An economic perspective on Alzheimer's disease.

The rapid growth of the world's Alzheimer's disease (AD) population has resulted in a tremendous financial burden on society, a situation exacerbated by the fact that the funding of health and social services faces increasing restrictions in the coming years. As a consequence, several cost-of-illness studies, aimed at assessing the total costs associated with the care of an AD patient or with individual components thereof, have been conducted, with a view to identifying areas in which costs might be reduced. For example, the Costs of Dementia (CoDem) study, described here, aims to give a profile of the total economic costs of AD in Italy. While this study found the number of Instrumental Activities of Daily Living lost to be the principal predictor of the weekly costs for home care, other studies have reported a correlation between total cost and Mini-Mental State Examination (MMSE) score. The basis for a correlation between cost and disease severity is discussed. Pharmacoeconomics aims to assess the cost effectiveness of interventions that may form part of an overall management strategy in AD. As institutionalization is the largest cost element in the care of any AD patient, efforts at cost containment have focused on maintaining patients at home for as long as possible. The results of studies on a number of interventions, namely, screening, reality orientation therapy, special care units, family interventions, and drug treatment, are discussed, although the costs and, indeed, the long-term benefits associated with many of these remain unknown. Although information concerning costs is essential in health resource allocation, it is also vital that meaningful ways in which to assess quality-of-life issues be developed as the basis for genuine cost-benefit judgments.     

Childhood epilepsy: a critical review of cost-of-illness studies.

Epilepsy is an illness with multiple consequences and costs for children, families and society. There are only a few studies published on the cost of childhood epilepsy. The different methodologies used in these studies make it difficult to compare them or even to compare the cost of childhood epilepsy treatment with that of adult epilepsy. Nevertheless, studies highlight important differences in the distribution of costs associated with childhood epilepsy and epilepsy in adults. It is understandable that direct costs represent the higher percentage of the total cost associated with childhood epilepsy treatment, given the higher number of hospital admissions and investigations, as well as the complexity of therapeutic trials, while indirect costs represent the greater proportion in adult epilepsy treatment. In addition to age, the total cost associated with epilepsy also depends on other factors such as seizure frequency, the moment at which the illness cost is estimated and the local health care system. In summary, chronic illnesses not only have an influence on the physical and psychological development of children, they also impose costs on the family and society. Childhood epilepsy has greater economic costs than those generated by more prevalent, chronic illnesses.     

Impact of nonadherence to antiepileptic drugs on health care utilization and costs: Findings from the RANSOM study

Purpose: To study the impact of nonadherence to antiepileptic drugs (AEDs) on health care utilization and direct medical costs in a Medicaid population. Methods: A retrospective cohort design was employed using state Medicaid claims data from Florida, Iowa, and New Jersey during the period from January 1997 to June 2006. Patients aged ≥18 years with one or more neurologist visit with an epilepsy diagnosis and two or more pharmacy claims for AEDs were included. Medication possession ratio (MPR) was used to evaluate AED adherence with MPR ≥ 0.80 considered adherent and <0.80 considered nonadherent. The association of nonadherence with utilization outcomes [hospitalizations, inpatient days, emergency department (ED), and outpatient visits] was assessed with univariate and multivariate Poisson regressions. Quarterly per‐patient inpatient, outpatient, ED, and pharmacy costs were calculated across nonadherent and adherent quarters for the younger than 65 population (under‐65) and cost differences were computed. Adjusted incremental costs of nonadherence were estimated with multivariate Tobit regression models. Results: A total of 33,658 patients were included (28,470 under‐65), together contributing 388,564 treated quarters (26% nonadherent). In multivariate analyses, AED nonadherence was associated with significantly higher incidence of hospitalizations [incident rate ratio (IRR) = 1.39, 95% confidence interval (CI) = 1.37–1.41], inpatient days (IRR = 1.76, 95% CI = 1.75–1.78), and ED visits (IRR = 1.19, 95% CI = 1.18–1.21). Nonadherence was associated with cost increases related to serious outcomes, including inpatient ($4,320 additional cost per quarter, 95% CI = $4,077–$4,564) and ED services ($303 additional cost per quarter, 95% CI = $273–$334), but lower costs for outpatient and pharmacy services, likely because of nonadherent behavior. Discussion: Nonadherence to AEDs appears to be associated with serious outcomes, as evidenced by increased utilization and costs of inpatient and ED services.     

The utility of neuropsychological consultation in identifying medical inpatients with suspected cognitive impairment at risk for greater hospital utilization

Objective: This was a retrospective study designed to examine the relationship between inpatient neuropsychological status and future utilization costs. Methods: We completed a retrospective chart review of 280 patients admitted to a large academic medical center who were referred for bedside neuropsychological evaluation. Patients were grouped based on neuropsychological recommendation regarding level of supportive needs post-discharge (low, moderate, high). Level of support was used as a gross surrogate indicator of cognitive status in this heterogeneous sample. We also included patients who refused assessment. Outcome variables included time to readmission, number of emergency department visits, inpatient admissions, length of hospitalization, and total costs of hospitalizations, 30 days and 1 year following discharge. Results: Multivariate analysis indicated patients who refused assessment had higher inpatient service utilization (number of ED visits, number of admissions, and total cost of hospitalization) compared to those with moderate needs. Also, high needs patients had higher total cost of hospitalization at 1 year, and those with low needs used the ED more, compared to those with moderate needs. Conclusions: Our findings replicate prior studies linking refusal of neuropsychological evaluation to higher service utilization costs, and suggest a nonlinear relationship between cognitive impairment severity and future costs for medical inpatients (different groups incur different types of costs). Results preliminarily highlight the potential utility of inpatient neuropsychological assessment in identifying patients at risk for greater hospital utilization, which may allow for the development of appropriate interventions for these patients.     

Assessing the societal impact of acetylcholinesterase inhibitor therapies

The symptomatology of Alzheimer disease (AD), its longevity, and associated cost make it an extremely challenging disease for individuals, their families, health care, and social support systems. Moreover, the expanding aging population worldwide means that strategies to contain costs are an urgent priority. As the largest component of the direct costs of AD is due to the cost of institutionalization, cost-containment strategies have focused on ways to maintain the AD patient in the community for as long as possible. Disease severity is a strong predictor of institutionalization, and patients' cognitive function (in the form of their Mini-Mental State Examination score) is frequently used as a prognostication of their living environment, and thus the overall cost of their care. Strategies to maintain patients at home are directed at either the patient's symptoms or the caregiver's ability to cope with those symptoms and the responsibilities of caregiving. Examples of strategies directed at the caregiver include education and support programs. Drug treatments, notably acetylcholinesterase inhibitors, present the best option for improving patient function, thereby preserving patient autonomy. A number of preliminary studies, whose results are summarized here, have demonstrated that the use of the acetylcholinesterase inhibitors tacrine, metrifonate and donepezil, and the glial cell modulator, propentofylline, results in reductions in the overall costs of care. Most health economic studies have focused only on comparison of the costs associated with paying for administering a treatment and the savings produced by postponed institutionalization. However, there is a growing realization that some measures of the quality of life or well-being of both patient and caregiver should also be incorporated. Thus, the health economics of dementia is an extremely complex area of study that is rapidly growing, due to the likelihood that cost-effectiveness will form the basis for future reimbursement decisions.     

Cost Effectiveness of Drive and Retrieve System in Hokkaido for Acute Ischemic Stroke Patient Treatment Using Geographic Information System

Background and Purpose: Although endovascular thrombectomy combined with recombinant tissue-type plasminogen activator is effective for treatment of acute ischemic stroke, regional disparities in implementation rates of those treatments have been reported. Drive and retrieve system, where a qualified neurointerventionist travels to another primary stroke center for endovascular thrombectomy, has been practiced in parts of Hokkaido, Japan. This study aims to simulate the cost effectiveness of the drive and retrieve system, which can be a method to enhance equality and cost effectiveness of treatments for acute ischemic stroke. Materials and methods: The number of patients who had acute ischemic stroke in 2015 is estimated. Those patients are generated according to the population distribution, and thereafter patient transport time is analyzed in the 3 scenarios (1) 60-minute drive scenario, (2) 90-minute drive scenario, in which the drive and retrieve system operates within 60-minute or 90-minute driving distance (3) without the system, using geographic information system. Incremental cost-effectiveness rate, quality-adjusted life years, and medical and nursing care costs are estimated from the analyzed transport time. Findings: The incremental cost-effectiveness rate by implementing the system was dominant. Cost reductions of $213,190 in 60-minute drive scenario, and $247,274 in the 90-minute scenario were expected, respectively. Such benefits are the most significant in Soya, Emmon, Rumoi, and Kamikawahokubu medical areas. Conclusions: The drive and retrieve system could enhance regional equality and cost effectiveness of ischemic stroke treatments in Hokkaido, which can be achieved using existing resources. Further studies are required to clarify its cost effectiveness from hospital perspective.     

Costing Behavioral Interventions: A Practical Guide to Enhance Translation

Background/Purpose  Cost and cost effectiveness of behavioral interventions are critical parts of dissemination and implementation into non-academic settings. Due to the lack of indicative data and policy makers’ increasing demands for both program effectiveness and efficiency, cost analyses can serve as valuable tools in the evaluation process. Methods  To stimulate and promote broader use of practical techniques that can be used to efficiently estimate the implementation costs of behavioral interventions, we propose a set of analytic steps that can be employed across a broad range of interventions. Results/Conclusions  Intervention costs must be distinguished from research, development, and recruitment costs. The inclusion of sensitivity analyses is recommended to understand the implications of implementation of the intervention into different settings using different intervention resources. To illustrate these procedures, we use data from a smoking reduction practical clinical trial to describe the techniques and methods used to estimate and evaluate the costs associated with the intervention. Estimated intervention costs per participant were $419, with a range of $276 to $703, depending on the number of participants.     

Service use and costs of supporting the most socially disabled patients in a hospital reprovision programme

Background The UK, in common with other Western countries, has seen a marked reduction in the number of long-stay hospital beds over the past few decades and most asylums have been closed. Whilst hospital closure and discharge programmes differ, a common characteristic is likely to be that those patients who are “difficult-to-place” in the community are amongst the last to be discharged. This paper compares service use and costs of difficult-to-place patients from two UK hospitals (Friern and Warley) and identifies predictors of cost. One of these hospitals (Warley) provided a more intensive programme of rehabilitation. Method The study included 84 patients (Friern 63, Warley 21). Patient characteristics prior to discharge were recorded. Service use was measured and costs calculated for the year following discharge. Comparisons were made between the Warley and Friern groups and cost predictors were identified using multiple regression analysis. Results Post-discharge accommodation, in-patient and outpatient costs were substantially higher for the Friern group, whilst the Warley group had higher day care costs. The total mean costs were ￡13,432 higher for the Friern group. However, non-accommodation costs were substantially higher for the Warley group. Patients with more social skills had higher non-accommodation costs. Higher total costs were associated with more self-care skills, fewer domestic skills and younger age. Longer length of stay prior to discharge was associated with higher non-accommodation and total costs. Conclusions The costs of care following discharge differed substantially between these two groups. This is partly a supply effect given the different strategies for caring for these difficult-to-place patients. In common with other studies, patient characteristics can explain some of the differences in future costs.     

Cost effectiveness of three child mental health assessment methods: computer-assisted assessment is effective and inexpensive

In order to survive severe funding reductions, community mental health centers (CMHCs) have implemented a number of systems-level interventions that attempt to minimize the impact of budget cuts on treatment effectiveness. The present study focused on ways to maintain the effectiveness of clinical assessment while lowering the assessment cost. The present study evaluated the relative cost effectiveness of three methods for collecting information and developing clinical assessment reports on children at a CMHC: (a) a traditional narrative clinical assessment report; (b) a form-style clinical assessment; and (c) a computer-assisted clinical assessment. The results revealed that the computer-assisted assessments was at least as effective as the two alternative assessment methods and only 20 percent to 45 percent as costly. The effect of using the computer-assisted assessments was reported to be favorable by therapists. While computer technology can be used to cut service delivery costs, the use of computers in CMHCs has generally been limited to administrative tasks, and clinical applications have been ignored.     

Mental health care costs: paucity of measurement

For an evaluation of a mental health care programme to be comprehensive, it should include an economic component. However, very few cost instruments appear to exist, and only one has been fully described in the literature. This paper seeks to review the studies where costs have been calculated. For this exercise to be facilitated the different elements which make up overall cost are described. A number of areas have experienced economic evaluations, and the more important studies are described. The paper concludes that all too often evaluations either fail to measure costs or do so in an incomplete and inappropriate way.     

Cost savings with nefazodone in treating depression

Pharmacoeconomic analysis of antidepressant therapy is an important tool for ensuring the most cost-cognizant approach to treat a particular mental disorder. As the number of effective antidepressant compounds continues to grow, the drug selection process must consider not only the cost of the drug itself, but also costs associated with treatment failure and management of untoward and unexpected side effects. In economic studies conducted in North America and England using a decision analysis model and a direct annual cost model, nefazodone has been shown to have an impact on costs associated with depression when compared with imipramine and fluoxetine. Nefazodone also can reduce depression-related anxiety and agitation symptoms early in treatment, and, because it improves subjective and objective sleep measures, use of concomitant anxiolytics or sedative-hypnotics with nefazodone has been shown to be less frequent and less costly than with selective serotonin reuptake inhibitors.     

Variables associated with emergency department and/or unplanned hospital utilization for children with epilepsy

In the United States, approximately one million people are evaluated annually in an emergency department (ED) for the diagnosis of a seizure or epilepsy. The highest percentages of these patients are less than five years of age. No studies have been performed on assessing potential variables associated with recurrent ED visits and/or unplanned hospitalizations for children with epilepsy. Institutional review board approval from Nationwide Children's Hospital was obtained prior to study initiation. An accountable care organization (ACO), Partner for Kids (PFK), database was searched for patients with the highest and the lowest number of ED visits and/or unplanned hospitalizations from 2007 through 2011 using ICD-9 codes of 345.xx and 780.39. The patients were stratified into a high and a low utilizer group. The total number of visits and their associated health care costs were noted for each patient. In total, 120 patients were included for review. Information on the total number of no-shows to outpatient neurology clinic visits and telephone calls to neurology triage nursing was noted. A chart review was performed by a pediatric epileptologist to determine if each individual patient was an appropriate candidate for an emergency seizure treatment. The dose of emergency seizure medication was cross-checked to the patient's actual dose during the time of ED or hospital presentation to determine if the dose given was high, low, or accurate based on dosing recommendations. Multivariable logistic regression was used to test the effects of factors. When controlling for other factors, patients who were given an incorrect or no emergency seizure dosing had a high probability of having multiple ED visits/unplanned hospitalizations compared with patients who were given correct dosing (odds ratio = 11.28, 95% CI of odds ratio = (2.42, 52.63), p value < 0.01 (p = 0.0021)). Using a similar model, patients who experienced a higher number of no-shows to clinic visits had a higher probability of having multiple ED visits/unplanned hospitalizations (odds ratio = 5.73 per 1 more number of no-show, 95% CI of odds ratio = (1.78, 18.44), p value < 0.01 (p = 0.0034)). Future studies are planned to target these risk factors with the goal of decreased ED and/or hospital utilization for children with epilepsy.     

Economic evaluations of novel antipsychotic medications: a literature review

Objective: To evaluate the evidence that novel antipsychotic medications offer a cost advantage compared to traditional antipsychotic medications. Methods: Literature for this review was identified through a computerized search of Medline, Healthstar and Psyc-INFO databases inclusive from January 1989 to January 2002. Articles included in the review were required to include cost evaluation and to be published in peer-reviewed journals. Results: Twenty-two studies met inclusion criteria. All five studies that used experimental designs found that second-generation antipsychotic medications were associated with a cost advantage or were cost-neutral, and, in some cases, improved quality of life. Of the ten studies using a pre-post design, four found an increase in total costs, six reported a decrease in total costs, and four reported increased effectiveness with use of a second-generation antipsychotic. All seven of the simulation studies reported a cost advantage for novel antipsychotics for specific patient populations under certain conditions. Conclusions: The majority of studies found that novel antipsychotics are at least cost-neutral and may offer cost advantages compared to traditional agents. Some studies also reported greater improvement in effectiveness and quality of life when novel antipsychotics were compared to traditional antipsychotic medications. However, it is difficult to draw firm conclusions given the small sample sizes and limited study designs available in this literature.     

Botulinum toxin treatment in neurological practice: how much does it really cost? A prospective cost-effectiveness study

Botulinum toxin (BTA) is a safe and effective therapeutic tool for many neurological conditions but few studies have investigated its real cost in neurological practice. We evaluated the daily cost of botulinum toxin type A (BTA) treatment through a cost effectiveness analysis alongside a prospective study of BTA injections at a French University Hospital over a 2-year follow-up period. The data of 3,108 BTA injections performed in 870 adult patients presenting with dystonia, facial hemispasm, or spasticity were entered in the database. Patients were questioned at each visit about the subjective effectiveness of the previous injection. The daily cost of BTA treatment was calculated as the ratio of each session's cost (including all additional costs) to the duration of subjective efficacy. The subjective rating of efficacy duration was 17.3 ± 7.7 weeks for facial hemispasm, 15.4 ± 7.7 for blepharospasm, 14.3 ± 6.7 for cervical dystonia, 14.5 ± 7.8 and 14.1 ± 7.4 weeks for upper and lower limb spasticity, respectively. The daily cost of BTA injections was 0.57 ± 0.20 for facial hemispasm, 0.95 ± 0.30 for blepharospasm, 2.85 ± 0.86 for cervical dystonia, 3.38 ± 1.49 and 3.62 ± 1.81 for upper and lower limb spasticity, respectively. When associated costs were considered, the daily cost of BTA injections was clearly increased (45-93%) in limb spasticity or rigidity but remained only modestly increased (15-37%) in other indications. These results obtained in a large cohort of patients show that BTA treatment has a low daily cost for a long-lasting effect, with a daily cost/benefit ratio that greatly depends on the indications.     

At What Cost? Using Cost Information for Purchasing and Providing Community Care for People with Learning Disabilities

An appreciation of costs and cost effectiveness has been central to policy initiatives, reports by the Audit Commission and the 1990 community care reforms. This paper argues the case for a more informed use of cost information in services for people with learning disabilities, using examples from research into the costs and outcomes of care in the community. Commissioners and providers of services should address a number of methodological considerations when using cost information to purchase services or review their competitiveness or cost-effectiveness. Principles for using information are offered, including comprehensiveness, taking account of variations, making comparisons and linking costs with outcomes. The wider implications for commissioners and providers are then discussed in the context of policy issues and management concerns.     

Economic impact of childhood/adolescent ADHD in a European setting: the Netherlands as a reference case

Attention-deficit/hyperactivity disorder (ADHD) is a highly prevalent psychiatric disorder in children/adolescents. This study reviews available European-based studies of ADHD-related costs and applies the findings to the Netherlands to estimate annual national costs for children/adolescents from a societal perspective. A systematic literature search was conducted for primary studies in Europe, published January 1, 1990 through April 23, 2013. Per-person cost estimates were converted to 2012 Euros and used to estimate annual national ADHD-related costs based on the Dutch 2011 census, ADHD prevalence rates, family composition, and employment rates. Seven studies met the inclusion criteria. The average total ADHD-related costs ranged from €9,860 to €14,483 per patient and annual national costs were between €1,041 and €1,529 million (M). The largest cost category was education (€648 M), representing 62 and 42 % of the low- and high-value overall national estimates, respectively. By comparison, ADHD patient healthcare costs ranged between €84 M (8 %) and €377 M (25 %), and social services costs were €4.3 M (0.3–0.4 %). While the majority of the costs were incurred by ADHD patients themselves, €161 M (11–15 %) was healthcare costs to family members that were attributable to having an ADHD child/adolescent. In addition, productivity losses of family members were €143–€339 M (14–22 %). Despite uncertainties because of the small number of studies identified and the wide range in the national cost estimates, our results suggest that ADHD imposes a significant economic burden on multiple public sectors in Europe. The limited number of European-based studies examining the economic burden of ADHD highlights the need for more research in this area.     

Clinical and economic outcomes--friend or foe?

The growing interest in analyzing the cost-effectiveness of interventions presents a challenge to anyone involved in dementia research. Although not yet often expressed as a formal requirement, drug authorities and budget holders also wish to have information on cost effectiveness. Clinical outcomes must therefore be combined with outcomes suitable for cost effectiveness analysis. However, issues about cost effectiveness are seldom included in empirical clinical trials, but are more often analyzed using modeling approaches. Clinical researchers and economists need to bridge these areas of potential conflict when long-term cost effectiveness is being considered. Randomized clinical trials (RCTs), observational studies, register data and economic models all have their advantages and drawbacks, and in making statements about cost effectiveness it is necessary to make a comprehensive judgment based on several methodological approaches. RCTs with a duration of at least 12 months should include assess-ments of resource utilization, and outcomes should offer a link to population-based cohort studies to discuss generalizability (e.g. a cognitive measure avail-able both in trials and cohort studies, such as the Mini-mental State Examination (MMSE), staging instruments, quality of life instruments) of the costs, while also serving as one source of modeling. Both dementia-specific and generic quality of life instruments are required. Models are necessary but must be transparent so that the assumptions on which the models are built can be critically analyzed.     

Pharmacoeconomic evaluation of medical treatment of epilepsy: where do we stand?

Qualitative and quantitative improvements of pharmaco-economic evaluation of antiepileptic drugs have been realized during the last decade. Assessment of medical treatments is mainly performed through cost-minimization studies, owing to similar effectiveness of AED. Studies recently published generally consider hypothetical cohorts of patients and assess resource utilization and medical effects on the basis of clinical trials and expert panels, limiting evaluation to direct costs. But they differ in numerous ways due to: the type of patients and treatment considered, the time span of evaluation, and cost measurement. Comparison between studies is therefore tricky but it seems that, when considering monotherapy treatments, carbamazepine and phenytoin are somewhat cheaper than valproate while lamotrigine is much more expensive but no more effective. However, these and other antiepileptic agents appear as close substitutes when prescribed as adjunctive treatments. Refined tools have been developed to take into account slight differences exhibited on certain outcomes. One direction currently under evaluation relates to quality of life, and this will probably leads to an increasing number of cost-utility studies. Some advances, regarding information on medical resources consumed and outcomes associated with alternative drugs, as well as methodological options, are still needed to fully develop pharmacoeconomic evaluation of antiepileptic treatments.     

Costes indirectos asociados al glioblastoma. Experiencia en un centro

Introduction

Glioblastoma is the most common primary brain tumour. Despite advances in treatment, its prognosis remains dismal, with a mean survival time of about 14 months. Many articles have addressed direct costs, those associated with the diagnosis and treatment of the disease. Indirect costs, those associated with loss of productivity due to the disease, have seldom been described.

Clinical trial-based cost-effectiveness analyses of antipsychotic use

OBJECTIVE: Second-generation antipsychotics make up one of the fastest growing segments of the rapidly growing pharmaceutical sector. Given limited health care resources, assessment of the value for the cost of second-generation antipsychotics relative to first-generation antipsychotics is critical for resource-allocation decisions. METHOD: With a MEDLINE search, the authors identified eight studies (based on six randomized clinical trials) that analyzed the cost-effectiveness of second-generation antipsychotics relative to first-generation antipsychotics in individuals with schizophrenia disorders. The authors reviewed appropriate methods of measurement, analysis, and design of cost-effectiveness studies in randomized clinical trials and evaluated the validity of economic results derived from the studies in light of appropriate methods. RESULTS: The eight randomized clinical trial-based cost-effectiveness studies of antipsychotic medications faced a variety of threats to validity related to 1) measurement of costs, 2) measurement of effectiveness, 3) analysis of costs, 4) measurement of sampling uncertainty, 5) analysis of incomplete cost data, 6) minimizing loss to follow-up, and 7) threats to external validity. CONCLUSIONS: Economic claims made by the authors of a number of trial-based economic evaluations have generally been favorable to second-generation antipsychotics. However, the methodological issues the authors of the current study identified suggest that there is no clear evidence that atypical antipsychotics generate cost savings or are cost-effective in general use among all schizophrenia patients. Psychiatrists, researchers, and administrators should consider the methodological issues highlighted in interpreting study results. These issues should be addressed in future trial designs.