The dementia difference: Investigating imbalances in the treatment of patients with dementia

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The March International Psychogeriatrics Article of the Month is entitled “Healthcare resource utilization and cost in dementia: are there differences between patients screened positive for dementia with and those without a formal diagnosis of dementia in primary care in Germany?” by Bernhard Michalowsky, Tilly Eichler, Jochen René Thyrian, Johannes Hertel, Diana Wucherer, Wolfgang Hoffmann and Steffen Flessa. This blog piece was written for us by one of the paper’s authors, Bernhard Michalowsky.

A precise formal diagnosis of dementia is enormously important to initiate adequate and appropriate treatment and care in dementia. Despite the fact that international standards and evidence based guidelines recommends a precise formal diagnosis, it is well known that dementia is under-diagnosed. Even in high income-countries, fifty to eighty per cent of people with dementia do not receive a formal dementia diagnosis. These persons were unnoticed in most studies, also in cost-of-illness studies. These studies revealed that dementia is associated with substantial and increasing health care costs, which adds to making dementia a serious health care priority. However, are there differences in treatment, in care and in overall healthcare costs between patients formally diagnosed with dementia and those without a formal diagnosis?

We have studied this question in our general-practitioner (GP) based sample of persons who screened positive for dementia and found a significant difference in treatment and care and in medical care cost between patients with and those without a formal dementia diagnosis.

We set out to study this issue within the ongoing DelpHi-MV (Dementia: life- and person-centered help in Mecklenburg-Western Pomerania) trial, a general practitioner-based, cluster-randomized, controlled, intervention trial in the primary care setting. Eligible patients were 70 years or older, living at home and screened in general practitioner (GP) practices for dementia using the DemTect. As published in this month´s issue of the journal we assessed individual data about the utilization of medical and formal health care services of 240 primary care patients. The costs were assessed from the perspective of insurance and the associations between dementia diagnosis and costs were evaluated using multiple linear regression models.

We found that patients formally diagnosed with dementia were treated significantly more often by a neurologist, but less often by all other outpatient specialists, and more often received anti-dementia drugs, but less additional drugs. The higher utilization of anti-dementia drugs and neurologists/ Psychiatrist is in line with the recommendations of evidence-based German guidelines. However, less treatment by outpatient physicians and with additional drugs is out of line with published studies. It is questionable if this corresponds to an inadequate treatment.

Furthermore, we found that diagnosed patients underwent shorter and less frequent planned in-hospital treatments, especially surgeries. This could mean that in hospital a premature discharge is forced and necessary surgeries were possibly omitted or unnecessary surgeries were not conducted because hospitalization is associated with deterioration in health outcomes. Taking all of this into account, dementia diagnosis was significantly associated with less total medical care costs.

What is the take home massage of this research? Actually, it seems to be that there are differences in treatment, care and healthcare cost between persons with dementia and those without a formal dementia diagnosis. Furthermore, dementia diagnosis seems to be beneficial for receiving dementia-specific treatment, but currently insufficient to ensure adequate in-hospital, out-patient specialists and overall medication treatment. This should be validated in further studies and improved in routine care.

The full paper “Healthcare resource utilization and cost in dementia: are there differences between patients screened positive for dementia with and those without a formal diagnosis of dementia in primary care in Germany?” is available free of charge for a limited time here.

The commentary paper “What is the potential for improving care and lowering cost for persons with dementia?” by Karen Davis, Amber Willink and Halima Amjad is also available free of charge here.

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