PND64
Comparing resource use in Alzheimer’s disease across three
European countries – 18-month results of the GERAS study
Mark Belger,1 Josep Maria Argimon,2 Richard Dodel,3 Josep Maria Haro,4 Anders Wimo,5 Catherine Reed1
1Eli
Lilly and Company Limited, Windlesham, UK; 2Servei Català de la Salut, Barcelona, Spain; 3Philipps-University, Marburg, Germany;
4Parc Santari Sant Joan de Déu, CIBERSAM, Universitat de Barcelona, Barcelona, Spain; 5Karolinska Institute, Stockholm, Sweden
• To compare drivers of societal costs for AD over 18 months in three European
countries (France, Germany and the UK), using prospectively collected data
from GERAS.
METHODS
Study Design
• GERAS was an 18-month, multicenter, prospective, non-interventional cohort
study conducted in France, Germany and the UK.3
• Eligible patients were community-dwelling patients with probable AD4
presenting during the course of normal clinical care.
• Other inclusion criteria were:
‒ Age ≥55 years
‒ Mini-Mental State Examination (MMSE)5 score of ≤26 points
‒ Having an informal (i.e. non-professional) caregiver who was willing to
participate in the study and undertook responsibility for the patient for at
least 6 months of the year.
• Patients and caregivers were stratified according to patient AD dementia
severity at baseline:
‒ mild AD dementia (MMSE score 21–26 points)
‒ moderate AD dementia (MMSE score 15–20 points)
‒ moderately severe/severe (MS/S) AD dementia (MMSE score <15
points).
Resource Use Estimates
• Data on patient and caregiver resource use were captured using the Resource
Utilization in Dementia (RUD) instrument.6
• Caregiver time was recorded as time spent on assisting the patient with basic
activities of daily living (ADL; e.g. eating, bathing, dressing, using the
bathroom), instrumental ADL (e.g. housework, shopping, medication use,
financial management), and supervision (i.e. preventing dangerous events,
such as risks of fire, walking onto a road alone, walking outside without
appropriate clothing).
• All baseline resource use was measured as activity in the previous month.
• At each 6-month visit resource use was measured as activity in:
‒ The previous month for caregiver time
‒ The previous 3 months for community care services and outpatient visits
‒ The previous 6 months for hospitalizations and other resource use items.
• To enable cross-country comparisons, a weighted score for all community care
services and all outpatient visits was calculated by multiplying the individual
resource item by the average of the unit costs for the three countries, and then
summing the weighted value.
Cost Estimates
• Monthly costs were estimated for each country by applying unit costs of
services and products (2010 values) to the health and community care
resource use data collected over the 18-month follow-up period.3
‒ Monthly costs included the cost of temporary or permanent
institutionalization.
‒ A zero cost value was applied to caregiver supervision time.
• UK costs in pounds sterling (£) were converted to Euros (€) using the
conversion rate £1=€1.1661, calculated as the average monthly exchange rate
for 2010.3
• Total societal costs for each country were calculated using an opportunity cost
approach taking into account productivity loss for working caregivers and lost
leisure time for non-working caregivers.
• Total societal costs were calculated by adding patient healthcare costs, patient
social care costs, and caregiver informal care costs.
Statistical Models
• Models for differences in resource use between countries were analyzed for
each resource use item, and adjusted for (in addition to country): patient age,
patient gender, MMSE severity group (mild, moderate, MS/S), number of
patient comorbidities, baseline total ADL score, caregiver age, caregiver
relationship (spouse, yes/no), caregiver working for pay and baseline score for
the resource use item.
• Country differences for each resource use item were analyzed by repeated
measures models of resource use at each 6-month visit.
• Least squares (LS) mean estimates and 95% confidence intervals (CI) are
presented by country from each model.
• Data from generalized linear models (GLM) with gamma distribution and loglink function (caregiver time, 3-month weighted scores for community care
services and outpatient visits) are presented as LS means.
• Data from logistic regression models (temporary accommodation, AD
medication, financial support received) are presented as odds ratios (OR); an
OR >1 represents an increased likelihood of that outcome compared with the
UK (reference country).
• Data from zero-inflated negative binomial distribution models (caregiver
missing work days, patient hospital stays, individual items for community care
services and outpatient visits) are presented as OR for having the event, and
the LS means of those having the event.
• Data from proportional hazards models (time to institutionalization) are
presented as hazard ratios (HR).
ISPOR 20th Annual European Congress; Milan, Italy; Nov 7 – 11, 2015
p-value*
Country
UK
Patients, N
419
550
526
Age, years
79.4 (6.81)
75.2 (7.55)
78.5 (7.79)
Time since diagnosis, years
54.2
<0.001
<0.001
2.5 (2.41)
2.0 (2.14)
2.2 (2.13)
0.009
20.3
16.2
15.0
<0.001
17.2 (5.73)
17.7 (6.72)
17.3 (6.40)
<0.001
Living alone in own home (%)
Baseline MMSE score
(range 0‒30)
49.6
UK
France
100
80
60
40
20
0
Baseline total ADL score
(range 0‒78)
47.4 (18.16)
Number of patient
comorbidities
46.8 (17.69)
1.4 (1.19)
1.2 (1.15)
419
550
526
67.9 (12.39)
65.9 (11.78)
68.3 (11.90)
0.001
62.4
67.8
61.8
0.004
Gender (% female)
Caregiver relationship to
patient (% spouse)
61.7
67.6
67.5
<0.001
21.5
28.6
Overall Costs and Resource Use
• Estimated mean 18-month societal costs per patient were €33,339 in France,
€37,899 in the UK, and €38,197 in Germany.
• Costs increased with increasing AD severity (Figure 1).
• Caregiver time spent on basic and instrumental ADL was the largest
component of total societal costs in all three countries (range: 53.8% in France
to 64.8% in the UK).
• The six resource use items with the greatest contribution to total costs in each
country are shown in Table 2.
• Caregivers in France and Germany spent significantly less time on
instrumental ADL than caregivers in the UK (Figure 2).
• Caregiver time spent on supervision did not differ between countries.
• Patients in France used more community care services than patients in
Germany or the UK (Figure 3).
Figure 1. Estimated Mean Total Societal Costs Per Patient Over 18
Months by Country and Severity
60,000
50,947
50,795
50,000
41,905
42,430
40,000
33,800
36,038
30,161
30,000
France
Germany
UK
26,017
23,883
10,000
Mild AD
Moderate AD
MS/S AD
CI, confidence interval; AD, Alzheimer’s Disease; MS/S,
moderately severe/severe
• ORs for individual services showed that patients in France were more likely to
receive home aid visits (OR 4.76 [95% CI 3.13, 7.14]; p<0.001) than patients
in the UK, but if the service was used, patients in the UK had more home aid
visits (3-month weighted score 43.5) than patients in the other two countries
(3-month weighted score 32.2 for France, 22.3 for Germany; p<0.001 vs. UK
for both countries).
• Compared with patients in the UK, patients in Germany (HR 0.59 [95% CI
0.41, 0.84]; p=0.0143) but not France (0.84 [0.60, 1.18]) showed a longer time
to institutionalization.
• The number of outpatient visits was significantly lower in the UK than in
France or Germany (Figure 3).
• The number of hospital stays and use of AD medication did not differ between
countries (Table 3).
• Patients in the UK were significantly more likely to receive financial support
than patients in France or Germany (Table 3).
12
Months
20
18
Germany
6
12
Months
18
France
800
700
600
500
400
300
200
100
0
6
Weighted outpatient visits
UK
900
12
Months
18
Germany
UK
350
300
250
200
150
100
50
0
6
12
Months
18
*Derived from repeated measures generalized linear models with gamma distribution and log-link
function, including all patients regardless of disease severity
CI, confidence interval; LS least squares
Table 3. Likelihood of Additional Resource Use in Past 6 Months
Relative to UK
Odds ratio (95% confidence interval)
France
Germany
UK (reference)
AD medications*
1.38 (0.75, 2.53)
1.23 (0.68, 2.22)
1.00
Caregiver missed
work days**
0.31 (0.04, 2.44)
0.19† (0.04, 0.85)
1.00
Hospital stay**
0.65 (0.39, 1.11)
0.81 (0.50, 1.32)
1.00
Financial support
received by
caregiver/patient*
0.10† (0.07, 0.16)
0.35† (0.25, 0.49)
1.00
*Derived from repeated measures logistic regression models; an OR >1 indicates greater use of AD
medications.
**Derived from a zero-inflated repeated measures generalized linear model with negative binomial
distribution
†p≤0.003 vs UK.
• Our analyses of resource use are only applicable to community-dwelling
patients and cannot be extended to patients living permanently in long-term
care.
• Resource use was collected at each visit via interview with the caregiver, so
may be subject to recall bias.
• We only analyzed time spent providing informal care by the primary caregiver,
which may result in the underestimation of informal caregiving time, as it is
possible that AD patients receive care from several family members.
CONCLUSIONS
• The 18-month GERAS study showed differences between France,
Germany and the UK in resource utilization for AD.
‒ These differences resulted in between-country differences in the total
societal costs of AD.
• Caregiver time was consistently the main contributor to 18-month total
societal costs.
• It is difficult to assess how differences in resource utilization contributed to
the overall cost differences between countries.
‒ However, some of the between-country differences in caregiver time
could be explained by differing use of community care services and
institutionalization.
• Other differences in resource use across countries reflect country-specific
health and social care systems, but had limited influence on differences in
total societal costs.
Table 2. The Top Six Resource Use Items in Each Country Over the
18-Month Period
France
Germany
UK
Caregiver time (53.8%)
Caregiver time (64.1%)
Caregiver time (64.8%)
2. Community care services (15.4%)
AD medication (13.9%)
Financial support (13.6%)
3.
AD medication (10.3%)
Outpatient visits (6.2%)
Institutionalization (7.8%)
4.
Institutionalization (6.5%)
Financial support (5.4%)
AD medication (7.5%)
5.
Outpatient visits (5.4%)
Institutionalization (4.8%)
Community care services (7.3%)
6.
40
LIMITATIONS
20,000
0
1.
60
Weighted community care services
score
0.460
Data are presented as means (SD) unless otherwise indicated. ADL, Activities of Daily Living;
MMSE, Mini-Mental State Examination
*p-values for comparison between countries derived from Cochran–Mantel–Haenszel tests for
categorical variables and analysis of variance (ANOVA) with independent factors for MMSE severity
and country for continuous variables.
80
Figure 3. Weighted Community Care Services Score and
Outpatient Visits in Each Country Over Time
0.020
20.5
100
*Derived from repeated measures generalized linear models with gamma distribution and log-link
function
ADL, Activities of Daily Living; CI, confidence interval; LS least squares
France
Caregiver working for pay (%)
UK
0
6
0.001
1.8 (1.27)
Caregivers, N
Age, years
45.5 (21.92)
Germany
120
LS mean (95% CI) caregiver hours*
Germany
62.3
Germany
Instrumental ADL
120
France
Gender (% female)
France
LS mean (95% CI) caregiver hours*
Baseline characteristic
Basic ADL
LS mean (95% CI) number of visits*
OBJECTIVE
Table 1. Patient and Caregiver Characteristics at Baseline
LS mean (95% CI) score*
• Studies from several European countries have shown that the total societal
costs of caring for patients with Alzheimer’s disease (AD) vary across countries
and regions.1,2
• Differences between countries and regions in healthcare system structure and
resource availability have a direct impact on resource utilization and costs.
• Some data on resource utilization in AD in Europe exist,2 but few studies have
examined resource use in multiple countries, included a large sample size and
prospective follow-up, used standardized measures of resource use, or
included the full range of AD severities.1,2
• GERAS was a prospective cohort study conducted in France, Germany and
the UK, designed to evaluate resource use and costs associated with AD for
community-dwelling patients and their caregivers.3
• Baseline data from GERAS showed that resource use and costs increased
with AD severity.3
Figure 2. Caregiver Time Spent on Basic and Instrumental ADL in
Each Country Over Time
RESULTS
Total mean (95% CI) societal costs (Euros)
BACKGROUND
Hospital stay (4.4%)
Hospital stay (4.1%)
Temporary accommodation (3.9%)
References
1.
2.
3.
4.
5.
6.
Jönsson L, Wimo A. Pharmacoeconomics 2009;27:391‒403.
Gustavsson A et al. J Nutr Health Aging 2010;14:648‒54.
Wimo A et al. J Alzheimers Dis 2013;36:385–99.
McKhann G et al. Neurology 1984;34:939–44.
Folstein MF et al. J Psychiatric Res 1975;12:189‒98.
Wimo A et al. In: Wimo A, Jönsson B, Karlsson G, Winblad B (Eds.). Health Economics of
Dementia. London: John Wiley and Sons, 1998; 465–99.
Acknowledgments
The authors would like to acknowledge Catherine Rees and Sue Chambers (Rx Communications,
Mold, UK) for medical writing assistance with the preparation of this poster, funded by Eli Lilly and
Company.
Sponsored by Eli Lilly and Company