Multimorbidity Patterns and 6-Year Risk of Institutionalization in Older Persons: The Role of Social Formal and Informal Care

ObjectivesThe aim was to evaluate patterns of multimorbidity that increase the risk of institutionalization in older persons, also exploring the potential buffering effect of formal and informal care.DesignProspective cohort study.Setting and ParticipantsThe population-based Swedish National study on Aging and Care in Kungsholmen, Stockholm, Sweden.MeasuresIn total, 2571 community-dwelling older adults were grouped at baseline according to their underlying multimorbidity patterns, using a fuzzy c-means cluster algorithm, and followed up for 6 years to test the association between multimorbidity patterns and institutionalization.ResultsSix patterns of multimorbidity were identified: psychiatric diseases; cardiovascular diseases, anemia, and dementia; metabolic and sleep disorders; sensory impairments and cancer; musculoskeletal, respiratory, and gastrointestinal diseases; and an unspecific pattern including diseases of which none were overrepresented. In total, 110 (4.3%) participants were institutionalized during the follow-up, ranging from 1.7% in the metabolic and sleep disorders pattern to 8.4% in the cardiovascular diseases, anemia, and dementia pattern. Compared with the unspecific pattern, only the cardiovascular diseases, anemia, dementia pattern was significantly associated with institutionalization [relative risk ratio (RRR) = 2.23; 95% confidence interval (CI) 1.07‒4.65)], after adjusting for demographic characteristics and disability status at baseline. In stratified analyses, those not receiving formal care in the psychiatric diseases pattern (RRR 3.34; 95% CI 1.20‒9.32) and those not receiving formal or informal care in the ‘cardiovascular diseases, anemia, dementia’ pattern (RRR 2.99; 95% CI 1.20‒7.46; RRR 2.79; 95% CI 1.16‒6.71, respectively) had increased risks of institutionalization.Conclusions and ImplicationsOlder persons suffering from specific multimorbidity patterns have a higher risk of institutionalization, especially if they lack formal or informal care. Interventions aimed at preventing the clustering of diseases could reduce the associated burden on residential long-term care. Formal and informal care provision may be effective strategies in reducing the risk of institutionalization.     

Effect of a Video-Assisted Advance Care Planning Intervention on End-of-Life Health Care Transitions Among Long-Stay Nursing Home Residents

ObjectiveTo determine the relationship between an advance care planning (ACP) video intervention, Pragmatic Trial of Video Education in Nursing Homes (PROVEN), and end-of-life health care transitions among long-stay nursing home residents with advanced illness.DesignPragmatic cluster randomized clinical trial. Five ACP videos were available on tablets or online at intervention facilities. PROVEN champions employed by nursing homes (usually social workers) were directed to offer residents (or their proxies) ≥1 video under certain circumstances. Control facilities employed usual ACP practices.Setting and ParticipantsPROVEN occurred from February 2016 to May 2019 in 360 nursing homes (119 intervention, 241 control) owned by 2 health care systems. This post hoc study of PROVEN data analyzed long-stay residents ≥65 years who died during the trial who had either advanced dementia or cardiopulmonary disease (advanced illness). We required an observation time ≥90 days before death. The analytic sample included 923 and 1925 advanced illness decedents in intervention and control arms; respectively.MethodsOutcomes included the proportion of residents with 1 or more hospital transfer (ie, hospitalization, emergency department use, or observation stay), multiple (≥3) hospital transfers during the last 90 days of life, and late transitions (ie, hospital transfer during the last 3 days or hospice admission on the last day of life).ResultsHospital transfers in the last 90 days of life among decedents with advanced illness were significantly lower in the intervention vs control arm (proportion difference = ?1.7%, 95% CI –3.2%, ?0.1%). The proportion of decedents with multiple hospital transfers and late transitions did not differ between the trial arms.Conclusions and ImplicationsVideo-assisted ACP was modestly associated with reduced hospital transfers in the last 90 days of life among nursing home residents with advanced illness. The intervention was not significantly associated with late health care transitions and multiple hospital transfers.     

Impact of Prior Home Care on Length of Stay in Residential Care for Australians With Dementia

ObjectivesTo assess the impact of home care on length-of-stay within residential care.DesignA retrospective observational data-linkage study.Setting and ParticipantsIn total there were 3151 participants from the 45 and Up Study in New South Wales, Australia with dementia who entered residential care between 2010 and 2014.MethodsSurvey data collected from 2006‒2009 were linked to administrative data for 2006‒2016. The highest level of home care a person accessed prior to residential care was defined as no home care, home support, low-level home care, and high-level home care. Multinomial logistic regression and Cox proportional hazards were used to investigate differences in activities of daily living, behavioral, and complex healthcare scales at entering residential care; and length-of-stay in residential care.ResultsPeople with prior high-level home care entered residential care needing higher assistance compared with the no home care group: activities of daily living [odds ratio (OR) 3.41, 95% confidence interval (CI) 2.14‒5.44], behavior (OR 2.61, 95% CI 1.69‒4.03), and complex healthcare (OR 2.02, 95% CI 1.06‒3.84). They had a higher death rate, meaning shorter length-of-stay in residential care (<2 years after entry: hazard ratio 1.12; 95% CI 0.89‒1.42; 2-4 years: hazard ratio 1.49; 95% CI 1.01‒2.21). Those using low-level home care were less likely to enter residential care needing high assistance compared to the no home care group (activities of daily living: OR 0.61, 95% CI 0.45‒0.81; behavioral: OR 0.72, 95% CI 0.54‒0.95; complex healthcare: OR 0.51, 95% CI 0.33‒0.77). There was no difference between the home support and no home care groups.ConclusionsHigh-level home care prior to residential care may help those with dementia stay at home for longer, but the low-level care group entered residential care at low assistance levels, possibly signaling lack of informal care and barriers in accessing higher-level home care.ImplicationsBetter transition options from low-level home care, including more timely availability of high-level care packages, may help people with dementia remain at home longer.     

The last 3 months of life: care, transitions and the place of death of older people

Many older people die in hospitals, whereas research indicates that they would prefer to die at home. Little is known about the factors associated with place of death. The aim of the present study was to investigate the care received by older people in the last 3 months of their life, the transitions in care and the predictors of place of death. In this population-based study, interviews were held with 270 proxy respondents to obtain data on 342 deceased participants (79% response rate) in the Longitudinal Aging Study Amsterdam. In the last 3 months of life, the utilisation of formal care increased. Half of the community-dwelling older people and their families were confronted with transitions to institutional care, in most cases to hospitals. Women relied less often on informal care only, and were more dependent than men on institutional care. For people who only received informal care, the odds of dying in a hospital were 3.68 times the odds for those who received a combination of formal and informal home care. The chance of dying in a hospital was also related to the geographical region. The authors argue that future research is needed into the association that they found in the present study, i.e. that decedents who received both formal and informal care were more likely to die at home. In view of the differences found in geographical region in relation to place of death, further investigation of regional differences in the availability and accessibility of care is indicated.     

Dementia and Poor Continuity of Primary Care Delay Hospital Discharge in Older Adults: A Population-Based Study From 2001 to 2016

ObjectivesDelayed discharge, remaining in acute care longer than medically necessary, reflects less than optimal use of hospital care resources and can have negative implications for patients. We studied (1) the change over time in delayed discharge in people with and without dementia, and (2) the association of delayed discharge with discharge destination and with the continuity of primary care prior to urgent admission.DesignA retrospective population-based study.Setting and ParticipantsDelayed discharge after urgent admission and length of delayed discharge were studied in all hospital users aged ≥70 years with at least 1 urgent admission in British Columbia, Canada, in years 2001/02, 2005/06, 2010/11, and 2015/16 (N = 276,299).MethodsLinked administrative data provided by Population Data BC were analyzed using generalized estimating equations (GEE), logistic regression analysis, and negative binomial regression analyses.ResultsDelayed discharge increased among people with dementia and decreased among people without dementia, whereas the length of delay decreased among both. Dementia was the strongest predictor of delayed discharge [odds ratio 4.76; 95% confidence interval (CI) 4.59–4.93], whereas waiting for long-term care placement [incidence rate ratio (IRR) 1.56; 95% CI 1.50–1.62] and dementia (IRR 1.50; 95% CI 1.45–1.54) predicted a higher number of days of delay. Continuity and quantity of care with the same physician before urgent admission was associated with a decreased risk of delayed discharge, especially in people with dementia.Conclusions and ImplicationsThis study demonstrates the need for better system integration and patient-centered care especially for people with dementia. Population aging will likely increase the number of patients at risk of delayed discharge. Delayed discharge is associated with both the patient's complex needs and the inability of the system to meet these needs during and after urgent care. Sufficient investments are needed in both primary care and long-term care resources to reduce delayed discharges.     

Important components for Dutch in‐home care based on qualitative interviews with persons with dementia and informal caregivers

BackgroundDementia care in the Netherlands is increasingly dependent on informal care and has the aim to keep persons with dementia at home for as long as possible. However, little is known about the preferences and needs of people with dementia living at home. Including people with dementia and their informal caregivers in research and policy creation could help to identify necessary forms of support, and tailor care to their personal preferences and needs.ObjectiveTo identify important components of in‐home care for persons with dementia and their informal caregivers in the Netherlands.DesignSemi‐structured interviews across the Netherlands, between March and June 2019 using thematic analysis.Setting and participantsPersons with dementia (n = 5) and informal caregivers (n = 14) were primarily recruited through dementia care organizations. Additionally, a case manager was recruited to reflect upon the semi‐structured interviews findings.ResultsFive themes concerning important care components were identified including the need for: a social network, formal care, information, emotional support and easier access to care. The complexity of the dementia care system posed a common difficulty for persons with dementia and informal caregivers.ConclusionThis study suggests that a dementia care package should be developed that includes both informal and formal care, the provision of information and emotional support, and help with access to care. The creation of this care package could help to tailor dementia care to the preferences and needs of the persons with dementia and their informal caregivers.     

The Costs of Dementia From the Societal Perspective: Is Care Provided in the Community Really Cheaper than Nursing Home Care?

ObjectiveTo compare the costs of care for community-dwelling dementia patients with the costs of care for dementia patients living in nursing homes from the societal perspective.DesignCross-sectional bottom-up cost of illness study nested within the multicenter German AgeCoDe-cohort.SettingCommunity and nursing homes.ParticipantsOne hundred twenty-eight community-dwelling dementia patients and 48 dementia patients living in nursing homes.InterventionNone.MeasurementsUtilization and costs of medical care and long term care, including formal and informal social and nursing care based on proxy interviews. Informal care was valued using the replacement cost method.ResultsUnadjusted mean annual total costs including informal care were €29,930 ($43,997) for community-dwelling patients and €33,482 ($49,218) for patients living in nursing homes. However, multiple regression analysis controlling for age, sex, deficits in basic and instrumental activities of daily living and comorbidity showed that living in the community significantly increased total costs by €11,344 ($16,676; P < .01) compared with living in a nursing home, mainly due to higher costs of informal care (+€20,585; +$30,260; P < .001).ConclusionFrom the societal perspective care for dementia patients living in the community tends to cost more than care in nursing homes when functional impairment is controlled for.     

Burdensome Transitions at the End of Life Among Long-Term Care Residents With Dementia

ObjectivesThe purpose of the study was to examine the frequency of burdensome care transitions at the end of life, the difference between different types of residential care facilities, and the changes occurring between 2002 and 2008.DesignA nationwide, register-based retrospective study.SettingResidential care facilities offering long-term care, including traditional nursing homes, sheltered housing with 24-hour assistance, and long-term care facilities specialized in care for people with dementia.Study groupAll people in Finland who died at the age of 70 or older, had dementia, and were in residential care during their last months of life.Main outcome measuresThree types of potentially burdensome care transition: (1) any transition to another care facility in the last 3 days of life; (2) a lack of continuity with respect to a residential care facility before and after hospitalization in the last 90 days of life; (3) multiple hospitalizations (more than 2) in the last 90 days of life. The 3 types were studied separately and as a whole.ResultsOne-tenth (9.5%) had burdensome care transitions. Multiple hospitalizations in the last 90 days were the most frequent, followed by any transitions in the last 3 days of life. The frequency varied between residents who lived in different baseline care facilities being higher in sheltered housing and long-term specialist care for people with dementia than in traditional nursing homes. During the study years, the number of transitions fluctuated but showed a slight decrease since 2005.ConclusionsThe ongoing change in long-term care from institutional care to housing services causes major challenges to the continuity of end-of-life care. To guarantee good quality during the last days of life for people with dementia, the underlying reasons behind transitions at the end of life should be investigated more thoroughly.     

Hospital Deaths Increased After Reforms Regardless of Dementia Status: An Interrupted Time-Series Analysis

ObjectivesDying in a hospital is highly stressful for older adults and families. Persons with dementia who are hospitalized are particularly vulnerable to negative outcomes. The objective of this study is to fill an evidence gap on whether the 2015 Dutch long-term care reforms were effective in increasing deaths at home while avoiding increases in hospital deaths for the total population aged ≥65 years and by dementia status.DesignWe used annual cross-sectional, nationally representative data from 2012 to 2017. We performed an interrupted time-series analyses to evaluate changes in location of death after the implementation of the Dutch long-term reforms.Setting and ParticipantsDutch population aged ≥65 years (N = 727,519) who died between 2012 and 2017 using data from Statistics Netherlands.MethodsThe primary outcome was death in a long-term care facility (LTCF), home, hospital, or elsewhere.ResultsAfter adjusting for seasonality and sex, we found significantly increased adjusted relative risk ratios (aRRRs) for the total older adult population having a death at home [aRRR 1.17, 95% confidence interval (CI) 1.12.-1.23] and hospital (1.09, 1.04-1.15) compared to deaths in an LTCF after the reforms. For persons with dementia (N = 81,373), hospital deaths increased (2.03, 1.37-3.01) compared with long-term care deaths after the implementation of the long-term care reforms; however, there was no change in the aRRR for death at home. For people without dementia (N = 646,146), we found increased aRRR for death at home (1.21, 1.16-1.28) and death at hospital (1.12, 1.07-1.19) vs LTCF deaths following the reforms.Conclusions and ImplicationsHospital and home deaths increased for the total population. Hospital deaths increased for persons with dementia after the long-term care reforms despite evidence of negative outcomes associated with end-of-life hospitalizations. The Netherlands may have overlooked the merits of home care and LTCFs, particularly for people with dementia.     

Formal and informal care for community‐dwelling frail elderly people over time: A comparison of integrated and usual care in the Netherlands

While integration has become a central tenet of community‐based care for frail elderly people, little is known about its impact on formal and informal care and their dynamics over time. The aim of this study was therefore to examine how an integrated care intervention for community‐dwelling frail elderly people affects the amount and type of formal and informal care over 12 months as compared to usual care. A quasi‐experimental design with a control group was used. Data regarding formal and informal care were collected from frail elderly patients (n = 207) and informal caregivers (n = 74) with pre/post‐questionnaires. Within‐ and between‐group comparisons and multiple linear regression analyses were performed. The results showed marginal changes over time in the amount of formal and informal care in both integrated care and usual care. However, different associations between changes in formal and informal care were found in integrated and usual care. Most notably, informal caregivers provided more instrumental assistance over time if formal caregivers provided less personal care (and vice versa) in integrated care but not in usual care. These results suggest that integrated care does not necessarily change the contribution of formal or informal care, but changes the interaction between formal (personal care) and informal (instrumental) activities. Implications and recommendations for research and practice are discussed. Trial registration: Current Controlled Trials ISRNT05748494.     

Instability in Caregivers’ Perception of Dementia as a Terminal Disease

ObjectivesFamily caregivers' perception that dementia is a terminal disease influence end-of-life (EoL) care of persons with severe dementia (PwSDs). Yet, this perception and the extent to which it changes over time is underexplored. We assessed PwSD caregivers’ perception of dementia as a terminal disease and changes in this perception over time.DesignProspective cohort.Setting and participantsTwo hundred fifteen primary informal caregivers of community-dwelling PWSDs in Singapore were surveyed every 4 months over a period of 16 months.MethodsWe assessed the proportion of caregivers who perceived that dementia is a terminal disease and the extent to which it changed between the previous time points. Using mixed effects multinomial regression models, we assessed factors associated with caregivers’ perception and changes in perception between consecutive time points.ResultsAt baseline, only 26% of the caregivers reported correctly that dementia is a terminal disease. This changed over time, not necessarily toward a correct perception. Caregivers of PwSDs with an acute medical condition in the last 4 months (risk ratio [RR] 2.19, 95% CI 1.21, 3.97) and those with higher functional dependence (RR 1.11, 95% CI 1.01,1.22) were more likely and those of older PwSDs were less likely (RR 0.87, 95% CI 0.81, 0.93) to perceive dementia as a terminal disease. Caregivers of PwSDs who had experienced an acute medical problem in the last 4 months (RR 1.58, 95% CI 1.00, 2.49) were also more likely to shift their perception toward being correct. Caregivers of PwSDs who had more agitation behaviors were more likely to shift their perception toward being incorrect (RR 1.04, 95% CI 1.00,1.07)Conclusions and ImplicationsFew caregivers perceived dementia as terminal, and this perception changed over time and differed according to age and the health status of PwSD. Results have implications regarding the frequency of prognostic discussions.     

Dementia Severity Associated With Increased Risk of Potentially Preventable Readmissions During Home Health Care

ObjectivesApproximately 14% of Medicare beneficiaries are readmitted to a hospital within 30 days of home health care admission. Individuals with dementia account for 30% of all home health care admissions and are at high risk for readmission. Our primary objective was to determine the association between dementia severity at admission to home health care and 30-day potentially preventable readmissions (PPR) during home health care. A secondary objective was to develop a dementia severity scale from Outcome and Assessment Information Set (OASIS) items based on the Functional Assessment Staging Tool (FAST).DesignRetrospective cohort study.Setting and participantsHome health care; 126,292 Medicare beneficiaries receiving home health care (July 1, 2013–June 1, 2015) diagnosed with dementia (ICD-9 codes).Measures30-day PPR during home health care. Dementia severity categorized into 6 levels (nonaffected to severe).ResultsThe overall rate of 30-day PPR was 7.6% [95% confidence interval (CI) 7.4, 7.7] but varied by patient and health care utilization characteristics. After adjusting for sociodemographic and clinical characteristics, the odds ratio (OR) for dementia severity category 6 was 1.37 (95% CI 1.29, 1.46) and the OR for category 7 was 1.94 (95% CI 1.64, 2.31) as compared to dementia severity category 1/2.Conclusions and implicationsDementia severity in the later stages is associated with increased risk for potentially preventable readmissions. Our findings suggest that individuals admitted to home health during the later stages of Alzheimer's disease and related dementias may require greater supports and specialized care to minimize negative outcomes such as readmissions. Development of a dementia severity scale based on OASIS items and the FAST is feasible. Future research is needed to determine effective strategies for decreasing potentially preventable readmissions of individuals with severe dementia who receive home health care. Future research is also needed to validate the proposed dementia severity categories used in this study.     

Integration Activities Between Hospitals and Skilled Nursing Facilities: A National Survey

ObjectivesIncreasing recognition of the adverse events older adults experience in post-acute care in skilled nursing facilities (SNFs) has led to multiple efforts to improve care integration between hospitals and SNFs. We sought to measure current care integration activities between hospitals and SNFs.DesignCross-sectional survey.Setting and ParticipantsA total of 500 randomly selected Medicare-certified SNFs in the United States in 2019. The survey inquired about 12 care integration activities with the 2 highest volume referring hospitals for each SNF.MethodsWe collapsed survey responses into 5 categories of integration based on high correlations between the individual measures. These were: (1) formal integration (co-location or co-ownership); (2) informal integration (eg, formal affiliation, participation in SNF collaborative, shared pay for performance, or clinical leadership meetings between hospital and SNF); (3) shared quality/safety activities (eg, initiatives to improve medication safety or reduce hospital admission); (4) shared care coordinators; and/or (5) shared supervising clinicians. We then conducted multivariate regressions to examine associations between different care integration activities and hospital/SNF characteristics.ResultsOur overall response rate was 53.0%, including 265 SNFs that represented 487 SNF-hospital pairs. Informal integration was most common (in 53.3% of pairs), whereas shared clinicians (43.0%), care coordinators (36.5%), shared quality/safety activities (35.1%), and formal integration (7.4%) were present in a minority. Hospital-SNF pairs had lower odds of being formally integrated if the SNF was for-profit compared with not-for-profit [odds ratio (OR) 0.11, 95% confidence interval (CI) 0.03–0.42, adjusted P = .04)] and higher odds of sharing quality improvement activities in metropolitan rather than rural areas (OR 4.06, 95% CI 1.80–9.17, adjusted P = .02) and in the Midwest compared with West (OR 2.95, 95% CI 1.44–6.06, adjusted P = .049).Conclusions and ImplicationsThese findings raise important questions about what is driving variability in hospital-SNF integration activities, and which activities may be most effective for improving transitional care outcomes.     

Cost-Effectiveness of an Online Intervention for Caregivers of People Living With Dementia

ObjectivesLittle evidence exists on costs or cost-effectiveness of online interventions for caregivers of people living with dementia. We aimed to assess cost-effectiveness of online cognitive behavioral therapy (CBT) for dementia caregivers with mild-to-moderate depression/anxiety, with or without telephone support, relative to a psychoeducational control treatment.DesignCost-effectiveness study of data from 3-armed randomized controlled trial comparing computerized CBT (cCBT) or telephone-supported cCBT (cCBT+Telephone) to modular online educational program on dementia (Psychoeducation).Setting and ParticipantsUK-resident adult dementia caregivers with mild-to-moderate anxiety/depression.Cost-effectiveness analysisWe calculated health and social care costs, from participant-reported data collected at baseline, 12, 26 weeks, costs of intervention delivery. We examined 3 outcomes: cost of one-point reduction in General Health Questionnaire–12 (GHQ-12) rating at 26-weeks, cost of prevented “caseness” on GHQ-12 at 26 weeks, and cost per quality-adjusted life year (QALY) based on Short Form–6 Dimensions (SF-6D) over 26 weeks.ResultsData from 176 participants (44 cCBT, 91 cCBT+Telephone, 41 Psychoeducation) were analyzed. Costs did not differ between cCBT and Psychoeducation; costs were £125 higher in cCBT+Telephone. Control and intervention groups did not differ on GHQ-12. Caseness was lower in cCBT+Telephone than Psychoeducation; cost of preventing a case was £610, and probability of cost-effectiveness on this outcome reached 98.5% at willingness to pay (WTP) of £12,900. Mean QALY did not differ between cCBT+Telephone and Psychoeducation. QALY gain in cCBT was 0.01 (95% CI 0.001, 0.021). Cost per QALY was £8130. Although base case probability of cost-effectiveness of cCBT was 93% at WTP-per-QALY of £27,600, sensitivity analyses suggested cCBT+Telephone was the more cost-effective.Conclusions and ImplicationsWe report preliminary evidence for adopting telephone-supported online CBT. This may be cost-effective in preventing a case of mental health disorder if, absent a societally accepted WTP threshold for this outcome, payers are willing to pay £12,900. Future research should investigate whether supported/unsupported online CBT improves health-related quality of life.     

Determinants of time to institutionalisation and related healthcare and societal costs in a community-based cohort of patients with Alzheimer’s disease dementia

Objectives

To examine the costs of caring for community-dwelling patients with Alzheimer’s disease (AD) dementia in relation to the time to institutionalisation.

Methods

GERAS was a prospective, non-interventional cohort study in community-dwelling patients with AD dementia and their caregivers in three European countries. Using identified factors associated with time to institutionalisation, models were developed to estimate the time to institutionalisation for all patients. Estimates of monthly total societal costs, patient healthcare costs and total patient costs (healthcare and social care together) prior to institutionalisation were developed as a function of the time to institutionalisation.

Results

Of the 1495 patients assessed at baseline, 307 (20.5%) were institutionalised over 36 months. Disease severity at baseline [based on Mini-Mental State Examination (MMSE) scores] was associated with risk of being institutionalised during follow up (p < 0.001). Having a non-spousal informal caregiver was associated with a faster time to institutionalisation (944 fewer days versus having a spousal caregiver), as was each one-point worsening in baseline score of MMSE, instrumental activities of daily living and behavioural disturbance (67, 50 and 30 fewer days, respectively). Total societal costs, total patient costs and, to a lesser extent, patient healthcare-only costs were associated with time to institutionalisation. In the 5 years pre-institutionalisation, monthly total societal costs increased by more than £1000 (€1166 equivalent for 2010) from £1900 to £3160 and monthly total patient costs almost doubled from £770 to £1529.

Conclusions

Total societal costs and total patient costs rise steeply as community-dwelling patients with AD dementia approach institutionalisation.

     

The Continuing Story of the Cost-Effectiveness of Photoselective Vaporization of the Prostate versus Transuretheral Resection of the Prostate for the Treatment of Symptomatic Benign Prostatic Obstruction

BackgroundIn 2008, a UK assessment of technologies for benign prostatic obstruction concluded negatively about photoselective vaporization of the prostate (PVP), and the 2010 National Institute for Health and Care Excellence guidance caused several UK institutions to abandon PVP.ObjectiveTo reassess the costs and effects of PVP versus transurethral resection of the prostate (TURP) on the basis of most recent data.MethodsThe same model was used as in 2008. Transition probabilities were estimated using a Bayesian approach updating the 2008 estimates with data from two meta-analyses and data from GOLIATH, the latest and largest trial comparing PVP with TURP. Utility estimates were from the 2008 assessment, and estimates of resource utilization and costs were updated. Effectiveness was measured in quality-adjusted life-years gained, and costs are in UK pounds. The balance between costs and effects was addressed by multivariate sensitivity analysis.ResultsIf the 2010 National Institute for Health and Care Excellence analysis would have updated the cost-effectiveness analysis with figures from its own meta-analysis, it would have estimated the change in quality-adjusted life-years at −0.01 (95% confidence interval [CI] −0.05 to 0.01) instead of at −0.11 (95% CI −0.31 to −0.01) as in the 2008 analysis. The GOLIATH estimate of −0.01 (95% CI −0.07 to 0.02) strengthens the conclusion of near equivalence. Estimates of additional costs vary from £491 (£21−£1286) in 2008 to £111 (−£315 to £595) for 2010 and to £109 (−£204 to £504) for GOLIATH. PVP becomes cost saving if more than 32% can be carried out as a day case in the United Kingdom.ConclusionsThe available evidence indicates that PVP can be a cost-effective alternative for TURP in a potentially broad group of patients.     

Economics of the Iceberg: Informal Care Provided to French Elderly with Dementia

ObjectivesDementia has a substantial effect on patients and their relatives, who have to cope with medical, social, and economic changes. In France, most elderly people with dementia live in the community and receive informal care, which has not been well characterized.MethodsUsing a sample of 4680 people aged 75 years and older collected in 2008 through a national comprehensive survey on health and disability, we compared the economic value of the care received by 513 elderly people with dementia to that received by a propensity score– matched set of older people without dementia.ResultsMore than 85% of elderly people with dementia receive informal care; the estimation of its economic value ranges from €4.9 billion (proxy good method) to €6.7 billion (opportunity cost method) per year.ConclusionsThe informal care provided to people with dementia has substantial annual costs; further work should be done to examine the social and economic roles foregone as a result of this care.