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Donepezil, rivastigmine, galantamine and memantine for ...

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112<br />

Economic analysis<br />

vascular dementia. The study examines the<br />

relationship between disease progression (using<br />

MMSE scores <strong>and</strong> the Barthel Index) <strong>and</strong> the cost<br />

of care. Patients were recruited to a study of<br />

behaviour in dementia. 155,156 The cohort was<br />

based in Ox<strong>for</strong>dshire, UK, <strong>and</strong> at the start of the<br />

study the patients were living at home with a carer<br />

able to give detailed in<strong>for</strong>mation about the<br />

patient. Patients (with carer support/input) were<br />

assessed at 4-monthly intervals between 1988–89<br />

<strong>and</strong> 1999. Assessment covered cognition,<br />

behaviour, ADL, carer in<strong>for</strong>mation <strong>and</strong> an<br />

assessment of resource use <strong>for</strong> health, social <strong>and</strong><br />

long-term services, including the setting of care.<br />

Subjects were classed as institutionalised when<br />

they were admitted to a hospital ward or a nursing<br />

home <strong>for</strong> permanent care. Items of resource use<br />

subject to data collection were hospitalisations,<br />

respite care, outpatient treatment, day care, home<br />

care by district nurses, community psychiatric<br />

nurses, home help, home care assistants, GP<br />

<strong>and</strong>/or practice nurse visits. Additionally, the use<br />

of special aids, adaptations, incontinence products<br />

<strong>and</strong> special dietary requirements were noted. Drug<br />

costs do not appear to have been included in the<br />

analysis, although up to 1999 treatment of AD had<br />

been largely palliative. Unit costs (1998 prices)<br />

were matched to resource use profiles <strong>and</strong> the<br />

study reports cost estimates on the basis of a fixedeffects<br />

regression model.<br />

Wolstenholme <strong>and</strong> colleagues report the total cost<br />

per patient over the course of the study to be<br />

£66,697 (SD £60,249), based on a mean follow-up<br />

over 40 months (range 1–132). Institutional care<br />

accounted <strong>for</strong> 69% of total cost. The authors also<br />

report cost by disease severity categories defined<br />

using MMSE <strong>and</strong> by Barthel Index categories;<br />

data by MMSE score are presented in Table 61.<br />

Cost pattern by Barthel Index categories showed a<br />

broadly similar pattern, increasing with severity.<br />

When examining the impact of different variables<br />

on the total costs of care, the authors report that<br />

ADL (Barthel Index scores) seemed to have a<br />

TABLE 61 Estimated annual cost by MMSE score, reported by Wolstenholme <strong>and</strong> colleagues 122<br />

much greater impact than cognitive changes on<br />

the health <strong>and</strong> social care resources used, with a<br />

1-point decline in MMSE associated with a £56<br />

increase in 4-monthly costs, compared with a £586<br />

increase in cost associated with a 1-point fall in the<br />

Barthel Index (event allowing <strong>for</strong> the shorter<br />

range in the Barthel Index). The authors also<br />

report that institutionalisation is associated with an<br />

additional 4-monthly cost of £8000. The analysis<br />

also examines the impact of variables on the time<br />

to institutionalisation, <strong>and</strong> one of the key findings<br />

of this study is that it may be inappropriate to<br />

model disease progression in dementia solely on<br />

the basis of measures of cognitive change.<br />

Netten <strong>and</strong> colleagues 130 present cost estimates <strong>for</strong><br />

elderly people with cognitive impairment, based<br />

on two surveys commissioned by the UK<br />

Department of Health: a longitudinal survey of<br />

publicly funded admission <strong>for</strong> those aged<br />

≥ 65 years (over 2500 persons) to residential <strong>and</strong><br />

nursing home care, <strong>and</strong> a cross-sectional survey of<br />

homes <strong>for</strong> elderly people (in<strong>for</strong>mation on 11,900<br />

residents). The surveys were not specific to AD or<br />

to patients with cognitive impairment, but data<br />

were available on cognitive impairment <strong>and</strong><br />

challenging behaviour via the Minimum Data Set<br />

(MDS) framework, using the MDS Cognitive<br />

Per<strong>for</strong>mance Scale (CPS), a seven-point scale<br />

providing in<strong>for</strong>mation on short-term memory loss,<br />

decision-making, communication <strong>and</strong> dependency.<br />

The MDS CPS has been shown to correspond<br />

closely to the MMSE. 157<br />

Netten <strong>and</strong> colleagues present findings on the<br />

weekly prices across residential care settings, with<br />

indications of differences <strong>for</strong> those severely<br />

cognitively impaired compared with all residents.<br />

Prices (1998–99 levels) did not differ greatly<br />

between privately <strong>and</strong> publicly funded settings.<br />

Nursing homes <strong>and</strong> dual-registered homes were<br />

more expensive than private <strong>and</strong> voluntary<br />

residential homes. Table 62 presents findings from<br />

Netten <strong>and</strong> colleagues on the weekly costs in the<br />

residential settings examined.<br />

AD severity MMSE score Estimated annual cost (1998 prices):<br />

mean (SD) (£)<br />

Mild >20 8,312 (5,602)<br />

Mild to moderate 15–20 11,643 (7,808)<br />

Moderate 10–14 15,681 (9,509)<br />

Severe

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