Health and social care service utilisation and associated expenditure among community-dwelling older adults with depressive symptoms

Shiyu Lu, Tianyin Liu, Gloria H Y Wong, Dara K Y Leung, Lesley C Y Sze, Wai-Wai Kwok, Martin Knapp, Vivian W Q Lou, Samson Tse, Siu-Man Ng, Paul W C Wong, Jennifer Y M Tang, Terry Y S Lum, Shiyu Lu, Tianyin Liu, Gloria H Y Wong, Dara K Y Leung, Lesley C Y Sze, Wai-Wai Kwok, Martin Knapp, Vivian W Q Lou, Samson Tse, Siu-Man Ng, Paul W C Wong, Jennifer Y M Tang, Terry Y S Lum

Abstract

Aims: Late-life depression has substantial impacts on individuals, families and society. Knowledge gaps remain in estimating the economic impacts associated with late-life depression by symptom severity, which has implications for resource prioritisation and research design (such as in modelling). This study examined the incremental health and social care expenditure of depressive symptoms by severity.

Methods: We analysed data collected from 2707 older adults aged 60 years and over in Hong Kong. The Patient Health Questionnaire-9 (PHQ-9) and the Client Service Receipt Inventory were used, respectively, to measure depressive symptoms and service utilisation as a basis for calculating care expenditure. Two-part models were used to estimate the incremental expenditure associated with symptom severity over 1 year.

Results: The average PHQ-9 score was 6.3 (standard deviation, s.d. = 4.0). The percentages of respondents with mild, moderate and moderately severe symptoms and non-depressed were 51.8%, 13.5%, 3.7% and 31.0%, respectively. Overall, the moderately severe group generated the largest average incremental expenditure (US$5886; 95% CI 1126-10 647 or a 272% increase), followed by the mild group (US$3849; 95% CI 2520-5177 or a 176% increase) and the moderate group (US$1843; 95% CI 854-2831, or 85% increase). Non-psychiatric healthcare was the main cost component in a mild symptom group, after controlling for other chronic conditions and covariates. The average incremental association between PHQ-9 score and overall care expenditure peaked at PHQ-9 score of 4 (US$691; 95% CI 444-939), then gradually fell to negative between scores of 12 (US$ - 35; 95% CI - 530 to 460) and 19 (US$ -171; 95% CI - 417 to 76) and soared to positive and rebounded at the score of 23 (US$601; 95% CI -1652 to 2854).

Conclusions: The association between depressive symptoms and care expenditure is stronger among older adults with mild and moderately severe symptoms. Older adults with the same symptom severity have different care utilisation and expenditure patterns. Non-psychiatric healthcare is the major cost element. These findings inform ways to optimise policy efforts to improve the financial sustainability of health and long-term care systems, including the involvement of primary care physicians and other geriatric healthcare providers in preventing and treating depression among older adults and related budgeting and accounting issues across services.

Keywords: Depression; elderly; health economics; health service research.

Conflict of interest statement

None.

Figures

Fig. 1.
Fig. 1.
Results of average marginal associations on care expenditures using PHQ-9 score as a continuous variable. Notes: Results controlled for gender, age, marital status, education, poverty status, living alone, cognitive function, chronic diseases and a history of a diagnosis of depression/anxiety. The marginal associations were calculated based on the two-part model analyses in online Supplementary Table 3. TPM, two-part model. The Patient Health Questionnaire-9 (PHQ-9) score ranged from 0 to 23 in this sample.

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