Changes in Outpatient Costs Following Screening and Diagnosis of Cognitive Impairment

Dementia is a common, costly, and often unrecognized problem in older adults. Early identification and intervention holds the promise of improving care through chronic disease management strategies. We integrated a program of screening, evaluation, and management for cognitive impairment into primary care. Here we report the impact of that program on total and line item outpatient costs. The Dementia Demonstration Project (DDP) employed specially trained Advanced Practice Registered Nurses functioning as Dementia Care Coordinators (DCCs) to lead interdisciplinary teams in the identification, evaluation, diagnosis and management of cognitive impairment (CI). Typical primary care clinics were identified at seven VA Medical Centers and the DDP was implemented in those clinics. The DCCs screened eligible veterans (age 70 and older, medically stable, able to comply with the screen, and without a prior diagnosis of CI) using the Mini-Cog at the time of a routine primary care clinic appointment. All patients newly diagnosed with CI, both in DDP and non-DDP PC clinics, who had data available for at least one year before and one year after diagnosis were analyzed. Risk adjusted differences in log transformed outpatient health care utilization and costs were analyzed using the mixed effects Poisson regression and difference-in-differences models. Of the 8278 veterans screened, 26% failed the screen. A total of 34% of those who failed completed a further evaluation and 95% of this group was found to have CI, including 76% with dementia. Data for one year before and after CI diagnosis were available on 347 DDP patients and 1261 non-DDP patients. Median DDP outpatient care costs declined over 54% (-$5,519) compared with 25% decline (-$1,759) in patients diagnosed in non-DDP clinics. Median number of line-item outpatient costs declined by 53% (-54) in the DDP patients compared to 32% (-21) in non-DDP patients. Diagnosing cognitive impairment was associated with a decrease in total and line item health care costs in the year following diagnosis compared to the year prior to diagnosis. The decreases were more dramatic in patients who were identified through cognitive screening and subsequently had case management available by a dementia care team.