A. Mark Fendrick

National Estimates of the Quantity and Cost of Informal Caregiving for the Elderly with Dementia

AbstractOBJECTIVE: Caring for the elderly with dementia imposes a substantial burden on family members and likely accounts for more than half of the total cost of dementia for those living in the community. However, most past estimates of this cost were derived from small, nonrepresentative samples. We sought to obtain nationally representative estimates of the time and associated cost of informal caregiving for the elderly with mild, moderate, and severe dementia. DESIGN: Multivariable regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people age 70 years or older (N=7,443). SETTING: National population-based sample of the community-dwelling elderly. MAIN OUTCOME MEASURES: Incremental weekly hours of informal caregiving and incremental cost of caregiver time for those with mild dementia, moderate dementia, and severe dementia, as compared to elderly individuals with normal cognition. Dementia severity was defined using the Telephone Interview for Cognitive Status. RESULTS: After adjusting for sociodemographics, comorbidities, and potential caregiving network, those with normal cognition received an average of 4.6 hours per week of informal care. Those with mild dementia received an additional 8.5 hours per week of informal care compared to those with normal cognition (P<.001), while those with moderate and severe dementia received an additional 17.4 and 41.5 hours (P<.001), respectively. The associated additional yearly cost of informal care per case was

Screening and surveillance for Barrett esophagus in high-risk groups: a cost-utility analysis.

3,630 for mild dementia,

Initial validation of a diagnostic questionnaire for gastroesophageal reflux disease

7,420 for moderate dementia, and

The Health Effects of Restricting Prescription Medication Use Because of Cost

17,700 for severe dementia. This represents a national annual cost of more than

Suboptimal Statin Adherence and Discontinuation in Primary and Secondary Prevention Populations

18 billion. CONCLUSION: The quantity and associated economic cost of informal caregiving for the elderly with dementia are substantial and increase sharply as cognitive impairment worsens. Physicians caring for elderly individuals with dementia should be mindful of the importance of informal care for the well-being of their patients, as well as the potential for significant burden on those (often elderly) individuals providing the care.

Impact Of Decreasing Copayments On Medication Adherence Within A Disease Management Environment

Context Barrett esophagus, a complication of gastroesophageal reflux disease (GERD), is associated with an increased risk for esophageal cancer. Some have proposed endoscopic screening for Barrett esophagus, followed by surveillance for cancer in patients with the disorder. Contribution The authors modeled the cost-effectiveness of screening 50-year-old white men with GERD. Screening followed by surveillance in patients with Barrett esophagus and dysplasia cost

Estimating the Cost of Informal Caregiving for Elderly Patients With Cancer

10 440 per quality-adjusted life-year (QALY). Surveillance of patients with Barrett esophagus but no dysplasia every 5 years would cost an additional

Alternative Management Strategies for Patients with Suspected Peptic Ulcer Disease

596 000 per QALY. Implications One-time screening for Barrett esophagus in 50-year-old men with GERD is reasonably cost-effective if surveillance is limited. The Editors Current guidelines from the American College of Gastroenterology recommend surveillance to detect cancer and dysplasia in patients with Barrett esophagus, a columnar-cell metaplasia that replaces the native squamous-cell epithelium of the distal esophagus (1). The costs and benefits of surveillance have been evaluated in retrospective studies (2-5) and formal decision analyses (6, 7). Barrett esophagus alone does not cause symptoms that would prompt endoscopic evaluation, and the question of whether screening strategies to detect Barrett esophagus are reasonable and, if so, in which patients is unresolved (8). Adding to the uncertainty is emerging evidence from prospective studies that the incidence of cancer in patients with Barrett esophagus may be considerably lower than previously reported (9, 10). In the absence of randomized, controlled trials of screening and surveillance in Barrett esophagus, the costs and benefits of strategies to decrease mortality rates from cancer are unknown. We used decision analysis to determine whether current recommendations for screening of patients with gastroesophageal reflux disease (GERD) represent cost-effective care. The cohort that we modeled consisted of white men 50 years of age who have symptoms of GERD, because this group is at high risk on the basis of epidemiologic evidence demonstrating an increased risk for esophageal adenocarcinoma compared with other groups [11-14]. Specifically, we examined strategies for screening patients with symptoms of GERD for the presence of Barrett esophagus, dysplasia, or cancer and compared these strategies with no screening for Barrett esophagus. Secondary objectives were 1) to determine whether more benefit was provided by the initial screening examination or by subsequent surveillance, 2) to evaluate different intervals of surveillance in patients with Barrett esophagus, and 3) to identify clinical variables critical to the determination of cost-effectiveness. Methods Patients The hypothetical cohort consisted of white men 50 years of age who had symptoms consistent with GERD (heartburn or acid regurgitation). These patients were assumed not to have symptoms or signs that would otherwise prompt endoscopic evaluation (dysphagia, anemia, weight loss, or bleeding) and had not been previously screened for Barrett esophagus. The analysis assumed that Barrett esophagus was defined by salmon-colored mucosa of any length at endoscopy and intestinal metaplasia on histologic examination. Intestinal metaplasia of the gastroesophageal junction in the absence of endoscopic identification of Barrett esophagus was not examined. It was assumed that all patients modeled for participation in screening and surveillance would be surgical candidates for esophagectomy and would consent to undergo this operation if esophageal cancer was diagnosed. The analysis followed the cohort until 80 years of age or death. Model A decision analysis model was created by using DATA 4.0 software (TreeAge, Williamstown, Massachusetts). A Markov model was used to analyze patients with symptomatic GERD (15, 16). Figure 1 shows a simplified outline of the structure of the Markov model. The actual model contains more than 7000 nodes (branch points) that encompass the natural history of patients with GERD compared to strategies of screening and surveillance for Barrett esophagus, dysplasia, and cancer. (The Appendix provides further information on model assumptions, including structure, transitions, utilities, and sensitivity analysis.) Figure 1. Markov model. Natural History Costs and quality-adjusted life-years (QALYs) without screening and surveillance for Barrett esophagus and adenocarcinoma of the esophagus were examined. Cancer would be diagnosed only if symptoms (dysphagia, weight loss, bleeding, or pain) prompted endoscopic evaluation. Depending on the stage of cancer at the time of diagnosis, palliation (esophageal stent or chemoradiation) or surgical resection could be attempted. Patients with unresectable disease accrued costs of hospice or palliative care. Patients in whom resection was attempted could die after the procedure or survive. Patients who survived surgery could be cured of cancer or experience persistent or recurrent cancer, rates of which depended on the stage of cancer at diagnosis. Death from causes other than adenocarcinoma of the esophagus was incorporated in an age-dependent manner. Screening and Surveillance The natural history analysis was compared to screening with two surveillance strategies. Both strategies used screening endoscopy at 50 years of age and biopsy done to confirm Barrett esophagus if abnormalities were seen at endoscopy. Identification of adenocarcinoma by the initial screening examination prompted esophagectomy or palliation, depending on the stage of tumor. Palliation was associated with costs of endoscopic stenting or chemotherapy and radiation. Surgery could result in perisurgical death, persistent or recurrent cancer, or cure. The first strategy limited surveillance to patients with Barrett esophagus with dysplasia at the initial examination. White men with symptoms of GERD would undergo screening endoscopy at 50 years of age; if Barrett esophagus without dysplasia or no Barrett esophagus was diagnosed, further surveillance would not be performed. Patients with Barrett esophagus with dysplasia would undergo surveillance endoscopy every 6 months for low-grade dysplasia or every 3 months for high-grade dysplasia as long as dysplasia was noted at least once during the preceding 12 months. Detection of cancer would prompt esophagectomy or palliation, depending on stage of disease at diagnosis. The second strategy also evaluated screening of white men with symptoms of GERD at 50 years of age. Patients with Barrett esophagus with dysplasia underwent surveillance as in the first strategy; however, those with Barrett esophagus without dysplasia were separately modeled to undergo surveillance endoscopy at intervals of 2, 3, 4, or 5 years. If intestinal metaplasia was not found on two consecutive surveillance endoscopies, surveillance ceased. Cancer was managed as in the first strategy. Endoscopy and biopsy was modeled to be an imperfect test: that is, false-positive and false-negative results would occur, thereby missing some cases of dysplasia or cancer and overdiagnosing other states. Procedure-related morbidity and mortality for surgery and endoscopy were included in the analysis. Adjustment for patient preferences for the various health states (utilities) was incorporated into the model. Differential rates of cure from cancer were assigned depending on the stage at diagnosis. Death from causes other than adenocarcinoma of the esophagus was incorporated in an age-dependent manner. All costs and benefits were discounted at 3% annually (0% to 5% annually in the sensitivity analysis). Transitions Transitions between health states of the Markov model were derived from the published literature. To assess key variables, the MEDLINE and EMBASE databases from 1970 to 2001 and abstracts from major gastroenterological scientific meetings from 1999 to 2001 were searched by using the terms Barretts esophagus, esophageal neoplasms, adenocarcinoma, precancerous conditions, and gastroesophageal reflux disease. If no data existed for a specified transition, the authors reached consensus. In addition to the base-case scenario, sensitivity analyses were performed using variations around each of the transitions supported by the literature (Table 1). Table 1. Model Assumptions Costs and Utilities Costs, not charges, were the basis for inputs used in this analysis. Costs included direct costs of care for delivery of services and were derived from published literature and 2001 data from the Health Care Financing Administration. Data on inpatient resource use from the Health Care Financing Administration were based on diagnosis-related groups and Current Procedural Terminology codes, whereas outpatient data were based on ambulatory payment classification and Current Procedural Terminology codes. Costs of endoscopy included biopsies and histologic interpretation. Costs are shown in Table 1. A third-party insurer perspective was taken (58-60). Patient preferences for different health states (utilities) were derived from the published literature, and outcomes were adjusted to derive QALYs (6, 7). Utilities were derived from expert opinion by using a time-tradeoff technique (7) and from responses by patients who had undergone esophagectomy for high-grade dysplasia or cancer (6). Costs of time lost from work and support required from family or friends and intangible losses due to pain and suffering were not incorporated. Sensitivity Analysis All assumptions for the model were varied over a wide range of values in a series of one-way sensitivity analyses. Published rates from the literature were used if available. In the absence of published data, baseline rates were halved and doubled with adjustment by consensus from the authors. Monte Carlo simulation was used to create a multi-way sensitivity analysis. Surgery for High-Grade Dysplasia In the base-case strategy, the diagnosis

Colorectal neoplasia screening with virtual colonoscopy: when, at what cost, and with what national impact?

OBJECTIVES:Brief, reliable, and valid self-administered questionnaires could facilitate the diagnosis of gastroesophageal reflux disease in primary care. We report the development and validation of such an instrument.METHODS:Content validity was informed by literature review, expert opinion, and cognitive interviewing of 50 patients resulting in a 22-item survey. For psychometric analyses, primary care patients completed the new questionnaire at enrollment and at intervals ranging from 3 days to 3 wk. Multitrait scaling, test–retest reliability, and responsiveness were assessed. Predictive validity analyses of all scales and items used specialty physician diagnosis as the “gold standard.”RESULTS:Iterative factor analyses yielded three scales of four items each including heartburn, acid regurgitation, and dyspepsia. Multitrait scaling criteria including internal consistency, item interval consistency, and item discrimination were 100% satisfied. Test–retest reliability was high in those reporting stable symptoms. Scale scores significantly changed in those reporting a global change. Regressing specialty physician diagnosis on the three scales revealed significant effects for two scales (heartburn and regurgitation). Combining the two significant scales enhanced the strength of the model. Symptom response to self-directed treatment with nonprescription antisecretory medications was highly predictive of the diagnosis also, although the item demonstrated poor validity and reliability.CONCLUSIONS:A brief, simple 12-item questionnaire demonstrated validity and reliability and seemed to be responsive to change for reflux and dyspeptic symptoms.

Predicting nursing home admission: Estimates from a 7-year follow-up of a nationally representative sample of older Americans

Background:High out-of-pocket expenditures for prescription medications could lead people with chronic illnesses to restrict their use of these medications. Whether adults experience adverse health outcomes after having restricted medication use because of cost is not known. Methods:We analyzed data from 2 prospective cohort studies of adults who reported regularly taking prescription medications using 2 waves of the Health and Retirement Study (HRS), a national survey of adults aged 51 to 61 in 1992, and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a national survey of adults aged 70 or older in 1993 (n = 7991). We used multivariable logistic and Poisson regression models to assess the independent effect on health outcomes over 2 to 3 years of follow up of reporting in 1995–1996 having taken less medicine than prescribed because of cost during the prior 2 years. After adjusting for differences in sociodemographic characteristics, health status, smoking, alcohol consumption, body mass index (BMI), and comorbid chronic conditions, we determined the risk of a significant decline in overall health among respondents in good to excellent health at baseline and of developing new disease-related adverse outcomes among respondents with cardiovascular disease, diabetes, arthritis, and depression. Results:In adjusted analyses, 32.1% of those who had restricted medications because of cost reported a significant decline in their health status compared with 21.2% of those who had not (adjusted odds ratio [AOR], 1.76; confidence interval [CI], 1.27–2.44). Respondents with cardiovascular disease who restricted medications reported higher rates of angina (11.9% vs. 8.2%; AOR, 1.50; CI, 1.09–2.07) and experienced higher rates of nonfatal heart attacks or strokes (7.8% vs. 5.3%; AOR, 1.51; CI, 1.02–2.25). After adjusting for potential confounders, we found no differences in disease-specific complications among respondents with arthritis and diabetes, and increased rates of depression only among the older cohort. Conclusions:Cost-related medication restriction among middle-aged and elderly Americans is associated with an increased risk of a subsequent decline in their self-reported health status, and among those with preexisting cardiovascular disease with higher rates of angina and nonfatal heart attacks or strokes. Such cost-related medication restriction could be a mechanism for worse health outcomes among low-income and other vulnerable populations who lack adequate insurance coverage.