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60 Interventions in Alzheimer’s Disease KCE Reports 111 Although modelling is necessary when long-term data are lacking, this is still an additional limitation of the modelling approaches for AD, which may then suffer from a lack of internal consistency. The published literature on the cost-effectiveness of AD medications so far is almost entirely comprised of industry-sponsored studies. Many of those studies are presented from an optimistic societal perspective (i.e. including caregiver time costs and therefore predicting cost savings) and are largely driven by optimistic differences in effectiveness of treatment compared with usual care (i.e. assuming that treatment may delay disease progression). The results of the economic evaluations assessing non-pharmaceutical interventions in AD patients were rather heterogeneous and inconclusive. Patients’ interventions were found neutral both in terms of costs and clinical outcome with a “day care” programme for the patient, while “group living” and “cognitive stimulation therapy” were associated with significant cognitive improvement at an either lower or equal cost compared to usual care. Caregivers support was assessed to be neither a cost-effective nor a clinically effective intervention in two RCT-based studies while it was considered to be the dominant option compared to usual care in two other model-based studies. Finally, based on the results of a single study, an occupational therapy targeting both the patient and his (her) carer was found to be highly cost-effective. Besides the heterogeneity of those results, these studies were further considered to be of poor quality and statistical power, thereby limiting the validity of their findings. In general, model-based economic evaluations of non-pharmaceutical interventions suffered from the same limitations as those described above for the evaluations of pharmaceutical interventions against AD. The quality of the RCT-based piggy-backed economic evaluations of non-pharmacological AD interventions was also controversial. The short-term outcomes used in those evaluations were changes in the scale score between AD interventions and usual care, for which significant differences were reported in the trial. The limitation with this approach is that such change in scale score do not translate easily into clinically meaningful final outcomes so that the results of such economic evaluations are hardly interpretable. Therefore, given the lack of consistency in the studies’ results and the numerous limitations of the economic evaluations and of their assumptions, more research is needed to draw firmer conclusions on the cost-effectiveness of pharmacological and non-pharmacological interventions in AD patients.
KCE Reports 111 Interventions in Alzheimer’s Disease 61 Key points • In the economic evaluations, ChEIs and memantine treatments for AD patients were found to be either cost saving or more costly and also more effective than usual care. • Most studies assumed that AD medications were effective in delaying institutionalisation and disease progression. The use of such longer-term endpoints that was modelled in the economic evaluations is controversial given the typically short-term follow-up of the trials of AD medication and given the current lack of evidence on longer-term outcomes in the trials. • Results of the economic evaluations of non-pharmaceutical interventions were heterogeneous, and the quality of the studies was poor. • Although of great interest, no economic evaluation assessing a combined pharmacological and non-pharmacological intervention could be identified. There was also no economic evaluation investigating whether an AD medication is more cost-effective than another. • In the future, ideally, valid data on the medium- to long-term cost and effectiveness of delayed institutionalisation or disease progression should best be available to be used in the economic evaluations of AD interventions. • One step in this direction is the study of Mittleman et al., 61 a high quality study demonstrating a significant reduction in the rate of institutionalisation with non-pharmacological interventions of AD patients’ caregivers. Economic studies based on the results of this study would be highly informative.
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