Can a Measure of the Amount of Assistance a Patient with Alzheimer's Disease Requires to Perform Daily Tasks Be Used to Evaluate Cost-effectiveness of Therapy?

A poster submitted for presentation at the 2009 International Conference on Alzheimer’s Disease (ICAD) by Daniel L. Murman, MD, University of Nebraska Medical Center, and colleagues asks a key question in this era of managed care, tightening healthcare budgets, and possible comprehensive healthcare reform: could a tool that measures the level of care needed by patients with Alzheimer’s disease (AD) be used to help evaluate the cost effectiveness of AD treatments and therapies?

This question is worth asking for a number of reasons, as formulary managers, PBMs, insurers, and other third-party payers must constantly weigh clinical efficacy against cost-effectiveness when deciding whether to approve coverage of or payment for treatments. Because of this, Murman and colleagues note that it is important to “develop methods for translating clinical changes into economic outcomes.”

One method for doing this and predicting resource use and cost may be to evaluate the level of assistance patients with AD require to perform daily tasks, using the Dependence Scale (DS), a well-established level-of-care measure in AD.

To determine the usefulness of DS score for predicting cost of care, the researchers performed a baseline assessment of a cohort of 133 caregiver/AD patient pairs, with follow-up every 12 months for two years. AD patients were age 50-85 years and met NINCDS-ADRDA criteria for AD. In addition to caregiver-assessed DS scores, patients were also assessed with MMSE, NPI, the Columbia University Parkinson’s Rating Scale (at baseline), and the Comorbid Illnesses with Cumulative Illness Rating Scale. The study also recorded demographic data (age, marital status, education, etc), resource utilization during the previous 12 months (medication use, doctor visits, hospitalization, and other measures), and unpaid caregiving time (using the Caregiver Activity Time Survey).

Analysis of the data revealed that direct cost of care was “best predicted by DS summated score, [extent of] comorbid illness, and marital status.” DS sum and extent of comorbid illness were the best predictors of total costs. By way of comparison, the annual total cost of care for a married patient with moderate comorbid illness and DS sum of 2 was $3,760; the cost for a patient with same marital status and comorbid illness, but with a DS sum of 12, was $50,476.

These findings show that “the DS is a significant and important predictor of economic outcomes in AD.” The authors conclude that “information such as this can assist in the development of pharmaco-economic models for evaluating the cost-effectiveness of new AD treatments.”

The Dependence Scale

These are the 13 items caregivers are asked to evaluate:

A. Does the patient need reminders or advice to manage chores, do shopping, cooking, play games or handle money?

B. Does the patient need help to remember important things such as appointments, recent events or names of family or friends?

C. Does the patient need frequent (at least once a month) help finding misplaced objects, keeping appointments or maintaining health or safety (locking doors, taking medication)?

D. Does the patient need household chores done for them?

E. Does the patient need to be watched or kept company when awake?

F. Does the patient need to be escorted when outside?

G. Does the patient need to be accompanied when bathing or eating?

H. Does the patient have to be dressed, washed and groomed?

I. Does the patient have to be taken to the toilet regularly to avoid incontinence?

J. Does the patient have to be fed?

K. Does the patient need to be turned, moved, or transferred?

L. Does the patient wear a diaper or a catheter?

M. Does the patient need to be tube fed?

Click here to access an Archives of Neurology article that explains how the Dependence Scale is administered and scored.

Abstracts of all 2009 ICAD poster presentations are available in Alzheimer's & Dementia: The Journal of the Alzheimer's Association, Volume 5, Issue 4, Supplement (July 2009), online here. (You’ll have to click the “Next issue” arrow to view the table of contents for the Supplement.)