July 20, 2010 (Honolulu, Hawaii) — Early detection, diagnosis, and care of individuals with newly diagnosed cognitive impairment and dementia can significantly reduce outpatient healthcare costs new research suggests.
Presented here at the Alzheimer’s Association International Conference on Alzheimer’s Disease 2010, results from the Dementia Demonstration Project (DDP) a multicenter pilot program conducted at 7 Veterans Affairs Medical Centers (VAMCs), show healthcare costs for 1 year before and after diagnosis decreased by $1741 in the year after diagnosis of cognitive impairment compared with the year before diagnosis.
Dr. J. Riley McCarten
According to principal investigator, J. Riley McCarten, MD, dementia is common, costly, and underrecognized in the United States.
“We know dementia is common and affects over 5 million Americans age 65 and older. But in fact most people [with dementia] don’t have a diagnosis. It’s a looming crisis, and a big part of that crisis is due to a lack of recognition which leads to poor quality care and more costly care,” said Dr. McCarten, medical director of the Geriatric Research, Education and Clinical Center at the Minneapolis VAMC.
Screening Well Accepted, But Most Declined Further Evaluation
For the DDP, advanced practice registered nurses were trained in screening, evaluating, and managing cognitive impairment. They were embedded into typical primary care clinics at 7 VA centers and functioned as dementia care coordinators to lead interdisciplinary teams in the identification evaluation and management of cognitive impairment.
A total of 8342 veterans 70 years and older who had no previous diagnosis of dementia were offered screening for cognitive impairment and 8063 (97%) accepted during a routine primary care visit using the 2-minute, 5-point, Mini-Cog test, where a clock-drawing test is combined with a 3-word recall test. The cutoff for a positive screen result was 3 points or less.
Of the total cohort, 2081 (26%) failed the initial screen and were offered further evaluation. Of these individuals, only 33% (n = 681) agreed to a comprehensive evaluation. Of this group, 95% were diagnosed as having cognitive impairment, including 77% (n = 521) with full-blown dementia.
Of 345 patients with complete data thus far, mean total healthcare cost in the year before diagnosis (minus the $800 cost of the evaluation) was $13,378. In the year after diagnosis, it decreased to $11,636 for a mean difference of $1741.
“Even after subtracting the cost of the workup and evaluation, we were able to save more than $1700 per patient on average. This is very important because I don’t think we were convinced that making an early diagnosis of dementia would save money in the short-term. Most of us believe it will save money in the long-term, through better management of late stage dementia. The rate of cognitive impairment was pretty high, and this translates into potential cost savings of billions of dollars,” said Dr. McCarten.
However, he added, quality of care, and not cost savings, is the DDP’s primary goal.
Stop the ‘Pop-Drop’
Typically, said Dr. McCarten, patients with undiagnosed dementia go from crisis to crisis, which includes frequent visits to the emergency department and extensive testing.
“Through early diagnosis and proper chronic disease management, we hope to prevent this type of approach to care and put an end to the so-called pop-drop, where dad (or mom) is regularly brought to the emergency department because the family doesn’t know what else to do,” he said. This type of acute care approach is expensive, ineffective, and grueling for patients and families, he added.
One of the major barriers to early diagnosis, said Dr. McCarten, is a lack of compensation. Diagnosing and managing cognitive impairment take time, and busy physicians, mainly family practitioners, are not adequately compensated.
“It is a remarkable thing that brain function is so undervalued. Every other organ system is more important than the brain as far as the healthcare system is concerned,” he said.
Typically, patients presenting to their family physician’s office are screened for cognitive impairment by being asked their name, the date, and where they are, said Dr. McCarten.
“This is dreadful. We need to do something more aggressive to assess cognitive impairment. Dementia or any kind of cognitive impairment is a serious healthcare issue, and we should be doing everything we can to look for it. We should reward people who find it and [penalize] those who ignore it. We need to get [patients] the care they need and we should do it now,” he added.
Applying the principles of chronic disease management — including screening, evaluation, and education of patients and their families — would help avoid unnecessary healthcare costs and alleviate much of the uncertainty and subsequent anxiety and stress associated with an undiagnosed condition.
Knowledge of what is ahead can help patients and families plan for the future, said Dr. McCarten.
“If we can make an early diagnosis, we can provide some direction to our patients and help them find resources. At the very least this type of approach will give us an opportunity to avoid crises,” he said.
Commenting on the study, Ralph Nixon, MD, PhD, professor of psychiatry and cell biology, New York University School of Medicine in New York City, and vice chairman of the Alzheimer Association’s Medical and Scientific Advisory Council, said the study has important implications for reducing personal health costs.
“[This study shows] that early detection can possibly reduce personal health costs and adds to the other benefits that the Alzheimer’s Association has been emphasizing for quite some time. Early detection empowers people and allows them to take control of their future, gain better access to appropriate healthcare services, and to take advantage of potential clinical trials and new treatments as they become available,” he said.