HEALTH ECONOMICS

Health Econ. 8: 363–365 (1999)

BOOK REVIEWS

BOOK REVIEWS

Health economics of dementia by A. WIMO, B. JON-

SSON, G. KARLSSON and B. WINBLAD. John Wiley &Sons, Chichester, 1998. No. of pages: 576. ISBN 0-471-98376-4.

Dementia, as part of the area of mental illness, hashistorically been underrepresented in the literature ofhealth economics. However, interest in mental healtheconomics has developed rapidly in recent years. Aspart of this we have seen a growing interest in thedementias, fuelled in recent years by such developmentsas the introduction of drugs aimed at persons withAlzheimer’s Disease. These drugs have generated muchdebate on their value and whether they should bepublicly funded.

This large volume comes as a timely addition to theliterature, covering many questions, subjects and tech-niques relevant to an economic understanding of de-mentia. As the editors observe in their preface, ‘this isthe first comprehensive book on the health economicsof dementia’.

The book splits contributions into four mainsections:

1. General Aspects—mainly covers diagnosis, epi-demiology and issues relating to care and services.

2. Health Economics Approaches to Dementia—amix of methodology and examples of evaluations.

3. Outcome Measurements—mainly covers severity,cognition and quality of life ratings.

4. Pharmacoeconomic Aspects—the issues surround-ing economic evaluation and more directly dis-cussed in relation to pharmaceuticals and clinicaltrials.

The first section (General Aspects) contains severalchapters that will be useful for economic researchersworking in this area. Fratiglioni introduces the classifi-cation and diagnostic systems for dementias and pro-vides a summary of the major epidemiologicalreferences. A key point that is discussed is the widevariety of factors influencing the institutionalization ofolder people with dementia. Johansson and Harkanssoncontribute chapters covering types of service provisionand finance. However, the reader will have to go fur-ther into the literature for a detailed understanding ofthis area. Whitlatch reviews the literature on Distressand Burden for Family Caregivers. This is a vital, butunderresearched topic and the author makes severalsuggestions as to the direction of future research.

The second section (Health Economics Approachesto Dementia) provides several chapters discussinghealth economics principles, but most fail to developthese beyond general points and do not actually bringout the particular and specific problems of evaluationof dementia. Exceptions include Knapp and Wig-glesworth (‘Costing Community Care . . . ’) and Koop-manschap and Brouwer (‘Indirect Costs and CostingInformal Care’). Much of the care burden in dementiais located in the community and is informal in charac-ter; therefore, the subject matter of these chapters iscentral to an economic understanding of dementia.

In the third section (Outcome Measurements), thebook moves into an area fundamental to all modes ofeconomic evaluation: how to measure the effects ofservices, care and treatments. Chapters by Reisberg etal., Nygard, Almkvist and others provide reviews anddiscussion of the standard scales of symptoms andcognitive functioning commonly used in clinical trials.Neumann et al. introduce the idea of using QALYs indementia evaluation and highlight the attendant diffi-culties. Unfortunately, there is little detail in their dis-cussion of, for example, the problem of elicitinginformation. These points are developed further in thechapter by Whitehouse.

The book draws to an end with a section on Pharma-coeconomic Aspects, which tackles issues of drug as-sessment and policy. Hill and McGettigan run overmuch familiar ground in discussing ‘Drug Authorities’Policy’, but do also cover the key points relevant toassessing dementia drugs, which they place in the con-text of other products aimed at chronic illnesses. LonSchneider contributes a practical chapter on ‘DesigningPhase III Trials’. As in other areas, the exclusioncriteria for such studies may exclude key groups, whosedisease may have a different natural history from oth-ers. But more specifically, these trials use outcomemeasures, such as ADAS and the MMSE, that may notaccurately describe the patient’s place in their commu-nity and may not relate to the economic impact oftreatment. This problem will be prevalent even wherewell-designed resource use instruments are used. Otherdifficulties in conducting clinical trials in patients withdementia include the high rates of institutionalizationor polypharmacy among this mainly elderly population.Delay in the point of institutionalization is used bysome analysis as an outcome measure, although this is

CCC 1057–9230/99/040363–03$17.50Copyright © 1999 John Wiley & Sons, Ltd.

BOOK REVIEWS364

actually influenced by many factors other than justseverity of disease.

In their final summary, the editors stress that ‘thehealth economics of dementia is in its infancy’. Theynote the limitations of prior research and set out anagenda, a set of considerations that should be incorpo-rated in future research.

In conclusion, this book is a useful introduction tothe study of dementia for health economists movinginto this field of work. It provides a useful introductionto aspects of health economics for other researchersinvolved in the study of dementia. However, there isplenty of scope for more work, practical and theoreti-cal, to define what is distinctive about the health eco-nomics of dementia.

ALAN STEWART

Zenaca Pharmaceuticals

Health, health care and health economics: perspecti6es ondistribution edited by M.L. BARER, T.E. GETZEN andG.L. STODDART. Wiley, Chichester, 1998. No. of pages:551. ISBN 0-471-97879-5.

This volume contains selected papers from the inauguraliHEA conference held in Vancouver in 1996. As such, itrecords an occasion of some importance in the evolutionof health economics. It is appropriate that a number ofthe contributions reflect on the current state of researchand practice in health economics and its relation to thewider discipline of economics.

Given the strong incentives for peer-reviewed journalpublications, one cannot expect to find papers that offerhighly original developments of the literature in a confer-ence volume such as this. In fact, the contribution thatranks highest in this respect (Bleichrodt) is reprintedfrom the Journal of Health Economics. This said,economists and others working in the health field willfind plenty to interest them, either in the form of detailedresearch into distributional equity or from more general,introspective discussions of health economics.

The editors have chosen not to split the papers up intodifferent sections. While this is understandable given thedifficulty such categorization creates with papers that donot quite fit, readers would have been helped by someguide as to the content of papers. Reinhardt’s paper,which was the opening address to the conference, appearsas Chapter 1. Placing it beside the other more reflectivecontributions would have been more helpful to thereader. The papers could be categorized as follows. First,there are empirical descriptions of the distribution ofhealth and/or health care in various geographic settings(Chernichovsky et al.—Russia; Gerdtham and Sund-berg—Sweden; Klavus and Hakkinen—Finland;Mayston—Australia; Mustard et al.—Canada; vanDoorslaer and Wagstaff—Europe and US). Second,

there are assessments of the distributional consequencesof specific health policies (Doherty and van Heever—South Africa; Liu et al.—China; Rodgers and Smith—US; Schneider-Bunner—Netherlands and UK). Third,there are two papers that discuss equity concepts andtheir potential incorporation into evaluations (Bleichrodtand Williams). The final group of papers are, to anextent, reflections on the current state of health econom-ics. Here we find contributions from some of the heavy-weights in the field (Culyer, Evans, Hurley, Mooney,Reinhardt and Rice). This leaves a paper by Bishai, whoestimates child health production functions using datafrom Bangladesh and the Philippines within the frame-work of an extended Grossman model.

The volume will be of greatest interest to thoseresearchers working in the area of distributional equity.The chapter by van Doorslaer and Wagstaff provides auseful overview of the methodologies they have devel-oped to measure inequalities in health and equity in thefinance and distribution of health care. Two papersconsider the geographic distribution of health care re-sources in the context of reforms in developing andtransition economies (Chernichovsky et al. and Dohertyand van Heever). Both draw attention to potentialconflict between movements toward fiscal federalism andthe pursuit of geographical equity.

The essays by Culyer, Evans, Hurley, Mooney, Rein-hardt and Rice contemplate the limitations and pitfallsof economics as they see it practised in the health field.There is little that is new in these essays. For example,the limitations of the Pareto Criterion in delivering socialdecisions is rehearsed in a number of places. This is notto say such arguments are unimportant. However,whether the profession is as forgetful, or unappreciative,of such points as these authors appear to believe iscertainly open to debate. On reading these essays, onegets the impression of some frustration with the powerexisting economic theories and methodologies can bringto bear on many important problems confronted in thehealth sector. While there is some, justified, self-congrat-ulation over the contribution economists have made tohealth policy, there is also some angst. Apparently,health economists are misunderstood, persist (con-sciously) with untenable assumptions, cannot, after all,provide all of the answers and are liable to be dismissedas ad hoc empiricists by their colleagues working moreelegantly in the mainstream. I found a lot to disagree within these essays, but there was also much wisdom and theexperience of being provoked to think about the currentstate of our art was an enjoyable one. While there is somedisagreement between the authors (e.g. over whetherextra-welfarism goes far enough), they are all, more orless, coming from the same perspective. A contributionfrom someone who feels less constrained within theneo-classical paradigm would have added to the debateand the fun.

OWEN O’DONNELLEconomics Department, Uni6ersity of Kent at Canterbury,

UK

Copyright © 1999 John Wiley & Sons, Ltd. Health Econ. 8: 363–365 (1999)