The European Journal of Health Economics

, Volume 20, Issue 8, pp 1207–1236 | Cite as

How relevant are social costs in economic evaluations? The case of Alzheimer’s disease

  • L. M. Peña-LongobardoEmail author
  • B. Rodríguez-Sánchez
  • J. Oliva-Moreno
  • I. Aranda-Reneo
  • J. López-Bastida
Original Paper



The main objective of this study was to analyse how the inclusion (exclusion) of social costs can alter the results and conclusions of economic evaluations in the field of Alzheimer’s disease interventions.


We designed a systematic review that included economic evaluations in Alzheimer’s disease. The search strategy was launched in 2000 and ran until November 2018. The inclusion criteria were: being an original study published in a scientific journal, being an economic evaluation of any intervention related to Alzheimer’s disease, including social costs (informal care costs and/or productivity losses), being written in English, using QALYs as an outcome for the incremental cost–utility analysis, and separating the results according to the perspective applied.


It was finally included 27 studies and 55 economic evaluations. Around 11% of economic evaluations changed their main conclusions. More precisely, three of them concluded that the new intervention became cost-effective when the societal perspective was considered, whereas when using just the health care payer perspective, the new intervention did not result in a cost–utility ratio below the threshold considered. Nevertheless, the inclusion of social cost can also influence the results, as 37% of the economic evaluations included became the dominant strategy after including social costs when they were already cost-effective in the health care perspective.


Social costs can substantially modify the results of the economic evaluations. Therefore, taking into account social costs in diseases such as Alzheimer’s can be a key element in making decisions about public financing and pricing of health interventions.


Alzheimer’s disease Economic evaluation Labour productivity Informal care Societal perspective Social costs Cost–effectiveness Cost–utility 

JEL Classification

I11 I15 I18 H0 



 This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 779312.


  1. 1.
    Drummond, M.: Twenty years of using economic evaluations for reimbursement decisions. What have we achieved? CHE Research Paper 75. Centre for Health Economics, University of York, UK (2002)Google Scholar
  2. 2.
    Paris, V., Belloni, A.: Value in pharmaceutical pricing. OECD Health Working Papers, No. 63, OECD (2013)Google Scholar
  3. 3.
    Oliva, J., Antoñanzas. F., Rivero-Arias, O.: Evaluación económica y la toma de decisiones en salud. El papel de la evaluación económica en la adopción y difusión de tecnologías sanitarias. Informe SESPAS 2008. Gac Sanit. 22(Suppl 1), 137–142 (2008)PubMedGoogle Scholar
  4. 4.
    Joo, H., George, M.G., Fang, J., et al.: A literature review of indirect costs associated with stroke. J. Stroke Cerebrovasc. Dis. 23(7), 1753–1763 (2014)PubMedPubMedCentralGoogle Scholar
  5. 5.
    Pares-Badell, O., Barbaglia, G., Jerinic, P., et al.: Cost of disorders of the brain in Spain. PLoS One 9(8), e105471 (2014)PubMedPubMedCentralGoogle Scholar
  6. 6.
    Leal, J., Luengo-Fernandez, R., Gray, A., et al.: Economic burden of cardiovascular diseases in the enlarged European Union. Eur. Heart J. 27, 1610–1619 (2006)PubMedGoogle Scholar
  7. 7.
    Luengo-Fernandez, R., Leal, J., Gray, A.M.: Cost of dementia in the pre-enlargement countries of the European Union. J. Alzheimers Dis. 27(1), 187–197 (2011)PubMedGoogle Scholar
  8. 8.
    Luengo-Fernandez, R., Leal, J., Gray, A.M., et al.: Economic burden of cancer across the European Union: a population-based cost analysis. Lancet Oncol. 14, 1165–1174 (2013)PubMedGoogle Scholar
  9. 9.
    Oliva-Moreno, J., Trapero-Bertran, M., Peña-Longobardo, L.M., et al.: The valuation of informal care in cost-of-illness studies: a systematic review. Pharmacoeconomics. 35(3), 331–345 (2017)PubMedGoogle Scholar
  10. 10.
    López-Bastida, J., Oliva-Moreno, J., Linertová, R., et al.: Social/economic costs and health-related quality of life in patients with rare diseases in Europe. Eur. J. Health Econ. 17(Suppl 1), 1–5 (2016)PubMedGoogle Scholar
  11. 11.
    Chari, A.V., Engberg, J., Ray, K.N., et al.: The opportunity costs of informal elder-care in the United States: new estimates from the American time use survey. Health Serv. Res. 50(3), 871–882 (2015)PubMedGoogle Scholar
  12. 12.
    Oliva-Moreno, J.: Loss of labour productivity caused by disease and health problems: what is the magnitude of its effect on Spain’s economy? Eur. J. Health Econ. 13(5), 605–614 (2012)PubMedGoogle Scholar
  13. 13.
    Peña, L.M., Aranda, I., Oliva-Moreno, J., et al.: Pérdidas laborales ocasionadas por los fallecimientos prematuros. un análisis del periodo 2005–2009. Revista Española de Salud Pública. 89(1), 39–50 (2015)Google Scholar
  14. 14.
    Arno, P.S., Levine, C., Memmott, M.M.: The economic value of informal caregiving. Health Aff. (Millwood). 18(2), 182–188 (1999)PubMedGoogle Scholar
  15. 15.
    Peña-Longobardo, L., Aranda-Reneo, I., Oliva, J., et al.: Evaluación de las pérdidas laborales provocadas enfermedades y lesiones en España en el año 2009. Revista de Evaluación de Programas y Políticas Públicas. 6, 66–85 (2016)Google Scholar
  16. 16.
    Oliva-Moreno, J., Peña-Longobardo, L.M., Vilaplana-Prieto, C.: An estimation of the value of informal care provided to dependent people in Spain. Appl. Health Econ. Health Policy. 13(2), 223–231 (2015)PubMedGoogle Scholar
  17. 17.
    Hollander, M.J., Liu, G., Chappell, N.L.: Who cares and how much? The imputed economic contribution to the Canadian healthcare system of middle-aged and older unpaid caregivers providing care to the elderly. Healthc. Q. 12(2), 42–49 (2009)PubMedGoogle Scholar
  18. 18.
    Paraponaris, A., Davin, B., Verger, P.: Formal and informal care for disabled elderly living in the community: an appraisal of French care composition and costs. Eur. J. Health Econ. 13(3), 327–336 (2012)PubMedGoogle Scholar
  19. 19.
    Krol, M., Papenburg, J., Tan, S.S., et al.: A noticeable difference? Productivity costs related to paid and unpaid work in economic evaluations on expensive drugs. Eur J Health Econ. 17(4), 391–402 (2016)PubMedGoogle Scholar
  20. 20.
    Krol, M., Papenburg, J., van Exel, J.: Does including informal care in economic evaluations matter? A systematic review of inclusion and impact of informal care in cost-effectiveness studies. Pharmacoeconomics. 33(2), 123–135 (2015)PubMedGoogle Scholar
  21. 21.
    GBD 2015 Mortality and Causes of Death Collaborators: Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 388, 1459–1544 (2016)Google Scholar
  22. 22.
    GBD 2015 DALYs and HALE Collaborators: Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388, 1603–1658 (2016)Google Scholar
  23. 23.
    Alzheimer’s Association: 2017 Alzheimer’s disease facts and figures. Alzheimers Dement. 13(4), 325–373 (2017)Google Scholar
  24. 24.
    Costa, N., Ferlicoq, L., Derumeaux-Burel, H., Rapp, T., Garnault, V., Gillette-Guyonnet, S., Andrieu, S., Vellas, B., Lamure, M., Grand, A., Molinier, L.: Comparison of informal care time and costs in different age-related dementias: a review. Biomed. Res. Int. 2013, 852368 (2013)PubMedGoogle Scholar
  25. 25.
    Mauskopf, J., Mucha, L.: A review of the methods used to estimate the cost of Alzheimer’s disease in the United States. Am. J. Alzheimers Dis. Other Demen. 26(4), 298–309 (2011)PubMedGoogle Scholar
  26. 26.
    Cappell, J., Herrmann, N., Cornish, S., Lanctôt, K.L.: The pharmacoeconomics of cognitive enhancers in moderate to severe Alzheimer’s disease. CNS Drugs 24(11), 909–927 (2010)PubMedGoogle Scholar
  27. 27.
    Wimo, A., Guerchet, M., Ali, G.C., Wu, Y.T., Prina, A.M., Winblad, B., Jönsson, L., Liu, Z., Prince, M.: The worldwide costs of dementia 2015 and comparisons with 2010. Alzheimers Dement. 13(1), 1–7 (2017)PubMedPubMedCentralGoogle Scholar
  28. 28.
    López Bastida, J., Oliva Moreno, J., Serrano Aguilar, P., Perestelo, Pérez L.: The social economics costs and quality of life of Alzheimer disease in Spain. Neurology. 67(12), 2186–2191 (2006)PubMedGoogle Scholar
  29. 29.
    Välimäki, T.H., Martikainen, J.A., Hongisto, K., Väätäinen, S., Sintonen, H., Koivisto, A.M.: Impact of Alzheimer’s disease on the family caregiver’s long-term quality of life: results from an ALSOVA followup study. Qual. Life Res. 25, 687–697 (2016)PubMedGoogle Scholar
  30. 30.
    Bremer, P., Cabrera, E., Leino-Kilpi, H., Lethin, C., Saks, K., Sutcliffe, C.: Informal dementia care: consequences for caregivers’ health and health care use in 8 European countries. Health Policy 119, 1459–1471 (2015)PubMedGoogle Scholar
  31. 31.
    Goren, A., Montgomery, W., Kahle-Wrobleski, K., Nakamura, T., Ueda, K.: Impact of caring for persons with Alzheimer’s disease or dementia on caregivers’ health outcomes: findings from a community based survey in Japan. BMC Geriatr. 16, 122 (2016)PubMedPubMedCentralGoogle Scholar
  32. 32.
    Mareque, M., Oliva Moreno, J.: Social costs of diseases: how relevant are they for economic evaluations? Rev. Esp. Salud Publica. 22, 92. pii: e201808051 (2018)Google Scholar
  33. 33.
    Saret, C.J., Winn, A.N., Shah, G., Parsons, S.K., Lin, P.-J., Cohen, J.T., et al.: Value of innovation in hematologic malignancies: a systematic review of published cost-effectiveness analyses. Blood 125(12), 1866–1869 (2015)PubMedPubMedCentralGoogle Scholar
  34. 34.
    Center for the Evaluation of Value and Risk in Health. The Cost-Effectiveness Analysis Registry [Internet]. (Boston), Institute for Clinical Research and Health Policy Studies, Tufts Medical Center. Accessed 4 Feb 2018
  35. 35.
    OECD, Eurostat and World Health Organization: A system of health accounts 2011, Revised edn. OECD Publishing, Paris (2017)Google Scholar
  36. 36.
    van den Berg, B., Brouwer, W.B., Koopmanschap, M.A.: Economic valuation of informal care. An overview of methods and applications. Eur. J. Health Econ. HEPAC Health Econ. Prev. Care. 5(1), 36–45 (2004)Google Scholar
  37. 37.
    Hoefman, R.J., van Exel, J., Brouwer, W.: How to include informal care in economic evaluations. PharmacoEconomics. 31(12), 1105–1119 (2013)PubMedGoogle Scholar
  38. 38.
    Krol, M., Brouwer, W., Rutten, F.: Productivity costs in economic evaluations: past, present, future. Pharmacoeconomics. 31(7), 537–549 (2013). CrossRefPubMedGoogle Scholar
  39. 39.
    Goodrich, K., Kaambwa, B., Al-Janabi, H.: The inclusion of informal care in applied economic evaluation: a review. Value Health. 15(6), 975–981 (2012)PubMedGoogle Scholar
  40. 40.
    Michaud, T.L., Kane, R.L., McCarten, J.R., Gaugler, J.E., Nyman, J.A., Kuntz, K.M.: Using cerebrospinal fluid biomarker testing to target treatment to patients with mild cognitive impairment: a cost-effectiveness analysis. PharmacoEconomics-Open. 2(3), 309–323 (2018)PubMedGoogle Scholar
  41. 41.
    Lamb, S.E., Mistry, D., Alleyne, S., Atherton, N., Brown, D., Copsey, B., et al.: Aerobic and strength training exercise programme for cognitive impairment in people with mild to moderate dementia: the DAPA RCT. Health Technol. Assess. (Winchester, England) 22(28), 1–202 (2018)Google Scholar
  42. 42.
    Hornberger, J., Bae, J., Watson, I., Johnston, J., Happich, M.: Clinical and cost implications of amyloid beta detection with amyloid beta positron emission tomography imaging in early Alzheimer’s disease—the case of florbetapir. Curr. Med. Res. Opin. 33(4), 675–685 (2017)PubMedGoogle Scholar
  43. 43.
    Tong, T., Thokala, P., McMillan, B., Ghosh, R., Brazier, J.: Cost effectiveness of using cognitive screening tests for detecting dementia and mild cognitive impairment in primary care. Int. J. Geriatr. Psychiatry 32(12), 1392–1400 (2017)PubMedGoogle Scholar
  44. 44.
    Knapp, M., King, D., Romeo, R., Adams, J., Baldwin, A., Ballard, C., Banerjee, S., Barber, R., Bentham, P., Brown, R.G., Burns, A., Dening, T., Findlay, D., Holmes, C., Johnson, T., Jones, R., Katona, C., Lindesay, J., Macharouthu, A., McKeith, I., McShane, R., O’Brien, J.T., Phillips, P.P.J., Sheehan, B., Howard, R.: Cost-effectiveness of donepezil and memantine in moderate to severe Alzheimer’s disease (the DOMINO-AD trial). Int. J. Geriatr. Psychiatry 32(12), 1205–1216 (2017)PubMedGoogle Scholar
  45. 45.
    Hornberger, J., Michalopoulos, S., Dai, M., Andrade, P., Dilla, T., Happich, M.: Cost-effectiveness of Florbetapir-PET in Alzheimer’s disease: a Spanish societal perspective. J. Ment. Health Policy Econ. 18(2), 63–73 (2015)PubMedGoogle Scholar
  46. 46.
    Saint-Laurent Thibault, C., Özer Stillman, I., Chen, S., Getsios, D., Proskorovsky, I., Hernandez, L., Dixit, S.: Cost-utility analysis of memantine extended release added to cholinesterase inhibitors compared to cholinesterase inhibitor monotherapy for the treatment of moderate-to-severe dementia of the Alzheimer’s type in the US. J. Med. Econ. 18(11), 930–943 (2015)PubMedGoogle Scholar
  47. 47.
    D’Amico, F., Rehill, A., Knapp, M., Aguirre, E., Donovan, H., Hoare, Z., Hoe, J., Russell, I., Spector, A., Streater, A., Whitaker, C., Woods, R.T., Orrell, M.: Maintenance cognitive stimulation therapy: an economic evaluation within a randomized controlled trial. J. Am. Med. Dir. Assoc. 16(1), 63–70 (2015)PubMedGoogle Scholar
  48. 48.
    Orgeta, V., Leung, P., Yates, L., Kang, S., Hoare, Z., Henderson, C., et al.: Individual cognitive stimulation therapy for dementia: a clinical effectiveness and cost-effectiveness pragmatic, multicentre, randomised controlled trial. Health Technol. Assess. (Winchester, England) 19(64), 1–108 (2015)Google Scholar
  49. 49.
    Touchon, J., Lachaine, J., Beauchemin, C., Granghaud, A., Rive, B., Bineau, S.: The impact of memantine in combination with acetylcholinesterase inhibitors on admission of patients with Alzheimer’s disease to nursing homes: cost-effectiveness analysis in France. Eur. J. Health Econ. 15(8), 791–800 (2014)PubMedGoogle Scholar
  50. 50.
    Sogaard, R., Sorensen, J., Waldorff, F.B., Eckermann, A., Buss, D.V., Phung, K.T., Waldemar, G.: Early psychosocial intervention in Alzheimer’s disease: cost utility evaluation alongside the Danish Alzheimer’s Intervention Study (DAISY). BMJ Open e004105 (2014)Google Scholar
  51. 51.
    Romeo, R., Knapp, M., Hellier, J., Dewey, M., Ballard, C., Baldwin, R., Bentham, P., Burns, A., Fox, C., Holmes, C., Katona, C., Lawton, C., Lindesay, J., Livingston, G., McCrae, N., Moniz-Cook, E., Murray, J., Nurock, S., O’Brien, J., Poppe, M., Thomas, A., Walwyn, R., Wilson, K., Banerjee, S.: Cost-effectiveness analyses for mirtazapine and sertraline in dementia: randomised controlled trial. Br. J. Psychiatry 202(2), 121–128 (2013)PubMedGoogle Scholar
  52. 52.
    Pfeil, A.M., Kressig, R.W., Szucs, T.D.: Alzheimer’s dementia: budget impact and cost-utility analysis of a combination treatment of a cholinesterase inhibitor and memantine in Switzerland. Swiss Med. Wkly 142, w13676 (2012)PubMedGoogle Scholar
  53. 53.
    Hartz, S., Getsios, D., Tao, S., Blume, S., Maclaine, G.: Evaluating the cost effectiveness of donepezil in the treatment of Alzheimer’s disease in Germany using discrete event simulation. BMC Neurol. 12, 2 (2012)PubMedPubMedCentralGoogle Scholar
  54. 54.
    Rive, B., Aarsland, D., Grishchenko, M., Cochran, J., Lamure, M., Toumi, M.: Cost-effectiveness of memantine in moderate and severe Alzheimer’s disease in Norway. Int. J. Geriatr. Psychiatry 27(6), 573–582 (2012)PubMedGoogle Scholar
  55. 55.
    Getsios, D., Blume, S., Ishak, K.J., Maclaine, G., Hernández, L.: An economic evaluation of early assessment for Alzheimer’s disease in the United Kingdom. Alzheimers Dement. 8(1), 22–30 (2012)PubMedGoogle Scholar
  56. 56.
    Guo, S., Getsios, D., Hernandez, L., Cho, K., Lawler, E., Altincatal, A., Lanes, S., Blankenburg, M.: Florbetaben PET in the early diagnosis of Alzheimer’s disease: a discrete event simulation to explore its potential value and key data gaps. Int J Alzheimers 548157 (2012)Google Scholar
  57. 57.
    Woods, R.T., Bruce, E., Edwards, R.T., Elvish, R., Hoare, Z., Hounsome, B., et al.: REMCARE: reminiscence groups for people with dementia and their family caregivers—effectiveness and cost-effectiveness pragmatic multicentre randomised trial. Health Technol. Assess. 16(48), v–xv, 1–116 (2012).
  58. 58.
    Lachaine, J., Beauchemin, C., Legault, M., Bineau, S.: Economic evaluation of the impact of memantine on time to nursing home admission in the treatment of Alzheimer disease. Can. J. Psychiatry 56(10), 596–604 (2011)PubMedGoogle Scholar
  59. 59.
    Nagy, B., Brennan, A., Brandtmüller, A., Thomas, S.K., Sullivan, S.D., Akehurst, R.: Assessing the cost-effectiveness of the rivastigmine transdermal patch for Alzheimer’s disease in the UK using MMSE- and ADL-based models. Int. J. Geriatr. Psychiatry 26(5), 483–494 (2011)PubMedGoogle Scholar
  60. 60.
    Getsios, D., Blume, S., Ishak, K.J., Maclaine, G.: Cost effectiveness of donepezil in the treatment of mild to moderate Alzheimer’s disease: a UK evaluation using discrete-event simulation. Pharmacoeconomics 28(5), 411–427 (2010)PubMedGoogle Scholar
  61. 61.
    López-Bastida, J., Hart, W., García-Pérez, L., Linertová, R.: Cost-effectiveness of donepezil in the treatment of mild or moderate Alzheimer’s disease. J. Alzheimers Dis. 16(2), 399–407 (2009)PubMedGoogle Scholar
  62. 62.
    Wolfs, C.A., Dirksen, C.D., Kessels, A., Severens, J.L., Verhey, F.R.: Economic evaluation of an integrated diagnostic approach for psychogeriatric patients: results of a randomized controlled trial. Arch. Gen. Psychiatry 66(3), 313–323 (2009)PubMedGoogle Scholar
  63. 63.
    Fuh, J.L., Wang, S.J.: Cost-effectiveness analysis of donepezil for mild to moderate Alzheimer’s disease in Taiwan. Int. J. Geriatr. Psychiatry 23(1), 73–78 (2008)PubMedGoogle Scholar
  64. 64.
    Kirbach, S., Simpson, K., Nietert, P.J., Mintzer, J.: A markov model of the cost effectiveness of olanzapine treatment for agitation and psychosis in Alzheimer’s disease. Clin. Drug Investig 28(5), 291–303 (2008)PubMedGoogle Scholar
  65. 65.
    Weycker, D., Taneja, C., Edelsberg, J., Erder, M.H., Schmitt, F.A., Setyawan, J., Oster, G.: Cost-effectiveness of memantine in moderate-to-severe Alzheimer’s disease patients receiving donepezil. Curr. Med. Res. Opin. 23(5), 1187–1197 (2007)PubMedGoogle Scholar
  66. 66.
    McMahon, P.M., Araki, S.S., Neumann, P.J., Harris, G.J., Gazelle, G.S.: Cost-effectiveness of functional imaging tests in the diagnosis of Alzheimer disease. Radiology 217(1), 58–68 (2000)PubMedGoogle Scholar
  67. 67.
    Reed, C., Happich, M., Argimon, J.M., Haro, J.M., Wimo, A., Bruno, G., Dodel, R., Jones, R.W., Vellas, B., Belger, M.: What drives country differences in cost of Alzheimer’s disease? an explanation from resource use in the GERAS study. J. Alzheimers Dis. 57(3), 797–812 (2017)PubMedGoogle Scholar
  68. 68.
    Jönsson, L., Wimo, A.: The cost of dementia in Europe: a review of the evidence, and methodological considerations. Pharmacoeconomics. 27(5), 391–403 (2009)PubMedGoogle Scholar
  69. 69.
    Chappell, N., Blandford, A.: Informal and formal care: exploring the complementarity. Ageing Soc. 11(03), 299–317 (1991)Google Scholar
  70. 70.
    Jimenez-Martin, S., Prieto, C.V.: The trade-off between formal and informal care in Spain. Eur. J. Health Econ. 13(4), 461–490 (2012)PubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Faculty of Social Science and LawUniversity of Castilla-La ManchaTalavera de la ReinaSpain
  2. 2.Faculty of Health ScienceUniversity of Castilla-La ManchaTalavera de la ReinaSpain

Personalised recommendations