±3.9, p=0.04) compared with the change in the other 2 groups. The DIT group showed a significant improvement in intake of carbohydrates (+15% vs. +1% in the MT and +3% in the UNG), protein (+8% vs. +2% in the MT and -3% in the UNG), vitamin B6 (+20% vs. +7% in the MT and +8% in the UNG), and vitamin B1 (+22% vs. +11% in the MT and 0% in the UNG). The DIT group had a significantly lower cost of physician visits than the other 2 groups ($172.1±232.0 vs. $417.2±368.0 in the MT and $428.1±382.3 in the UNG, p=0.005).

CONCLUSION

Intensive dietary intervention was moderately effective in lowering cost of services used and improving medical and nutritional status among community dwelling older adults.

Life-course socioeconomic position and incidence of dementia and cognitive impairment without dementia in older Mexican Americans: results from the Sacramento area Latino study on aging

There have been few investigations of the link between changes in life-course socioeconomic position (SEP) and cognitive decline or incidence of dementia. The authors examined the impact of changes in life-course SEP on incidence of dementia and cognitive impairment but not dementia (CIND) over a decade of follow-up. Participants of Mexican origin (n = 1,789) were members of the Sacramento Area Latino Study on Aging cohort. Incidence of dementia/CIND was ascertained by using standard diagnostic criteria. SEP indicators at 3 life stages (childhood, adulthood, and midlife) were used to derive a measure of cumulative SEP (range, 0 to 8) and SEP mobility. Nearly 24% of the sample maintained a low SEP throughout life. Hazard ratios and 95% confidence intervals were computed from Cox proportional hazards regression models. In fully adjusted models, participants with a continuously high SEP had lower hazard ratios for dementia/CIND compared with those with a continuously low SEP at all 3 life stages (hazard ratio = 0.49, 95% confidence interval: 0.24, 0.98; P = 0.04). In age-adjusted models, participants experienced a 16% greater hazard of dementia/CIND with every 1-unit increase in cumulative SEP disadvantage across the life course (hazard ratio = 1.16, 95% confidence interval: 1.01, 1.33; P = 0.04). Early exposures to social disadvantage may increase the risk of late-life dementia.

Reducing case ascertainment costs in U.S. population studies of Alzheimer's disease, dementia, and cognitive impairment-Part 2

Dementia of the Alzheimer's type (DAT) is a major public health threat in developed countries where longevity has been extended to the eighth decade of life. Estimates of prevalence and incidence of DAT vary with what is measured, be it change from a baseline cognitive state or a clinical diagnostic endpoint, such as Alzheimer's disease. Judgment of what is psychometrically "normal" at the age of 80 years implicitly condones a decline from what is normal at the age of 30. However, because cognitive aging is very heterogeneous, it is reasonable to ask "Is 'normal for age' good enough to screen for DAT or its earlier precursors of cognitive impairment?" Cost containment and accessibility of ascertainment methods are enhanced by well-validated and reliable methods such as screening for cognitive impairment by telephone interviews. However, focused assessment of episodic memory, the key symptom associated with DAT, might be more effective at distinguishing normal from abnormal cognitive aging trajectories. Alternatively, the futuristic "Smart Home," outfitted with unobtrusive sensors and data storage devices, permits the moment-to-moment recording of activities so that changes that constitute risk for DAT can be identified before the emergence of symptoms.

[Use and abuse of drugs in cognitive impairment patients]

INTRODUCTION

Irrational use of drugs for the treatment of cognitive impairment can increase health costs in developing countries.

OBJECTIVE

to analyze the pattern of drug prescription related to the treatment of patients with dementia and to compare them with the income of patients.

PATIENTS

313 community-based outpatients that seeked medical advice for memory problems, in the Memory Center of Zubizarreta General Hospital (Buenos Aires, Argentina), were prospectively assessed during a period of a year.

RESULTS

Patients' mean income was 502.81 "Pesos Argentinos" which is equivalent to US$152 per month (2007). Fourty one point fifty five percent (41.55%) of the patients had dementia, 15.65% psychiatric diseases, 15.01% mild cognitive impairment and 27.79% were normal. Patients received an average of 2.84 drugs/day, 20% of the patients took at least one drug for cognitive impairment (9.85% memantine, 6.38% donepezil and 4% nootropics, cerebral vasodilators or antioxidants), and 39.3% received psychotropic medication (28.11% benzodiazepines and 9.26 % atypical antipsychotics). Twelve point seventy six percent (12.76%) of the patients with mild cognitive impairment were treated with antidementials, 5.74% of normal subjects received antidementials. 4% of patients were exclusively treated with free samples.

CONCLUSION

In our sample irrational degree of using antidemential drugs and psychotropic agents was found.

Telecommunications technology in cognitive rehabilitation

Cognitive disorders are a common long-term consequence of many forms of acquired neurological damage of different aetiology. The already high prevalence of diseases causing cognitive deficits (in particular stroke) is expected to increase in the near future, leading to a greater need for cognitive rehabilitation. The impact of cognitive impairment on daily functioning may be even greater than that of physical limitations in affected patients, contributing to the high cost of brain disorders. New technologies, including telerehabilitation, may provide an effective response to this challenge, allowing increased access to rehabilitation services as well as reduced care costs for individuals needing cognitive rehabilitation.

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.

Activity and Life After Survival of a Cardiac Arrest (ALASCA) and the effectiveness of an early intervention service: design of a randomised controlled trial

BACKGROUND

Cardiac arrest survivors may experience hypoxic brain injury that results in cognitive impairments which frequently remain unrecognised. This may lead to limitations in daily activities and participation in society, a decreased quality of life for the patient, and a high strain for the caregiver. Publications about interventions directed at improving quality of life after survival of a cardiac arrest are scarce. Therefore, evidence about effective rehabilitation programmes for cardiac arrest survivors is urgently needed. This paper presents the design of the ALASCA (Activity and Life After Survival of a Cardiac Arrest) trial, a randomised, controlled clinical trial to evaluate the effects of a new early intervention service for survivors of a cardiac arrest and their caregivers.

METHODS/DESIGN

The study population comprises all people who survive two weeks after a cardiac arrest and are admitted to one of the participating hospitals in the Southern part of the Netherlands. In a two-group randomised, controlled clinical trial, half of the participants will receive an early intervention service. The early intervention service consists of several consultations with a specialised nurse for the patient and their caregiver during the first three months after the cardiac arrest. The intervention is directed at screening for cognitive problems, provision of informational, emotional and practical support, and stimulating self-management. If necessary, referral to specialised care can take place. Persons in the control group will receive the care as usual. The primary outcome measures are the extent of participation in society and quality of life of the patient one year after a cardiac arrest. Secondary outcome measures are the level of cognitive, emotional and cardiovascular impairment and daily functioning of the patient, as well as the strain for and quality of life of the caregiver. Participants and their caregivers will be followed for twelve months after the cardiac arrest.A process evaluation will be performed to gain insight into factors that might have contributed to the effectiveness of the intervention and to gather information about the feasibility of the programme. Furthermore, an economic evaluation will be carried out to determine the cost-effectiveness and cost-utility of the intervention.

DISCUSSION

The results of this study will provide evidence on the effectiveness of this early intervention service, as well as the cost-effectiveness and its feasibility.

TRIAL REGISTRATION

Current Controlled Trials [ISRCTN74835019].

Physicians' attitudes about artificial feeding in older patients with severe cognitive impairment in Japan: a qualitative study

Background

The question of whether to withhold artificial nutrition and hydration (ANH) from severely cognitively impaired older adults has remained nearly unexplored in Japan, where provision of ANH is considered standard care. The objective of this study was to identify and analyze factors related to the decision to provide ANH through percutaneous endoscopic gastrostomy (PEG) in older Japanese adults with severe cognitive impairment.

Methods

Retrospective, in-depth interviews with thirty physicians experienced in the care of older, bed-ridden, non-communicative patients with severe cognitive impairment. Interview content included questions about factors influencing the decision to provide or withhold ANH, concerns and dilemmas concerning ANH and the choice of PEG feeding as an ANH method. The process of data collection and analysis followed the Grounded Theory approach.

Results

Data analysis identified five factors that influence Japanese physicians' decision to provide ANH through PEG tubes: (1) the national health insurance system that allows elderly patients to become long-term hospital in-patients; (2) legal barriers with regard to limiting treatment, including the risk of prosecution; (3) emotional barriers, especially abhorrence of death by 'starvation'; (4) cultural values that promote family-oriented end-of-life decision making; and (5) reimbursement-related factors involved in the choice of PEG. However, a small number of physicians did offer patients' families the option of withholding ANH. These physicians shared certain characteristics, such as a different perception of ANH and repeated communication with families concerning end-of-life care. These qualities were found to reduce some of the effects of the factors that favor provision of ANH.

Conclusion

The framework of Japan's medical-legal system unintentionally provides many physicians an incentive to routinely offer ANH for this patient group through PEG tubes. It seems apparent that end-of-life education should be provided to medical providers in Japan to change the automatic assumption that ANH must be provided.

Hospitalization of Nursing Home Residents With Cognitive Impairments: The Influence of Organizational Features and State Policies

PURPOSE

The purpose of this study was to quantify the effect of specific nursing home features and state Medicaid policies on the risk of hospitalization among cognitively impaired nursing home residents.

DESIGN AND METHODS

We used multilevel logistic regression to estimate the odds of hospitalization among long-stay (>90 days) nursing home residents against the odds of remaining in the nursing home over a 5-month period, controlling for covariates at the resident, nursing home, and county level. We stratified analyses by resident diagnosis of dementia.

RESULTS

Of 359,474 cognitively impaired residents, 49% had a diagnosis of dementia. Of those, 16% were hospitalized. The probability of hospitalization was negatively associated with the presence of a dementia special care unit (adjusted odds ratio [AOR] = 0.90, 95% confidence interval [CI] = 0.86-0.94) and with a high prevalence of dementia in the nursing home (AOR = 0.96, 95% CI = 0.88-1.03). Higher Medicaid payment rates were associated with reduced likelihood of hospitalization (AOR = 0.95, 95% CI = 0.90-1.00), whereas any bed-hold policy substantially increased that likelihood (AOR = 1.44, 95% CI = 1.12-1.86). We observed similar results for residents without a dementia diagnosis.

IMPLICATIONS

Directed management of chronic conditions, as indicated by facilities' investment in special care units, reduces the risk of hospitalization, but the effect of bed-hold policies illustrates how fragmentation in the financing system impedes these efforts.

To what extent does IQ 'explain' socio-economic variations in function?

Background

The aims of this study were to examine the extent to which higher intellectual abilities protect higher socio-economic groups from functional decline and to examine whether the contribution of intellectual abilities is independent of childhood deprivation and low birth weight and other socio-economic and developmental factors in early life.

Methods

The Maastricht Aging Study (MAAS) is a prospective cohort study based upon participants in a registration network of general practices in The Netherlands. Information was available on 1211 men and women, 24 – 81 years old, who were without cognitive impairment at baseline (1993 – 1995), who ever had a paid job, and who participated in the six-year follow-up. Main outcomes were longitudinal decline in important components of quality of life and successful aging, i.e., self-reported physical, affective, and cognitive functioning.

Results

Persons with a low occupational level at baseline showed more functional decline than persons with a high occupational level. Socio-economic and developmental factors from early life hardly contributed to the adult socio-economic differences in functional decline. Intellectual abilities, however, took into account more than one third of the association between adult socio-economic status and functional decline. The contribution of the intellectual abilities was independent of the early life factors.

Conclusion

Rather than developmental and socio-economic characteristics of early life, the findings substantiate the importance of intellectual abilities for functional decline and their contribution – as potential, but neglected confounders – to socio-economic differences in functioning, successful aging, and quality of life. The higher intellectual abilities in the higher socio-economic status groups may also underlie the higher prevalences of mastery, self-efficacy and efficient coping styles in these groups.

Community-level socio-economic status and cognitive and functional impairment in the older population

BACKGROUND

This study aimed to determine if people living in communities with higher socio-economic deprivation are at an increased risk of cognitive and functional impairment even after controlling for the effects of individual socio-economic status.

METHODS

We analysed cross-sectional data from the Medical Research Council Cognitive Function and Ageing Study which consists of a community-based sample of Cambridgeshire, Gwynedd, Newcastle, Nottingham and Oxford. The study included 13 004 men and women aged 65 years and over who were randomly selected from Family Health Services Authority computerized records after being stratified to ensure equal numbers of those aged 75 years and over and those under 75 years. The outcome measures were cognitive impairment (Mini-Mental State Exam 0-21) and functional impairment (Instrumental Activities of Daily Living and/or Activities of Daily Living disability).

RESULTS

Individuals living in more deprived areas, as measured by the Townsend deprivation score, were found to have a higher prevalence of cognitive impairment [odds ratio (OR) (most deprived versus least deprived quintile) = 2.3; 95% confidence interval (CI)1.8-3.0; P < 0.001] and functional impairment [OR (most deprived versus least) = 1.6; 95% CI 1.4-1.9; P < 0.001] after controlling for age, sex, centre effects, education and social class.

CONCLUSIONS

There is a significantly higher prevalence of cognitive impairment and functional impairment in elderly individuals living in socio-economically deprived areas regardless of their own socio-economic status. This evidence is of relevance for informing public health policy and those allocating resources for the long-term care of the elderly.

ADCS Prevention Instrument Project: overview and initial results

One objective of the Alzheimer's Disease Cooperative Study (ADCS) is to develop new or improved instruments and assessment methods for evaluating treatment efficacy in Alzheimer disease (AD) clinical trials. The ADCS Instrument Committee has previously helped to define the state of the art in assessment for AD and Mild Cognitive Impairment clinical trials. We are now entering an exciting era of primary prevention trials to evaluate promising treatments that may delay disease onset and there is a need to develop appropriate instruments for these trials. The ADCS instrument committee has undertaken a project to develop instruments for prevention studies that assess domains known to be important in AD. Prevention trials are long and require large numbers of subjects, making them costly and requiring a high burden of participation for subjects. The current study focused on developing instruments that can be completed at home and in the clinic. The instruments are being evaluated in a cohort of nondemented elderly participating in a 4-year longitudinal study that simulates the design of a primary prevention trial. This report describes the design, baseline characteristics, and some longitudinal outcomes of the study cohort through the completion of the first 2 years of follow-up. We also describe the assessment domains to be measured with our new experimental instruments. This study recruited 644 subjects, 75 years of age and older. Participation in a "book club" that provided free books of interest to elders was offered as a recruitment incentive. Approximately 23% had some mild cognitive symptoms consistent with a Clinical Dementia Rating of 0.5. All subjects received a standardized in-clinic evaluation at baseline, which is repeated annually for 4 years to identify cases suspected of developing dementia and to measure longitudinal change on established clinical assessments. Subjects completed a set of self-administered experimental instruments at home or in the clinic designed to assess cognitive function and behavior, global change, activities of daily living, quality of life, and resource use. An additional "mail-in cognitive function questionnaire" was obtained separately by mail, 1 month before the other assessments. To evaluate the feasibility, efficiency, and validity of the home-based instruments in comparison with acquiring the same information during a clinic visit, subjects were randomized to 1 of 2 conditions in which the baseline and annual follow-up assessments are completed either at home ("home group") or at the study site during their clinic visits ("clinic group"). This initial report describes the ongoing 4-year longitudinal study and provides baseline results, which confirm the feasibility of obtaining home-based clinical information via mail or telephone. Initial results for the experimental instruments and for the book club are reported in separate accompanying articles.

Social-economic costs and quality of life of Alzheimer disease in the Canary Islands, Spain

OBJECTIVES

To examine the economic burden (direct and indirect costs) of Alzheimer disease (AD) and to analyze the impact on health-related quality of life (HRQOL) for patients with AD and caregivers in 2001 in the Canary Islands, Spain.

METHODS

Two hundred thirty-seven patients (61% of those contacted) were recruited from the Alzheimer's Disease Association in the Canary Islands. Demographic, health resources utilization, informal care, indirect costs, and quality of life data were collected from primary caregivers of patients as proxy respondents. HRQOL was measured for patients and caregivers with the generic questionnaire EQ-5D.

RESULTS

The average annual cost per patient with AD was 28,198 (36,144 US dollars). The most important categories of costs were for informal care and drugs. Costs increased with cognitive impairment with an average annual cost of 14,956 (19,171 US dollars) for mild, 25,562 (32,765 US dollars) for moderate, and 41,669 (53,411 US dollars) for severe patients. The total cost of patients with AD in Canary Islands was 259 (332 US dollars) million. The HRQOL with the EQ-5D social tariff was 0.29 for patients and 0.67 for caregivers. The EQ-5D VAS (thermometer) score was 42 for patients and 62 for caregivers.

CONCLUSIONS

Direct health care costs of AD represented 2.4% of the total public health care expenditure in the Canary Islands. Across all severity levels, we estimated a total annual cost of 10 (13 US dollars) billion for AD patients older than 65 years in Spain. The degree of severity of the patients with AD substantially influenced the quality of life of the patients but not that of the caregivers.

Neuropsychiatric disorders in HIV infection: impact of diagnosis on economic costs of care

BACKGROUND

HAART is associated with a growing prevalence of HIV-associated neuropsychiatric disorders (NPD) despite improved overall survival.

OBJECTIVE

To investigate the added direct costs of medical care for patients with and without NPD.

METHODS

Nine dimensions of patient-specific costs [as costs per patient per month (CPM)] were followed prospectively between 1997 and 2003 in a community-based HIV/AIDS clinic for HIV-1-seropositive patients with a diagnosis of NPD (n = 188) and without (n = 153). Patients with NPD were stratified into subgroups of cognitive impairment (CI), peripheral neuropathies (PN), or other neuropsychiatric disorders (OND).

RESULTS

Compared with the non-NPD group ($916), patients in the NPD group showed an increased mean CPM during the 12-month intervals immediately preceding and subsequently following NPD diagnosis [$1371 (P < 0.001) and 1463 US dollars (P < 0.001), respectively], but not at 18 months prior to diagnosis (1061 US dollars; P > 0.05). Intragroup comparisons between 12 month post-diagnosis and 18 month pre-diagnosis showed a mean CPM increased of 67% (1613 US dollars; P < 0.001) with CI, 31% (1490 US dollars; P < 0.01) with PN, and 33% (1362 US dollars; P < 0.01) with OND. Increased numbers of clinic and physician visits, non-antiretroviral drugs and home care accounted for the higher mean CPM (P < 0.05) both pre-and post-diagnosis within the NPD group.

CONCLUSIONS

Neuropsychiatric disorders in patients with HIV/AIDS increase medical costs both before and after diagnosis, primarily owing to the management of the neuropsychiatric illness. Cost analyses offer useful measures of evolving patient needs, and provide a basis for allocation of healthcare resources.

Schizophrenia patients with cognitive deficits: factors associated with costs

Cognitive deficits in people with schizophrenia are associated with poor functioning and lower quality of life. Because few studies have examined their relationship with service use or costs, it is unclear whether effective cognitive remediation interventions have potential for economic impacts. This study examined associations between cognition and costs among people with schizophrenia. Baseline data collected between 1999 and 2002 from a randomized controlled trial of cognitive remediation therapy were analyzed. A total of 85 participants were recruited from a London mental health trust if they had a diagnosis of schizophrenia, evidence of cognitive/social functioning difficulties, and at least 1 year since first contact with psychiatric services. Cognition levels, social functioning, symptoms, sociodemographic characteristics, and retrospective use of health/social care and other resources were measured. Average public sector costs were estimated to be 15 078 pounds(23 824 dollars) for a 6-month period. Associations between health/social care costs and type and severity of cognition were examined using structural equation models. No significant relationships were found between cognition and costs in a model based on 3 independent constituent components of cognition (cognitive shifting, verbal working memory, and response inhibition), although a model with covarying cognition components fitted the observed data well. A model with cognition as a single construct both fitted well and showed a significant relationship. In people with schizophrenia and severe cognitive impairment, improvements in either overall cognition or specific cognitive components may impact on costs. Further investigation in larger samples is needed to confirm this finding and to explore its generalizability to those with less severe deficits.

Determinants of costs of care for patients with Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD), the most common cause of dementia, is a major cause of disability and care burden in the elderly. This study aims to estimate the costs of formal and informal care and identity determinants of care costs.

MATERIALS AND METHODS

Two hundred and seventy-two (AD) patients and their caregivers were recruited among patients attending regular visits at six memory clinic in Sweden, Denmark, Norway and Finland. Patients with a diagnosis of AD and with an identifiable primary caregiver were eligible for inclusion. Data was collected by questionnaires at baseline, and at scheduled follow-up visits after 6 months and again after 12 months. Cognitive function was assessed with the Mini Mental State Examination (MMSE) and behavioural disturbances were measured using a brief version of the neuropsychiatric inventory (NPI).

RESULTS

Total annual costs were on average 172,000 SEK, ranging from 60,700 SEK in mild dementia to 375,000 SEK in severe dementia. Costs for community care (special accommodation, home help, etc.) constituted about half of total costs of care and increase sharply with increasing cognitive impairment. Informal care costs, valued at the opportunity cost of the caregiver's time, make up about a third of total costs and also increased significantly with disease severity. Medical care costs (inpatient care, outpatient care, pharmaceuticals), on the other hand, were not significantly related to disease severity. Regression analysis confirmed a strong association between costs and cognitive function, between patients as well as within patients over time. There was also a significant influence on costs from behavioural disturbances. Sensitivity analysis showed that the method chosen to value informal care can have considerable impact on results.

CONCLUSIONS

Costs of care in patient with AD are high and related to dementia severity as well as presence of behavioural disturbances. The cost estimates presented have implications for future economic evaluation of treatments for Alzheimer's disease.

Setting eligibility criteria for a care-coordination benefit

OBJECTIVES

To examine different clinically relevant eligibility criteria sets to determine how they differ in numbers and characteristics of individuals served.

DESIGN

Cross-sectional analysis of the 2000 wave of the Health and Retirement Study (HRS), a nationally representative longitudinal health interview survey of adults aged 50 and older.

SETTING

Population-based cohort of community-dwelling older adults, subset of an ongoing longitudinal health interview survey.

PARTICIPANTS

Adults aged 65 and older who were respondents in the 2000 wave of the HRS (n=10,640, representing approximately 33.6 million Medicare beneficiaries).

MEASUREMENTS

Three clinical criteria sets were examined that included different combinations of medical conditions, cognitive impairment, and activity of daily living/instrumental activity of daily living (ADL/IADL) dependency.

RESULTS

A small portion of Medicare beneficiaries (1.3-5.8%) would be eligible for care coordination, depending on the criteria set chosen. A criteria set recently proposed by Congress (at least four severe complex medical conditions and one ADL or IADL dependency) would apply to 427,000 adults aged 65 and older in the United States. Criteria emphasizing cognitive impairment would serve an older population.

CONCLUSION

Several criteria sets for a Medicare care-coordination benefit are clinically reasonable, but different definitions of eligibility would serve different numbers and population groups of older adults.

Chronic neurocognitive effects of critical illness

PURPOSE OF REVIEW

Until relatively recently critical care practitioners have focused on survival of their patients and not long-term outcomes. An increasing body of research has examined patient outcomes beyond discharge from the intensive care unit and hospital. One area of focus is neurobehavioral outcomes including neurocognitive sequelae and neuropsychiatric disorders such as depression and anxiety. Cognitive functions are brain-based or mental activities that involve acquiring, storing, retrieving, and using information and include domains such as memory, attention, executive function, mental processing speed, spatial abilities, and general intelligence. It is known from other medical specialties that impaired cognitive function can have a broad, substantial, and long-lasting impact on a patient's life. This paper examines the current evidence for neurocognitive impairments in survivors of critical illness.

RECENT FINDINGS

Recent studies support the hypothesis that critical illness can lead to significant impairments in neurocognitive function. Current work indicates that the neurocognitive impairments can last for months or years after a patient arrives home and may have important consequences for quality of individual and family life and for ability to return to work as well as substantial economic costs. The mechanisms of neurocognitive impairments are not fully understood, but in acute respiratory distress syndrome hypoxemic burden appears important.

SUMMARY

Among the potential consequences of critical illness are now included neurocognitive impairments. Future research should include the search for strategies for the early identification of neurocognitive impairments, mechanisms of brain injury, and therapeutic modalities designed to prevent or decrease neurocognitive morbidity.

Delirium: acute cognitive dysfunction in the critically ill

PURPOSE OF REVIEW

The management of sepsis and the multiple organ dysfunction syndrome has traditionally been centered on dysfunction of organs other than the brain (e.g., heart, lungs, or kidneys), although the brain is one of the most prevalent organs involved. Recent studies indicate that nonpulmonary acute organ dysfunction may contribute significantly to mortality and other important clinical outcomes. Acute confusional states (delirium) occur in 10 to 60% of the older hospitalized population and in 60 to 80% of patients in the intensive care unit, yet go unrecognized by the managing physicians and nurses in 32 to 66% of cases. Delirium is an important independent prognostic determinant of hospital outcomes, including duration of mechanical ventilation, nursing home placement, functional decline, and death. Recently, new monitoring instruments have been validated for monitoring of delirium in noncommunicative patients receiving mechanical ventilation. Hence, critical care physicians and nurses should routinely assess their patients for delirium and develop strategies for its prevention and treatment.

RECENT FINDINGS

This state-of-the-art review discusses in depth the delirium monitoring instruments, the pathophysiology and risk factors of delirium, its prognostic implications, and strategies (including ongoing clinical trials) to prevent and treat delirium.

SUMMARY

Delirium is extremely common and has significant prognostic implications in critically ill patients. Routine monitoring and a multimodal approach to prevent or reduce the prevalence of delirium are of paramount importance.

American Community Survey: earnings and employment for persons with traumatic brain injury

In 2000, the United States Census Bureau began the annual American Community Survey (ACS), which collects data on earnings and employment for persons with various types of impairment. One of the impairments is cognitive disability, defined as existing when a person has a condition lasting six months or more that results in difficulty learning, remembering, or concentrating. Individuals with such limitations are often defined as having mild traumatic brain injury (TBI). Persons with mild TBI often retain the ability to work competitively. Such individuals, however, typically earn less when employed year-round, full-time than do persons without disability and have lower levels of employment, resulting in reduced worklife expectancy. This article focuses on the effects of cognitive disability on earnings and employment. The ACS data are reported by gender and education level for those without disability or with cognitive disability. Employment levels are translated into worklife expectancies and the method of conversion through use of a joint probability of life, participation, and employment is examined.

Testing the dose-response specification in epidemiology: public health and policy consequences for lead

Statistical evaluation of the dose-response function in lead epidemiology is rarely attempted. Economic evaluation of health benefits of lead reduction usually assumes a linear dose-response function, regardless of the outcome measure used. We reanalyzed a previously published study, an international pooled data set combining data from seven prospective lead studies examining contemporaneous blood lead effect on IQ (intelligence quotient) of 7-year-old children (n = 1,333). We constructed alternative linear multiple regression models with linear blood lead terms (linear-linear dose response) and natural-log-transformed blood lead terms (log-linear dose response). We tested the two lead specifications for nonlinearity in the models, compared the two lead specifications for significantly better fit to the data, and examined the effects of possible residual confounding on the functional form of the dose-response relationship. We found that a log-linear lead-IQ relationship was a significantly better fit than was a linear-linear relationship for IQ (p = 0.009), with little evidence of residual confounding of included model variables. We substituted the log-linear lead-IQ effect in a previously published health benefits model and found that the economic savings due to U.S. population lead decrease between 1976 and 1999 (from 17.1 microg/dL to 2.0 microg/dL) was 2.2 times (319 billion dollars) that calculated using a linear-linear dose-response function (149 billion dollars). The Centers for Disease Control and Prevention action limit of 10 microg/dL for children fails to protect against most damage and economic cost attributable to lead exposure.

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.

Health policy for persons with intellectual disability: experiences from Israel

Intellectual disability (ID) is a life-long disability characterized by impaired cognitive and adaptive skills. Over the past few decades, a shift has occurred in the conceptualization and treatment of people with ID and research in health policy and health-care delivery has become increasingly global with a notable disparity between the developed and developing world. This review presents a literature overview of global health policy for ID with the intent to focus specifically on the policy and treatment within Israel. The methodology involved sites visits to care centers, discussions with stakeholders in health policy, and a literature review. We believe that Israel is in a unique position between a developed and developing culture. In particular, the distinct problems faced by the Arab and Bedouin community in terms of ID must be formally accounted for in Israel's future policies. Research from the developing world would be instructive to this end. The global approach in this presentation led to certain policy recommendations that take into account the uniqueness of Israel's position from a social, economic, religious, and demographic perspective. It is the hope that this paper will lead to an increased awareness of the challenges faced by persons with ID and their providers in all sectors of Israeli society and that the necessary policy recommendations will ultimately be adopted.

Explaining the Link Between Low Socioeconomic Status and Psychopathology: Testing Two Mechanisms of the Social Causation Hypothesis

Two mechanisms of the hypothesized social causation of psychopathology--differential incidence and cumulative prevalence--were tested over 9 years in a nationally representative sample of 1,075 children and youths, ages 8-17 at Time 1 (1986). Analyses using parental responses on behavior checklists at 4 time points showed significant increases in clinical elevations for those of the lowest socioeconomic status (SES) on anxious/depressed, somatic complaints, thought problems, delinquent, and aggressive syndromes. This SES-linked differential incidence supports the social causation hypothesis that factors associated with SES contribute to variations in levels of psychological problems. SES-linked differential cumulative prevalence was found for withdrawn and somatic complaints; this finding indicates that low-SES cases do not improve as much as do middle- and high-SES cases, which results in greater accumulation of low-SES cases.

Medicare and Medicaid Home Health and Medicaid Waiver Services for Dually Eligible Older Adults: Risk Factors for Use and Correlates of Expenditures

PURPOSE

The purpose of this work was to, among frail dually eligible older adults, determine risk factors for the likelihood of using Medicare home health and Medicaid home health services and to, among service users, determine correlates of Medicare home health, Medicaid home health, and Medicaid waiver service expenditures.

DESIGN AND METHODS

Dually eligible individuals enrolled in Connecticut's Medicaid home- and community-based services (HCBS) waiver program for the aged (N = 5,232) were identified from a statewide database containing person-level linked data from Medicare claims, Medicaid claims, and uniform clinical assessment forms. Expenditures, based on claims data, were observed from the month following clinical assessment over the period August 1995 to December 1997.

RESULTS

In multivariate models controlling for medical conditions and sociodemographic variables, similar functional disability measures were strongly associated with the probability of the use of, and expenditures for, Medicare home health and Medicaid home health services; severe cognitive impairment was strongly associated with greater Medicaid waiver service expenditures.

IMPLICATIONS

Given the similarity of factors associated with Medicare and Medicaid home health service use and expenditures, greater integration of Medicare and Medicaid financing, reimbursement, and delivery strategies for home health services may be feasible and warranted for dually eligible older adults enrolled in state Medicaid HCBS waiver programs.

Awareness of financial skills in dementia

The present study examined the relations among levels of cognitive functioning, executive dysfunction, and awareness of financial management capabilities among a sample of 42 community-dwelling persons with dementia. Financial tasks on the Measure of Awareness of Financial Skills (MAFS) were dichotomized as simple or complex based on Piaget's operational levels of childhood cognitive development. Severity of global cognitive impairment and executive dysfunction were significantly related to awareness of financial abilities as measured by informant-participant discrepancy scores on the MAFS. For persons with mild and moderate/severe dementia, and persons with and without executive dysfunction, proportions of awareness within simple and complex financial task categories were tabulated. Significantly less awareness of financial abilities occurred on complex compared with simple tasks. Individuals with mild dementia were significantly less aware of abilities on complex items, whereas persons with moderate/severe dementia were less aware of abilities, regardless of task complexity. Similar patterns of awareness were observed for individuals with and without executive dysfunction. These findings support literature suggesting that deficits associated with dementia first occur for complex cognitive tasks involving inductive reasoning or decision-making in novel situations, and identify where loss of function in the financial domain may first be expected.

The generational transmission of socioeconomic inequalities in child cognitive development and emotional health

Socioeconomic inequalities in the health of adults have been largely attributed to lifestyle inequalities. The cognitive development (CD) and emotional health (EH) of the child provides a basis for many of the health-related behaviours which are observed in adulthood. There has been relatively little attention paid to the way CD and EH are transmitted in the foetal and childhood periods, even though these provide a foundation for subsequent socioeconomic inequalities in adult health. The Mater-University of Queensland Study of Pregnancy (MUSP) is a large, prospective, pre-birth cohort study which enrolled 8556 pregnant women at their first clinic visit over the period 1981-1983. These mothers (and their children) have been followed up at intervals until 14 years after the birth. The socioeconomic status of the child was measured using maternal age, family income, and marital status and the grandfathers' occupational status. Measures of child CD and child EH were obtained at 5 and 14 years of age. Child smoking at 14 years of age was also determined. Family income was related to all measures of child CD and EH and smoking, independently of all other indicators of the socioeconomic status of the child. In addition, the grandfathers' occupational status was independently related to child CD (at 5 and 14 years of age). Children from socioeconomically disadvantaged families (previous generations' socioeconomic status as well as current socioeconomic status) begin their lives with a poorer platform of health and a reduced capacity to benefit from the economic and social advances experienced by the rest of society.

Cost of fetal alcohol spectrum disorders

Fetal alcohol syndrome (FAS) is a common identifiable teratogenic cause of mental retardation, neurological deficit, mental disorders, and developmental disabilities. Accurate estimates of the cost of care for persons with FAS are essential for appropriate funding of health care, developmental disabilities services, special education, and other service systems, as well as prioritizing funding of public health prevention efforts. The cost of care for individuals with FAS can be conceptualized as the annual cost of care for one person or a population, or as the lifetime cost of care for an individual. Annual cost estimates for the United States range from $75 million in 1984 to $4.0 billion in 1998. Estimates of lifetime cost vary from $596,000 in 1980 to $1.4 million in 1988. After adjustments for changes in inflation and population, 2002 estimates of total annual cost and lifetime cost are higher. FAS is increasingly being recognized as a large public health problem with high potential for the prevention of future cases and for the prevention of excess disability and premature mortality in persons who are affected. Each day, from 6-22 infants with FAS are born in the United States, and as many as 87-103 more are born with other impairments resulting from prenatal alcohol exposure. Updated and improved cost data on FAS should be a research priority.

The Rapid Dementia Screening Test (RDST): a new economical tool for detecting possible patients with dementia

The Rapid Dementia Screening Test (RDST) is a new psychometric screening tool to support the diagnosis of dementia. It includes two parts--a word generation task and a number transcoding task; it is short (taking approximately 3 min) and easy to administer, and it is well accepted by patients. After transformation of the raw scores in two age groups (under and over 60 years), the assessed cognitive abilities can be interpreted as age-appropriate or below average with good sensitivity and specificity, and subsequent diagnostic measures can be determined accordingly. The RDST is thus an economical tool for detecting demented patients by general practitioners.

The potential economic consequences of cognitive improvement with losartan

In a clinical trial, treatment of mild-moderate hypertensive patients with losartan (50 mg) increased Mini-Mental State Examination (MMSE) scores by 4 points from baseline over a 26-month period, compared with a 1-point increase in patients treated with hydrochlorothiazide (25 mg). This study explores the potential economic consequences of this improvement in cognitive function in a population of elderly hypertensive patients in Sweden. Resource use and MMSE data for 437 hypertensive, non-demented subjects aged 75 years and above, were taken from a population-based study in Sweden. MMSE scores were strongly related with costs of care due to higher utilization of home help and special living arrangements in patients with low scores. A 1-point difference in MMSE was associated with a difference in the annual cost of care of approximately 5700 Swedish kronor (SEK). Over 26 months, the potential cost savings from the 4-point improvement observed with losartan was estimated to be between 24700 and 43700 SEK. This can be compared with the acquisition cost of losartan; approximately 5700 SEK over the study period. Thus, an improvement in cognitive function of the magnitude documented in the study of losartan vs hydrochlorothiazide, may translate into economic benefits beyond those expected in terms of blood pressure control.

Pharmacoeconomics of mild cognitive impairment

There is little written about the pharmacoeconomics of mild cognitive impairment (MCI), particularly with regard to intervention. The aim of the paper is to highlight methodological issues and to present some results that are of importance when drug interventions of MCI are discussed. There is a relationship between severity of dementia and costs, but to what extent such results can be extrapolated to MCI is not known. Even if it is logical to consider a postponement of the shift from MCI to dementia as cost effective, this statement must be proven, particularly in light of the insufficient knowledge about the effects of anti-dementia drugs on survival. From the Kungsholmen project in Sweden, there are indications that the postponement between MCI and manifest dementia may result in short-term benefits (a few years) of about SEK50,000 (5300 US dollars).