title: Effectiveness and costs of phototest in dementia and cognitive impairment screening.
abstract: BACKGROUND
  To assess and compare the effectiveness and costs of Phototest, Mini Mental State Examination (MMSE), and Memory Impairment Screen (MIS) to screen for dementia (DEM) and cognitive impairment (CI).
  
  
  METHODS
  A phase III study was conducted over one year in consecutive patients with suspicion of CI or DEM at four Primary Care (PC) centers. After undergoing all screening tests at the PC center, participants were extensively evaluated by researchers blinded to screening test results in a Cognitive-Behavioral Neurology Unit (CBNU). The gold standard diagnosis was established by consensus of expert neurologists. Effectiveness was assessed by the proportion of correct diagnoses (diagnostic accuracy [DA]) and by the kappa index of concordance between test results and gold standard diagnoses. Costs were based on public prices and hospital accounts.
  
  
  RESULTS
  The study included 140 subjects (48 with DEM, 37 with CI without DEM, and 55 without CI). The MIS could not be applied to 23 illiterate subjects (16.4%). For DEM, the maximum effectiveness of the MMSE was obtained with different cutoff points as a function of educational level [k = 0.31 (95% Confidence interval [95%CI], 0.19-0.43), DA = 0.60 (95%CI, 0.52-0.68)], and that of the MIS with a cutoff of 3/4 [k = 0.63 (95%CI, 0.48-0.78), DA = 0.83 (95%CI, 0.80-0.92)]. Effectiveness of the Phototest [k = 0.71 (95%CI, 0.59-0.83), DA = 0.87 (95%CI, 0.80-0.92)] was similar to that of the MIS and higher than that of the MMSE. Costs were higher with MMSE (275.9 ± 193.3€ [mean ± sd euros]) than with Phototest (208.2 ± 196.8€) or MIS (201.3 ± 193.4€), whose costs did not significantly differ. For CI, the effectiveness did not significantly differ between MIS [k = 0.59 (95%CI, 0.45-0.74), DA = 0.79 (95%CI, 0.64-0.97)] and Phototest [k = 0.58 (95%CI, 0.45-0.74), DA = 0.78 (95%CI, 0.64-0.95)] and was lowest for the MMSE [k = 0.27 (95%CI, 0.09-0.45), DA = 0.69 (95%CI, 0.56-0.84)]. Costs were higher for MMSE (393.4 ± 121.8€) than for Phototest (287.0 ± 197.4€) or MIS (300.1 ± 165.6€), whose costs did not significantly differ.
  
  
  CONCLUSIONS
  MMSE is not an effective instrument in our setting. For both DEM and CI, the Phototest and MIS are more effective and less costly, with no difference between them. However, MIS could not be applied to the appreciable percentage of our population who were illiterate.
authors.affiliation: Cognitive Behavioral Neurology Unit, Service of Neurology, Virgen de las Nieves University Hospital, Carretera de Jaen s/n, 18013-Granada, Spain. ccarnero@neurocenter.es
authors.forename: Cristobal
authors.initials: C
authors.lastname: Carnero-Pardo
authors.forename: Beatriz
authors.initials: B
authors.lastname: Espejo-Martinez
authors.forename: Samuel
authors.initials: S
authors.lastname: Lopez-Alcalde
authors.forename: Maria
authors.initials: M
authors.lastname: Espinosa-Garcia
authors.forename: Carmen
authors.initials: C
authors.lastname: Saez-Zea
authors.forename: Rosa
authors.initials: R
authors.lastname: Vilchez-Carrillo
authors.forename: Elisa
authors.initials: E
authors.lastname: Hernandez-Torres
authors.forename: Jose L
authors.initials: JL
authors.lastname: Navarro-Espigares
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003072:Cognition Disorders / Q000175:diagnosis*; D003704:Dementia / Q000175:diagnosis*; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000191:economics* / Q000379:methods*; D009483:Neuropsychological Tests