world alzheimer report 2016: improving healthcare for people living with dementia

World Alzheimer Report 2016:Improving healthcare for people living

with dementia

COVERAGE, QUALITY AND COSTS NOW AND IN THE FUTURE

2016 Alzheimers NZ Biennial Conference and 19th Asia Pacific Regional Conference of Alzheimer’s Disease International, Wellington, New Zealand.

Adelina Comas-HerreraPersonal Social Services Research Unit (PSSRU)London School of Economics and Political [email protected]@adelinacohe

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About the report:

• Authors: Martin Prince, Adelina Comas-Herrera, Martin Knapp, Maelenn Guerchet, Maria Karagiannidou.

• Commissioned by Alzheimer’s Disease International.

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www.alz.co.uk/worldreport2016

Disclaimer

The opinions, comments and interpretations of all the material presented here are my own and not those of my current and former co-authors and research funders.

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THE NUMBER OF PEOPLE LIVING WITH DEMENTIA IS GROWING ALL OVER THE WORLDAnd at a much faster pace in low- and middle-income countries

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The majority of people with dementia live in low and middle income countries (LMICs)


The global prevalence of dementia


Source: estimates from the World Alzheimer Report 2015, Prince et al.

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Canada, 59%

China, 70%

Indonesia, 87%

Mexico, 95%

New Zealand, 60%

South Africa, 48%

South Korea, 110%

Switzerland, 45%

0% 20% 40% 60% 80% 100% 120%

Canada

China

Indonesia

Mexico

New Zealand

South Africa

South Korea

Switzerland

% change in the numbers of people living with dementia, 2015 to 2030

HOW TO EXPAND CARE SUSTAINABLYDementia Healthcare Pathways: exploring task-shifting and task sharing

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Why do we start with dementia healthcare pathways?

• Diagnostic: gateway for access to health & social care. But low coverage: 40-50% in most HIC, around 5-10% in most LMIC

• Lack of specialist services: very few in LMIC. In HIC, struggle to keep up with rapidly increasing numbers

• Even interventions with a strong evidence-base (e.g. anti-dementia drugs) are not being delivered to all who might benefit

• Most health expenditure for people with dementia is for hospital care: potential to reduce avoidable hospitalisations

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Two different challenges:

• High Income Countries: Adapting well-established health systems, dominated by a tradition of “curative” health care, to the needs of increasing numbers of people with dementia.

• Low and Middle Income Countries: Developing new health care provision to meet the needs of increasing numbers of people with dementia (and other chronic conditions).• Context: rapid ageing, competing demands and low resource

availability.

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How can we do better in healthcare for people with dementia?• Improve diagnosis rates, and access to:

• Post-diagnostic support

• Continuing care and treatments that moderate symptoms (anti-dementia drugs, non-pharmacological therapies)

• Prevention of additional risks (falls, UTIs, etc).

• End-of-life care

• Ensure that access to healthcare for other comorbiditiesis timely and appropriate for a person with dementia

• In the event of new treatments that alter course of dementia, we need healthcare systems capable of delivering them.

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Expanding healthcare for people with dementia: task-shifting and task-sharing

• Task-shifting: delegating selected tasks to existing or new health professional cadres with either less training or narrowly tailored training.

• Task-sharing: in reality, almost all task-shifted models of service delivery include an element of task-sharing between specialist and non-specialist services.

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Task-shifting (contd.)

• Shifting tasks from higher to lower skilled workers (eg from a neurologist specialist doctor to a general practitioner)

• Shifting tasks from workers with general training to workers with specific training for a particular task (e.g. from a GP to a dementia case manager).

• Assumptions: • The unit cost of task-shifted option is cheaper, and that the quality of care

and outcomes are equivalent.

• Less-specialised staff are more numerous and can be trained more quickly: the dementia healthcare workforce could be scaled up more quickly.

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Evidence on task-shifting so far:

With adaptation and appropriate training and supervision, it is feasible for interventions usually delivered by specialist doctors to be taken on by non-specialists (and non-doctors) without adverse effect on clinical outcomes (growing evidence of moderate quality).

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Proposal: a task-shifted dementia healthcare pathway1. Diagnostic (mostly primary care, GPs and case

managers)

2. Initial treatment and post-diagnostic support:1. Assessment for anti-dementia drugs

2. Post-diagnostic support package

3. Carer training and support

3. Continuing care1. Anti-dementia medication reviews

2. Management of behavioural and psychological symptoms

3. Case management

4. End of Life care

Complex cases referred to specialist pathway

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COSTING DEMENTIA HEALTHCARE PATHWAYS

Affordability in the context of expanded demand for care

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Costing a task-shifted dementia healthcare pathway: 2015-2030Methods:• Demographic & prevalence data to calculate N of people

with dementia in 2015 and 2030.• Assuming diagnostic rates increase (50% in 2015 to 75%

in 2030 for HIC; 10% to 50% in LMIC).• Apply unit costs to different elements of the care pathway.• Assume real costs of care increase in line with GDP per

capita.• For HIC we also compared with the cost of a “typical”

specialist care pathway.• We only cost dedicated dementia pathway, not all

health care use by people with dementia.

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Comparable unit costs of care?• Difficult to obtain unit costs for most services and most

countries.• Calculated “international unit costs”:

• Used Unit costs of Care from the UK (PSSRU Unit Costs 2015 and DH) to obtain the relative cost difference between care professionals (and interventions/services/tests/drugs).

• Used WHO Choice 2008 unit costs of care data to obtain the relative unit costs differences between countries (in PPP International $ and including the UK).

• Adjusted the “between country cost differences” for changes in PPP 2008 to 2015, between each country and the UK.

• Adjusted the 2015 UK Unit costs to reflect country differences and applied exchange rate to US$ 2015.

• Where local data was available (e.g. costs of GP, specialists, nurses, or for particular drugs or tests, this was used).

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Some costing considerations:

• The relative cost of different healthcare professionals is not the same (i.e. in the UK GPs unit costs are higher than specialists).

• Not all professionals are the same: most primary care doctors in rural China do not have a university degree.

• There are huge differences in the costs of drugs, depending on patent durations, policies with regards generics and additional prescription fees.

• The costs of equipment such as MRI scans can also be very different in LMIC and HIC.

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Proportional contribution to the costs of different parts of the pathway, 2015.

Canada China Indonesia Mexico South Africa

South Korea Switzerland

Specialist Task-shifted

Task-shifted

Task-shifted

Task-shifted

Task-shifted



Staff 67.9% 50.4% 4.6% 16.6% 42.8% 15.2% 8.6% 4.2% 39.1% 23.3%

Neuroimaging 7.4% 2.5% 1.4% 1.6% 0.5% 0.5% 1.1% 0.2% 6.0% 1.6%

Anti-dementia drugs 19.7% 34.0% 91.9% 81.5% 54.7% 84.0% 88.8% 93.4% 48.0% 63.1%

Hospital stays 5.0% 9.6% 1.3% 0.2% 1.9% 0.3% 1.5% 1.8% 5.4% 8.0%

Other 0.1% 3.5% 0.7% 0.1% 0.0% 0.1% 0.0% 0.4% 1.4% 4.0%

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Cost of the pathways in 2030, with current local drug prices vs. England drug prices (in US$), assuming we reach 50% diagnostic rate in HIC and 75% in LMIC

If all countries had the same drug prices as England’s prices today (uprated)Canada China Indonesia Mexico South

AfricaSouth Korea Switzerland

2030 Specialist Task-shifted

Task-shifted

Task-shifted

Task-shifted

Task-shifted



Cost of pathways(millions)

629 311 260 24 27 5 213 129 186 103

Cost per person with dementia

761 377 16 11 17 17 212 120 960 530

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Current drug prices, upratedCanada China Indonesia Mexico South

AfricaSouth Korea Switzerland

2030 Specialist Task-shifted

Task-shifted

Task-shifted

Task-shifted

Task-shifted



Cost of pathways(millions)

756 438 2,660 384 48 26 1,652 1,568 334 251

Cost per person with dementia

914 530 164 169 30 93 1,641 1,558 1,723 1,294

DEMENTIA HEALTHCARE PATHWAYS:Healthcare system contexts (China, Indonesia, South Korea)

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Canada:

• National clinical standards already support a task-shifted approach with central role for primary care.

• Despite national clinical guidelines, variability in implementation across and within regions.

• Difficulties with access to care in rural and remote areas (role for technology?).

• Higher rates of undiagnosed dementia for people in nursing homes, suggesting poor access to healthcare.

• Lack of a National Dementia Strategy makes it difficult to coordinate research and programmes to improve care.

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Mexico

• Fragmented healthcare financing and provision system, resulting in unequal coverage.

• Relatively low availability of healthcare services and small role of primary care.

• Consolidated drug purchasing helps ensure affordable medication.

• National Dementia Plan: emphasis on training of staff and increasing public awareness.

• To deliver improved dementia healthcare coverage it would be fundamental to ensure consistency across the insurance schemes and to strengthen the role of primary care.

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CONCLUSIONSAnd important questions for further research

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Conclusions (1): affordability

• The costs of the dementia healthcare pathways are relatively low, compared to overall health spending.

• In countries where generics are not available or not widely prescribed, specially if wages are low, anti-dementia drugs may not be cost-effective.

• If, by 2030, drug costs were low, the cost of implementing the task-shifted pathway would be 40% lower than the specialist pathway (in all the HIC modelled).

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Healthcare system features needed to improve coverage sustainably:

• Universal Health Coverage,

• a central role (gate-keeping) for primary care,

• low out-of-pocket payments,

• dedicated dementia plans

• improved dementia training for all healthcare staff

• access to drugs at generic prices

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Conclusions (2):Necessary healthcare system conditions

Questions for future research:

• Modelling the impact of improving coverage of diagnostic and continuing care using a task-shifted model:• What will be the impact on improved outcomes (cognition, quality

of life, etc.)?

• Does it result in a reduction in avoidable admissions and other “bad costs of care”?

• We still know relatively little about what works in dementia care, treatment and support.

• And we know even less about how to translate evidence to different countries with different economic contexts.

• Extending the pathways to cover all the care, treatment and support for people with dementia and their carers (health, social care, family care).

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