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This study aims to develop and validate a prediction model of societal costs during a period of 6-months in older community care-recipients across multiple European countries. Participants were older community care-recipients from 5 European countries. The outcome measure was mean 6-months total societal costs of resource utilisation (healthcare and informal care). Potential predictors included sociodemographic characteristics, functional limitations, clinical conditions, and diseases/disorders. The model was developed by performing Linear Mixed Models with a random intercept for the effect of country and validated by an internal-external validation procedure. Living alone, caregiver distress, (I)ADL impairment, required level of care support, health instability, presence of pain, behavioural problems, urinary incontinence and multimorbidity significantly predicted societal costs during 6 months. The model explained 32% of the variation within societal costs and showed good calibration in Iceland, Finland and Germany. Minor model adaptations improved model performance in The Netherland and Italy. The results can provide a valuable orientation for policymakers to better understand cost development among older community care-recipients. Despite substantial differences of countries' care systems, a validated cross-national set of key predictors could be identified. [ABSTRACT FROM AUTHOR]

Background: Problem gambling is a public health issue affecting both the gamblers, their families, their employers, and society as a whole. Recent law changes in Sweden oblige local and regional health authorities to invest more in prevention and treatment of problem gambling. The economic consequences of gambling, and thereby the potential economic consequences of policy changes in the area, are unknown, as the cost of problem gambling to society has remained largely unexplored in Sweden and similar settings.Methods: A prevalence-based cost-of-illness study for Sweden for the year 2018 was conducted. A societal approach was chosen in order to include direct costs (such as health care and legal costs), indirect costs (such as lost productivity due to unemployment), and intangible costs (such as reduced quality of life due to emotional distress). Costs were estimated by combining epidemiological and unit cost data.Results: The societal costs of problem gambling amounted to 1.42 billion euros in 2018, corresponding to 0.30% of the gross domestic product. Direct costs accounted only for 13% of the total costs. Indirect costs accounted for more than half (59%) of the total costs, while intangible costs accounted for 28%. The societal costs were more than twice as high as the tax revenue from gambling in 2018. Direct and indirect costs of problem gambling combined amounted to one third of the equivalent costs of smoking and one sixth of the costs of alcohol consumption in Sweden.Conclusions: Problem gambling is increasingly recognized as a public health issue. The societal costs of it are not negligible, also in relation to major public health issues of an addictive nature such as smoking and alcohol consumption. Direct costs for prevention and treatment are very low. A stronger focus on prevention and treatment might help to reduce many of the very high indirect and intangible costs in the future. [ABSTRACT FROM AUTHOR]

Background: For the case of multiple sclerosis, research on gender differences from a health economics perspective has not received much attention. However, cost-of-illness analyses can provide valuable information about the diverse impact of the disease and thus help decision-makers to allocate scarce resources. The aim of this study was to describe healthcare resource use and associated societal costs from a gender perspective. In particular, we aimed to identify how resource utilization potentially differs in certain cost components between men and women. Methods: Clinical and economic data were extracted from two prospective, multicentre, non-interventional, observational studies in Germany. Information on health resource use was obtained from all patients on a quarterly basis using a validated questionnaire. Cost analyses were conducted from the societal perspective including all direct (healthcare-related) and indirect (work-related) costs, regardless of who bears them. Gender-related differences were analysed by a multivariable generalized linear model with a negative binomial distribution and log link function due to the right-skewed distribution pattern of cost data. In addition, costs for men and women were descriptively analysed within subgroups of two-year disease activity. Results: In total, 2095 patients (women-to-men ratio of 2.7:1) presented a mean age of 41.85 years and a median Expanded Disability Status Scale of 2 (interquartile range 1–3.5) (p > 0.30 for gender-related differences). Women and men did not statistically differ in total quarterly costs (€2329 ± €2570 versus €2361 ± €2612). For both, costs were higher with advancing disease severity and indirect costs were the main societal cost driver. Regarding healthcare-related resources, women incurred higher costs for ambulant consultations [incidence rate ratio (IRR) 1.16, confidence interval (CI) 1.04–1.31], complementary medicine (IRR 2.41, CI 1.14–5.06), medical consumables (IRR 2.53, CI 1.69–3.79) and informal care (IRR 2.79, CI 1.56–5.01). Among indirect costs, we found higher costs for men for presenteeism (IRR 0.62; CI 0.53–0.72) and higher costs for women for disability pension (IRR 1.62; CI 1.23–2.13). Conclusions: Multiple sclerosis poses a significant economic burden on patients, families and society. While the total economic burden did not differ between male and female patients, we found gender differences in specific cost items that are similar to those in the wider non-MS population. [ABSTRACT FROM AUTHOR]

Background: Colorectal surgery is associated with postoperative ileus (POI). Despite its widespread manifestation, the influence of POI on recovery, quality of life (QoL), and costs is largely unknown. The aim of this study was to assess whether the inflammatory processes found in experimental studies are also evident in patients undergoing colorectal surgery. In addition, the impact of POI on short and long‐term QoL and costs was investigated. Methods: We analyzed the outcomes of the SANICS‐II trial, including prospective evaluation of inflammatory parameters in blood samples, costs from a societal perspective and QoL, using validated questionnaires. Outcomes were compared between patients with and without POI, and in particular patients with POI as unique complication. Key Results: A total of 265 patients (POI, n = 66 vs non‐POI, n = 199) were included and 38/66 had POI as only complication. CRP levels were significantly increased on postoperative day (POD) 1, 2, 3, and 4 in patients with POI. Furthermore, plasma levels of cytokines IL‐6, Il‐8 and IL‐10 were significantly increased the first 2 days after resection. Patients with POI had a higher overall complication rate and a reduced QoL 3 months postoperatively, even in the only POI group. Moreover, mean societal cost per patient with POI was 38%‐47% higher at 3 months postoperatively. Conclusions & Inferences: Supporting findings from experimental studies, inflammatory parameters were increased in patients with only POI and comparable with all patients with POI. These results demonstrate the impact and large contribution of POI in postoperative inflammation, costs and QoL in patients undergoing colorectal surgery. [ABSTRACT FROM AUTHOR]

To investigate resource use and time investments of healthcare professionals, patients and their family and to compare healthcare and societal costs of one single hospital-based and one single home-based subcutaneous administration of trastuzumab in The Netherlands. We conducted a bottom-up micro-costing study. Patients diagnosed with HER2+ early or metastatic breast cancer were recruited in four Dutch hospitals. For healthcare costs, data were collected on drug use, consumables, use of healthcare facilities, time of healthcare professionals, and travelling distance of the nurse. For societal costs, data were collected on patient and family costs (including travelling expenses and time of informal caregivers) and productivity losses of paid and unpaid work. Societal costs of one single administration of SC trastuzumab were €1753 within the home-based and €1724 within the hospital-based setting. Drug costs of trastuzumab were identical in both settings (€1651). Healthcare costs were higher for home-based administration (€91 versus €47) mainly because of more time of healthcare professionals (110 versus 38 minutes). Costs for patient and family were, however, lower for home-based administration due to travelling expenses (€7 versus €0) and time of informal caregivers (€14 versus €4). Costs for productivity losses were similar for both settings. Home-based subcutaneous administration of trastuzumab is more time consuming for healthcare professionals and therefore more costly than hospital-based administration. The total budget impact can be large considering that a large number of patients receive a large number of cycles of oncology treatments. If home-based administration is the way forward, novel approaches are crucial for ensuring efficiency of home-based care. • Home-based administration of SC trastuzumab almost triples the time of healthcare professionals. • Healthcare costs are almost twice as much for home-based than for hospital-based administration. • Patient and family costs are almost five times lower for home-based than for hospital-based administration. [ABSTRACT FROM AUTHOR]

Objectives: Psoriatic arthritis (PsA) is associated with serious productivity impairment. Secukinumab, a fully human IL-17A inhibitor, provides sustained relief from PsA symptoms. This study estimates the societal economic benefits of using secukinumab instead of conventional disease-modifying anti-rheumatic drugs (DMARDs) for treating patients with active PsA in Germany from 2016 to 2030.Methods: A Markov and a population model simulated the functional impairment of German PsA patients. The relationship between functional impairment and work productivity was used to determine the productivity difference in the populations treated with secukinumab and csDMARDs. The corresponding gains in productive time were allocated to paid and unpaid activities and valued according to gross value added (GVA). Since increased productivity has the potential to stimulate greater macroeconomic effects, indirect and induced GVA effects were calculated as well.Results: The use of secukinumab reduces the productivity impairment in the target population on average by 13 percentage points. This difference could generate 32 million active and productive hours until the year 2030, which translates to GVA equivalents of €1.3 billion. Including indirect and induced effects yield an economic estimate of €2.7 billion GVA equivalent.Conclusions: The improvements in PsA-related functional impairment could lead to sizable productivity effects within the economy. [ABSTRACT FROM AUTHOR]

Background: There is limited research quantifying the direct and indirect economic costs associated with intellectual disability (ID) in Australia. Costs incurred by families, governments and broader society include time spent providing care, absenteeism and increased healthcare utilisation. The purpose of this research is to quantify the costs associated with ID in childhood using a range of methods to collect cost data. Methods: Costs included healthcare service utilisation, pharmaceutical use, caregiver productivity losses and time spent providing care because of the child's disability. The sample comprised caregivers with a child with ID aged between 2 and 10 years old recruited in Australia. Healthcare service utilisation and pharmaceutical use were obtained from routinely collected administrative claims data. Healthcare utilisation not captured in the routinely collected administrative data and absenteeism data were obtained from a retrospective recall‐based questionnaire. Time spent providing care because of the child's disability was obtained using a time‐use diary. Results: The total cost of ID in Australia was estimated to be AUD 72 027 per year per child, and the total cost of ID in childhood was estimated to be AUD 12.5 billion per year. The cost to governments of ID in childhood was estimated to be AUD 6385 per child per year, resulting in a total cost to government of AUD 1.1 billion per year. Conclusions: This is the first study to estimate the direct and indirect costs associated with ID in childhood. The results of this research demonstrate the considerable economic impact of ID in childhood on families, governments and broader society in terms of both direct and indirect costs. An understanding of the cost implications of any intervention are critical in assisting policymakers in planning and prioritising of health services. [ABSTRACT FROM AUTHOR]

This summary article compares government revenue from the sale and distribution of alcohol to the societal costs caused by alcohol use for the year 2014. Statistics Canada data reported government revenue of $10.9 billion; however, this was offset by net societal costs of $14.6 billion, as reported by Canada's national substance use surveillance system, the Canadian Substance Use Costs and Harms project. The societal costs include health care, economic loss of production, criminal justice and other direct costs. Though revenue from alcohol sales has been described as a benefit to public coffers, accounting that includes costs incurred shows that all provinces and territories in Canada are running an alcohol deficit, totalling $3.7 billion nationally. [ABSTRACT FROM AUTHOR]

Yusuke Nakamura,1 Jörg Mahlich1,2 1Health Economics, Janssen Pharmaceutical K.K., Tokyo, Japan; 2Düsseldorf Institute for Competition Economics (DICE), University of Düsseldorf, Düsseldorf, Germany Background: No study has examined the financial impact of relapses on schizophrenia from the perspective of Japanese society. This study aimed to estimate the societal costs in Japan caused by the relapses of schizophrenia.Methods: The societal costs in Japan in 2013 due to relapses of schizophrenia were estimated by summing the productivity loss and deadweight loss caused by schizophrenia relapses in 2013. Deterministic sensitivity analysis was conducted for deadweight loss rate, relapse rate, and patient income.Results: Japan incurred JPY 55,039 million societal costs because of relapses in 2013. This consists of JPY 3,990 million for productivity loss and JPY 51,049 million for deadweight loss. Rate of deadweight loss is the most significant cost driver in the sensitivity analysis.Conclusion: Relapses of schizophrenia could generate huge amount of societal costs by reducing labor productivity and economic efficiency. To curb these costs, relapse prevention is desired in treating schizophrenia. Keywords: schizophrenia, relapses, societal costs, productivity loss, deadweight loss, Japan

Objectives To evaluate the costs of quad-helix (QH) and removable expansion plate (EP) treatments performed either in specialist or general dentistry for the correction of unilateral posterior crossbite with functional shift in the mixed dentition. Trial design Four-arm parallel group multicentre randomized controlled trial. Materials and methods One hundred and ten patients with unilateral posterior crossbite with functional shift were recruited. The patients were randomized by an independent person not involved in the trial. The randomization used blocks of 20 and into the following four groups: QH treatments in specialist orthodontic clinics (QHS), QH treatments in general dentistry (QHG), EP treatments in specialist orthodontic clinics (EPS), and EP treatments in general dentistry (EPG). Blinding was accomplished of the outcome assessor and data analyst. A cost analysis was performed with reference to intention-to-treat (ITT), regarding direct costs, indirect costs, and societal costs (the sum of direct and indirect costs) for calculations of successful treatments alone and for retreatments when required. To determine which alternative has the lower cost, a cost-minimization analysis was undertaken, based on that the outcome of the treatment alternatives were broadly equivalent, so the difference between them reduces to a comparison of costs. Results In the QHS group, 28 of 28 patients were successfully corrected compared to 23 of 27 in the QHG group. Treatment with expansion plate was less successful: 18 of 27 patients in the EPS group and 18 of 28 in the EPG group. QH treatment performed in specialist orthodontic clinics had significantly lower costs than QH or EP treatment accomplished in general dentistry as well as EP treatments in specialist orthodontic clinics. Limitations Costs depend on local factors and should not be directly extrapolated to other locations. Conclusion Treatment of unilateral posterior crossbite in the mixed dentition is recommended to be performed by a specialist orthodontist using the QH appliance. Trial registration The trial was not registered. [ABSTRACT FROM AUTHOR]

Objective: There is little information on cost-of-illness among patients diagnosed with Crohn's disease (CD) and ulcerative colitis (UC) in Denmark. The objective of this study was to estimate the average 5-year societal costs attributable to CD or UC patients in Denmark with incidence in 2003–2015, including costs related to health care, prescription medicine, home care and production loss. Materials and methods: A national register-based, cost-of-illness study was conducted using an incidence-based approach to estimate societal costs. Incident patients with CD or UC were identified in the National Patient Registry and matched with a non-IBD control from the general population on age and sex. Attributable costs were estimated applying a difference-in-difference approach, where the total costs among individuals in the control group were subtracted from the total costs among patients. Results: CD and UC incidence fluctuated but was approximately 14 and 31 per 100,000 person years, respectively. The average attributable costs were highest the first year after diagnosis, with costs equalling €12,919 per CD patient and €6,501 per UC patient. Hospital admission accounted for 36% in the CD population and 31% in the UC population, the first year after diagnosis. Production loss exceeded all other costs the third-year after diagnosis (CD population: 52%; UC population: 83%). Conclusions: We found that the societal costs attributable to incident CD and UC patients are substantial compared with the general population, primarily consisting of hospital admission costs and production loss. Appropriate treatment at the right time may be beneficial from a societal perspective. [ABSTRACT FROM AUTHOR]

Purpose: Previous studies found higher levels of pain severity and disability to be associated with higher costs and lower health-related quality of life. However, these findings were based on cross-sectional data and little is known about the longitudinal relationships between pain severity and disability versus health-related quality of life and costs among chronic low back pain patients. This study aims to cover this knowledge gap by exploring these longitudinal relationships in a consecutive cohort.Methods: Data of 6316 chronic low back pain patients were used. Measurements took place at 3, 6, 9, and 12 months. Pain severity (Numeric pain rating scale; range: 0-100), disability (Oswestry disability index; range: 0-100), health-related quality of life (EQ-5D-3L: range: 0-1), societal and healthcare costs (cost questionnaire) were measured. Using linear generalized estimating equation analyses, longitudinal relationships were explored between: (1) pain severity and health-related quality of life, (2) disability and health-related quality of life, (3) pain severity and societal costs, (4) disability and societal costs, (5) pain severity and healthcare costs, and (6) disability and healthcare costs.Results: Higher pain and disability levels were statistically significantly related with poorer health-related quality of life (pain intensity: - 0.0041; 95% CI - 0.0043 to - 0.0039; disability: - 0.0096; 95% CI - 0.0099 to - 0.0093), higher societal costs (pain intensity: 7; 95% CI 5 to 8; disability: 23; 95% CI 20 to 27) and higher healthcare costs (pain intensity: 3; 95% CI 2 to 4; disability: 9; 95% CI 7 to 11).Conclusion: Pain and disability were longitudinally related to health-related quality of life, societal costs, and healthcare costs. Disability had a stronger association with all outcomes compared to pain. [ABSTRACT FROM AUTHOR]

Background: Shoulder instability is associated with decreased functioning. The associated costs could be substantial and interesting to clinicians, researchers, and policy makers. This prospective observational study aims to (1) estimate productivity losses and healthcare expenses following the nonoperative treatment of shoulder instability and (2) identify patient characteristics that influence societal costs. Methods: One hundred and thirty-two patients completed a questionnaire regarding production losses and healthcare utilization following consecutive episodes of shoulder instability. Productivity losses were calculated using the friction cost approach. Healthcare utilization was evaluated using standard costs. analysis of variance test was used to assess which patient characteristics are related to productivity losses and healthcare expenses. Societal costs were assessed using multilevel analyses. Bootstrapping was used to estimate statistical uncertainty. Results: Mean productivity losses are €1469, €881, and €728 and mean healthcare expenses are €3759, €3267, and €2424 per patient per dislocation for the first, second, and third dislocation. Productivity losses decrease significantly after the second (mean difference €−1969, 95%CI= −3680 to −939) and third (mean difference €−2298, 95%CI= −4092 to −1288) compared to the first dislocation. Conclusions: Nonoperative treatment of shoulder instability has substantial societal costs. Level of Evidence: III, economic analysis. [ABSTRACT FROM AUTHOR]

Background Previous studies have shown that increasing antibacterial resistance (ABR) globally will cause extensive morbidity, deaths and escalated health care costs. Methods To project economic consequences of resistance to antibacterial drugs for the Swedish health care sector, we used an individual-based microsimulation model, SESIM. Health care consumption was represented as increased numbers of hospital days, outpatient visits and contact tracing for individuals getting clinical infections or becoming asymptomatic carriers. The risk of contracting a resistant bacterium was calculated using the incidence of mandatorily notifiable ABR in Sweden. Results We estimate accumulated additional health care costs attributable to notifiable ABR from 2018 until 2030 to EUR 406 million and EUR 1, 503 million until 2050. Until 2030 the largest proportion, more than EUR 247 million (EUR 958 million until 2050), was due to ESBL, followed by methicillin resistant Staphylococcus aureus, carbapenemase-producing Enterobacteriaceae, vancomycin-resistant Enterococci and penicillin non-susceptible Pneumococci which incurred costs of EUR 128 million (EUR 453 million, 2050), EUR 15 million (EUR 58 million, 2050), EUR 13 million (EUR 28 million, 2050) and EUR 2 million (EUR 6 million, 2050), respectively. Conclusions Projections concerning the future costs of ABR can be used to guide priorities and distribution of limited health care resources. Our estimates imply that costs in Sweden will have doubled by 2030 and increased more than 4-fold by 2050 if present trends continue and infection control practices remain unchanged. Still, indirect societal costs and costs for non-notifiable resistance remain to be added. [ABSTRACT FROM AUTHOR]

Chronic obstructive pulmonary disease (COPD) is a significant and disabling condition that entails high economic burden for society. The aim of this article is to assess cost studies of COPD and analyze cross-country cost comparisons in Asia-Pacific. A systematic literature search from October 2000 to October 2018 was conducted using PubMed, MEDLINE, and EMBASE to identify relevant studies. Costs reported by the different studies were converted to 2017 US dollars using the consumer price index for medical care. The quality of the studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards. Ten studies (6 countries and 11 estimates) were identified and included for full review after consideration of the inclusion and exclusion criteria. Annual total societal costs of COPD ranged from $4398 to $23 049 per capita in Japan and $453 to $12 167 in South Korea. There were no intracountry comparison estimates for the remaining countries (Singapore: $2700; Taiwan: $4000; China: $3942; and Thailand: $1105). In addition, there were estimates of partial costs in Singapore and Taiwan. Results of this review showed high cost variations between countries, with estimates in 2 countries (Japan and South Korea) exceeding those in UK and USA. Wide variation in disease cost estimates will continue to exist as long as there are differences in cost methodologies, disease severities included, and data limitation. We propose that researchers conducting burden-of-illness studies use standard methods and reporting formats to support cross-country comparisons. [ABSTRACT FROM AUTHOR]

Background It is common practice to require patients to stop smoking prior to elective plastic surgery procedures. Scarce research exists describing the impact on mortality and associated societal cost savings with regard to smoking cessation in aesthetic surgery. Objectives Our objective is to demonstrate that smoking cessation in anticipation for aesthetic surgery significantly reduces mortality and increases societal cost savings. Methods We performed a systematic literature review of 5 common aesthetic procedures (reduction mammaplasty, breast augmentation, facelift, rhinoplasty, and abdominoplasty) to determine patient smoking rates and subsequent recidivism. Sensitivity analyses estimated life years saved using ranges of recidivism from our literature review and assessed total lifetime savings, including direct and productivity costs, while adjusting for inflation (3%) and interest (5%). One life saved was equated to 45 life years saved. Results Between May 2008 and May 2013, 7867 patients stopped smoking prior to undergoing aesthetic plastic surgery procedures. Assuming a reported recidivism rate of 68%, smoking cessation prior to aesthetic plastic surgery is associated with 429 lives saved and a total lifetime savings of $524.4 million over the five-year period. Total lives saved ranged from 214 (84% recidivism) to 885 (34% recidivism), and total lifetime cost savings ranged from $262.2 million (84% recidivism) to $1.08 billion (34% recidivism). Conclusions Presently, smoking cessation before aesthetic surgery significantly saves patient lives with yearly $104.9 million of societal cost savings in the United States. Future reductions in the presently high recidivism rate would lead to additional lives saved and reduced societal costs. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]

Objectives: To examine the costs of caring for community-dwelling patients with Alzheimer's disease (AD) dementia in relation to the time to institutionalisation.Methods: GERAS was a prospective, non-interventional cohort study in community-dwelling patients with AD dementia and their caregivers in three European countries. Using identified factors associated with time to institutionalisation, models were developed to estimate the time to institutionalisation for all patients. Estimates of monthly total societal costs, patient healthcare costs and total patient costs (healthcare and social care together) prior to institutionalisation were developed as a function of the time to institutionalisation.Results: Of the 1495 patients assessed at baseline, 307 (20.5%) were institutionalised over 36 months. Disease severity at baseline [based on Mini-Mental State Examination (MMSE) scores] was associated with risk of being institutionalised during follow up (p < 0.001). Having a non-spousal informal caregiver was associated with a faster time to institutionalisation (944 fewer days versus having a spousal caregiver), as was each one-point worsening in baseline score of MMSE, instrumental activities of daily living and behavioural disturbance (67, 50 and 30 fewer days, respectively). Total societal costs, total patient costs and, to a lesser extent, patient healthcare-only costs were associated with time to institutionalisation. In the 5 years pre-institutionalisation, monthly total societal costs increased by more than £1000 (€1166 equivalent for 2010) from £1900 to £3160 and monthly total patient costs almost doubled from £770 to £1529.Conclusions: Total societal costs and total patient costs rise steeply as community-dwelling patients with AD dementia approach institutionalisation. [ABSTRACT FROM AUTHOR]

Objective To analyse cost-effectiveness of anchorage reinforcement with buccal miniscrews and with molar blocks. We hypothesized that anchorage with miniscrews is more cost-effective than anchorage with molar blocks. Trial design A single-centre, two-arm parallel-group randomized controlled trial. Methods Adolescents (age 11–19 years) in need of treatment with fixed appliance, premolar extractions, and en masse retraction were recruited from one Public Dental Health specialist centre. The intervention arm received anchorage reinforcement with buccal miniscrews during space closure. The active comparator received anchorage reinforcement with molar blocks during levelling/alignment and space closure. The primary outcome measure was societal costs defined as the sum of direct and indirect costs. Randomization was conducted as simple randomization stratified on gender. The patients, caregivers, and outcome assessors were not blinded. Results Eighty patients were randomized into two groups. The trial is completed. All patients were included in the intention-to-treat analysis. The median societal costs for the miniscrew group were €4681 and for the molar block group were €3609. The median of the difference was €825 (95% confidence interval (CI) 431–1267). This difference was mainly caused by significantly higher direct costs consisting of material and chair time costs. Differences in chair time costs were related to longer treatment duration. No serious harms were detected, one screw fractured during insertion and three screws were lost during treatment. Generalizability and limitations The monetary variables are calculated based on a number of local factors and assumptions and cannot necessarily be transferred to other countries. Variables such as chair time, number of appointments, and treatment duration are generalizable. Owing to the study protocol, the benefit of miniscrews as a stable anchorage has not been fully utilized. Conclusions When only moderate anchorage reinforcement is needed, miniscrews are less cost-effective than molar blocks. The initial hypothesis was rejected. Miniscrews provide better anchorage reinforcement at a higher price. They should be used in cases where anchorage loss cannot be accepted. Trial registration NCT02644811 [ABSTRACT FROM AUTHOR]

Abstract Background Ambulatory antibiotic prescribing contributes to the development of antibiotic resistance and increases societal costs. Here, we estimate the hidden societal cost of antibiotic resistance per antibiotic prescribed in the United States. Methods In an exploratory analysis, we used published data to develop point and range estimates for the hidden societal cost of antibiotic resistance (SCAR) attributable to each ambulatory antibiotic prescription in the United States. We developed four estimation methods that focused on the antibiotic-resistance attributable costs of hospitalization, second-line inpatient antibiotic use, second-line outpatient antibiotic use, and antibiotic stewardship, then summed the estimates across all methods. Results The total SCAR attributable to each ambulatory antibiotic prescription was estimated to be $13 (range: $3–$95). The greatest contributor to the total SCAR was the cost of hospitalization ($9; 69 % of the total SCAR). The costs of second-line inpatient antibiotic use ($1; 8 % of the total SCAR), second-line outpatient antibiotic use ($2; 15 % of the total SCAR) and antibiotic stewardship ($1; 8 %). This apperars to be an error.; of the total SCAR) were modest contributors to the total SCAR. Assuming an average antibiotic cost of $20, the total SCAR attributable to each ambulatory antibiotic prescription would increase antibiotic costs by 65 % (range: 15–475 %) if incorporated into antibiotic costs paid by patients or payers. Conclusions Each ambulatory antibiotic prescription is associated with a hidden SCAR that substantially increases the cost of an antibiotic prescription in the United States. This finding raises concerns regarding the magnitude of misalignment between individual and societal antibiotic costs.

Abstract Background Alzheimer’s disease (AD), the commonest cause of dementia, represents a significant cost to UK society. This analysis describes resource utilisation, costs and clinical outcomes in non-institutionalised patients with AD in the UK. Methods The GERAS prospective observational study assessed societal costs associated with AD for patients and caregivers over 18 months, stratified according to baseline disease severity (mild, moderate, or moderately severe/severe [MS/S]). All patients enrolled had an informal caregiver willing to participate in the study. Healthcare resource utilisation was measured using the Resource Utilization in Dementia instrument, and 18-month costs estimated by applying unit costs of services and products (2010 values). Total societal costs were calculated using an opportunity cost approach. Results Overall, 526 patients (200 mild, 180 moderate and 146 MS/S at baseline) were recruited from 24 UK centres. Mini-Mental State Examination (MMSE) scores deteriorated most markedly in the MS/S patient group, with declines of 3.6 points in the mild group, 3.5 points in the moderate group and 4.7 points in the MS/S group; between-group differences did not reach statistical significance. Patients with MS/S AD dementia at baseline were more likely to be institutionalised (Kaplan–Meier probability 28% versus 9% in patients with mild AD dementia; p

Introduction: Canadian distillers and brewers have claimed that between 50% and 80% of the price of alcoholic drinks are government taxes. These claims were made in campaigns to decrease alcohol taxation. Methods: We investigated these claims using publicly available Statistics Canada data and provincial-level product sales data and breakdowns of the prices of typical alcohol beverages in major market sectors. Results: In all cases, the rate of total sales tax and excise taxation are mostly between 20% and 30% of final retail prices, well below the industry claims. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to assess and relate the societal costs of reducing large overjet with a prefabricated functional appliance (PFA), or a slightly modified Andresen activator (AA), using a cost-minimization analysis (CMA). Design, settings, and participants A multicentre, prospective, randomized clinical trial was conducted with patients from 12 general dental practices. Ninety-seven patients with an Angle Class II, division 1 malocclusion, and an overjet of ≥6 mm were randomly allocated by lottery to treatment with either a PFA or an AA. The PFA and AA groups consisted of 57 and 40 subjects, respectively. Blinding was not performed. Duration of treatment, number of scheduled/unscheduled appointments, and retreatment were registered. Direct and indirect costs were analysed with reference to intention-to-treat (ITT), successful (S), and unsuccessful (US) outcomes. Societal costs were described as the total of direct and indirect costs, not including retreatments. Interventions Treatment with a PFA or an AA. Results The direct and societal costs were significantly lower for the PFA than for the AA group. The number of visits was lower in the PFA group, when ITT was considered, and for the US cases as well. No difference in retreatment rate could be seen between the groups. Limitations Costs depend on local factors and thus should not be generalized to other settings. Harms No harms were detected during the study. Conclusion The success rate of the both appliances was low. However, the PFA was the preferred approach for reduction of a large overjet in mixed dentition, since it minimized costs and there were no difference in clinical outcomes between PFA and AA. Registration This trial was registered at ‘FoU i Sverige’ (http://www.fou.nu/is/sverige), registration number: 97131. Protocol The protocol was not published before trial commencement. [ABSTRACT FROM AUTHOR]

Background: Recent campaigns (e.g., the American Board of Internal Medicine Foundation’s Choosing Wisely) reflect the increasing role that physicians are expected to have in stewarding health care resources. We examine whether physicians believe they should pay attention to societal costs or refuse requests for costly interventions with little chance of patient benefit. Methods: We conducted a secondary analysis of data from a 2010 national survey of 2016 U.S. physicians sampled from the AMA Physician Masterfile. Criterion measures were agreement or disagreement with two survey items related to costs of care. We also examined whether physicians’ practice and religious characteristics were associated with their responses. Results: The adjusted response rate was 62% (1156/1878). Forty-seven percent of physicians agreed that physicians “should not consider the societal cost of medical care when caring for individual patients,” whereas 69% agreed that physicians “should refuse requests from patients or their families for costly interventions that have little chance of benefitting the patient.” Physicians in specialties that care for patients at the end of life were more supportive of refusing such costly interventions. We did not find consistent associations between physicians’ religiosity and their responses to these items, though those least supportive of taking into account societal cost were disproportionately from Christian affiliations. Conclusion: Physicians were nearly evenly divided regarding whether they should help control societal costs when caring for individual patients, but a strong majority agreed that physicians should refuse costly interventions that have little chance of benefit. [ABSTRACT FROM AUTHOR]

Understanding the economic impact of psychological and social forms of workplace aggression to society could yield important insights into the magnitude of this occupational phenomenon. The objective of this systematic review was to collate, summarise, review and critique, and synthesise the cost of psychosocial workplace aggression at the individual- and societal-level. A peerreviewed research protocol detailing the search strategy, study selection procedures and data extraction process was developed a priori. Both the academic and grey literatures were examined. To allow for basic comparison, all costs were converted and adjusted to reflect 2014 US dollars. Twelve studies, from 5 national contexts, met the inclusion criteria and were reviewed: Australia (n = 2), Italy (n = 1), Spain (n = 1), the United Kingdom (n = 3) and the United States (n = 5). The annual cost of psychosocial workplace aggression varied substantially, ranging between $114.64 million and $35.9 billion. Heterogeneity across studies was found, with noted variations in stated study aims, utilised prevalence statistics and included costs. The review concludes that existing evidence attests to the substantial cost of psychosocial workplace aggression to both the individual and society, albeit such derived estimates are likely gross underestimates. The findings highlight the importance of interpreting such figures within their conceptual and methodological contexts. [ABSTRACT FROM AUTHOR]

Background: No study has examined the financial impact of relapses on schizophrenia from the perspective of Japanese society. This study aimed to estimate the societal costs in Japan caused by the relapses of schizophrenia. Methods: The societal costs in Japan in 2013 due to relapses of schizophrenia were estimated by summing the productivity loss and deadweight loss caused by schizophrenia relapses in 2013. Deterministic sensitivity analysis was conducted for deadweight loss rate, relapse rate, and patient income. Results: Japan incurred JPY 55,039 million societal costs because of relapses in 2013. This consists of JPY 3,990 million for productivity loss and JPY 51,049 million for deadweight loss. Rate of deadweight loss is the most significant cost driver in the sensitivity analysis. Conclusion: Relapses of schizophrenia could generate huge amount of societal costs by reducing labor productivity and economic efficiency. To curb these costs, relapse prevention is desired in treating schizophrenia. [ABSTRACT FROM AUTHOR]

Background & objectives: Visceral leishmaniasis, locally known as kala-azar (KA) has beenconsidered as a major public health problem in Bangladesh, India and Nepal that affects 100,000people per year with 147 million people at risk. Elimination of infectious disease is an ultimategoal of the public health system, therefore, the efforts have recently gained momentum from variousorganizations and governments to expand KA interventions in the endemic countries. The paperaims to estimate discounted net benefits and internal rate of return (IRR) to evaluate the economicfeasibility for elimination of KA by utilizing available secondary information.Methods: Cross-sectional data were collected from different sources to estimate societal costs ofand benefits from KA interventions with a 13-year project period. Total costs are estimated basedon the unit cost of inputs used for interventions. The benefits are derived from productivity changeand resources saved due to reduction of KA incidence. Net benefits and IRRs are estimated basedon standard procedures used in the field of economics, subsequently the sensitivity analysis isconducted.Results: A total discounted net benefit of KA intervention is Nepalese Rupees (NRs) 65,287 millionwith 35% IRR. The result suggests that for every rupee invested in KA intervention at present willyield NRs 71 in future. The regional benefits from the interventions will be greater than the sum ofbenefits gained by the individual country due to its nature of public goods.Conclusion: Elimination of KA is a good investment opportunity for the Government andinternational partners involved in the health sector.

Background: Alzheimer's disease (AD), the commonest cause of dementia, represents a significant cost to UK society. This analysis describes resource utilisation, costs and clinical outcomes in non-institutionalised patients with AD in the UK. Methods: The GERAS prospective observational study assessed societal costs associated with AD for patients and caregivers over 18 months, stratified according to baseline disease severity (mild, moderate, or moderately severe/severe [MS/S]). All patients enrolled had an informal caregiver willing to participate in the study. Healthcare resource utilisation was measured using the Resource Utilization in Dementia instrument, and 18-month costs estimated by applying unit costs of services and products (2010 values). Total societal costs were calculated using an opportunity cost approach. Results: Overall, 526 patients (200 mild, 180 moderate and 146 MS/S at baseline) were recruited from 24 UK centres. Mini-Mental State Examination (MMSE) scores deteriorated most markedly in the MS/S patient group, with declines of 3.6 points in the mild group, 3.5 points in the moderate group and 4.7 points in the MS/S group; between-group differences did not reach statistical significance. Patients with MS/S AD dementia at baseline were more likely to be institutionalised (Kaplan-Meier probability 28% versus 9% in patients with mild AD dementia; p < 0.001 for difference across all severities) and had a greater probability of death (Kaplan-Meier probability 15% versus 5%; p = 0.013) at 18 months. Greater disease severity at baseline was also associated with concomitant increases in caregiver time and mean total societal costs. Total societal costs of £43,560 over 18 months were estimated for the MS/S group, versus £25,865 for the mild group and £30,905 for the moderate group (p < 0.001). Of these costs, over 50% were related to informal caregiver costs at each AD dementia severity level. Conclusions: This study demonstrated a mean deterioration in MMSE score over 18 months in patients with AD. It also showed that AD is a costly disease, with costs increasing with disease severity, even when managed in the community: informal caregiver costs represented the main contributor to societal costs. [ABSTRACT FROM AUTHOR]

Background: Ambulatory antibiotic prescribing contributes to the development of antibiotic resistance and increases societal costs. Here, we estimate the hidden societal cost of antibiotic resistance per antibiotic prescribed in the United States. Methods: In an exploratory analysis, we used published data to develop point and range estimates for the hidden societal cost of antibiotic resistance (SCAR) attributable to each ambulatory antibiotic prescription in the United States. We developed four estimation methods that focused on the antibiotic-resistance attributable costs of hospitalization, second-line inpatient antibiotic use, second-line outpatient antibiotic use, and antibiotic stewardship, then summed the estimates across all methods. Results: The total SCAR attributable to each ambulatory antibiotic prescription was estimated to be $13 (range: $3-$95). The greatest contributor to the total SCAR was the cost of hospitalization ($9; 69 % of the total SCAR). The costs of second-line inpatient antibiotic use ($1; 8 % of the total SCAR), second-line outpatient antibiotic use ($2; 15 % of the total SCAR) and antibiotic stewardship ($1; 8 %). This apperars to be an error.; of the total SCAR) were modest contributors to the total SCAR. Assuming an average antibiotic cost of $20, the total SCAR attributable to each ambulatory antibiotic prescription would increase antibiotic costs by 65 % (range: 15-475 %) if incorporated into antibiotic costs paid by patients or payers. Conclusions: Each ambulatory antibiotic prescription is associated with a hidden SCAR that substantially increases the cost of an antibiotic prescription in the United States. This finding raises concerns regarding the magnitude of misalignment between individual and societal antibiotic costs. [ABSTRACT FROM AUTHOR]

How did a country in the middle of Western Europe, starting almost from scratch, reach the European top 3 in terms of solar PV capacity in five years? And what were the costs? We provide a systematic chronological review of the different governmental support instruments that drove the exponential growth of the solar energy market in the Flanders region of Belgium and calculate their relative contributions. The results of the economic calculations show that green electricity certificates had by far the greatest effect on both the rise and stagnation of the market, costing about 1.5 billion euro only for 2006–2013. The long-term societal costs of such growth proved to be even higher (6.7 billion for 2014–2031) and unevenly distributed, with residents paying the highest price via their energy bills. Companies continuously adapted their organizations to enact the available support instruments. Counter-intuitively, the substantial support shifted the attention of companies to the larger systems, even though the incentive for investment in PV was lower than for the smaller systems. [ABSTRACT FROM AUTHOR]

Snow is a critically important and rapidly changing feature of the Arctic. However, snow-cover and snowpack conditions change through time pose challenges for measuring and prediction of snow. Plausible scenarios of how Arctic snow cover will respond to changing Arctic climate are important for impact assessments and adaptation strategies. Although much progress has been made in understanding and predicting snow-cover changes and their multiple consequences, many uncertainties remain. In this paper, we review advances in snow monitoring and modelling, and the impact of snow changes on ecosystems and society in Arctic regions. Interdisciplinary activities are required to resolve the current limitations on measuring and modelling snow characteristics through the cold season and at different spatial scales to assure human well-being, economic stability, and improve the ability to predict manage and adapt to natural hazards in the Arctic region. [ABSTRACT FROM AUTHOR]

Background: The interRAI-Home Care (interRAI-HC) instrument is commonly used in routine care to assess care and service needs, resource utilisation and health outcomes of community dwelling home care clients. Potentially, the interRAI-HC can also be used to calculate societal costs in economic evaluations. The purpose of this study was to assess the convergent validity of the interRAI-HC instrument in comparison with the RUD Lite instrument for the calculation of societal costs among care-dependent community dwelling older adults.Methods: A within-subject design was used. Participants were 65 years and older and received professional community care in five countries. The RUD Lite was administered by trained (research) nurses or self-reports within 4 weeks after the interRAI-HC assessment. Agreement between the interRAI-HC and RUD Lite estimates was assessed using Spearman's correlation coefficients. We hypothesised that there was strong correlation (Spearman's ρ > 0.5) between resource utilisation estimates, costs of care estimates and total societal cost estimates derived from both instruments.Results: Strong correlation was found between RUD Lite and interRAI-HC resource utilisation assessments for eight out of ten resource utilisation items. Total societal costs according to the RUD Lite were statistically significantly lower than according to the interRAI-HC (mean difference €-804, 95 % CI -1340; -269). The correlation between the instruments for total societal costs and all six cost categories was strong.Conclusions: The interRAI-HC has good convergent validity as compared with the RUD-Lite instrument to estimate societal cost of resource utilisation in community dwelling older adults. Since interRAI-HC assessments are part of routine care in many community care organisations and countries already, this finding may increase the feasibility of performing economic evaluations among community dwelling older adults. [ABSTRACT FROM AUTHOR]

The individual burden of disease in hand eczema patients is considerable. However, little is known about the socio-economic impact of this disease. The aims of this review were to evaluate the literature on cost-of-illness in hand eczema, and to compose a checklist for future use. The literature was retrieved from the MEDLINE and EMBASE databases up to October 2015. Quality evaluation was based on seven relevant items in cost-of-illness studies. Cost data (direct and indirect) were extracted and converted into euros (2014 price level) by use of the Dutch Consumer Price Index. Six articles were included. The mean annual total cost per patient ranged from €1712 to €9792 (direct cost per patient, €521 to €3829; and indirect cost per patient, €100 to €6846). Occupational hand eczema patients showed indirect costs up to 70% of total costs, mainly because of absenteeism. A large diversity in hand eczema severity was found between studies. The socio-economic burden of hand eczema is considerable, especially for more severe and/or occupational hand eczema. Absenteeism from paid work leads to a high total cost-of-illness, although disregard of presenteeism often leads to underestimation of indirect costs. Differences in included cost components, the occupational status of patients and hand eczema severity make international comparison difficult. A checklist was added to standardize the approach to cost-of-illness studies in hand eczema. [ABSTRACT FROM AUTHOR]

Background Context: In the 1980s, a new implant was developed to treat patients with intermittent neurogenic claudication caused by lumbar spinal stenosis (LSS). This implant is now widely used.Purpose: The objective of this study is to determine whether a favorable cost-effectiveness for interspinous process devices (IPDs) compared with conventional bony decompression is attained.Study Design/setting: Cost-utility analysis was performed alongside a double-blind randomized controlled trial. Five neurosurgical centers (including one academic and four secondary level care centers) included participants for this study.Patient Sample: One hundred fifty-nine patients with LSS were treated with the implantation of IPD and with bony decompression. Eighty participants received an IPD, and seventy-nine participants underwent spinal bony decompression.Outcome Measures: Outcome measures were quality-adjusted life-years (QALYs) and societal costs in the first year (estimated per quarter), estimated from patient-reported utilities (US and The Netherlands EuroQol 5D [EQ-5D] and EuroQol visual analog scale) and diaries on costs (health-care costs, patient costs, and productivity costs).Methods: All analyses followed the intention-to-treat principle. Given the statistical uncertainty of differences between costs and QALYs, cost-effectiveness acceptability curves graph the probability that a strategy is cost effective, as a function of willingness to pay. Paradigm Spine funded this trial but did not have any part in data analysis or the design and preparation of this article.Results: According to the EQ-5D, the valuation of quality of life after IPD and decompression was not different. Mean utilities during all four quarters were, not significantly, less favorable after IPD according to the EQ-5D with a decrease in QALYs according to the US EQ-5D of 0.024 (95% confidence interval, -0.031 to 0.079). From a health-care perspective, the costs of IPD treatment were higher (difference €3,030 per patient, 95% confidence interval, €561-€5,498). This significant difference is mainly because of additional cost of implants of €2,350 apiece. From a societal perspective, a nonsignificant difference of €2,762 (95% confidence interval, -€1,572 to €7,095) in favor of conventional bony decompression was found.Conclusions: Implantation of IPD as indirect decompressing device is highly unlikely to be cost effective compared with bony decompression for patients with intermittent neurogenic claudication caused by LSS.Trial Registration: Dutch Trial Register Number: NTR1307. [ABSTRACT FROM AUTHOR]

Background: This study aimed at describing pain-related health care resource use, direct costs, and productivity loss among patients suffering from fibromyalgia syndrome (FMS).Methods: A cost-of-illness study with a sample of 57 adults having a diagnosis of FMS was conducted in the province of Quebec (Canada). Data regarding FMS-related direct costs and productivity loss from paid and unpaid work over a three-month period were collected using a standardized structured telephone interview protocol. Direct costs were valued in 2009 Canadian dollars using a societal perspective.Results: Results showed that average direct costs over a three-month period added up to $951 per patient (SD: $710), which could be translated in a mean annual cost of $3804. The purchase of prescribed medications led to the highest costs (mean: $329, SD: $321), followed by consultations to health care professionals other than physicians (mean: $129, SD: $222) and physicians consultations (mean: $98, SD: $116). Results further showed a high economic burden for patients themselves, aside from costs covered by public or private insurers. Among the subsample of participants who had a paid job (45.6%), an average of 5.6 days (SD: 13.2) were lost due to pain during the past three months. Among those who were not employed (54.4%), an average of 25.1 days in household productivity (SD: 24.8) were lost.Conclusions: FMS is associated with a substantial socioeconomic burden. Further research is clearly needed to improve the management of this type of disorder and make better decisions regarding resource allocation. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to determine the economic burden from a societal perspective and the health-related quality of life (HRQOL) of patients with Duchenne muscular dystrophy (DMD) in Europe.Methods: We conducted a cross-sectional study of patients with DMD from Bulgaria, France, Germany, Hungary, Italy, Spain, Sweden, and the UK. Data on demographic characteristics, healthcare resource utilization, informal care, labor productivity losses, and HRQOL were collected from the questionnaires completed by patients or their caregivers. HRQOL was measured with the EuroQol 5-domain (EQ-5D) questionnaire. Costs have been estimated from a societal perspective adopting a bottom-up approach.Results: A total of 422 questionnaires were included in the study; 268 of which were collected from patients with DMD and 154 from caregivers. The average annual cost per person in 2012 ranged from €7657 in Hungary to €58,704 in France. Direct non-healthcare costs are the main component of whole costs and informal care is the main driver of non-healthcare costs. Costs are also shown to differ between children and adults. With regard to HRQOL of adult patients, the EQ-5D VAS score and EQ-5D index scores were 50.5 and 0.24, respectively. The corresponding EQ-5D VAS and EQ-5D index scores for caregivers were 74.7 and 0.71, respectively.Conclusions: We have estimated the average annual cost per patient with DMD in eight European countries adopting a social perspective, and to our knowledge this is the first study with such a wide perspective. The results on costs show a considerable gap between Eastern and Western European countries. Non-healthcare costs range from 64 to 89 % of overall costs and informal care is to a great extent the main driver of this cost category. The HRQOL of people with DMD is much lower than that of the general population. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to determine the economic burden from a societal perspective and the health-related quality of life (HRQOL) of patients with haemophilia in Europe.Methods: We conducted a cross-sectional study of patients with haemophilia from Bulgaria, France, Germany, Hungary, Italy, Spain Sweden and the UK. Data on demographic characteristics, health resource utilisation, informal care, loss of labour productivity and HRQOL were collected from the questionnaires completed by patients or their caregivers. HRQOL was measured with the EuroQol 5-domain (EQ-5D) questionnaire. The costs have been estimated from a societal perspective adopting a bottom-up approach.Results: A total of 401 questionnaires were included in the study, of which 339 were collected from patients with haemophilia and 62 from caregivers. The lowest average annual cost per person was reported in Bulgaria (€6,660) and the highest in Germany (€194,490). Our results demonstrate both a large difference from country to country in the average annual cost per patient in 2012 and the driving role of drugs in costs. Drugs represent nearly 90 % of direct healthcare costs in a majority of the countries analysed (Hungary, Italy, Spain and Germany). In Bulgaria, France and Sweden, however, healthcare services (visits, tests and hospitalisations) prevail. Costs are also shown to differ between children and adults. The mean EQ-5D index score for adult patients was 0.69 and mean EQ-5D VAS was 66.6. The mean EQ-5D index score for carers was 0.87 and mean EQ-5D VAS was 75.5. In the disability score, 60 % showed no disability and measuring caregiver burden with the Zarit Index produced an overall mean score of 25.3.Conclusion: We have shown that haemophilia is associated with a substantial economic burden and impaired HRQOL. Studies on cost of illness and HRQOL are important for haemophilia as the future of this disease is likely to change with the development of new innovative treatments. The introduction of these treatments will most likely impact future costs related to haemophilia. [ABSTRACT FROM AUTHOR]

Private and societal costs have their origin in the classic and neo-classic era. The market, based on private costs, ignores externalities, while actors fail to gain access to information on societal costs, causing a gap. The best practice price (BPP), a sustainability metric, can fill this information gap. Based on science and the weighted opinions of stakeholders, best practices for basic production factors such as land, labor, and natural resources are identified and their costs calculated. Producers can use these data to calculate the BPP of their products. Besides the market price (the price to be paid), the BPP is mentioned on the invoice and price tag as representing the costs of production according to the best practices. The ratio of market price (MP) to the BPP - the BP ratio (BPR) - makes comparison of different products possible. Using the BPR, producers, public entities, and consumers can set goals for sustainable production or consumption. [ABSTRACT FROM AUTHOR]

Objectives: Dementia poses a substantial economic burden on society. Knowing which factors predict high costs in dementia may help to better target interventions and optimize resource allocation. This study aimed to identify predictors of the total societal costs in dementia patients and their informal caregivers.Design: Prospective cohort study with 2-year follow up.Setting and Participants: 192 community-dwelling patients with dementia and their primary informal caregivers in the Netherlands.Measurements: Data on health care resource utilization, informal carer time and caregivers' work absenteeism were collected by cost diaries and interviews. Predictors of total costs were identified for patient-caregiver dyads, and for patients and informal caregivers separately by performing univariate and multivariate generalized linear models.Results: Societal costs of patient-caregiver dyads averaged €75,084 (SEM: €4,263) in the first year and €99,369 (SEM: €6,441) in the second year. Sixty percent was attributed to costs of informal care. Patient impairments in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), disruptions during daily activities of the caregiver, and receiving case management were significantly associated with higher costs in dyads. The same predictors remained significant for patients' costs separately, and for informal caregivers, a poorer caregiver's quality of life and having more chronic diseases determined higher costs.Conclusions: The societal costs of dementia are substantial and mainly due to high costs of informal care. The burden for caregivers caused by a disrupted schedule and patients' ADL and IADL dependencies contributed most to the total costs. Interventions targeting these factors effectively might result in relevant economic benefits for society. [ABSTRACT FROM AUTHOR]