The Effect of a Disease Management Intervention on Quality and Outcomes of Dementia Care: A Randomized, Controlled Trial

Department of Neurology, University of California, Los Angeles, VA Greater Los Angeles Healthcare System, Los Angeles, California 90095-1769, USA.
Annals of internal medicine (Impact Factor: 17.81). 11/2006; 145(10):713-26. DOI: 10.7326/0003-4819-145-10-200611210-00004
Source: PubMed


Adherence to dementia guidelines is poor despite evidence that some guideline recommendations can improve symptoms and delay institutionalization of patients.
To test the effectiveness of a dementia guideline-based disease management program on quality of care and outcomes for patients with dementia.
Clinic-level, cluster randomized, controlled trial.
3 health care organizations collaborating with 3 community agencies in southern California.
18 primary care clinics and 408 patients with dementia age 65 years or older paired with 408 informal caregivers.
Disease management program led by care managers and provided to 238 patient-caregiver pairs at 9 intervention clinics for more than 12 months.
Adherence to 23 guideline recommendations (primary outcome) and receipt of community resources and patient and caregiver health and quality-of-care measures (secondary outcomes).
The mean percentage of per-patient guideline recommendations to which care was adherent was significantly higher in the intervention group than in the usual care group (63.9% vs. 32.9%, respectively; adjusted difference, 30.1% [95% CI, 25.2% to 34.9%]; P < 0.001). Participants who received the intervention had higher care quality on 21 of 23 guidelines (P < or = 0.013 for all), and higher proportions received community agency assistance (P < or = 0.03) than those who received usual care. Patient health-related quality of life, overall quality of patient care, caregiving quality, social support, and level of unmet caregiving assistance needs were better for participants in the intervention group than for those in the usual care group (P < 0.05 for all). Caregiver health-related quality of life did not differ between the 2 groups.
Participants were well-educated, were predominantly white, had a usual source of care, and were not institutionalized. Generalizability to other patients and geographic regions is unknown. Also, costs of a care management program under fee-for-service reimbursement may impede adoption.
A dementia guideline-based disease management program led to substantial improvements in quality of care for patients with dementia. Current Controlled Trials identifier: ISRCTN72577751.

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Available from: Barbara G Vickrey, Dec 01, 2014
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    • "Despite a lack of difference between treatment arms, quality of care process indicators had considerably greater adherence across both treatment arms with all quality indicators demonstrating higher adherence at follow-up; 11 out of 19 indicators achieved more than double the proportion of completed indicators at baseline. Moreover, comparisons to quality of care data from the ACCESS study (Vickrey et al., 2006; see Table 6) using the same indicators, demonstrates comparable proportional increases in adherence with higher proportional increases in adherence in 7 of the 12 follow-up indicators. "
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    ABSTRACT: To compare the effectiveness and costs of telephone-only approach to in-person plus telephone for delivering an evidence-based, coordinated care management program for dementia. We randomized 151 patient-caregiver dyads from an underserved predominantly Latino community to two arms that shared a care management protocol but implemented in different formats: in-person visits at home and/or in the community plus telephone and mail, versus telephone and mail only. We compared between-arm caregiver burden and care-recipient problem behaviors (primary outcomes) and patient-caregiver dyad retention, care quality, health care utilization, and costs (secondary outcomes) at 6- and 12-months follow-up. Care quality improved substantially over time in both arms. Caregiver burden, care-recipient problem behaviors, retention, and health care utilization did not differ across arms but the in-person program cost more to deliver. Dementia care quality improved regardless of how care management was delivered; large differences in effectiveness or cost offsets were not detected. © The Author(s) 2015.
    Journal of Aging and Health 02/2015; 27(5). DOI:10.1177/0898264315569454 · 1.56 Impact Factor
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    • "Vickrey et al have suggested that fee-for-service remuneration can limit adoption of CM.10 In contrast, capitation under Medicare-managed care is more likely to favor CM becoming the “usual” practice.10 "
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    ABSTRACT: Background The purpose of this study was to examine factors associated with the implementation of case management (CM) interventions in primary health care (PHC) and to develop strategies to enhance its adoption by PHC practices. Methods This study was designed as a systematic mixed studies review (including quantitative and qualitative studies) with synthesis based on the diffusion of innovation model. A literature search was performed using MEDLINE, PsycInfo, EMBASE, and the Cochrane Database (1995 to August 2012) to identify quantitative (randomized controlled and nonrandomized) and qualitative studies describing the conditions limiting and facilitating successful CM implementation in PHC. The methodological quality of each included study was assessed using the validated Mixed Methods Appraisal Tool. Results Twenty-three studies (eleven quantitative and 12 qualitative) were included. The characteristics of CM that negatively influence implementation are low CM intensity (eg, infrequent follow-up), large caseload (more than 60 patients per full-time case manager), and approach, ie, reactive rather than proactive. Case managers need specific skills to perform their role (eg, good communication skills) and their responsibilities in PHC need to be clearly delineated. Conclusion Our systematic review supports a better understanding of factors that can explain inconsistent evidence with regard to the outcomes of dementia CM in PHC. Lastly, strategies are proposed to enhance implementation of dementia CM in PHC.
    Clinical Interventions in Aging 06/2014; 9:915-28. DOI:10.2147/CIA.S64723 · 2.08 Impact Factor
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    • "Naglie et al. found that test-retest reliability exceeded the standard for adequate reliability of 0.70 in those with mild dementia (ICC = 0.75) [22]. Vickrey et al. [23] found that the mean HUI multi-attribute utility score for 408 primary care patients with dementia was 0.54 (SD = 0.23) and the mean one year change was -0.30 among 240 dementia patients who remained in their own home after one year of receiving the dementia care program whereas the mean one year change was -0.76 among 29 dementia patients who moved into a skilled nursing home facility. "
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    ABSTRACT: Background Dementia affects over 4 million people in the US and is frequently unrecognized and underdiagnosed in primary care. Routine dementia screening in primary care is not recommended by the US Preventive Services Task Force due to lack of empirical data on the benefits and harms of screening. This trial seeks to fill this gap and contribute information about the benefits, harms, and costs of routine screening for dementia in primary care. Methods/Design Single-blinded, parallel, randomized controlled clinical trial with 1:1 allocation. A total of 4,000 individuals aged ≥65 years without a diagnosis of dementia, cognitive impairment, or serious mental illness receiving care at primary care practices within two cities in Indiana. Subjects will be randomized to either i) screening for dementia using the Memory Impairment Screen Telephone version or ii) no screening for dementia. Subjects who screen positive for dementia will be referred to the local Aging Brain Care program that delivers an evidence-based collaborative care model for dementia and depression. Research assistants will administer the 15-item Health Utility Index, Patient Health Questionnaire, Generalized Anxiety Disorder Scale, and Medical Outcomes Study at baseline, 1, 6, and 12 months. Information about advanced care planning will be collected at baseline and 12 months. All enrollees’ medical records will be reviewed to collect data on health care utilization and costs. Discussion We have two primary hypotheses; first, in comparison to non-screened subjects, those who are screened and referred to a dementia collaborative care program will have a higher health-related quality of life as measured by the Health Utility Index at 12 months post-screening. Second, in comparison to non-screened subjects, those who are screened and referred to a dementia collaborative care program will not have higher depression or anxiety at one month post-screening as measured by the Patient Health Questionnaire and Generalized Anxiety Disorder Scale scales. Our secondary hypothesis is that screened subjects will have an Incremental Cost-Effectiveness Ratio below the maximum acceptable threshold of $60,000 per quality adjusted life year saved at 12 months. Trial registration Ongoing; registered on September 19, 2012. Identifier: 2012 NCT01699503.
    Trials 06/2014; 15(1):209. DOI:10.1186/1745-6215-15-209 · 1.73 Impact Factor
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