Cognitive impairment may augment healthcare burden in SG

An ageing population and a greater incidence of cognitive impairment (CI) are expected to put a strain on healthcare resources through the increased use of emergency department (ED) visits and unplanned admissions, suggests a Singapore study.

“Efforts should be made to identify the most at-risk patients with CI, including which components of CI (eg, behavioural/psychological issues, physical/functional decline) have the largest impact, and take appropriate remediation strategies,” said the investigators, who examined differences in healthcare utilization and cost between those with and without CI.

This study data linked to the Singapore Chinese Health Study cohort to estimate regression-adjusted differences in annual healthcare utilization and costs by CI status determined by the modified Mini-Mental State Exam.

The investigators stratified estimates by ex ante mortality risk constructed from out-of-sample Cox model predictions applied to the full sample. They also performed a separate analysis restricted to decedents. These estimates were used to project differential healthcare costs by CI status over 5 years.

Annual healthcare costs were 17 percent higher among patients with CI than those without CI (SGD 4,870 vs SGD 4,177; p<0.01). When looking into the greater mortality risk, patients with CI had 9-percent to 17-percent greater cost over 5 years (SGD 2,500 to SGD 3,600), depending on their age. [Ann Acad Med Singap 2024;53:233-240]

“Using our annual estimates and assuming 44,000 individuals have CI in Singapore, the aggregate burden is about SGD 134 million over 5 years, or SGD 27 million annually,” the investigators said. [https://vizhub.healthdata.org/gbd-results/]

“This figure represents only 0.1 percent of the nation’s total health expenditure today, but it is likely to rise dramatically in the future given the ageing population and rising rate of CI,” they added. [https://apps.who.int/nha/database/Home/Index/en]

There had been several cost-of-illness studies for CI conducted in the past, but only two focused on its impact on healthcare utilization at the end-of-life. [Inquiry 2017;54:0046958017696757; Health Aff (Millwood) 2014;33:683-90]

“Our findings are largely consistent with results from these studies,” the investigators said.

ED visits

Notably, the increased cost of healthcare was driven primarily by more ED visits and subsequent admissions (ie, unplanned). However, these differences decreased in the last year of life when costs increased exponentially for those with and without CI.

“Our results show that the bulk of the CI burden is from ED visits and unplanned admissions,” the investigators said. The most common causes for ED visits among patients with CI were as follows: heart failure, urinary tract infection, fall-related injuries, and pneumonia. [Alzheimer Dis Assoc Disord 2016;30:35-40]

Therefore, “[f]uture research should investigate the extent to which such cases can be avoided or diverted to lower-cost outpatient and community care settings, and whether strategies to do so are cost-effective,” they added.

The current study had some limitations. First, estimates were only for medical costs and did not include the cost of private primary care clinics, nursing homes, other noninstitutional care, and large indirect costs related to informal caregiving. [Am J Geriatr Psychiatry 2019;27:1206-1215; Int J Environ Res Public Health 2021;18]

Second, estimates were based on the Chinese Singaporean population only. Finally, the investigators measured CI status just once at the beginning of the study. [J Am Geriatr Soc 2008;56:2061-2068; Curr Alzheimer Res 2017;14:620-627; J Alzheimers Dis 2019;71:341-351]