Alzheimer's Disease Care: Costs and Potential Savings

Health Affairs

Volumn 17, Issue 6, 1998, Pages 206-216

  Leon, Joel ^a   Cheng, Chong Kuo ^b   Neumann, Peter J ^b  

^a Center for Health Affairs   (United States)

^b NONE

Author keywords

[No Author keywords available]

Indexed keywords

AGED; ALZHEIMER DISEASE; ARTICLE; CAREGIVER; COST CONTROL; CROSS-SECTIONAL STUDY; ECONOMICS; FEMALE; HEALTH CARE COST; HUMAN; MALE; RESIDENTIAL HOME; STATISTICS; UNITED STATES;

AGED; AGED, 80 AND OVER; ALZHEIMER DISEASE; CAREGIVERS; COST SAVINGS; CROSS-SECTIONAL STUDIES; FEMALE; HEALTH CARE COSTS; HUMANS; MALE; RESIDENTIAL FACILITIES; UNITED STATES;

EID: 0005059880     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.17.6.206     Document Type: Article

References (38)

1. U.S. General Accounting Office, Alzheimer's Disease: Estimates of Prevalence in the United States, Pub. no. HEHS-98-16 (Washington: GAO, 28 January 1998).
2. Ibid.; GAO, Long-Term Care - Consumer Protection and Quality-of-Care Issues in Assisted Living, Pub. no. HEHS-97-93 (Washington: GAO, 15 May 1997); and D. Evans et al., "Risk of Death from Alzheimer's Disease in a Community Population of Older Persons," American Journal of Epidemiology 134, no. 4 (1991): 403-412.
3. Ibid.; GAO, Long-Term Care - Consumer Protection and Quality-of-Care Issues in Assisted Living, Pub. no. HEHS-97-93 (Washington: GAO, 15 May 1997); and D. Evans et al., "Risk of Death from Alzheimer's Disease in a Community Population of Older Persons," American Journal of Epidemiology 134, no. 4 (1991): 403-412.
4. Ibid.; GAO, Long-Term Care - Consumer Protection and Quality-of-Care Issues in Assisted Living, Pub. no. HEHS-97-93 (Washington: GAO, 15 May 1997); and D. Evans et al., "Risk of Death from Alzheimer's Disease in a Community Population of Older Persons," American Journal of Epidemiology 134, no. 4 (1991): 403-412.
5. Such studies include R. Ernst and J. Hay, "The U.S. Economic and Social Costs of Alzheimer's Disease Revisited," American Journal of Public Health 84, no. 8 (1994): 1261-1264; D.P. Rice et al., "The Economic Burden of Alzheimer's Disease Care," Health Affairs (Summer 1993): 164-176; and C. Henke and M. Burchmore, "The Economic Impact of Tacrine in the Treatment of Alzheimer's Disease," Clinical Therapeutics 19, no. 2 (1997): 330-345. A more complete reference list is available from the authors at Project HOPE Center for Health Affairs, Suite 600, 7500 Old Georgetown Road, Bethesda, Maryland 20814.
6. Such studies include R. Ernst and J. Hay, "The U.S. Economic and Social Costs of Alzheimer's Disease Revisited," American Journal of Public Health 84, no. 8 (1994): 1261-1264; D.P. Rice et al., "The Economic Burden of Alzheimer's Disease Care," Health Affairs (Summer 1993): 164-176; and C. Henke and M. Burchmore, "The Economic Impact of Tacrine in the Treatment of Alzheimer's Disease," Clinical Therapeutics 19, no. 2 (1997): 330-345. A more complete reference list is available from the authors at Project HOPE Center for Health Affairs, Suite 600, 7500 Old Georgetown Road, Bethesda, Maryland 20814.
7. Such studies include R. Ernst and J. Hay, "The U.S. Economic and Social Costs of Alzheimer's Disease Revisited," American Journal of Public Health 84, no. 8 (1994): 1261-1264; D.P. Rice et al., "The Economic Burden of Alzheimer's Disease Care," Health Affairs (Summer 1993): 164-176; and C. Henke and M. Burchmore, "The Economic Impact of Tacrine in the Treatment of Alzheimer's Disease," Clinical Therapeutics 19, no. 2 (1997): 330-345. A more complete reference list is available from the authors at Project HOPE Center for Health Affairs, Suite 600, 7500 Old Georgetown Road, Bethesda, Maryland 20814.
8. Examples of small restricted samples include J. Hay and R. Ernst, "The Economic Costs of Alzheimer's Disease," American Journal of Public Health 77, no. 7 (1987): 1169-1175; E.J. Souetre et al., "Economic Analysis of Alzheimer's Disease in Outpatients: Impact of Symptom Severity," International Psychogeriatrics 7, no. 1 (1995): 115-22; and H.G. Welch et al., "The Cost of Institutional Care in Alzheimer's Disease: Nursing Home and Hospital Use in a Prospective Cohort," Journal of the American Geriatric Society 40, no. 3 (1992): 221-224. Examples of samples limited to community residents include M. Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home," American Journal of Public Health 83, no. 3 (1993): 338-341; and Welch et al., "The Cost of Institutional Care in Alzheimer's Disease." An example of a synthetic sample is Hay and Ernst, "The Economic Costs of Alzheimer's Disease." Questionable approaches to establish diagnosis are in M. Stommel et al., "The Costs of Family Contributions to the Care of Persons with Dementia," Gerontologist 34, no. 2 (1994): 199-205; and Rice et al., "The Economic Burden of Alzheimer's Disease Care." Questionable approaches to measure disease severity are in Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home;" and Ernst and Hay, "The U.S. Economic and Social Costs of Alzheimer's Disease Revisited."
9. Examples of small restricted samples include J. Hay and R. Ernst, "The Economic Costs of Alzheimer's Disease," American Journal of Public Health 77, no. 7 (1987): 1169-1175; E.J. Souetre et al., "Economic Analysis of Alzheimer's Disease in Outpatients: Impact of Symptom Severity," International Psychogeriatrics 7, no. 1 (1995): 115-22; and H.G. Welch et al., "The Cost of Institutional Care in Alzheimer's Disease: Nursing Home and Hospital Use in a Prospective Cohort," Journal of the American Geriatric Society 40, no. 3 (1992): 221-224. Examples of samples limited to community residents include M. Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home," American Journal of Public Health 83, no. 3 (1993): 338-341; and Welch et al., "The Cost of Institutional Care in Alzheimer's Disease." An example of a synthetic sample is Hay and Ernst, "The Economic Costs of Alzheimer's Disease." Questionable approaches to establish diagnosis are in M. Stommel et al., "The Costs of Family Contributions to the Care of Persons with Dementia," Gerontologist 34, no. 2 (1994): 199-205; and Rice et al., "The Economic Burden of Alzheimer's Disease Care." Questionable approaches to measure disease severity are in Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home;" and Ernst and Hay, "The U.S. Economic and Social Costs of Alzheimer's Disease Revisited."
10. Examples of small restricted samples include J. Hay and R. Ernst, "The Economic Costs of Alzheimer's Disease," American Journal of Public Health 77, no. 7 (1987): 1169-1175; E.J. Souetre et al., "Economic Analysis of Alzheimer's Disease in Outpatients: Impact of Symptom Severity," International Psychogeriatrics 7, no. 1 (1995): 115-22; and H.G. Welch et al., "The Cost of Institutional Care in Alzheimer's Disease: Nursing Home and Hospital Use in a Prospective Cohort," Journal of the American Geriatric Society 40, no. 3 (1992): 221-224. Examples of samples limited to community residents include M. Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home," American Journal of Public Health 83, no. 3 (1993): 338-341; and Welch et al., "The Cost of Institutional Care in Alzheimer's Disease." An example of a synthetic sample is Hay and Ernst, "The Economic Costs of Alzheimer's Disease." Questionable approaches to establish diagnosis are in M. Stommel et al., "The Costs of Family Contributions to the Care of Persons with Dementia," Gerontologist 34, no. 2 (1994): 199-205; and Rice et al., "The Economic Burden of Alzheimer's Disease Care." Questionable approaches to measure disease severity are in Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home;" and Ernst and Hay, "The U.S. Economic and Social Costs of Alzheimer's Disease Revisited."
11. Examples of small restricted samples include J. Hay and R. Ernst, "The Economic Costs of Alzheimer's Disease," American Journal of Public Health 77, no. 7 (1987): 1169-1175; E.J. Souetre et al., "Economic Analysis of Alzheimer's Disease in Outpatients: Impact of Symptom Severity," International Psychogeriatrics 7, no. 1 (1995): 115-22; and H.G. Welch et al., "The Cost of Institutional Care in Alzheimer's Disease: Nursing Home and Hospital Use in a Prospective Cohort," Journal of the American Geriatric Society 40, no. 3 (1992): 221-224. Examples of samples limited to community residents include M. Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home," American Journal of Public Health 83, no. 3 (1993): 338-341; and Welch et al., "The Cost of Institutional Care in Alzheimer's Disease." An example of a synthetic sample is Hay and Ernst, "The Economic Costs of Alzheimer's Disease." Questionable approaches to establish diagnosis are in M. Stommel et al., "The Costs of Family Contributions to the Care of Persons with Dementia," Gerontologist 34, no. 2 (1994): 199-205; and Rice et al., "The Economic Burden of Alzheimer's Disease Care." Questionable approaches to measure disease severity are in Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home;" and Ernst and Hay, "The U.S. Economic and Social Costs of Alzheimer's Disease Revisited."
12. Examples of small restricted samples include J. Hay and R. Ernst, "The Economic Costs of Alzheimer's Disease," American Journal of Public Health 77, no. 7 (1987): 1169-1175; E.J. Souetre et al., "Economic Analysis of Alzheimer's Disease in Outpatients: Impact of Symptom Severity," International Psychogeriatrics 7, no. 1 (1995): 115-22; and H.G. Welch et al., "The Cost of Institutional Care in Alzheimer's Disease: Nursing Home and Hospital Use in a Prospective Cohort," Journal of the American Geriatric Society 40, no. 3 (1992): 221-224. Examples of samples limited to community residents include M. Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home," American Journal of Public Health 83, no. 3 (1993): 338-341; and Welch et al., "The Cost of Institutional Care in Alzheimer's Disease." An example of a synthetic sample is Hay and Ernst, "The Economic Costs of Alzheimer's Disease." Questionable approaches to establish diagnosis are in M. Stommel et al., "The Costs of Family Contributions to the Care of Persons with Dementia," Gerontologist 34, no. 2 (1994): 199-205; and Rice et al., "The Economic Burden of Alzheimer's Disease Care." Questionable approaches to measure disease severity are in Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home;" and Ernst and Hay, "The U.S. Economic and Social Costs of Alzheimer's Disease Revisited."
13. Examples of small restricted samples include J. Hay and R. Ernst, "The Economic Costs of Alzheimer's Disease," American Journal of Public Health 77, no. 7 (1987): 1169-1175; E.J. Souetre et al., "Economic Analysis of Alzheimer's Disease in Outpatients: Impact of Symptom Severity," International Psychogeriatrics 7, no. 1 (1995): 115-22; and H.G. Welch et al., "The Cost of Institutional Care in Alzheimer's Disease: Nursing Home and Hospital Use in a Prospective Cohort," Journal of the American Geriatric Society 40, no. 3 (1992): 221-224. Examples of samples limited to community residents include M. Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home," American Journal of Public Health 83, no. 3 (1993): 338-341; and Welch et al., "The Cost of Institutional Care in Alzheimer's Disease." An example of a synthetic sample is Hay and Ernst, "The Economic Costs of Alzheimer's Disease." Questionable approaches to establish diagnosis are in M. Stommel et al., "The Costs of Family Contributions to the Care of Persons with Dementia," Gerontologist 34, no. 2 (1994): 199-205; and Rice et al., "The Economic Burden of Alzheimer's Disease Care." Questionable approaches to measure disease severity are in Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home;" and Ernst and Hay, "The U.S. Economic and Social Costs of Alzheimer's Disease Revisited."
14. Examples of small restricted samples include J. Hay and R. Ernst, "The Economic Costs of Alzheimer's Disease," American Journal of Public Health 77, no. 7 (1987): 1169-1175; E.J. Souetre et al., "Economic Analysis of Alzheimer's Disease in Outpatients: Impact of Symptom Severity," International Psychogeriatrics 7, no. 1 (1995): 115-22; and H.G. Welch et al., "The Cost of Institutional Care in Alzheimer's Disease: Nursing Home and Hospital Use in a Prospective Cohort," Journal of the American Geriatric Society 40, no. 3 (1992): 221-224. Examples of samples limited to community residents include M. Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home," American Journal of Public Health 83, no. 3 (1993): 338-341; and Welch et al., "The Cost of Institutional Care in Alzheimer's Disease." An example of a synthetic sample is Hay and Ernst, "The Economic Costs of Alzheimer's Disease." Questionable approaches to establish diagnosis are in M. Stommel et al., "The Costs of Family Contributions to the Care of Persons with Dementia," Gerontologist 34, no. 2 (1994): 199-205; and Rice et al., "The Economic Burden of Alzheimer's Disease Care." Questionable approaches to measure disease severity are in Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home;" and Ernst and Hay, "The U.S. Economic and Social Costs of Alzheimer's Disease Revisited."
15. Examples of small restricted samples include J. Hay and R. Ernst, "The Economic Costs of Alzheimer's Disease," American Journal of Public Health 77, no. 7 (1987): 1169-1175; E.J. Souetre et al., "Economic Analysis of Alzheimer's Disease in Outpatients: Impact of Symptom Severity," International Psychogeriatrics 7, no. 1 (1995): 115-22; and H.G. Welch et al., "The Cost of Institutional Care in Alzheimer's Disease: Nursing Home and Hospital Use in a Prospective Cohort," Journal of the American Geriatric Society 40, no. 3 (1992): 221-224. Examples of samples limited to community residents include M. Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home," American Journal of Public Health 83, no. 3 (1993): 338-341; and Welch et al., "The Cost of Institutional Care in Alzheimer's Disease." An example of a synthetic sample is Hay and Ernst, "The Economic Costs of Alzheimer's Disease." Questionable approaches to establish diagnosis are in M. Stommel et al., "The Costs of Family Contributions to the Care of Persons with Dementia," Gerontologist 34, no. 2 (1994): 199-205; and Rice et al., "The Economic Burden of Alzheimer's Disease Care." Questionable approaches to measure disease severity are in Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home;" and Ernst and Hay, "The U.S. Economic and Social Costs of Alzheimer's Disease Revisited."
16. Examples of small restricted samples include J. Hay and R. Ernst, "The Economic Costs of Alzheimer's Disease," American Journal of Public Health 77, no. 7 (1987): 1169-1175; E.J. Souetre et al., "Economic Analysis of Alzheimer's Disease in Outpatients: Impact of Symptom Severity," International Psychogeriatrics 7, no. 1 (1995): 115-22; and H.G. Welch et al., "The Cost of Institutional Care in Alzheimer's Disease: Nursing Home and Hospital Use in a Prospective Cohort," Journal of the American Geriatric Society 40, no. 3 (1992): 221-224. Examples of samples limited to community residents include M. Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home," American Journal of Public Health 83, no. 3 (1993): 338-341; and Welch et al., "The Cost of Institutional Care in Alzheimer's Disease." An example of a synthetic sample is Hay and Ernst, "The Economic Costs of Alzheimer's Disease." Questionable approaches to establish diagnosis are in M. Stommel et al., "The Costs of Family Contributions to the Care of Persons with Dementia," Gerontologist 34, no. 2 (1994): 199-205; and Rice et al., "The Economic Burden of Alzheimer's Disease Care." Questionable approaches to measure disease severity are in Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home;" and Ernst and Hay, "The U.S. Economic and Social Costs of Alzheimer's Disease Revisited."
17. Examples of small restricted samples include J. Hay and R. Ernst, "The Economic Costs of Alzheimer's Disease," American Journal of Public Health 77, no. 7 (1987): 1169-1175; E.J. Souetre et al., "Economic Analysis of Alzheimer's Disease in Outpatients: Impact of Symptom Severity," International Psychogeriatrics 7, no. 1 (1995): 115-22; and H.G. Welch et al., "The Cost of Institutional Care in Alzheimer's Disease: Nursing Home and Hospital Use in a Prospective Cohort," Journal of the American Geriatric Society 40, no. 3 (1992): 221-224. Examples of samples limited to community residents include M. Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home," American Journal of Public Health 83, no. 3 (1993): 338-341; and Welch et al., "The Cost of Institutional Care in Alzheimer's Disease." An example of a synthetic sample is Hay and Ernst, "The Economic Costs of Alzheimer's Disease." Questionable approaches to establish diagnosis are in M. Stommel et al., "The Costs of Family Contributions to the Care of Persons with Dementia," Gerontologist 34, no. 2 (1994): 199-205; and Rice et al., "The Economic Burden of Alzheimer's Disease Care." Questionable approaches to measure disease severity are in Weinberger et al., "Expenditures in Caring for Patients with Dementia Who Live at Home;" and Ernst and Hay, "The U.S. Economic and Social Costs of Alzheimer's Disease Revisited."
18. G. McKhann et al., "Clinical Diagnosis of Alzheimer's Disease: Report of the NINCDS-ADRDA Work Group under the Auspices of Department of Health and Human Services Task Force on Alzheimer's Disease," Neurology 34, no. 7 (1984): 939-944. (ADRDA was later renamed the Alzheimer's Association, but the criteria continue to carry the older designation.)
19. Donors from the MCBS were matched to sample Alzheimer's disease patients using age, sex, race, marital status, income, and health status. Caregivers were asked about the patient's use of services but were not asked about quantity. For service use, national monthly estimates from various secondary sources were applied to those who indicated use (see Note 7).
20. Unit cost for hospital days, ER and doctor visits, prescribed medications, SNF days, personal care, and homemaker services were derived from the 1994 MCBS data for Alzheimer's disease beneficiaries. Cost and average weekly use for adult day care came from the nationwide surveys from Partners in Caregiving: Dementia Services Program, Bowman Gray School of Medicine, Wake Forest University. Service use estimates for personal care and homemaker services came from the 1994 Medicare claim files covering Alzheimer's disease patients. Unit costs for intermediate nursing home care came from the National Evaluation of Special Care Units (NESCU) project, and costs for assisted living facilities came from a 1996 national survey of assisted living facilities (see Note 2). 8. CPI cost adjusters were obtained from Health Care Financing Review 18, no. 4 (1997): 156.
21. In this section all reported significant differences between two means are based on t-test; where noted, one-way analysis of variance (ANOVA) was used for comparison involving multiple means. Complete methodological details are available from the authors.
22. Although the increased level of institutionalization is driven by the construction of the sample, it is not an unreasonable assumption to expect that within the population of persons with dementia, the more severely impaired would more likely be found in residential settings (see Exhibit 1).
23. 2): In calculating the average net cost increases for total costs and informal care, the correction factor is subtracted from the amount attributable to disease severity.
24. After controlling for differences in disease severity and number of comorbid conditions.
25. Such an improvement would be from a CDR of 1 down to a CDR of 0.5 or, conversely, a delay in the progression from 0.5 to 1.
26. Such an improvement would be from a CDR of 2 back to 1 or a delay in the progression from 1 to 2.
27. 2 = 4; 4 × 77.72 = $310.88).
28. GAO, Alzheimer's Disease.
29. The National Institute on Aging (NIA) estimates that there were approximately 3.7 million persons with Alzheimer's disease in 1996, compared with the GAO's estimate of 1.9 million. Using NIA estimates, total costs in 1996 for the mildly impaired and the moderately/severely impaired reached $42.4 billion and $46.3 billion, respectively, and $88.7 billion across all levels.
30. Our total per patient cost estimates are lower than the estimates provided by others primarily because we used more conservative hourly wage rates in calculating the costs of informal care, we restricted the range of informal time to defined ranges, and we used the lower cost of assisted living when estimating the costs of residential care. Previous studies rely exclusively on the higher costs of nursing home care. Our estimates also reflect more finely tuned approximations because of our ability to classify patients by Alzheimer's disease severity. More details are available from the authors.
31. Study limitations include a cross-sectional view of a non-randomly selected sample in which most of the service use data are based on family caregivers' recall. In addition, the estimates of service use of certain categories services do not come directly from the cross-sectional survey but rather from a combination of survey data and secondary sources.
32. J. Leon, "Characteristics of Dementia Admissions to Standard Nursing Homes and to Special Care Units," American Journal of Alzheimer's Disease 13, no. 1 (1998): 15-28; and G. Strahan, "An Overview of Nursing Homes and Their Current Residents: Data from the 1995 National Nursing Home Survey," Advance Data from Vital and Health Statistics, DHHS Pub. no. (PHS)97-1250 (Washington: U.S. Government Printing Office, 1997).
33. J. Leon, "Characteristics of Dementia Admissions to Standard Nursing Homes and to Special Care Units," American Journal of Alzheimer's Disease 13, no. 1 (1998): 15-28; and G. Strahan, "An Overview of Nursing Homes and Their Current Residents: Data from the 1995 National Nursing Home Survey," Advance Data from Vital and Health Statistics, DHHS Pub. no. (PHS)97-1250 (Washington: U.S. Government Printing Office, 1997).
34. Henke and Burchmore, "The Economic Impact of Tacrine."
35. K. Maslow, "Current Knowledge about Special Care Units: Findings of a Study by the U.S. Office of Technology Assessment," Alzheimer Disease and Associated Disorders 8, no. 1 (1994): S14-S40.
36. L. Fratiglioni et al., "Prevalence of Alzheimer's Disease and Other Demetias in an Elderly Urban Population: Relationship with Age, Sex, and Education," Neurology 41, no. 12 (1991): 1886-1892.
37. J. Leon et al., "Health Related Quality of Life and Health Service Utilization for Mild, Moderate, and Severely Impaired Alzheimer's Disease Patients: A Cross-Sectional Study," Neurology 50, no. 4-S4 (1998): A302.
38. R. Mollica and K. Snow, State Assisted Living Policy: 1996 (Portland, Maine: National Academy for State Health Policy, November 1996).