Costs of Medical Care for Dementia Patients in Taiwan: A Population-Based Study L.-J. E. Ku 1, T.-H. Lu 1, S.-L. Wu 1, M.-C. Pai 2* 古 鯉 榕, 呂 宗 學, 吳 士 良, 白 明 奇 April 19, 2013 1 Institute of Public Health, National Cheng Kung Univ, 2 Department of Neurology and Alzheimer s Disease Research Center, National Cheng Kung Univ Hospital, Tainan, Taiwan 1
Dementia in Taiwan Prevalence of dementia in Taiwan The disease prevalence is clearly on the rise, from 0.7% in 1996 to 4.97% in 2011 (Chien et al., 2008; DOH, 2013) Economic burden of dementia in Taiwan The first cost estimate published in 2002 was US$10,333- $23,691 (Chou et al., 2000) An updated cost estimate of $US14,398 for dementia patients who are living at home (Kuo et al., 2010) However, neither estimates included direct medical costs paid for by health insurance The cost of illness for dementia in Taiwan is yet to be known 2
Costs of dementia in the world Cost per person with dementia in US$ Asia Pacific High Income 12243 1852 14693 29057 Source: World Alzheimer Report, 2010, Table 11 & 15 3
Objectives To estimate treated prevalence and incidence rates of dementia in Taiwan among National Health Insurance (NHI) enrollees. To estimate medical costs for patients with dementia paid by the NHI To estimate the effect of using selected cognitive enhancers on health care costs among patients with dementia 4
Cognitive enhancers (CE) included in our study Category Cholinesterase Inhibitors (Che-I) NMDA Smart drugs Drug name Donepezil Rivastigmine Galantamine hydrobro Memantine Dihydroergotoxine Piracetam Nicergoline Callirein Ginkgo biloba Pentoxifylline 5
Reimbursement of pharmaceutical therapy for dementia in Taiwan Therapy for dementia with ChE-I and NMDA is covered by NHI in Taiwan since 2000 but with strict payment regulations Subjects must be the patients of mild or moderate AD must have complete case studies of clinical symptoms, blood tests, cognitive tests also requires neuro image such as brain CT or MRI Patients with cerebral vascular disease history were excluded Therapy with ChE-I and NMDA is no longer covered if the MMSE score worsened by more than 2 points or the CDR worsened by 1 grade On the other hands, vasodilators, also known as smart drugs are covered by NHI with no string attached 6
Methods Data source: Taiwan s National Health Insurance Research Database (NHIRD) Includes ambulatory care visits, inpatient admissions, and prescription drug use. Inclusion criteria: Senile or pre-senile organic psychotic condition (ICD-9-CM code 290), or Dementia in conditions classified elsewhere (294.1), or Alzheimer s disease (331.0) Study period: 2008-2011 Sample size: 425,074 persons with at least one diagnosis of dementia 91,814 persons who has ever used a cognitive enhancer 7
Cost of illness study approaches Key Distinctions Gross costs Net costs Top-down approach Bottom-up approach Prevalence approach Incidence approach 8
Statistical analysis Calculated annual treated prevalence and incidence rates Stratified by dementia subtype and gender Adjusted costs difference estimated using two-part model The first-part was a logit regression predicting any expenditure The second-part expenditure regression used a gamma regression with a log link Covariates controlled included age, gender and 16 conditions in the Charlson Comorbidity Index With propensity score adjustment 9
Results PRELIMINARY FINDINGS: PLEASE DO NOT CITE WITHOUT PERMISSION OF THE AUTHORS 10
Table 1. Number of prevalent and incident cases of dementia among 65 and above, 2009-2011 Prevalent Cases Incident Cases Overall Subtypes** Overall Subtypes** Year AD VAD Other type AD VAD Other type 2009 128,953 104,167 19,551 5,521 N/A N/A N/A N/A 2010 141,545 114,762 21,634 5,508 56,165 44,902 8,178 3,196 2011 154,576 125,622 23,357 5,977 55,001 44,212 7,916 3,004 Table 2. Treated prevalent and incident rates of dementia and its subtypes*, 2009-2011 Prevalent Cases Incident Cases Overall Subtypes** Overall Subtypes** Year AD VAD Other type AD VAD Other type 2009 5.3% 4.3% 0.8% 0.2% N/A N/A N/A N/A 2010 5.7% 4.6% 0.9% 0.2% 2.3% 1.8% 0.3% 0.1% 2011 6.2% 5.0% 0.9% 0.2% 2.2% 1.8% 0.3% 0.1% *The denominator of prevalence rate and incidence rates was the total number of population aged 65 and above in a given year; Subtypes were based on ICD-9-CM codes: 290+331 for AD; 290.4 for AD; the rest are other type. 11
25% 20% 15% Figure 1. Share of utilization and expenditures on cognitive enhancers (CE) among dementia patients in Taiwan 20.9% 20.6% 23.1% Share of dementia patients taking drug(%) 10% 5% 0% 3.2% 3.0% 3.2% 2009 2010 2011 Share of total drug expenditures spent on CEs among dementia patients (%) 12
Table 3. Profile of utilization and expenditures on cognitive enhancers (CE) in Taiwan Drug categories Che-I NMDA Smart drugs Year Total Dementia patients No. of users Share among CE users (%) $Che-I /$CE (%) No. of users Share among CE users (%) $NMDA/ $CE (%) No. of users Share among CE users (%) $Smart drug / $CE (%) 2009 128,953 4,880 18.1% 71.8% 1,245 4.6% 9.3% 21,747 80.5% 18.8% 2010 141,545 5,534 19.0% 76.6% 1,541 5.3% 9.2% 23,048 79.1% 14.2% 2011 154,576 6,704 18.8% 77.2% 1,951 5.5% 9.4% 28,297 79.4% 13.5% 13
Table 4. The mean costs and utilization patterns of selected cognitive enhancers Variable Che-I NMDA Smart drugs Average numbers of users per year 5,706 1,579 26,364 Characteristics of users Gender(percentage of female users) 60.0% 64.3% 52.0% Age 78.8 80.7 80.5 Dementia subtype AD 93.4% 93.3% 83.8% VAD 3.7% 4.9% 16.0% Other Type 2.9% 1.8% 0.1% Comorbidity measured in CCI 2.6 2.5 3.3 Mean costs and utilization patterns* Annual number of prescriptions per patient 7.4 6.3 5.1 Cost per prescription 2,654 1,302 164 Annual drug expenditure 45,225 38,742 41,970 Annual outpatient expenditure** 67,104 56,438 75,205 Annual inpatient expenditure 96,812 112,232 191,076 Annual total medical care costs 95,789 95,521 169,184 Data Source: 2009-2011 NHIRD including patients aged 65+ and with at least one Dx of dementia; *All expenditures in NT$ (Exchange rate $US: $NT=1: 30) and reported among users of specific service; **Outpatient expenditure also includes drug expenditure 14
Table 5.Annual adjusted medical care costs by use of any cognitive enhancers Annual expenditure category User (N=91,814) Non-user (N=333,260) Cost difference* 95% CI p-value Total expenditure 110,698 119,388-8,690 (-9959, -7420) <0.001 Outpatient expenditure 59,025 53,146 5,879 ( 5543, 6215) <0.001 Inpatient expenditure 124,676 142,133-17,457 ( -18611, -16303) <0.001 Drug expenditure 33,560 30,595 2,965 (2666, 3263) <0.001 Data Source: 2009-2011 NHIRD including patients aged 65+ and with at least one Dx of dementia; All expenditures in NT$ (Exchange rate $US: $NT=1: 30) and reported among users of specific service *Costs differences were derived from two-part regression model with propensity score adjustments and controlling for drug user status, age, gender, and 16 comorbid conditions. 15
Summary of Findings Prevalence estimates of dementia in our study (5.3-6.2%) was slightly higher than the latest national estimate of 4.97% (DOH, 2013) The average annual medical costs of dementia in Taiwan were US$4024 (NT$120,747) per patient, of which US$1082 (NT$ 32,462) were on drug reimbursement. the average spending on ChE-I and NMDA were US$639 and US$282 per drug user, respectively 16
Discussion Our study found the medical costs of dementia in Taiwan to be high (US$4024) Comparable to the medical costs (US$4766) of dementia in high income countries* Two times more than the medical costs of dementia (US$1852) in the Asia Pacific High Income* But the use of cognitive enhancers in Taiwan was limited both in dollars and in the number of patients Use of cognitive enhancers was associated with lower total health expenditure Pharmaceutical therapy seem to be cost-saving Especially with lower inpatient costs *Source: World Alzheimer Report, 2010 17
Policy Implication The strict insurance payment rules in Taiwan may have prevented greater utilization of pharmaceutical therapy for dementia 18
Thank You Li-Jung E. Ku, Institute of Public Health, National Cheng Kung Univ eljku@mail.ncku.edu.tw 19