Arthur S. Zbrozek

Model of Complications of NIDDM: II. Analysis of the health benefits and cost-effectiveness of treating NIDDM with the goal of normoglycemia

OBJECTIVE To analyze the health benefits and economics of treating NIDDM with the goal of normoglycemia. RESEARCH DESIGN AND METHODS Incidence-based simulation model of NIDDM was used. Hazard rates for complications were adjusted for glycemia using risk gradients from the Diabetes Control and Complications Trial. Treatment costs were estimated from national survey data and clinical trials. Incremental costs and benefits were expressed in present value dollars (3% discount rate). Life-years were adjusted for quality of life, yielding quality-adjusted life-years (QALYs). RESULTS Comprehensive treatment of NIDDM that maintains an HbA1c value of 7.2% is predicted to reduce the cumulative incidence of blindness, end-stage renal disease, and lower-extremity amputation by 72, 87, and 67%, respectively. Cardiovascular disease risk increased by 3% (no effect of treating glycemia is assumed). Life expectancy increased 1.39 years. The cost of treating hyperglycemia increased by almost twofold, which is partially offset by reductions in the cost of complications. The estimated incremental cost/QALY gained is

Predicting 10‐Year Care Requirements for Older People with Suspected Alzheimer's Disease

16,002. Treatment is more cost-effective for those with longer glycemic exposure (earlier onset of diabetes), minorities, and those with higher HbA1c under standard care. CONCLUSIONS The incremental effectiveness of treating NIDDM with the goal of normoglycemia is estimated to be ∼

Estimation and Validation of a Multiattribute Model of Alzheimer Disease Progression

16,000/QALY gained, which is in the range of interventions that are generally considered cost-effective.

Baseline differences and trajectories of change for deceased, placed, and community residing Alzheimer disease patients.

OBJECTIVE: To describe the types and costs of care received for 10 years after the identification of an older person with suspected Alzheimers disease (AD) by using data from 3254 patients with suspected AD who participated in the National Long Term Care Survey (NLTCS).

P-148: The resource utilization in dementia (RUD) instrument is valid to assess informal care time in dementia

Objectives. To estimate and validate a multiattribute model of the clinical course of Alzheimer disease (AD) from mild AD to death in a high-quality prospective cohort study, and to estimate the impact of hypothetical modifications to AD progression rates on costs associated with Medicare and Medicaid services. Data and Methods. The authors estimated sex-specific longitudinal Grade of Membership (GoM) models for AD patients (103 men, 149 women) in the initial cohort of the Predictors Study (1989—2001) based on 80 individual measures obtained every 6 mo for 10 y. These models were replicated for AD patients (106 men, 148 women) in the 2nd Predictors Study cohort (1997—2007). Model validation required that the disease-specific transition parameters be identical for both Predictors Study cohorts. Medicare costs were estimated from the National Long Term Care Survey. Results. Sex-specific models were validated using the 2nd Predictors Study cohort with the GoM transition parameters constrained to the values estimated for the 1st Predictors Study cohort; 57 to 61 of the 80 individual measures contributed significantly to the GoM models. Simulated, cost-free interventions in the rate of progression of AD indicated that large potential cost offsets could occur for patients at the earliest stages of AD. Conclusions. AD progression is characterized by a small number of parameters governing changes in large numbers of correlated indicators of AD severity. The analysis confirmed that the progression of AD represents a complex multidimensional physiological process that is similar across different study cohorts. The estimates suggested that there could be large cost offsets to Medicare and Medicaid from the slowing of AD progression among patients with mild AD. The methodology appears generally applicable in AD modeling.

P4-211: Who best to rate an Alzheimer’s disease (AD) patient’s quality of life: Patient or caregiver? The case for a mixed perspective

This study identifies predictors of placement or death in a large ethnically/racially diverse sample of moderately impaired Alzheimer disease patients residing in the community. Patients and caregivers were followed for 18 months with 4 assessments at 6-month intervals. Multinomial regression was used to identify caregiver and patient baseline characteristics and changes over time as predictors of patient placement in a long-term care facility (n=180), patient death (not preceded by placement, n=187), or remaining in the community at home (n=583). Our findings reveal important differences between death and placement when compared with continued home care. Both death and placement are significantly associated with increased activities of daily living limitations (Exp(B)=1.285, P=0.017; Exp(B)=0.1.202, P=0.038, for death and placement, compared with home care, respectively), having a nonspouse caregiver [Exp(B)=0.325, P=0.026; Exp(B)=0.386, P=0.050, for death and placement, respectively], and being a male patient [Exp(B)=0.367, P=0.003; Exp(B)=0.439, P=0.016, for death and placement, respectively]. Death and placement differ with respect to health service use, race, and group assignment. Whites are more likely to be placed rather than remain at home when compared with African American [Ex(B)=0.520, P=0.028] or Hispanic [Exp(B)=0.338, P<0.005] patients, whereas being assigned to the control condition as opposed to active treatment [Exp(B)=0.515, P=0.008], having a male caregiver [Exp(B)=0.482, P=0.043], and increasing patient health service use [Exp(B)=1.105, P=0.015] are associated with increased mortality. Placed and deceased patients are further differentiated from each other by the fact that caregivers of placed patients report an increase in being bothered by memory problems when compared with caregivers of deceased patients [Exp(B)=0.577, P=0.006]. Patients who are placed, died, or remain at home have unique trajectories, which vary as a function of the reference group used for comparison. Increasing bother with memory problems is uniquely associated with placement relative to death while increasing health service use in the form of physician contacts and nurses visits is uniquely associated with death among community residing Alzheimer disease patients.

Book Review: Quality of Life and Pharmacoeconomics: An Introduction

Background: Informal care is a significant component of the societal resource use and costs in dementia care. Thus it is fundamental that assessments of informal care are valid. Objective: This study aimed to analyse the validity of time estimates in the Resource Utilization in Dementia (RUD) instrument in a community setting. Methods: Comparisons between diaries, recall and time observations with agreement statistics. Results: Fourteen married and cohabiting pairs were included, participating in 47 diaries and 30 observation sessions. The agreement between diary time and estimated time was very good for personal ADL (intraclass correlation (ICC) 0.93), good for supervision (ICC 0.87) and total time (ICC 0.91) and lower but acceptable for instrumental ADL (ICC 0.75). Exclusion of outliers with 24 hours of total time estimates in the diaries did not change the ICC figures (PADL 0.94, IADL 0.83, supervision 0.89, total time 0.90). Regarding observed time vs estimated time, the corresponding figures were for personal ADL (ICC 0.81), for instrumental ADL (ICC 0.74), for supervision (ICC 0.78) and for total time (ICC 0.80). Conclusion: Recall, which is the least time demanding method for collecting data on informal care, is with the RUD instrument a valid method to assess the amount of informal care. Assessment of IADL is, however, a bit problematic.

Model of Complications of NIDDM: II

Background: Health preference measures such as the Health Utilities Index II (HUI) have an essential role in assessing the overall value of an AD intervention. Unfortunately, persons with AD have impairments in their awareness of both cognitive and functional disabilities. Hence, their HUI self-assessments may not adequately capture the extent of their disabilities. Caregiver reports may address this shortcoming, but caregivers may not adequately report patient experiences of pain, mood, mobility and sensation. Objective(s): To examine the validity of a HUI scoring algorithm that mixes patient and caregiver subscales. Methods: Data were used from 110 community dwelling persons with very mild to moderate AD and their family caregivers to create a mixed HUI using patient self rated pain, mood, mobility and sensation; and caregiver rated cognition and usual care. This HUI score was compared to patient self rated and caregiver rated HUI scores and relevant co-variates. Results: Inspection of mean HUI scores showed that the mixed perspective produced HUI scores of 0.78 ( 0.16). These are intermediate between the patients’ self-ratings 0.88 ( 0.15) and the caregivers’ direct ratings 0.72 ( 0.18) of the patient. Whereas 32 (29%) patients rated themselves without any disability (a HUI score of 1.0), the mixed perspective produced no score of 1.0. Univariate correlations showed that the mixed perspective was well correlated with both the patient (r 0.74, p 0.0001) and caregiver rated (r 0.76, p 0.0001) HUI. The following table shows associations between the three perspectives and patient cognition (3MSE), patient and caregiver ratings of patient activities of daily living (IADL), and patient mood (GDS). Asterisks indicate correlations with a p-value less than 0.05. Conclusions: A HUI scoring algorithm that combines patients’ self-ratings of mood and pain with characteristics caregivers typically assess, cognition and usual care, produces HUI scores that generally reflect the presence of at least some disability in persons with AD. In addition, only the mixed perspective has associations with measures of cognition, function and mood.

P2-323 Generic measures of health related quality of life in persons with mild to moderate AD

The streamlined Quality of Life and Pharmacoeconomics: An Introduction is useful both for readers requiring an initial introduction and for a more advanced audience interested in refresher material. The premise of the book, which is based on Spilker’s classic Quality of Life and Pharmacoeconomics in Clinical Trials, 2nd ed., is that some readers would benefit from a book that offers an integrated overview of approaches to quality of life assessment, evaluations of outcomes, and pharmacoeconomic methods. As an experienced researcher in this field, I found the construction to be logical, balanced, and well referenced. The text is divided into seven sections that review “key aspects of health-related quality of life and the essentials of pharmacoeconomics.” While the book has no glaring problems, two areas in particular, both in Chapter 7, are addressed in an insufficient manner. In part 5 (page 231), the issues regarding clinical trial cost collection were not fully analyzed, which leaves the reader with a lack of essential information. In addition, the tradeoffs made when choosing between analytic methods should be delineated more clearly. Those distal to the field still have misunderstandings, and the consolidation of methods is often essential. The concept of and the issues surrounding methods consolidation could be conveniently addressed in the section under Common Issues (pages 240–1). One issue that was not addressed that would have been timely and instructive relates to the ongoing controversy surrounding utilities as a measure of social value. This issue is not new, but it has not been laid to rest, and a short statement regarding the issues and sufficient references would have been appropriate in either Chapter 6 or 7. This book is not as academic as either Cost-Effectiveness in Health and Medicine1 or Methods for the Economic Evaluation of Health Care Programmes.2 While it has many strengths and serves as a valuable reference for the field, the price seems excessive for audiences that would best be served by the material presented in this “easy-to-understand introduction to an increasingly critical aspect of health care.”