Dementia Care Mapping and Patient-Centred Care in Australian residential homes: An economic evaluation of the CARE Study, CHERE Working Paper 2008/4

Background: As the population ages, the incidence of dementia and its burden on society will increase. The economic costs of dementia are high, particularly for persons in the mid and late stages of the disease, when formal care arrangements such as nursing home placement are required. The need for care is often precipitated by the development of behavioural and psychological symptoms of dementia (BPSD) which also severely affect the quality of life of affected persons and their carers The Caring for Aged-Care REsident Study (CARES), the first randomised controlled trial to evaluate Dementia Care Mapping (DCM) and Person Centred Care (PCC), demonstrated that either of the two interventions improved outcomes compared to Usual Care (UC) on the primary outcome measure, the Cohen-Mansfield Agitation Inventory (CMAI). This study reports the results of an economic evaluation which was undertaken in conjunction with the trial. This information will provide additional information to assist policy makers in making choices between competing options. Methods: Fifteen nursing homes were randomised to one of three conditions: DCM, PCC or Usual Care (UC). The sample consisted of 360 residents with dementia. Data were collected at baseline, three months, and eight months by assessors blind to group assignment. In addition to the CMAI, data were collected about the use and costs of health care resources and pharmacological interventions. Total costs associated with each of the interventions were estimated, which were contrasted with the outcomes using standard health economics methodology. Results: Over one year, the cost per residential setting of implementing DCM and PCC relative to UC was $10,034 and$2,250 respectively. The additional cost per resident-level unit improvement in CMAI post-intervention (at follow-up) relative to UC was $48.95 ($46.89) for DCM and $8.01 ($6.43) for PCC. Compared to DCM, PCC produced a greater reduction in anxiety and agitation at a lower cost. Therefore, DCM was dominated by PCC and removed from the economic evaluation. Sensitivity analysis suggests this result is robust to changing model parameters. Conclusions: PCC provides a greater decrease in agitation and related behavioural and psychological symptoms of dementia, compared with DCM, at a lower cost and is the preferred option for cost-effectiveness. While there is no existing standard for a reasonable cost for a point improvement in CMAI, the cost per unit under PCC seems acceptable.Dementia, patient centred care

In hospital study: Do older people, carers and older people, carers and nurses share the same priorities of care in the acute aged care setting?

The aim of the INHospital study was to compare the level of importance of care priorities and satisfaction levels with care among patients, carers, and nurse caregivers in the acute aged care setting. The INHospital study used sequential mixed methods approach for data collection. Survey data was completed within five metropolitan acute aged care wards on patients in acute aged care wards (n=78), their carers (n=45) and nurses (n=37). The Caring Activity Scale (CAS) survey was administered to participants in order to determine and compare the perceptions of the importance and satisfaction of care. Semi-structured interviews of patients (n=7) and carers (n=7) were conducted after completion of the CAS survey. This qualitative data aimed to probe more deeply into the patient\u27s and carer\u27s care priorities and satisfaction as measured in the CAS. The CAS data demonstrated that patients, carers and nurses rated implementing, observing and reporting doctor\u27s orders similarly, while differences between groups were observed in relation to prioritising physical and psychosocial care and discharge. There were significant differences between patients, carers and nurses on overall importance (p=0.001) and satisfaction in respect of nursing care (p=0.001). Qualitative data generated five themes 1) Nurses doing the best they can in challenging circumstances; 2) Achieving a balancing act in a pressured environment; 3) Striving to maintain and sustain independence; 4) The discharge process: not a shared priority; and 5) Challenges of the carer role. A key implication of this study is the incongruence between what patients consider a priority for care and the priority ascribed to those tasks by nurses. Qualitative findings added depth to the survey data and qualified responses by confirming that patients thought that nurses did the best they could within a culture of busyness, while patients strived to maintain and sustain their own independence. However, the themes of managing the discharge process and carer burden arose mainly from the carer semi-structured interviews