Cost Of Care For People Research Articles

Who pays and who benefits? How different models of shared responsibilities between formal and informal carers influence projections of costs of dementia management

BackgroundThe few studies that have attempted to estimate the future cost of caring for people with dementia in Australia are typically based on total prevalence and the cost per patient over the average duration of illness. However, costs associated with dementia care also vary according to the length of the disease, severity of symptoms and type of care provided. This study aimed to determine more accurately the future costs of dementia management by taking these factors into consideration.MethodsThe current study estimated the prevalence of dementia in Australia (2010-2040). Data from a variety of sources was recalculated to distribute this prevalence according to the location (home/institution), care requirements (informal/formal), and dementia severity. The cost of care was attributed to redistributed prevalences and used in prediction of future costs of dementia.ResultsOur computer modeling indicates that the ratio between the prevalence of people with mild/moderate/severe dementia will change over the three decades from 2010 to 2040 from 50/30/20 to 44/32/24.Taking into account the severity of symptoms, location of care and cost of care per hour, the current study estimates that the informal cost of care in 2010 is AU$3.2 billion and formal care at AU$5.0 billion per annum. By 2040 informal care is estimated to cost AU$11.6 billion and formal care $AU16.7 billion per annum. Interventions to slow disease progression will result in relative savings of 5% (AU$1.5 billion) per annum and interventions to delay disease onset will result in relative savings of 14% (AU$4 billion) of the cost per annum.With no intervention, the projected combined annual cost of formal and informal care for a person with dementia in 2040 will be around AU$38,000 (in 2010 dollars). An intervention to delay progression by 2 years will see this reduced to AU$35,000.ConclusionsThese findings highlight the need to account for more than total prevalence when estimating the costs of dementia care. While the absolute values of cost of care estimates are subject to the validity and reliability of currently available data, dynamic systems modeling allows for future trends to be estimated.

Developing a national dementia strategy for Ireland

Ireland’s population whilst young by European standards is ageing. At present, about 11% of Irish people are aged 65 and over, but over the next 50 years this figure is expected to reach about 25% (Eurostat, 2008). In line with population ageing, over the next three decades, number of Irish people diagnosed with dementia will also increase, from current estimates of around 38 000 to future estimates of 50 000 by 2016, 70 000 by 2026 and to over 100 000 by the year 2036 (O’Shea, 2007). Like in other Western countries, in Ireland most people diagnosed with dementia live at home and are cared for by family members and by community support services (O’Shea and O’Reilly, 1999). About 4000 are aged less than 65 and this younger cohort places different and significant demands on the health and social care system and on family members. There is also considerable regional variation in the prevalence of dementia across the country, with the West of Ireland because of its demographic profile, supporting the largest number of people (O’Shea and O’Reilly, 1999). Whilst undoubtedly home care may place strain on family members, Irish research has shown that overwhelmingly this is the type of care older people themselves prefer (Garavan et al., 2001). Comparative cost estimates derived from an analysis of a number of European dementia studies reflect low per capita per annum costs of care for people with dementia in Ireland with other European countries such as Finland, Norway and Belgium spending a vast amount more per capita on dementia compared with Ireland (OECD, 2004).

The Increased Cost of Medical Services for People Diagnosed With Primary Open-Angle Glaucoma: A Decision Analytic Approach

Glaucoma accounts for more than 11% of all cases of blindness in the United States, but there have been few studies of economic impact. We examine incremental cost of primary open-angle glaucoma considering both visual and nonvisual medical costs over a lifetime of glaucoma. A decision analytic approach taking the payor's perspective with microsimulation estimation. We constructed a Markov model to replicate health events over the remaining lifetime of someone newly diagnosed with glaucoma. Costs of this group were compared with those estimated for a control group without glaucoma. The cost of management of glaucoma (including medications) before the onset of visual impairment was not considered. The model was populated with probability data estimated from Medicare claims data (1999 through 2005). Cost of nonocular medications and nursing home use was estimated from California Medicare claims, and all other costs were estimated from Medicare claims data. We found modest differences in the incidence of comorbid conditions and health service use between people with glaucoma and the control group. Over their expected lifetime, the cost of care for people with primary open-angle glaucoma was higher than that of people without primary open-angle glaucoma by $1688 or approximately $137 per year. Among Medicare beneficiaries, glaucoma diagnosis not found to be associated with significant risk of comorbidities before development of visual impairment. Further study is necessary to consider the impact of glaucoma on quality of life, as well as aspects of physical and visual function not captured in this claims-based analysis.

Service use and cost of mental disorder in older adults with intellectual disability

The cost of caring for people with intellectual disability currently makes up a large proportion of healthcare spending in western Europe, and may rise in line with the increasing numbers of people with intellectual disability now living to old age. To report service use and costs of older people with intellectual disability and explore the influence of sociodemographic and illness-related determinants. We collected data on receipt and costs of accommodation, health and personal care, physical as well as mental illness, dementia, sensory impairment and disability in a representative sample of adults with intellectual disability aged 60 years and older (n = 212). The average weekly cost in GBP per older person was 790 pounds (41,080 pounds per year). Accommodation accounted for 74%. Overall costs were highest for those living in congregate settings. Gender, intellectual disability severity, hearing impairment, physical disorder and mental illness had significant independent relationships with costs. Mental illness was associated with an additional weekly cost of 202 pounds. Older adults with intellectual disability comprise about 0.15-0.25% of the population of England but consume up to 5% of the total personal care budget. Interventions that meet needs and might prove to be cost-effective should be sought.

Costs of care for people living with combined HIV/AIDS, chronic mental illness, and substance abuse disorders

To determine healthcare access and costs for triply diagnosed adults, we examined baseline data from the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study, a multi-site cohort study of HIV+ adults with co-occurring mental and substance abuse disorders conducted between 2000 and 2004. Baseline interviews were conducted with 1138 triply diagnosed adults in eight predominantly urban sites nationwide. A modified version of Structured Interview for DSM-IV Axis I Disorders (SCID) was used to assign Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses for the preceding year. Utilization of a broad range of inpatient and outpatient services and medications over the preceding three months was patient-reported in face-to-face interviews. We then applied nationally representative unit costs to impute average monthly expenditures. We measured (poor) access to care during the three-month period by whether the patient had: (a) no outpatient medical visits; (b) at least one emergency room visit without an associated hospitalization; and (c) at least one hospitalization. At baseline, mean expenditures were $3880 per patient per month. This is nearly twice as high as expenditures for HIV/AIDS patients in general. Inpatient care (36%), medications (33%), and outpatient services (31%) each accounted for roughly one-third of expenditures. Expenditures varied by a factor of 2:1 among subgroups of patients, with those on Medicare or Medicaid, not in stable residences, or with poor physical health or high viral loads exhibiting the highest costs. Access to care was worse for women and those with low incomes, unstable residences, same-sex exposure, poor physical or mental health, and high viral loads. We conclude that HIV triply diagnosed adults account for roughly one-fifth of medical spending on HIV patients and that there are large variations in utilization/costs across patient subgroups. Realized access is good for many triply diagnosed patients, but remains suboptimal overall. Deficiencies in HIV care are unevenly distributed, tending to concentrate on already disadvantaged populations.

The Cost of Care for People With Impaired Vision in Australia

To prospectively collect data on the providers, types, and costs of care for people with impaired vision in Australia. Adults with impaired vision, visual acuity worse than 20/40, were recruited from clinics, vision rehabilitation agencies, and support groups. Participants completed daily diaries for 12 months, entering information on the amount of time they used caregivers and providers and types of care. Demographic information was obtained from questionnaires. The cost of care was calculated using mean hourly wage rates. The mean age of the 114 participants was 66.5 years (standard deviation [SD], 19.7) with 64% of participants female; 105 of 114 participants relied on a caregiver at least once during the 12 months. The mean amount of yearly caregiver time used was 152.2 hours (SD, 193; median, 81.3; range, 1-851 hours). The median time represents 4.6% of a working week. There were no significant associations of age, sex, type, or place of residence with the amount of care received (P > or = .1). As most of the caregivers were family members who assisted with transport, written communications, and personal affairs, the "opportunity costs" were calculated. The median annual opportunity cost was A$915 (US $710) (range, $A0-$9653 [US $0-$7491]). This study prospectively obtained data for the cost of caregivers for people with impaired vision. The degree of vision impairment was not associated with the amount of care used but showed a threshold effect: when vision is impaired to the extent that people cannot legally hold a driver's license, reliance on caregivers appears to be independent of the severity of loss of vision.

Dementia Diagnosis in Primary Care: Thinking Outside the Educational Box

Dementia syndromes are common, increasing in prevalence and are the largest cause of disability in industrialized societies. The costs of care for people with dementia in the UK are greater than the annual expenditure on heart disease, stroke and cancer, combined. Delayed recognition of dementia is common in community settings, but its causes are poorly understood. Specialists tend to identify lack of diagnostic skills amongst primary care physicians as the main cause, and attempt to remedy these limitations with training and the use of brief instruments for assessing cognition. This approach appears to have had little impact over the last decade. There are fundamental misunderstandings regarding how the diagnostic characteristics of dementia syndromes diverge from the cognitive changes of normal aging, and how dementia emerges through the personality of the individual. This paper discusses the factors/processes involved in these changes in cognitive function, behavior and personality and why recognition of dementia in primary care is problematic, especially at an early stage. The important and tractable factors impeding earlier recognition of dementia in primary care include deficits in management (rather than diagnostic) skills amongst primary care practitioners and lack of adequate specialist support (including psychology and social work expertise) over the long term. Nevertheless, we believe that the diagnosis and early clinical management of dementia can be achieved in the setting of primary care. The pattern of interweaving psychological, social and economic factors relevant to the needs of individual patients and their carers can be taken into account and met in the community, providing sufficient expert resources are available and systematically organized. This paper explores the different dimensions of relevant management skills and systems and makes proposals regarding changes in primary and secondary care that will increase earlier diagnosis in the community.

Pharmaco-economic issues for diabetes therapy

A systematic review was undertaken to analyse pharmaco-economic issues in diabetes, with evidence selected on the basis of relevance and immediacy. Pharmaco-economics in diabetes primarily relates to making choices about antidiabetic pharmaceuticals, and this is being influenced by global trends. Trends include increasing numbers of patients with diabetes, with increasing costs of caring for people with diabetes, and an ever-present focus on the costs of pharmaceuticals which are predicted to increase as the pace of development of new medications parallels the increasing incidence of the condition. These developments have influenced the demand for health care in diabetes in the last decade, and will continue to determine this in the coming decade. Recent national experiences are cited to illustrate current issues and to focus specifically upon the challenges facing a raft of new diabetes treatment options now hitting the marketplace, although supported by fewer completed long-term trials. It can be anticipated that these newer agents will be appraised for their cost-effectiveness or value for money. Economic analyses for some of the new technologies are summarized; in general, the peer-reviewed publications using well-accepted and validated models have reported thatthese technologies are cost-effective. Endorsement of any technology in a national setting is not awarded simply because the incremental cost-effectiveness ratio (ICER) falls below the threshold regarded as value for money. In most national observations the reviewers expressed concerns about assumptions used in economic modelling which resulted in the ICERs being deemed optimistic at best, generally highly uncertain, and resulting in the cost-effectiveness appearing better than it really would be in clinical practice. This has often led to the authorities concluding that the price advantage of new technologies over comparators could not be justified, essentially leading to restrictions in use compared to their licence. In general, a paucity of robust evidence on longer-term outcome data together with a lack of health-related quality of life (HRQOL) data collected in a reliable manner in appropriate patients and amenable to utility (and hence quality adjusted life year or QALY) estimation have resulted in problems for these new drugs atthe so-called fourth (cost-effectiveness) hurdle. In the light of these findings, the implications for generating credible fit-for-purpose cost-effectiveness analyses of new technologies in diabetes are discussed. Throughout this chapter, the interested reader is referred to a number of excellent review articles for further details.

Dementia Strategy will require better training

Dementia is widely acknowledged to be one of the most signifi cant health issues facing the UK and the NHS. As the population ages, the numbers of people diagnosed with dementia are growing, and are expected to double to 1.4 million over the next 30 years (Department of Health (DH), 2008). Dementia is currently estimated to cost the UK £17 billion a year, and the cost of caring for people with dementia is expected to treble in the next 30 years to over £50 billion a year. The health minister, Ivan Lewis MP, launched a Department of Health consultation ‘Transforming the Quality of Dementia Care’ (DH, 2008) recently. This consultation will inform a National Dementia Strategy for England, and one of the key aims is to ensure accurate and early diagnosis. The consultation follows the launch of the Alzheimer's Society (2008) campaign ’Worried about your memory?’ which aims to prompt people concerned about memory loss, or that of a relative, to seek medical advice.

Pharmaco-economic issues for diabetes therapy

A systematic review was undertaken to analyse pharmaco-economic issues in diabetes, with evidence selected on the basis of relevance and immediacy. Pharmaco-economics in diabetes primarily relates to making choices about antidiabetic pharmaceuticals, and this is being influenced by global trends. Trends include increasing numbers of patients with diabetes, with increasing costs of caring for people with diabetes, and an ever-present focus on the costs of pharmaceuticals which are predicted to increase as the pace of development of new medications parallels the increasing incidence of the condition. These developments have influenced the demand for health care in diabetes in the last decade, and will continue to determine this in the coming decade. Recent national experiences are cited to illustrate current issues and to focus specifically upon the challenges facing a raft of new diabetes treatment options now hitting the marketplace, although supported by fewer completed long-term trials. It can be anticipated that these newer agents will be appraised for their cost-effectiveness or value for money. Economic analyses for some of the new technologies are summarized; in general, the peer-reviewed publications using well-accepted and validated models have reported that these technologies are cost-effective. Endorsement of any technology in a national setting is not awarded simply because the incremental cost-effectiveness ratio (ICER) falls below the threshold regarded as value for money. In most national observations the reviewers expressed concerns about assumptions used in economic modelling which resulted in the ICERs being deemed optimistic at best, generally highly uncertain, and resulting in the cost-effectiveness appearing better than it really would be in clinical practice. This has often led to the authorities concluding that the price advantage of new technologies over comparators could not be justified, essentially leading to restrictions in use compared to their licence. In general, a paucity of robust evidence on longer-term outcome data together with a lack of health-related quality of life (HRQOL) data collected in a reliable manner in appropriate patients and amenable to utility (and hence quality adjusted life year or QALY) estimation have resulted in problems for these new drugs at the so-called fourth (cost-effectiveness) hurdle. In the light of these findings, the implications for generating credible fit-for-purpose cost-effectiveness analyses of new technologies in diabetes are discussed. Throughout this chapter, the interested reader is referred to a number of excellent review articles for further details.

Nurses need to assess problems related to stress in care giving.

The cost of caring for people with dementia is enormous in monetary and psychological terms. Carers experience emotional, physical and financial stress, depression and poor quality of life. The result may be poor standards of care, neglect or even abuse. To reduce stress, nurses need to better understand individual carer's experience to provide the appropriate support. The diagnosis of dementia leads to many losses and caregivers experience grief, which can be similar to that of bereavement. This is described as 'disenfranchised grief' because it cannot be publicly acknowledged and is not socially supported as happens with death. This study found that the behaviour most strongly associated with burden was aggression, including suspicion, making accusations and talking in a threatening manner. They also found that caregivers with higher income and higher levels of education had lower levels of burden. They suggest that these people developed more effective skills in managing the problems of care and stress. The authors conclude that more intervention is needed to decide how best to support caregivers, and that nurses in the community are in the best position to assess in problems related to stress in care giving.

Caring for a relative with dementia: family caregiver burden

This paper is a report of part of a study to investigate the burden experienced by families giving care to a relative with dementia, the consequences of care for the mental health of the primary caregiver and the strategies families use to cope with the care giving stressors. The cost of caring for people with dementia is enormous, both monetary and psychological. Partners, relatives and friends who take care of patients experience emotional, physical and financial stress, and care giving demands are central to decisions on patient institutionalization. A volunteer sample of 172 caregiver/care recipient dyads participated in the study in Cyprus in 2004-2005. All patients were suffering from probable Alzheimer's type dementia and were recruited from neurology clinics. Data were collected using the Memory and Behaviour Problem Checklist, Burden Interview, Center for Epidemiological Studies-Depression scale and Ways of Coping Questionnaire. The results showed that 68.02% of caregivers were highly burdened and 65% exhibited depressive symptoms. Burden was related to patient psychopathology and caregiver sex, income and level of education. There was no statistically significant difference in level of burden or depression when patients lived in the community or in institutions. High scores in the burden scale were associated with use of emotional-focused coping strategies, while less burdened relatives used more problem-solving approaches to care-giving demands. Caregivers, especially women, need individualized, specific training in how to understand and manage the behaviour of relatives with dementia and how to cope with their own feelings.

Disease management: promising, but not yet proven

One of the biggest long-term fiscal challenges for industrialized countries is controlling the cost of care for people with chronic illnesses, such as heart disease and diabetes. In 1998, for examp...

Dementia in Long-Term Care

A majority of residents in long-term care facilities (LTCF) are cognitively impaired. Dementia is either the reason they are in such facilities in the first place, or it develops as they “age in place.” Whereas only 5% to 10% of all seniors are demented, at least two-thirds of nursing home residents in the United States have dementia, a figure that is true for the United Kingdom as well. Residents of assisted-living and residential care facilities are generally less impaired than residents of skilled nursing facilities, but 24% had at least mild dementia in one study. and 21% at least moderate dementia in another. These figures are for LTCF that do not even specialize in dementia care. Facilities specializing in dementia care are increasingly popular and account for a large but unknown percentage of the LTC dementia population. It is clear that large numbers of seniors with dementia are in some type of institutional care. A Canadian study indicates that over a 4-year period, there is a 50.9% chance of a person with dementia living at home to be institutionalized, with a median time to placement of 41 months from the time of diagnosis. Given that over half of patients with dementia will need institutional care, it is no wonder that such care constitutes the major portion of added costs of care for people with dementia. This is arguably the single most common disabling and costly geriatric syndrome in long-term care. In this supplement to the Journal of the American Medical Directors Association, we review important aspects of dementia in long-term care. The opening article by Singer and Luxenberg provides an overview of the diagnosis and treatment of dementia in LTCF, with a focus on Alzheimer’s disease (AD). After this, a series of articles covers the diagnosis and treatment of the common non-AD dementias. Jennifer Merrilees and Bruce Miller review frontotemporal dementia, Joseph Quinn discusses vascular dementia, and Andrew Gustavson and Jeffrey Cummings summarize the evidence for use of acetylcholinesterase inhibitors in other neuropsychiatric disorders. The treatment of psychiatric symptoms associated with dementia is covered by Donna Masterman, and depression in dementia is reviewed by Elaine Peskind. Our hope is that this supplement will provide you with a broad, practical, and detailed overview of dementia in the long-term care setting, adding the latest clinical science to decisions you make everyday on behalf of your patients. We thank Pfizer Inc. for its support of this supplement through an unrestricted educational grant.

Containing the Cost of Care for People Living with HIV/AIDS

This article examines Medicaid managed care's potential impact on people living with HIV/AIDS. The incongruence of the philosophy behind providing health and social services to people living with HIV/AIDS and with the philosophy behind the medical model of managed care is discussed. Health and social policy issues that various states have had to face concerning Medicaid managed care's administration of health benefits for people living with HIV/AIDS are examined. Research on managed care is employed to extrapolate potential managed care models that states might use to administer the health benefits for people living with HIV/AIDS. Finally, policy and research agendas are proposed to begin investigating Medicaid managed care's potential impact on people living with HIV/AIDS.

Cost of illness of Alzheimer's disease: how useful are current estimates?

The goal of this literature review was to determine the validity and policy relevance of recent estimates from many countries of Alzheimer's disease (AD) costs. We searched Medline and other databases for English-language peer-reviewed journals on total, direct, indirect, and per case cost of AD that used 1985-2000 data. We adjusted costs of U.S. studies for inflation. We adjusted non-U.S. studies by that country's medical cost inflation rate and purchasing power parity (PPP). Of 71 studies identified, 21 met all criteria for inclusion. Annual inflation adjusted U.S. total costs of AD varied from $5.6 billion to $88.3 billion. AD total per case (direct and indirect) costs varied from $1,500 to $91,000; indirect/family costs varied from $3,700 to $21,000. Among non-U.S. studies, AD annual adjusted per case costs varied from PPP $2,300 to PPP $30,000. Cost variation was due to diverse study methods, data sources, services included, and lack of clear differentiation between cost of AD and cost of caring for people with AD. The cost of AD is high, although reliable estimates are not available. Costs are likely to rise given expected demographic shifts in all countries. The widely variable cost estimates call into question the real costs of Alzheimer's disease and their applicability to policy initiatives.

CDC contributions to women's health: focusing on prevention in midlife.

201 MANY NOTABLE PUBLIC HEALTH achievements occurred during the 1900s. Two of the great public health achievements for the 20th century specifically focused on women—healthier mothers and babies and family planning. During the 20th century, the health and life expectancy of people residing in the United States improved dramatically.1 Prevention played a significant role then, and it continues to plays a significant role today. Although the health and safety of women have improved, much remains to be done. For women in their midlife, 45–64 years of age, the leading causes of death include cancer, heart disease, and cerebrovascular disease. The challenges lie in reducing some of the risk factors responsible for many chronic diseases, such as obesity, smoking, and lack of physical activity. Chronic diseases account for 70% of all deaths in the United States. The medical care costs of people with chronic diseases account for more than 60% of the nation’s medical care costs, and chronic diseases account for one third of the years of potential life lost before age 65. Women comprise more than half the people who die each year of cardiovascular disease.2 The Centers for Disease Control and Prevention (CDC) protects people’s health and safety by preventing and controlling diseases and injuries, enhances health decisions by providing credible information on critical health issues, and promotes healthy living through strong partnerships with local, national, and international organizations. With a diverse array of programs and activities that focus on women at every stage of life, CDC makes contributions to better understand and use prevention to reduce illness, disability, and death and to improve the quality of life. Much of this is possible because of the vital partnerships with public and private entities, such as state and local public health agencies, practicing health professionals, schools and universities, community organizations, industry and labor, foundations, and international organizations. Partnerships between CDC and women’s health advocacy groups, minority organizations, professional associations, and others have helped increase the number and type of prevention programs available to women. They have increased the understanding of the challenges, gaps, and opportunities and helped to develop innovative solutions to address some of these issues. Such partnerships have also enhanced policy development and fueled agencies, organizations, and individuals to take action. For CDC, the focus of the research and programs is prevention. Although some of the research and programs are well established, others are small, and still others are new. The expectation is that each has or will contribute to the science, understanding, policy, program design, quality of service, decision making, or action taken to improve the health and safety of women.

Time trends in cost of caring for people with gastroesophageal reflux disease

OBJECTIVE: Increasing acceptance of the many permutations of gastroesophageal reflux disease (GERD) has led to diverse study of the disease and its effects. The goal of this study was to estimate medical care costs attributable to a defined GERD population over time. Methods: A retrospective cohort control design was used. All participants were identified from the database of a managed care organization serving 300,000 people in the northeastern United States. The index population (n = 600) was defined as anyone who obtained medical services during 1997 or 1998, for any International Classification of Diseases (ninth revision, Clinical Modification) codes suggestive of GERD, and/or anyone who received at least one prescription and one refill for antisecretory or GERD medications during at least two 3-month periods in 1997 or 1998. A matched cohort (n = 600) without any diagnosis of GERD was randomly selected as a control group. Both populations were observed restrospectively from January 1, 1990 through December 31, 1998. Results: The cost of treating GERD averaged around $510 per year, about 15% of all medical costs for those with GERD. Treating people with GERD was about 2-fold more costly than treating those without GERD, a marginal cost of $1500 to $2000 per annum. Conclusion: Although GERD is a low-cost disease to treat, the cost of treating people with GERD is subtantially greater than that for a comparable population without GERD. Two explanations may account for the large difference of costs between the study populations. First, the GERD group may be sicker than the control group. Disease severity variables and diagnoses associated with GERD were more commonly diagnosed in the GERD group. Second, an additional disease that is not treated appropriately increases the cost of treatment geometrically for all diseases.

Estimating the Costs of Caring for People with Alzheimer Disease in California: 2000-2040

The costs of caring for people with Alzheimer disease (AD) in California are estimated using data from a study of the costs of caring for community-resident and institutionalized people with AD, combined will prevalence and population projections. Costs for community-resident patients will increase 83 percent in the period 2000 ($23.4 billion) to 2020 ($42.8 billion), and will grow an additional 59 percent from 2020 to 2040 ($68.1 billion). Costs for AD patients in institutions will increase 84 percent from 2000 ($2.5 billion) to 2020 ($4.6 billion), and will grow an additional 61 percent from 2020 to 2040 ($7.4 billion), assuming the supply of nursing home beds meets projected demand. Total costs of caring for AD patients will nearly triple between 2000 and 2040. The rapid aging of the U.S. population makes more aggressive societal action necessary if the personal and societal burden of Alzheimer's disease is to be reduced in the future.

A Fully Integrated Clinical Information System to Support Management of End-Stage Renal Disease

End-stage renal disease (ESRD) is relatively rare, but very costly. The ESRD population in the US is elderly, over 40% have diabetes mellitus, and most have additional comorbid conditions. Concerns about the quality and cost of care for people with ESRD in the US prompted the Healthcare Financing Administration (HCFA) to launch a demonstration project to determine whether disease management might improve care at reduced cost. It also stimulated health plans in the private sector to begin contracting with newly formed ESRD disease management organizations (DMOs). We describe the clinical information system developed by one such organization, RMS Disease Management, an affiliate of Baxter Healthcare Corporation. The system was designed to function within disparate medical care delivery systems and regions, without adding work for providers or health plans. A point-of-care system was implemented using a client server configuration. Data were entered on laptops and uploaded over high-speed lines to a central site. The system was developed over 14 months and implemented in 12 regions in 1998 under a contract with Humana, a national health plan. Highly experienced, locally recruited nephrology nurses co-ordinated care and entered data. The data included standard quality indicators, performance measures and key outcomes, along with data on patient assessment, care management, and comorbid conditions. We have compiled 35 000 months of patient care experience in the past three years, and entered 4000 patients with ESRD into the program. The system has provided comparisons of data at the regional and national levels, an independent reference for auditing claims, rapid turn-around of data to drive outcomes management, and the ability to link all components of care management. The system configuration is scalable and has functioned well across multiple sites of care while maintaining the privacy and security of patient data. Future plans include migration to an internet-based platform, adoption of handheld devices for data entry, and development of an Internet site where patients, their caregivers and their providers can interact. The system is designed to accomodate the evolving scope of disease management for ESRD, broadening to embrace multiple comorbid conditions and increasing its focus on prevention Wellness.