The increasing prevalence of dementia with population aging has heightened interest in understanding patterns of utilization and health expenditures in persons with dementia (PWD) among policy officials, practicing physicians, and health system. While a substantial part of this interest is concerned with the high costs of care for people diagnosed with dementia (Kelley et al., Reference Kelley, McGarry, Fahle, Marshall, Du and Skinner2015), less attention has been focused on the costs and consequences of missed or delayed diagnosis in those who screen positive for dementia. The article on “Healthcare resource utilization and cost in dementia: are there differences between patients screened positive for dementia with and those without a formal diagnosis of dementia in primary care in Germany?” by Michalowsky and colleagues (Michalowsky et al., Reference Michalowsky, Eichler, Thyrian, Wucherer, Hoffmann and Flessa2015) in this issue makes a particularly important contribution in this regard.

The authors found evidence that formal diagnosis contributed to greater use of anti-dementia drugs and care from specialists such as neurologists or psychiatrists. PWD with a formal diagnosis of dementia were less likely to receive elective surgical interventions such as surgeries on hip, knee, eye, hands, or prostate. This may reflect preferences among patients with diagnosed dementia and their family caregivers to avoid the burden of surgery, including greater risk of complications such as delirium. Measures of patient outcome and quality of life may need to give more weight to individualized preferences and disease prognosis in the case of PWD.

The finding that total cost of care was not significantly higher for formally diagnosed PWD is encouraging. Direct medical care costs are in fact lower for PWD with formal diagnoses. The higher cost of anti-dementia drug treatment and specialist care would appear to be offset by savings in other areas such as reduced elective surgery and shorter length of in-hospital stay. The savings in medical care cost with no change in total cost suggests that formal care may be making up the difference.

Overall, the study suggests that care can be improved without leading to an increase in total direct cost through better screening for dementia in primary care. With proper referral and diagnosis, care can be rebalanced toward services that improve quality of life such as anti-dementia drugs and formal home care and support. By applying a framework of evidence-based care (German Association of Psychiatry Psychotherapy and Psychosomatics and German Association for Neurology, 2009), the authors identified where care gaps existed for all PWD, primarily in the receipt of non-medication treatment.

Countries around the world are grappling with issues of how best to care for and finance care for PWD. International comparisons can have great value in pointing to best practices and identification of areas of needed improvement (Davis and Ballreich Reference Davis and Ballreich2014; Davis et al., Reference Davis, Stremikis, Squires and Schoen2014). In addition, given that informal care accounts for a large proportion of dementia-related costs (Kelley et al., Reference Kelley, McGarry, Fahle, Marshall, Du and Skinner2015), examining differences in informal care utilization and costs will also be important to understanding total societal costs and areas for improvement.

Given the high proportion of PWD without a formal diagnosis, a better understanding of the costs and consequences is an important first step. This contribution from Michalowsky and colleagues (Michalowsky et al., Reference Michalowsky, Eichler, Thyrian, Wucherer, Hoffmann and Flessa2015) suggests that policy-makers may not need to be so fearful of the costs associated with bringing the undiagnosed out of the shadows and instead look for effective ways of doing so.