Keynote paper at the 2016 Alzheimers NZ Biennial Conference and 19th Asia Pacific Regional Conference of Alzheimer’s Disease International, Wellington, New Zealand, November 2016

1. World Alzheimer Report 2016:
Improving healthcare for people living
with dementia
COVERAGE, QUALITYAND 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-Herrera
Personal Social Services Research Unit (PSSRU)
London School of Economics and Political Science
a.comas@lse.ac.uk
@adelinacohe
1

2. About the report:
• Authors: Martin Prince,
Adelina Comas-
Herrera, Martin Knapp,
Maelenn Guerchet,
Maria Karagiannidou.
• Commissioned by
Alzheimer’s Disease
International.
2
www.alz.co.uk/worldreport2016

3. 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.
3

4. THE NUMBER OF PEOPLE
LIVING WITH DEMENTIA IS
GROWING ALL OVER THE
WORLD
And at a much faster pace in low- and middle-income
countries
4

5. The majority of people with dementia live in
low and middle income countries (LMICs)
www.alz.co.uk/worldreport2015

6. The global prevalence of dementia
www.alz.co.uk/worldreport2015

7. Source: estimates from the World Alzheimer Report 2015,
Prince et al.
7
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

8. HOW TO EXPAND CARE
SUSTAINABLY
Dementia Healthcare Pathways: exploring task-shifting
and task sharing
8

9. 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
9

10. 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.
10

11. 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 comorbidities
is 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.
11

12. 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.
12

13. 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.
13

14. 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).
14

15. Proposal: a task-shifted dementia
healthcare pathway
1. 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 care
1. 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
15

16. COSTING DEMENTIA
HEALTHCARE PATHWAYS
Affordability in the context of expanded demand for care
16

17. Costing a task-shifted dementia
healthcare pathway: 2015-2030
Methods:
• 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.
17

18. 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).
18

19. 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.
19

20. 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
Specialist Task-
shifted
Specialist 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%
20

21. Cost of the pathways in 2030, with current local drug
prices vs. England drug prices (in US$),
assuming we reach 50% diagnosticrate 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
Africa
South Korea Switzerland
2030 Specialist Task-
shifted
Task-
shifted
Task-
shifted
Task-
shifted
Task-
shifted
Specialist Task-
shifted
Specialist 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
21
Current drug prices, uprated
Canada China Indonesia Mexico South
Africa
South Korea Switzerland
2030 Specialist Task-
shifted
Task-
shifted
Task-
shifted
Task-
shifted
Task-
shifted
Specialist Task-
shifted
Specialist 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

22. DEMENTIA HEALTHCARE
PATHWAYS:
Healthcare system contexts (China, Indonesia, South
Korea)
22

23. 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.
23

24. 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.
24

25. CONCLUSIONS
And important questions for further research
25

26. 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).
26

27. 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
27
Conclusions (2):
Necessary healthcare system conditions

28. 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).
28