L. Lewis

Early intervention in Alzheimer’s disease: a health economic study of the effects of diagnostic timing

BackgroundIntervention and treatment in Alzheimer’s disease dementia (AD-dementia) can be cost effective but the majority of patients are not diagnosed in a timely manner. Technology is now available that can enable the earlier detection of cognitive loss associated with incipient dementia, offering the potential for earlier intervention in the UK health care system. This study aimed to determine to what extent the timing of an intervention affects its cost-effectiveness.MethodsUsing published data describing cognitive decline in the years prior to an AD diagnosis, we modelled the effects on healthcare costs and quality-adjusted life years of hypothetical symptomatic and disease-modifying interventions. Early and standard interventions were assumed to have equal clinical effects, but the early intervention could be applied up to eight years prior to standard diagnosis.ResultsA symptomatic treatment which immediately improved cognition by one MMSE point and reduced in efficacy over three years, would produce a maximum net benefit when applied at the earliest timepoint considered, i.e. eight years prior to standard diagnosis. In this scenario, the net benefit was reduced by around 17% for every year that intervention was delayed. In contrast, for a disease-modifying intervention which halted cognitive decline for one year, economic benefits would peak when treatment effects were applied two years prior to standard diagnosis. In these models, the maximum net benefit of the disease modifying intervention was fifteen times larger than that of the symptomatic treatment.ConclusionTimeliness of intervention is likely to have an important impact on the cost-effectiveness of both current and future treatments. Healthcare policy should aim to optimise the timing of AD-dementia diagnosis, which is likely to necessitate detecting and treating patients several years prior to current clinical practice.

High readmission rates are associated with a significant economic burden and poor outcome in patients with grade III/IV acute GvHD

Graft‐versus‐host disease (GvHD) is a common complication following haematopoietic stem cell transplant but little is published about the impact of this condition on hospital readmission rates. We report a retrospective analysis of readmission rates and associated costs in 187 consecutive allogeneic transplant patients to assess the impact of GvHD. The overall readmission rate was higher in patients with GvHD (86% (101/118) vs. 59% (41/69), p < 0.001). The readmission rate was higher both in the first 100 d from transplant (p = 0.02) and in the first year following transplant (p < 0.001). 151/455 (33%) of all readmission episodes occurred within 100 d of transplant. The mean number of inpatient days was significantly higher in patients with grade III/IV acute GvHD (101 d) compared with those with grade I/II GvHD (70 d; p = 0.003). The mean cost of readmission was higher in patients with GvHD (£28 860) than in non‐GvHD patients (£13 405; p = 0.002) and in patients with grade III/IV GvHD (£40 012) compared with those patients with grade I/II GvHD (£24 560; p = 0.038). Survival was higher in those with grade I/II GvHD (55%) compared to grade III/IV GvHD (14%; p < 0.001). This study shows the high economic burden and poor overall survival associated with grade III/IV GvHD.

A United Kingdom-based economic evaluation of ranibizumab for patients with retinal vein occlusion (RVO).

Abstract Objective: This study compares the cost-effectiveness of intravitreal ranibizumab vs observation and/or laser photocoagulation for treatment of macular edema secondary to retinal vein occlusion in a UK-based model. Methods: A Markov model was constructed using transition probabilities and frequency of adverse events derived using data from the BRAVO, CRUISE, and HORIZON trials. Outcomes associated with treatments and health states were combined to predict overall health costs and outcomes for cohorts treated with each option. Results: In branch retinal vein occlusion, ranibizumab produced a gain of 0.518 quality-adjusted life years at an incremental cost of £8141, compared with laser photocoagulation. The incremental cost-effectiveness ratio was £15,710 per quality-adjusted life year, and the incremental cost per month free from blindness was £658. In central retinal vein occlusion, ranibizumab produced a gain of 0.539 quality-adjusted life years at an incremental cost of £9216, compared with observation only. The incremental cost-effectiveness ratio was £17,103, and the incremental cost per month free from blindness was £423. Conclusions: These incremental cost-effectiveness ratios are below the £20,000–30,000 range typically accepted as a threshold for cost-effectiveness. This suggests that ranibizumab may be regarded as a cost-effective therapy for patients with macular edema secondary to retinal vein occlusion, relative to grid laser photocoagulation (for BRVO) and observation (for CRVO). Limitations include sparse data for utilities associated with the severity of visual impairment in the WSE in patients with RVO. A lack of direct comparative evidence between ranibizumab and the dexamethasone intravitreal implant for the treatment of BRVO and CRVO and the infeasibility of an indirect comparison due to significant heterogeneity in trial designs prevented the inclusion of this treatment as a comparator in the Markov model.

THE SENSITIVITY AND SPECIFICITY OF COMPUTERISED OR PAPER-AND-PENCIL COGNITIVE ASSESSMENTS USED IN PRIMARY CARE IMPACT THE COST-EFFECTIVENESS OF THE DEMENTIA DIAGNOSTIC PATHWAY

Background: Theory of Mind (ToM) is generally known as an important psychological domain since the eighties, clinical investigations in dementia are scarce. We therefore sought to assess ToM in a large sample of nursing home residents with dementia. We aimed to analyze whether a cognitive impaired person is able to attribute a mental state to oneself and others. We presented firstrespectively second-order-false-belief-tasks. There are only few studies showing the results of such tasks in patients with dementia. Methods:Our hypothesis is a relationship between the degree of severity of the mental deterioration and the corresponding understanding of false beliefs. From a total sample of 397, there were 125 residents of nursing homes who accepted the requirements of our study. A well-established deception task worked out in the research of ToM was modified, the first-respectively second-order-false-belief-tasks were presented to the test persons. Results: A Spearman correlation analysis showed a relationship between the mental deterioration and the lack of recognition of false beliefs in others (r1⁄4 -.396, p< .01).Conclusions:ToM is a necessary life skill for understanding intentions of other persons, which is not least essential in view of the assessment of financial capacity. Regarding limitations of the study, further investigations are required to demonstrate deficits of ToM in nursing home residents.

Early detection of mild cognitive impairment: Would it be cost-effective?

*p<.05, **p<.01 y CDR-Global was not normally distributed and a Spearman’s rho evaluationwas used for correlation analysis between the CDR-Global, CST-Score and CST-time CDR-SOB (Clinical Dementia Rating Scale-Sum of Boxes, ADAS-Cog Total (Alzheimer’s Disease Assessment Scale, Cognitive Subscale Total Score), ADAS-Cog Revised (Alzheimer’s Disease Assessment Scale, Cognitive Subscale Total Score Revised), CDR-Global (Clinical Dementia Rating Scale-Global). Poster Presentations: P3 P638