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110 Economic analysis survey studies often related to dementia rather than AD. 122;130 Cost estimates tend to be based on data analysis (involving assumptions) and modelling, to determine estimates of care (based on various inputs to packages of care) over time, namely annual average cost estimates. Selected UK cost studies Gray and Fenn 126 present findings from a costing study using a burden of illness (BOI) framework. The study uses aggregate data on relevant cost areas (hospitalisation, primary care) together with epidemiological data on AD to estimate the costs associated with AD. Estimates are based on a ‘topdown’ approach to the allocation of costs. The analysis, like many BOI studies, is not precise and is subject to a number of fairly broad assumptions and calculations; however, the findings are illustrative of the level of cost expected in AD, largely at an aggregate level. Gray and Fenn suggest that it costs ~£1.04 billion (1990–91 prices) to provide healthcare and social services support to people aged ≥ 65 years with AD in England. The study finds that most of the cost burden, around 65%, is on payments for residential and nursing home care, with a further 25% of total costs associated with hospital-based care. The BOI study presents estimates by age grouping, but does not consider cost estimates by disease severity. The estimates from Gray and Fenn were used in the cost-effectiveness study by Fenn and Gray, 91 where they are updated to 1997 prices, presenting an estimate of the cost per AD patient in long-term institutional care at £18,162, while the cost of patients in a home setting was estimated at £1899 (to include GP visits, outpatient attendance, day care and respite care, short inpatient stays and services such as meals on wheels). Costing studies from the PSSRU have been published to inform on the costs of care for the elderly and demented patient population. 118,120,153 The PSSRU research used data from the OPCS disability survey (1985–86) to estimate the proportions of people with cognitive impairment in different types of care – private households, residential and nursing homes, and hospitals. Costs of care packages for each of these types of care were then calculated using a variety of cost sources, some dating back to the early or mid 1980s, with costs updated to 1992–93 prices. The OPCS survey included all people with dementia regardless of underlying cause; the proportion of people with AD was not recorded, and cognitive disability was measured using the OPCS SEVINT scale. Stewart 121 drew together a number of work TABLE 57 Estimate of cost of care for people with dementia aged ≥ 75 years, by setting of care Care location Estimated annual cost (1996 prices) (£) Living alone in a private household 12,331 Living with others in private household 14,132 Residential accommodation 24,801 Source: Stewart. 121 areas, 118,120 to present cost estimates for those elderly and demented patients over 75 years old by three categories of residential setting: living alone in private household, living with others in a private household and living in residential accommodation (see Table 57). There remains some uncertainty over the components of cost included in the cost estimates presented by Stewart. The discussion paper states that the cost items included are direct costs of formal health and social care with informal care excluded, but data used by Stewart are from Kavanagh and colleagues, 120 which include informal care and accommodation costs. Data from Kavanagh and colleagues, 120 which forms the basis for the cost estimates presented by Stewart, 121 are presented in Tables 58 and 59. It can be seen from the data that around 23% of the care costs (e.g. living alone/with others in a private household) fall on the NHS and PSS budget. Stewart 121 has also transformed the SEVINT scores (13-point scale) onto the MMSE scale (30 points) in order to calculate cost estimates by MMSE score (category) (see Table 60), but not every point on the MMSE score is represented. Therefore, it is unclear how the costs for AD disease severity levels, which are each defined by a particular range of the MMSE, were derived. The cost estimates presented by Stewart were based on the proportions of patients in each category of care (with residential care subdivided by four further settings of care) and cost data for care in each location, with estimates updated to 1996 prices. O’Shea and O’Reilly 152 present findings from a BOI study of dementia, incorporating direct, indirect, formal and informal costs. They present findings for costs across acute hospital care, psychiatric care, family care, primary and
TABLE 58 Summary of average weekly care package costs, 1992–93 prices Health Technology Assessment 2006; Vol. 10: No. 1 Care location DHA (£) FHSA (£) SSD (£) DSS/clients Total (£) (£) Living alone in private household 17.46 3.03 27.26 164.30 212.05 Living with others in private household 33.21 3.19 20.13 186.98 243.51 Local authority residential home 8.15 8.15 326.02 12.20 354.52 Private and voluntary residential home 5.30 5.30 65.72 164.19 240.51 Private and voluntary nursing home 7.77 7.77 143.52 178.64 337.70 Long-stay hospital 739.95 0.00 21.94 11.20 773.09 Living with others in private household with 57.94 3.19 41.60 186.98 289.71 improved respite support Living alone in private household with improved 41.52 3.03 58.61 164.30 267.46 home care NHS nursing home 420.95 0.00 0.00 12.20 433.15 Enhanced local authority homes provision 5.78 2.60 402.65 12.20 423.23 DHA, District Health Authority; DSS, Department of Social Services; FHSA, Family Health Service Authority; SSD, Social Services Department. Source: Kavanagh et al. 120 TABLE 59 Average weekly costs for people living in private households, 1992–93 costs, by the funding source Funder Living alone (£) Living with others (£) District health authority 17.46 33.21 Department of Social Services 27.26 20.13 Family Health Service Authority DSS (Department of Social Services) clients and their families 3.03 3.19 Informal care 49.23 69.14 Personal consumption 74.9 77.67 Accommodation costs 40.17 40.17 Total 212.05 243.51 Source: Kavanagh et al. 120 using OPCS data. TABLE 60 Cost estimates for people with dementia aged ≥ 75 years, by different levels of severity OPCS SEVINT MMSE Estimated cost per year (£) 0 26 13,826 1 16,805 2 15,828 3.5 19 15,449 4.5 18 15,767 6 17 16,385 7 16 17,071 8 14 17,859 9.5 11 17,234 10.5 8 17,407 12 1 17,809 13 20,112 Source: Stewart. 121 © Queen’s Printer and Controller of HMSO 2006. All rights reserved. community care and residential care (study related to Ireland, not England and Wales). Not all areas of cost could be estimated owing to scarcity of data, and they do not include day care services, day hospital services or drug costs. Various data sources were used in estimating costs including national data sources, survey data and dementiaspecific data. The estimate for the annual cost per patient (Ireland) of residential care is £16,299, based on data from the Department of Health (1995) and case-study work published by Blackwell and colleagues. 154 The average weekly cost of residential care (across various settings) was £312. The estimate for the annual cost per patient for community care is £1054. Wolstenholme and colleagues 122 report a retrospective analysis of a longitudinal data set for a cohort of 100 patients diagnosed with AD or 111
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Health Technology Assessment 2006;
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The clinical and cost-effectiveness
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Objectives: To provide an update re
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List of abbreviations .............
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AChEI acetylcholinesterase inhibito
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Epidemiology and background Alzheim
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Galantamine Five published economic
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TABLE 1 Estimated prevalence of AD
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as one component of their care. A n
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