Stopping antipsychotic drug therapy in demented nursing home patients: a randomized, placebo-controlled study--the Bergen District Nursing Home Study (BEDNURS)

BACKGROUND: Despite modest efficacy, unpredictable individual utility, and a high rate of adverse effects, behavioural and psychological symptoms of dementia (BPSD) are common determinants for antipsychotic drug therapy in nursing home patients. AIMS: To explore the impact on BPSD of stopping long-term antipsychotic treatment in nursing home patients with dementia. METHODS: Fifty-five patients (43 women; mean age 84.1) taking haloperidol, risperidone, or olanzapine for BPSD were randomly assigned to cessation (intervention group, n = 27) or continued treatment with antipsychotic drugs (reference group, n = 28) for 4 consecutive weeks. The Neuropsychiatric Inventory (NPI) Questionnaire was used to examine changes in behavioural and psychological symptoms. RESULTS: By study completion, 23 of the 27 intervention group patients were still off antipsychotics. Symptom scores (NPI) remained stable or even improved in 42 patients (intervention group, 18 out of 27; reference group, 24 out of 28; p = 0.18). As compared to patients with stable or improved symptom scores, patients with behavioural deterioration after antipsychotic cessation used higher daily drug doses at baseline (p = 0.42). CONCLUSION: A large share of elderly nursing home patients on long-term treatment with antipsychotics for BPSD, do well without this treatment. Standardized symptom evaluations and drug cessation attempts should therefore be undertaken at regular intervals. Copyright (c) 2008 John Wiley & Sons, Ltd.     

Cost of care for Medicaid recipients with serious mental illness and HIV infection or AIDS

OBJECTIVE: To assist in developing public policy about the feasibility of HIV prevention in community mental health settings, the cost of care was estimated for four groups of adults who were eligible to receive Medicaid: persons with serious mental illness and HIV infection or AIDS, persons with serious mental illness only, persons with HIV infection or AIDS only, and a control group without serious mental illness, HIV infection, or AIDS. METHODS: Claims records for adult participants in Medicaid fee-for-service systems in Philadelphia during 1996 (N=60,503) were used to identify diagnostic groups and to construct estimates of reimbursement costs by type of service for the year. The estimates included all outpatient and inpatient treatment costs per year per person and excluded pharmacy costs and the cost of nursing home care. Persons with severe mental illness, HIV infection, or AIDS had received those diagnoses between 1985 and 1996. RESULTS: Persons with comorbid serious mental illness and HIV infection or AIDS had the highest annual medical and behavioral health treatment expenditures (about $13,800 per person), followed by persons with HIV infection or AIDS only (annual expenditures of about $7,400 per person). Annual expenditures for persons with serious mental illness only were about $5,800 per person. The control group without serious mental illness, HIV infection, or AIDS had annual expenditures of about $1,800 per person. CONCLUSIONS: Given the high cost of treating persons with comorbid serious mental illness and HIV infection or AIDS, the integration of HIV prevention into ongoing case management for persons with serious mental illness who are at risk of infection may prove to be a cost-effective intervention strategy.     

Parkinson's disease and nursing home placement: the economic impact of the need for care

Background and Purpose:  To examine the relative risk (RR) for living in nursing homes for patients with Parkinson's disease (PD) compared with the general population and to ascertain society's costs related to nursing home placement for this patient group.
Methods:  We evaluated the frequency of admission to nursing homes in a cross-sectional study and during a 12-year follow-up study of 108 patients with PD and 864 controls who were matched for age and sex. The RR for living in a nursing home was calculated at baseline and during follow-up. On the basis of 2007 prices, we estimated the costs per person year of survival for patients with PD and controls.
Results:  The RR for living in a nursing home at baseline was 5.0 for patients with PD and 4.8 during follow-up. Patients with PD caused 4.8 times higher costs for nursing home placement with euro 18 875 versus euro 3978 per individual and year. The annual costs for institutional care of patients with PD in Norway were euro 132 million.
Conclusion:  Patients with PD have a substantially higher risk for living in nursing homes than the general population. This causes high costs to society. Therapeutic interventions to prevent or delay nursing home admissions are therefore important.     

Alzheimer's disease and other dementia in nursing homes: levels of management and cost.

OBJECTIVE: To estimate comparative management levels and the annual cost of caring for a nursing home resident with and without dementia. METHOD: Data from the 1995 Massachusetts Medicaid nursing home database were used to examine residents with Alzheimer's disease, other types of dementia, and no dementia to determine care and dependency levels. Massachusetts Medicaid 1997 per-diem rates for each of 10 designated management levels were applied accordingly to residents in each level to estimate annual care costs. Costs from this analysis are reported in 1997 U.S. dollars. RESULTS: Of the 49,724 nursing home residents identified, 26.4% had a documented diagnosis of dementia. On average, a resident with dementia requires 229 more hours of care annually than one without dementia, resulting in a mean additional cost of $3,865 per patient with dementia per year. CONCLUSIONS: Dementia increases the care needs and cost of caring for a nursing home resident.     

The economic burden of depression

This article provides estimates of direct treatment costs and indirect costs from lost productivity associated with the morbidity and mortality of depression. Data are based on epidemiologic estimates of the prevalence of major depressive illness and on the number of suicides assumed to be secondary to depression. The number of hospitalizations, hospital days, physician and mental health provider visits, home/nursing home costs, and pharmaceutical costs are estimated. The direct and indirect costs are estimated to be approximately $16.3 billion per year. These economic figures provide a lower-bound estimate of the full economic burden of major depression and further emphasize the need for timely recognition and treatment to potentially minimize the negative impact of the illness on society.     

Effectiveness of antipsychotic therapy in a naturalistic setting: a comparison between risperidone, perphenazine, and haloperidol

BACKGROUND: Therapeutic ineffectiveness and noncompliance with antipsychotic agents are major contributors to rehospitalization in patients with psychotic disorders. It is unknown whether risperidone's favorable side effect profile compared with that of the conventional antipsychotics results in improved compliance and reduced hospitalizations in a naturalistic setting. The purpose of this study was to test the hypothesis that treatment with risperidone reduces readmission rates and associated costs when compared with treatment with perphenazine or haloperidol. METHOD: Inpatients prescribed either risperidone, perphenazine, or haloperidol between January 1, 1995, and December 31, 1995, as a single oral antipsychotic at discharge were retrospectively identified. Data were collected for that index hospitalization and for a 1-year follow-up period. Primary outcome measures included re-admission rates, changes in antipsychotic therapy, anticholinergic drug use, and costs. RESULTS: There were 202 evaluable patients (81 treated with risperidone, 78 with perphenazine, and 43 with haloperidol). Baseline demographics were similar between groups except that more patients in the risperidone group had a primary diagnosis of psychotic disorder or had been hospitalized in the year prior to study. The percentage of patients readmitted during the 1-year follow-up period was similar among drug groups (41% risperidone, 26% perphenazine, and 35% haloperidol) when controlled for baseline differences in diagnosis and hospitalization history (p = .32). Anticholinergic drug use was more common in the haloperidol group (p = .004). Mean yearly cost (drug + hospitalization) in the risperidone group was $20,317, nearly double that in the other treatment groups (p < .001). CONCLUSION: The results from this naturalistic study indicate that the high cost of risperidone is not offset by a reduction in readmission rates when compared with conventional antipsychotics.     

Cost evaluation of risperidone compared with olanzapine

This study evaluated costs associated with risperidone and olanzapine treatment for schizophrenia. Data were collected from the Department of Veterans Affairs computerized database nine months before and nine months after patients began continuous treatment with risperidone (N=23) or olanzapine (N=47). Both agents were associated with significant reductions in psychiatric hospitalization costs. Median increases in antipsychotic costs were significantly higher for patients treated with olanzapine ($1,892) than for those treated with risperidone ($733). Mean dosages were 3.5 mg per day for the risperidone group and 18 mg per day for the olanzapine group. Although both treatments were associated with similar reductions in costs of psychiatric inpatient and outpatient care, it was significantly less expensive to prescribe risperidone than olanzapine.     

Medical-care costs associated with posttraumatic stress disorder in Vietnam veterans

OBJECTIVE: This study examined the relationship between medical-care costs of Vietnam veterans and predictor factors, including posttraumatic stress disorder (PTSD). METHOD: We merged medical-care cost data from the Department of Veterans' Affairs and the Health Insurance Commission with data from an epidemiological study of 641 Australian Vietnam veterans. Posttraumatic stress disorder and other factors were examined as predictors of medical-care cost using regression analysis. RESULTS: We found that a diagnosis of PTSD was associated with medical costs 60% higher than average. Those costs appeared to be partly associated with higher treatment costs for physical conditions in those with PTSD and also related mental health comorbidities. Major predictors of medical-care cost were age ($137 per year for each 5-year increase in age) and number of diagnoses reported ($81 to $112 per year for each diagnosis). Mental health factors such as depression ($14 per year for each symptom reported) and anxiety ($27 per year for each symptom reported) were also important predictors. CONCLUSIONS: The findings indicate that, however they are incurred, high healthcare and, presumably, also economic and personal costs are associated with PTSD. There is an important social obligation as well as substantial economic reasons to deal with these problems. From both perspectives, continued efforts to identify and implement effective prevention and treatment programs are warranted.     

Costs of outpatient anticoagulant treatment in patients with cerebral and peripheral arterial occlusive disease

BACKGROUND AND OBJECTIVE: Knowledge of the costs of oral anticoagulant (AC) treatment may be relevant for resource allocation. Also, the incremental costs may be compared with other treatments for health care policy decisions. In this report, we have assessed actual costs of anticoagulant therapy in anticoagulation clinics (AC-clinic) in three different settings in the Netherlands. METHODS: Costs of anticoagulant drug supply and costs as a result of INR-adjustment procedures were estimated. We compared the total costs of treatment in patients treated after minor cerebral ischaemia in the Stroke Prevention in Reversible Ischemia Trial (SPIRIT) and in patients treated because of peripheral arterial occlusive disease in the Dutch Bypass Oral anticoagulants or Aspirin Trial (BOA). RESULTS: Costs of monitoring ranged between Euro 6.44 and Euro 9.87 per visit for monitoring at the AC-clinic and at home, respectively. The annual costs of administering anticoagulant drugs ranged between Euro 83 (phenprocoumon) and 107 (acenocoumarol). Variation in the overall actual annual costs of AC treatment was caused by the number of monitoring visits, the distribution of home and clinic visits and, to a lesser extent, the medication used. Annual costs of AC therapy for patients in SPIRIT was Euro 239 and for patients in BOA Euro 312. Overall costs of anticoagulant therapy were about 3 to 4-fold higher than standard treatment with aspirin. CONCLUSIONS: Although the actual costs of anticoagulant therapy may be substantially higher than that of other antithrombotic therapies, its cost-effectiveness depends highly on efficacy.     

Cost analysis of treating schizophrenia with amisulpride: naturalistic mirror image study

The aim of the study was to examine the costs of schizophrenia treatment using the atypical antipsychotic amisulpride relative to treatment with other antipsychotics. Service use data were collected for one year of amisulpride treatment. The patients were also assessed with the Global Assessment of Functioning (GAF) scale and scales of Quality of Life. These were compared with retrospectively collected data for the 1-year period prior to the patients commencing amisulpride. The findings indicate that, compared with the year before, the clinical and quality of life scores improved during the year of treatment with amisulpride. There was a numerical reduction of total costs, as well as costs of in- and out-patient service use per patient per year during the year on amisulpride compared with the year before the patients started amisulpride. Patients on amisulpride spent fewer days as acute in-patients, but stayed longer in rehabilitation wards. Amisulpride treatment may lead to a reduction in the cost of treating schizophrenia in comparison with treatment with other antipsychotic medications.     

Antiseizure,antidepressant, and antipsychotic medication prescribing in elderly nursing home residents

ObjectiveThe incidence of epilepsy is highest in the elderly and the prevalence of epilepsy is higher in nursing home residents than in other cohorts. Co-medications that act in the central nervous system (CNS) are frequently prescribed in this population. The objective was to identify the most commonly prescribed antiseizure drugs (ASDs) and determine the frequency of use of antipsychotic and antidepressant medications in elderly nursing home residents receiving ASDs.MethodsData were obtained from a pharmacy database serving 18,752 patients in Minnesota and Wisconsin nursing homes. Prescribing information was available on ASD, antidepressant, and antipsychotic drugs on one day in October 2013. The frequency distribution by age, formulation, trademarked/generic drugs, route of administration, and multiple drug combinations were determined.ResultsOverall, 66.8% of 18,752 residents received at least one CNS-active drug as classified by the Generic Product Identifier classification system. For those 65 years and older, ASDs were prescribed for 14.3% residents. Gabapentin comprised 7.3%; valproate 3.0%; levetiracetam 1.8%; and phenytoin 0.9%. An antidepressant was used in 64.2% of persons prescribed an ASD. Antidepressant use varied for specific ASDs and ranged from 50 to 75%. An antipsychotic medication was used in 30% of persons prescribed an ASD and ranged from 16.8 to 54.2% for specific ASDs. Both antidepressant and antipsychotic use occurred in 22.2% of persons prescribed an ASD, respectively.SignificanceThe pattern of CNS-active drug use has changed from previous years in this geographic region. Use of phenytoin has declined markedly, but antidepressant use has increased substantially. The CNS side effect profile of these medications and the possible long-term consequences in this population can greatly complicate their therapy.     

Costs of epilepsy in an intermediate care facility for persons with mental retardation

Epilepsy is a significant comorbid condition in institutionalized persons with developmental disabilities and may contribute significant additional costs. This study was conducted to provide an estimate of the costs of epilepsy from the institutional perspective. Costs were measured retrospectively for 50 persons with epilepsy and 50 persons without epilepsy matched by severity of developmental disability. A time and motion study was employed to assign opportunity costs to documented nursing and physician activities. Two separate methods of attribution were used and incremental costs attributable to epilepsy were found to be approximately $825 and $918 per person over a 6-month period. The following categories accounted for costs: personnel (47.0%), drug (39.6%), hospitalization (9.4%), and laboratories/procedures (4.0%). Results are useful for describing the economic burden of epilepsy.     

Economic evaluation of spinal cord stimulation for chronic reflex sympathetic dystrophy

OBJECTIVE: To evaluate the economic aspects of treatment of chronic reflex sympathetic dystrophy (RSD) with spinal cord stimulation (SCS), using outcomes and costs of care before and after the start of treatment. METHODS: Fifty-four patients with chronic RSD were randomized to receive either SCS together with physical therapy (SCS+PT; n = 36) or physical therapy alone (PT; n = 18). Twenty-four SCS+PT patients responded positively to trial stimulation and underwent SCS implantation. During 12 months of follow-up, costs (routine RSD costs, SCS costs, out-of-pocket costs) and effects (pain relief by visual analogue scale, health-related quality of life [HRQL] improvement by EQ-5D) were assessed in both groups. Analyses were carried out up to 1 year and up to the expected time of death. RESULTS: SCS was both more effective and less costly than the standard treatment protocol. As a result of high initial costs of SCS, in the first year, the treatment per patient is $4,000 more than control therapy. However, in the lifetime analysis, SCS per patient is $60,000 cheaper than control therapy. In addition, at 12 months, SCS resulted in pain relief (SCS+PT [-2.7] vs PT [0.4] [p < 0.001]) and improved HRQL (SCS+PT [0.22] vs PT [0.03] [p = 0.004]). CONCLUSIONS: The authors found SCS to be both more effective and less expensive as compared with the standard treatment protocol for chronic RSD.     

What happens to patients after five years of intensive case management stops?

Seventy-two patients who received five years of intensive case management services were transferred into mainstream community mental health center services with a much higher patient-to-staff ratio. At the end of a two-year follow-up, 91 percent of the patients were still receiving treatment. Compared with the previous five years, hospitalizations during the follow-up period increased, but not significantly so. Contacts with mainstream CMHC services increased significantly. Overall costs in constant 1979 dollars showed a nonsignificant decrease, dropping by about $1,500 per patient per year. The staff time and resources gained by the programmatic changes were used to treat a larger number of chronic patients seeking services.