A more precise diagnosis by means of amyloid PET contributes to delayed institutionalization, lower mortality, and reduced care costs in a tertiary memory clinic setting.

INTRODUCTION: We aim to study the effect of a more precise diagnosis, by means of amyloid positron emission tomography (PET), on institutionalization, mortality, and health-care costs. METHODS: Between October 27, 2014 and December 31, 2016, we offered amyloid PET to all patients as part of their diagnostic work-up. Patients who accepted to undergo amyloid PET (n = 449) were propensity score matched with patients without amyloid PET (n = 571, i.e., no PET). Matched groups (both n = 444) were compared on rate of institutionalization, mortality, and health-care costs in the years after diagnosis. RESULTS: Amyloid PET patients had a lower risk of institutionalization (10% [n = 45] vs. 21% [n = 92]; hazard ratio [HR] = 0.48 [0.33-0.70]) and mortality rate (11% [n = 49] vs. 18% [n = 81]; HR = 0.51 [0.36-0.73]) and lower health-care costs in the years after diagnosis compared to matched no-PET patients (ß = -4573.49 [-6524.76 to -2523.74], P-value < 0.001). DISCUSSION: A more precise diagnosis in tertiary memory clinic patients positively influenced the endpoints of institutionalization, death, and health-care costs.

Examining the Role of Aging Perceptions in Subjective Cognitive Decline.

OBJECTIVE: While subjective cognitive decline (SCD) is gaining ground as a "preclinical" risk state for Alzheimer disease, its utility depends on our understanding of the factors linked to SCD. Rarely examined sociocultural factors including perceptions of aging may relate to the subjective experience of cognitive aging. Identifying such associations will help to refine the utility of SCD as an early marker of AD while setting the stage for addressing modifiable factors contributing to SCD. METHODS: The study consisted of N=136 participants (68% female; 73% White; 22% Black race, age mean =74.72; education mean =16.01). Questionnaires assessed SCD, depressive symptoms, and age perceptions (essentialist aging beliefs, subjective age, age group identification, and explicit/implicit age stereotypes). Cognitive functioning was measured with a semantic interference and learning task. RESULTS: SCD was correlated with essentialist aging beliefs, age identification, and depressive symptoms [ rrange =0.18 to 0.22, Prange =0.009 to 0.02, confidence interval (CI) range =0.00-0.39]. Essentialist aging beliefs were correlated with subjective age and age group identification ( rrange =0.22 to 0.42, Prange <0.001 to 0.003, CI range =0.08-0.57). Both age group identification and essentialism were correlated with depressive symptoms ( rrange =0.22, Prange =0.009 to 0.01, CI range =0.04-0.39). In the adjusted regression model including depressive symptoms, age perceptions, and SCD, only SCD was associated with cognition ( b =-0.31, P <0.001). CONCLUSION: Although correlated with SCD, perceptions of aging do not explain the relationship between SCD and performance on a sensitive cognitive test among older adults.

Cost-effectiveness of full endoscopic versus open discectomy for sciatica.

OBJECTIVE: To assess the costs and cost-effectiveness of percutaneous transforaminal endoscopic discectomy (PTED) compared with open microdiscectomy among patients with sciatica. METHODS: This economic evaluation was conducted alongside a 12-month multicentre randomised controlled trial with a non-inferiority design, in which patients were randomised to PTED or open microdiscectomy. Patients were aged from 18 to 70 years and had at least 6 weeks of radiating leg pain caused by lumbar disc herniation. Effect measures included leg pain and quality-adjusted life years (QALYs), as derived using the EQ-5D-5L. Costs were measured from a societal perspective. Missing data were multiply imputed, bootstrapping was used to estimate statistical uncertainty, and various sensitivity analyses were conducted to determine the robustness. RESULTS: Of the 613 patients enrolled, 304 were randomised to PTED and 309 to open microdiscectomy. Statistically significant differences in leg pain and QALYs were found in favour of PTED at 12 months follow-up (leg pain: 6.9; 95% CI 1.3 to 12.6; QALYs: 0.040; 95% CI 0.007 to 0.074). Surgery costs were higher for PTED than for open microdiscectomy (ie, €4500/patient vs €4095/patient). All other disaggregate costs as well as total societal costs were lower for PTED than for open microdiscectomy. Cost-effectiveness acceptability curves indicated that the probability of PTED being less costly and more effective (ie, dominant) compared with open microdiscectomy was 99.4% for leg pain and 99.2% for QALYs. CONCLUSIONS: Our results suggest that PTED is more cost-effective from the societal perspective compared with open microdiscectomy for patients with sciatica. TRIAL REGISTRATION NUMBER: NCT02602093.

Five-year cost-effectiveness analysis of the European Fans in Training (EuroFIT) physical activity intervention for men versus no intervention.

OBJECTIVES: Increasing physical activity reduces the risk of chronic illness including Type 2 diabetes, cardiovascular disease and certain types of cancer. Lifestyle interventions can increase physical activity but few successfully engage men. This study aims to investigate the 5 year cost-effectiveness of EuroFIT, a program to improve physical activity tailored specifically for male football (soccer) fans compared to a no intervention comparison group. METHODS: We developed a Markov cohort model in which the impact of improving physical activity on five chronic health conditions (colorectal cancer, Type 2 diabetes, coronary heart disease, stroke and depression) and mortality was modelled. We estimated costs from a societal perspective and expressed benefits as quality adjusted life years (QALYs). We obtained data from a 4-country (England, Netherlands, Portugal and Norway) pragmatic randomised controlled trial evaluating EuroFIT, epidemiological and cohort studies, and meta-analyses. We performed deterministic and probabilistic sensitivity analyses to assess the impact of uncertainty in the model's parameter values on the cost-effectiveness results. We used Monte Carlo simulations to estimate uncertainty and presented this using cost-effectiveness acceptability curves (CEACs). We tested the robustness of the base case analysis using five scenario analyses. RESULTS: Average costs over 5 years per person receiving EuroFIT were €14,663 and per person receiving no intervention €14,598. Mean QALYs over 5 years were 4.05 per person for EuroFIT and 4.04 for no intervention. Thus, the average incremental cost per person receiving EuroFIT was €65 compared to no intervention, while the average QALY gain was 0.01. This resulted in an ICER of €5206 per QALY gained. CEACs show that the probability of EuroFIT being cost-effective compared to no intervention is 0.53, 0.56 and 0.58 at thresholds of €10,000, €22,000 and €34,000 per QALY gained, respectively. When using a time horizon of 10 years, the results suggest that EuroFIT is more effective and less expensive compared to (i.e. dominant over) no intervention with a probability of cost-effectiveness of 0.63 at a threshold of €22,000 per QALY gained. CONCLUSIONS: We conclude the EuroFIT intervention is not cost-effective compared to no intervention over a period of 5 years from a societal perspective, but is more effective and less expensive (i.e. dominant) after 10 years. We thus suggest that EuroFIT can potentially improve public health in a cost-effective manner in the long term.

Costs of Mental Health Services in Czechia: Facilitating an Evidence-Based Reform of Psychiatric Care.

BACKGROUND: Information about unit costs of psychiatric care is largely unavailable in Central and Eastern Europe, which poses an obstacle to economic evaluations as well as evidence-based development of the care in the region. OBJECTIVE: The objective of this study was to calculate the unit costs of inpatient and community mental health services in Czechia and to assess the current practices of data collection by mental healthcare providers. METHODS: We used bottom-up microcosting to calculate unit costs from detailed longitudinal accounts and records kept by three psychiatric hospitals and three community mental health providers. RESULTS: An inpatient day in a psychiatric hospital costs 1504 Czech koruna (CZK; €59), out of which 75% is consumed by hotel services and the rest by medication and therapies. The costed inpatient therapies include individual therapies provided by a psychiatrist or psychologist, consultations with a social worker, group therapies, organised cultural activities and training activities. As regards the community setting, we costed daycare social facilities, case management services, sheltered housing, supported housing, crisis help, social therapeutic workshops, individual placement and support, and self-help groups. CONCLUSIONS: The unit costs enable assigning financial value to individual items monitored by the Czech version of the Client Service Receipt Inventory, and thus estimation of costs associated with treatment of mental health problems. The employed methodology might serve as a guideline for the providers to improve data collection and to calculate costs of services themselves, with this information likely becoming more crucial for payers in the future.

Expenditures on Mental Health Care in the Czech Republic in 2015.

Expenditures on mental health care in the Czech Republic are not being published regularly, yet they are indispensable for evaluation of the ongoing reform of Czech mental health care. The main objective of this study is to estimate the size of these expenditures in 2015 and make a comparison with the last available figures from the year 2006. The estimation is based on an OECD methodology of health accounts, which structures health care expenditures according to health care functions, provider industries, and payers. The expenditures are further decomposed according to diagnoses, and inputs used in service production. The amount spent on mental health care in 2015 reached more than 13.7 billion Czech korunas (EUR 501.6 million), which represented 4.08% of the total health care expenditures. This ratio is almost identical with the 2006 share (4.14%). There are no significant changes in the relative expenditures on mental health care and in the structure of service provision. The Czech mental health care system remains largely hospital based with most of all mental health care expenditures being spent on inpatient care. Future developments in the expenditures will indicate the success of the current effort to deinstitutionalise mental health care.

The Potential Impact of Alzheimer's Disease Early Treatment on Societal Costs of Care in Czechia: A Simulation Approach.

BACKGROUND: In Czechia, only about a quarter of people suffering from the Alzheimer's disease (AD) receive (usually belated) treatment. Because of their more rapid cognitive decline, untreated patients require extensive assistance with basic daily activities earlier than those receiving treatment. This assistance provided at home and nursing homes represents a substantial economic burden. AIMS OF THE STUDY: To calculate lifetime costs of care per AD patient and to evaluate potential care savings from early treatment. METHODS: We use Monte Carlo simulation to model lifetime societal costs of care per patient under two different scenarios. In the first one, a cohort of 100,000 homogeneous patients receives usual care under which the majority of patients are undiagnosed or diagnosed late. The second scenario models a hypothetical situation in which an identical cohort of patients starts receiving treatment early after the disease onset. Data on the rates of cognitive decline for treated and untreated patients, and survival probability for AD patients are derived from foreign clinical studies. Information on costs and population characteristics is compiled on the basis of published Czech research and databases. RESULTS: Early treatment of AD decreases social lifetime costs of care. This result holds true regardless of gender, age at which the disease is contracted, or whether the patient lives at home or uses a social residential service. The potential savings amount up to Euro 26,800 (23,500) per woman (man), being negatively correlated with the age at which the disease onsets as well as the delay between the onset and treatment initiation DISCUSSION: The results suggest that early treatment of AD would decrease costs of care in Czechia. The main limitation of the simulation arises from the fact that missing domestic information was substituted by input from foreign clinical trials or simplifying assumptions. Because of insufficient data, we do not model hospitalization risk; on the other hand, introduction of this risk into our model would likely increase the savings from early treatment. IMPLICATIONS FOR HEALTH POLICIES: Makers of AD policies ought to appreciate the trade-off between costs of daily assistance in untreated patients and health care costs in treated patients, notwithstanding that the costs of assistance are largely born by households rather than public budgets. Our results show that the savings on costs of assistance brought about by early treatment would exceed the additional costs of treatment. IMPLICATIONS FOR FURTHER RESEARCH: A number of missing or insufficient data about the Czech Alzheimer's population were identified. In addition, to determine the total societal cost-effect of early treatment, further research ought to evaluate the related increase in detection costs. Finally, it should also assess cost-effectiveness of early treatment by considering its impact on patients' utility.