Development of DEMQOL-U and DEMQOL-PROXY-U: generation of preference-based indices from DEMQOL and DEMQOL-PROXY for use in economic evaluation

DEMQOL and DEMQOL-Proxy: a Rasch analysis among those diagnosed with dementia

Background

In previous work we concluded that DEMQOL and DEMQOL-Proxy can provide robust measurement of HRQL in dementia when scores are derived from analysis using the Rasch model. As the study sample included people with mild cognitive impairment, we undertook a replication study in the subsample with a diagnosis of dementia (PWD). PWD constitute the population for whom DEMQOL and DEMQOL-Proxy were originally developed.

Methods

We conducted a Rasch model analysis using the RUMM2030 software to re-evaluate DEMQOL (441 PWD) and DEMQOL-Proxy (342 family carers). We evaluated scale to sample targeting, ordering of item thresholds, item fit to the model, and differential item functioning (sex, age, severity, relationship), local independence, unidimensionality and reliability.

Results

For both DEMQOL and DEMQOL-Proxy, results were highly similar to the results in the original sample. We found the same problems with content and response options.

Conclusions

DEMQOL and DEMQOL-Proxy can provide robust measurement of HRQL in people with a diagnosis of dementia when scores are derived from analysis using the Rasch model. As in the wider sample, the problems identified with content and response options require qualitative investigation in order to improve the scoring of DEMQOL and DEMQOL-Proxy.

A validation study of the ICECAP-O in informal carers of people with dementia from eight European Countries

PURPOSE

The pressure on healthcare budgets remains high, partially due to the ageing population. Economic evaluation can be a helpful tool to inform resource allocation in publicly financed systems. Such evaluations frequently use health-related outcome measures. However, in areas such as care of older people, improving health outcomes is not necessarily the main focus of care interventions and broader outcome measures, including outcomes for those providing informal care, may be preferred when evaluating such interventions. This paper validates a recently introduced well-being measure, the ICECAP-O, in a population of informal carers for people with dementia from eight European countries.

METHODS

Convergent and discriminant validity tests were performed to validate the ICECAP-O using data obtained in a sample of 451 respondents from Germany, Ireland, Italy, the Netherlands, Norway, Portugal, Sweden and the UK. These respondents completed a number of standardized questionnaires within the framework of the Actifcare project.

RESULTS

The ICECAP-O performed well among informal carers, in terms of both convergent and discriminant validity. In the multivariate analysis, it was found to be significantly associated with the age of the person with dementia, EQ-5D-5L health problem index of the person with dementia, carer-patient relationship, care recipient CDR, carer LSNS Score, the PAI score, and Perseverance Time.

CONCLUSION

The ICECAP-O appears to be a valid measure of well-being in informal carers for people with dementia. The ICECAP-O may therefore be useful as an outcome measure in economic evaluations of interventions aimed at such informal carers, when these aim to improve well-being beyond health.

Health-related quality-of-life assessment in dementia: Evidence of cross-cultural validity in Latin America

All health-related quality-of-life (HRQL) measures for dementia have been developed in high-income countries and none were validated for cross-cultural use. Yet, the global majority of people living with dementia reside in low- and middle-income countries. We therefore investigated the measurement invariance of a set of self- and informant-report HRQL measures developed in the United Kingdom when used in Latin America. Self-reported HRQL was obtained using (DEMQOL) at a memory assessment service in the United Kingdom (n = 868) and a population cohort study in Latin America (n = 417). Informant reports were collected using DEMQOL-Proxy at both sites (n = 909 and n = 495). Multiple-group confirmatory bifactor models for ordered categorical item responses were estimated to evaluate measurement invariance. Results support configural, metric, and scalar invariance for the concept of general HRQL in DEMQOL and DEMQOL-Proxy. The dominant impact of general HRQL on item responses was evident across U.K. English and Ibero American Spanish versions of DEMQOL (ωh = 0.87-0.90) and DEMQOL-Proxy (ωh = 0.88-0.89). Ratings of "positive emotion" did not show a major impact on general HRQL appraisal, particularly for Latin American respondents. Item information curves show that self- and informant-reports were highly informative about the presence rather than the absence of HRQL impairment. We found no major difference in conceptual meaning, sensitivity, and relevance of DEMQOL and DEMQOL-Proxy for older adults in the United Kingdom and Latin America. Further replication is needed for consensus over which HRQL measures are appropriate for making cross-national comparisons in global dementia research. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Study protocol for a randomised controlled trial assessing the clinical and cost-effectiveness of the Journeying through Dementia (JtD) intervention compared to usual care

INTRODUCTION

Services are being encouraged to provide postdiagnostic treatment to those with dementia but the availability of evidence-based interventions following diagnosis has not kept pace with increase in demand. To address this need, the Journeying through Dementia (JtD) intervention was created. A randomised controlled trial (RCT), based on a pilot study, is in progress.

METHODS AND ANALYSIS

The RCT is a pragmatic, two-arm, parallel group trial designed to test the clinical and cost-effectiveness of JtD compared with usual care. Recruitment will be through NHS services, third sector organisations and Join Dementia Research. The sample size is 486 randomised (243 to usual care and 243 to the intervention usual care). Participants can choose to ask a friend or relative (supporter) to become involved in the study. The primary outcome measure for participants is Dementia-Related Quality of Life (DEMQOL), collected at baseline and at 8 months' postrandomisation. Secondary outcome measures will be collected from participants and supporters at those visits. Participants will also be followed up at 12 months' postrandomisation with a reduced set of measures. A process evaluation will be conducted through qualitative and fidelity substudies. Analyses will compare the two arms of the trial on an intention to treat as allocated basis. The primary analyses will compare the mean DEMQOL scores of the participants at 8 months between the two study arms. A cost-effectiveness analysis will consider the incremental cost per Quality Adjusted Life Years of the intervention compared with usual care. Qualitative and fidelity substudies will be analysed through framework analysis and fidelity assessment tools respectively.

ETHICS AND DISSEMINATION

REC and HRA approval were obtained. A Data Monitoring and Ethics Committee has been constituted. Dissemination will be via publications, conferences and social media. Intervention materials will be made open access.

TRIAL REGISTRATION NUMBER

ISRCTN17993825.

Developing a cerebral palsy-specific preference-based measure for a six-dimensional classification system (CP-6D): protocol for a valuation study

INTRODUCTION

Cerebral palsy (CP) is a lifelong condition. The CP quality of life (CPQOL) instrument is a frequently used disease-specific instrument to assess health-related quality of life (HRQoL) in people with CP, but it cannot be used to generate quality-adjusted life years (QALY) which are the basis of cost utility analysis (CUA). Generic utility instruments (such as the EQ-5D or SF-6D) that are used to value HRQOL may be insensitive to small but important health changes in children with CP. This study aims to generate a preference-based scoring algorithm for the CP six dimensions (CP-6D), a classification system developed from the CPQOL.

METHODS AND ANALYSIS

A discrete choice experiment with duration (DCEtto) will be administrated to value health states described by the CP-6D classification system. These health states will be presented to members of Australian general population and parents of children with CP via an online survey. Conditional logit regression will be used to produce the utility algorithm for CP-6D.

ETHICS AND DISSEMINATION

The Griffith University Human Research Ethics Committee approved for the study (reference HREC/number 2018/913). The developed algorithm can be applied to previous and future economic evaluation of interventions and treatments targeting people with CP which have used either the CPQOL or CP-6D.

Advancing Long-Term Care Science Through Using Common Data Elements: Candidate Measures for Care Outcomes of Personhood, Well-Being, and Quality of Life

To support the development of internationally comparable common data elements (CDEs) that can be used to measure essential aspects of long-term care (LTC) across low-, middle-, and high-income countries, a group of researchers in medicine, nursing, behavioral, and social sciences from 21 different countries have joined forces and launched the Worldwide Elements to Harmonize Research in LTC Living Environments (WE-THRIVE) initiative. This initiative aims to develop a common data infrastructure for international use across the domains of organizational context, workforce and staffing, person-centered care, and care outcomes, as these are critical to LTC quality, experiences, and outcomes. This article reports measurement recommendations for the care outcomes domain, focusing on previously prioritized care outcomes concepts of well-being, quality of life (QoL), and personhood for residents in LTC. Through literature review and expert ranking, we recommend nine measures of well-being, QoL, and personhood, as a basis for developing CDEs for long-term care outcomes across countries. Data in LTC have often included deficit-oriented measures; while important, reductions do not necessarily mean that residents are concurrently experiencing well-being. Enhancing measurement efforts with the inclusion of these positive LTC outcomes across countries would facilitate international LTC research and align with global shifts toward healthy aging and person-centered LTC models.

Should we provide outreach rehabilitation to very old people living in Nursing Care Facilities after a hip fracture? A randomised controlled trial

OBJECTIVE

to determine whether a 4-week postoperative rehabilitation program delivered in Nursing Care Facilities (NCFs) would improve quality of life and mobility compared with receiving usual care.

DESIGN

parallel randomised controlled trial with integrated health economic study.

SETTING

NCFs, in Adelaide South Australia.

SUBJECTS

people aged 70 years and older who were recovering from hip fracture surgery and were walking prior to hip fracture.

MEASUREMENTS

primary outcomes: mobility (Nursing Home Life-Space Diameter (NHLSD)) and quality of life (DEMQOL) at 4 weeks and 12 months.

RESULTS

participants were randomised to treatment (n = 121) or control (n = 119) groups. At 4 weeks, the treatment group had better mobility (NHLSD mean difference -1.9; 95% CI: -3.3, -0.57; P = 0.0055) and were more likely to be alive (log rank test P = 0.048) but there were no differences in quality of life. At 12 months, the treatment group had better quality of life (DEMQOL sum score mean difference = -7.4; 95% CI: -12.5 to -2.3; P = 0.0051), but there were no other differences between treatment and control groups. Quality adjusted life years (QALYs) gained over 12 months were 0.0063 higher per participant (95% CI: -0.0547 to 0.0686). The resulting incremental cost effectiveness ratios (ICERs) were $5,545 Australian dollars per unit increase in the NHLSD (95% CI: $244 to $15,159) and $328,685 per QALY gained (95% CI: $82,654 to $75,007,056).

CONCLUSIONS

the benefits did not persist once the rehabilitation program ended but quality of life at 12 months in survivors was slightly higher. The case for funding outreach home rehabilitation in NCFs is weak from a traditional health economic perspective.

TRIAL REGISTRATION

ACTRN12612000112864 registered on the Australian and New Zealand Clinical Trials Registry. Trial protocol available at https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 361980.

Cost-effectiveness analysis of English memory assessment services 2 years after first consultation for patients with dementia

OBJECTIVES

This paper aims to compare changes over 2 years in patients' health-related quality of life (HRQL) with the health and social care costs of diagnosis and treatment of people newly referred to memory assessment services (MAS).

METHODS

We analysed observational data from 1318 patients referred to 69 MAS who completed resource use and HRQL questionnaires at baseline 3, 6, 12, and 24 months. We reported mean differences in HRQL (disease-specific DEMQOL and generic EQ-5D-3 L), quality-adjusted life years (QALYs), costs and cost-effectiveness between baseline, and 2-year follow-up.

RESULTS

Two years after referral to MAS, patients reported a higher DEMQOL score (mean gain 4.47, 95% confidence interval, 3.08-5.90) and EQ-5D-3 L (0.014, -0.011 to 0.039). Mean total costs and QALYs over 24 months was £2411 (£1721-£2873) and 0.027 (0.003-0.051), respectively. Assuming that patients' HRQL would not have altered over the 2 years had they not attended MAS, these outcomes suggest an incremental cost-effectiveness ratio of £89 546 (£38 123-£145 864) based on changes in EQ-5D-3 L. If we assumed that patients' HRQL would have declined by about 10% over this period had they not attended MAS, the cost-effectiveness ratio would be £25 056. The largest MAS (N = 32; 46%) with over 50 new patients a month were more likely to be cost-effective than smaller ones (P < 0.01).

CONCLUSIONS

MAS are effective and can be cost-effective for diagnosing and treating people with suspected dementia. Large variations in costs between clinics suggest that many MAS could improve their cost-effectiveness.

Use of Checklists in Reviews of Health Economic Evaluations, 2010 to 2018

OBJECTIVE

It is useful for reviewers of economic evaluations to assess quality in a manner that is consistent and comprehensive. Checklists can allow this, but there are concerns about their reliability and how they are used in practice. We aimed to describe how checklists have been used in systematic reviews of health economic evaluations.

METHODS

Meta-review with snowball sampling. We compiled a list of checklists for health economic evaluations and searched for the checklists' use in systematic reviews from January 2010 to February 2018. We extracted data regarding checklists used, stated checklist function, subject area, number of reviewers, and issues expressed about checklists.

RESULTS

We found 346 systematic reviews since 2010 that used checklists to assess economic evaluations. The most common checklist in use was developed in 1996 by Drummond and Jefferson, and the most common stated use of a checklist was quality assessment. Checklists and their use varied within subject areas; 223 reviews had more than one reviewer who used the checklist.

CONCLUSIONS

Use of checklists is inconsistent. Eighteen individual checklists have been used since 2010, many of which have been used in ways different from those originally intended, often without justification. Different systematic reviews in the same subject areas would benefit from using one checklist exclusively, using checklists as intended, and having 2 reviewers complete the checklist. This would increase the likelihood that results are transparent and comparable over time.

Improving the quality of life of care home residents with dementia: Cost-effectiveness of an optimized intervention for residents with clinically significant agitation in dementia

INTRODUCTION

To examine whether an optimized intervention is a more cost-effective option than treatment as usual (TAU) for improving agitation and quality of life in nursing home residents with clinically significant agitation and dementia.

METHODS

A cost-effectiveness analysis within a cluster-randomized factorial study in 69 care homes with 549 residents was conducted. Each cluster was randomized to receive either the Well-being and Health for people with Dementia (WHELD) intervention or TAU for nine months. Health and social care costs, agitation, and quality of life outcomes were evaluated.

RESULTS

Improvements in agitation and quality of life were evident in residents allocated to the WHELD intervention group. The additional cost of the WHELD intervention was offset by the higher health and social care costs incurred by TAU group residents (mean difference, £2103; 95% confidence interval, -13 to 4219).

DISCUSSION

The WHELD intervention has clinical and economic benefits when used in residents with clinically significant agitation.

Item distribution, internal consistency, and structural validity of the German version of the DEMQOL and DEMQOL-proxy

Background

Accurate assessment of health-related quality of life as an endpoint in intervention studies is a major challenge in dementia research. The DEMQOL (29 items) and the proxy version (32 items), which is partly based on the DEMQOL, are internationally used instruments. To date, there is no information on the structural validity, item distribution, or internal consistency for the German language version of these questionnaires.

Methods

This psychometric study is based on a secondary data analysis of a sample of 201 outpatients with a mild form of Alzheimer’s disease (AD) and their informal caregivers. The informal caregivers who were interviewed were involved in the care of the person with AD several times per week. The analysis for the evaluation of the structural validity was performed using Mokken scale analysis. The internal consistency was calculated using the ρ of the Molenaar Sijtsma statistic and Cronbach’s α.

Results

For both versions, four subscales were identified: [A] “positive emotions”, [B] “negative emotions”, [C] “physical and cognitive functioning”, and [D] “daily activities and social relationships”. For both instruments, the internal consistency of all subscales was considered “good” (ρ = 0.71–0.88, α = 0.72–0.87).

Conclusions

The results are a first indication of good construct validity of the instruments used for the German setting. We recommend further investigations of the test-retest reliability and the inter-rater reliability of the proxy instrument.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0930-0) contains supplementary material, which is available to authorized users.

The 'Better Conversations with Primary Progressive Aphasia (BCPPA)' program for people with PPA (Primary Progressive Aphasia): protocol for a randomised controlled pilot study

Background

Primary progressive aphasia is a language-led dementia, often associated with frontotemporal dementia. It presents as insidious deterioration of language skills (e.g. naming objects and understanding complex sentences), with relative sparing of cognitive skills initially. There is little research examining the effectiveness of communication skills training for primary progressive aphasia, yet speech and language therapists (SLTs) report regularly using this in clinical practice. ‘Better Conversations with Primary Progressive Aphasia’ has potential to reduce barriers and increase facilitators to conversation and consequently improve confidence in communication and quality of life for people living with primary progressive aphasia and their conversation partners. The aim of this pilot study is to examine the feasibility of running a trial of the ‘Better Conversations with Primary Progressive Aphasia’ intervention.

Methods

A single blind, randomised controlled pilot study will recruit 42 participants with primary progressive aphasia and their conversation partners across seven UK National Health Service Trusts. Participants will be randomised on a 1:1 basis, stratified by site, to receive either the ‘Better Conversations with Primary Progressive Aphasia’ intervention (21 couples) or no speech and language therapy treatment (21 couples). Participants are recruited by SLTs who will conduct pre-intervention assessment (week 1) and deliver the intervention (weeks 2 to 5). Junior researchers, who are blinded to allocation, will complete post-intervention measures (week 6). SLTs complete 9 h of training to prepare them to deliver the intervention. The primary objective of the study is to establish for a phase III effectiveness study whether the program can be delivered as intended in a UK National Health Service setting. Specifically, it will establish (1) the acceptability of randomisation, (2) an assessment of treatment fidelity to determine necessary levels of SLT training, (3) the most appropriate primary outcome measure, (4) sample size requirements, (5) predicted patient recruitment and retention rates and (6) refined inclusion criteria.

Discussion

Insights from this study will be of relevance to guide development of future research and in particular, trials of therapeutic interventions in PPA, as well as for clinical care for this population.

Trial registration

Retrospectively registered 28/02/2018 ISRCTN10148247

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0349-6) contains supplementary material, which is available to authorized users.

Agents of change: establishing quality improvement collaboratives to improve adherence to Australian clinical guidelines for dementia care

BACKGROUND

Dissemination of clinical practice guidelines alone is insufficient to create meaningful change in clinical practice. Quality improvement collaborative models have potential to address the evidence-practice gap in dementia care because they capitalise on known knowledge translation enablers and incorporate optimal approaches to implementation. Non-pharmacological interventions focused on promoting independence are effective and favoured by people with dementia and their carers but are not routinely implemented. The objective of this translational project is to assess the impact of quality improvement collaboratives (QICs) on adherence to non-pharmacological recommendations from the Clinical Practice Guidelines for Dementia in Australia.

METHODS

This project will employ an interrupted time-series design with process evaluation to assess the impact, uptake, feasibility, accessibility, cost, and sustainability of the QICs over 18 months. Thirty clinicians from across Australia will be invited to join the QICs to build their capacity in leading innovation in dementia care. Clinicians will participate in a training program and be supported to develop and implement a quality improvement project unique to their service context using plan-do-study-act cycles. Regular online meetings with their peers in the QIC will facilitate benchmarking and problem-solving. Clinicians will describe their practice via monthly checklists, and guideline adherence will be determined against a set of defined criteria. Phone interviews with up to 180 client dyads will be used to assess satisfaction with care and client outcomes. Clinician interviews and field note data will be used to explore implementation and costs. Involvement of people with dementia and carers will be embedded in the study design, conduct, and reporting, in addition to clinical and industry expertise.

DISCUSSION

The quality of dementia care in Australia is largely dependent on the clinician involved and the extent to which they apply best available evidence in their practice. This study will determine the elements of this multifaceted implementation strategy that contributed to guideline adherence and client outcomes. The findings will inform future translational approaches to improving care and outcomes for people with dementia and their carers.

TRIAL REGISTRATION

Registered with the Australian New Zealand Clinical Trials Registry 21 February 2018 ( ACTRN12618000268246 ).

Economics of dementia: A review of methods

Given the expected increase in the number of people with dementia in the coming years, it is anticipated that the resources necessary to support those with dementia will significantly increase. There will therefore likely be increased emphasis on how best to use limited resources across a number of domains including prevention, diagnosis, treatment and supporting informal caregivers. There has been increasing use of economic methods in dementia in the past number of years, in particular, cost-of-illness analysis and economic evaluation. This paper reviews the aforementioned methods and identities a number of methodological issues that require development. Addressing these methodological issues will enhance the quality of economic analysis in dementia and provide some useful insights about the best use of limited resources for dementia.

Quality of life in older adults following a hip fracture: an empirical comparison of the ICECAP-O and the EQ-5D-3 L instruments

Background

The purpose of this study was to empirically compare the performance of two generic preference based quality of life instruments, EQ-5D-3 L (with a health and physical function focus) and ICECAP-O (with a wellbeing and capability focus), in a population of older Australians following hip fracture.

Methods

Older adults or their family member proxies (in cases of severe cognitive impairment) following surgery to repair a fractured hip were invited to take part in this cross sectional study. Inclusion criteria included an age of 60 years or older, confirmed falls-related hip fracture and those receiving current palliative care or consented to other research studies were excluded. 87 participants completed the ICECAP-O and EQ-5D-3 L instruments between one and three weeks post-surgery.

Results

For the hip fracture population, the mean ICECAP-O score was 0.639 (SD 0.206, n = 82) and the mean EQ-5D-3 L utility score was 0.545 (SD 0.251, n = 87). There was a statistically significant positive correlation between the ICECAP-O and EQ-5D-3 L scores (r = 0.529, p = < 0.001).

Conclusions

Study findings indicate significant impairments in quality of life post hip fracture. In multiple regression analyses, age and health-related QoL (measured by the EQ-5D) were significant determinants of ICECAP-O scores, while proxy respondent status, age, and capability-related QoL (measured by the ICECAP-O) were significant determinants of EQ-5D scores. Approaches to measuring and valuing quality of life in this sample, should consider the target domains of the intervention in their choice of instrument. Studies aiming to measure the impact of interventions targeting broader domains of wellbeing and QoL should consider including a broader measure of QoL in conjunction with a HRQoL measure.

Associations between the Drug Burden Index, Potentially Inappropriate Medications and Quality of Life in Residential Aged Care

BACKGROUND

Inappropriate polypharmacy may negatively impact the quality of life of residents in aged care facilities, but it remains unclear which medications may influence this reduced quality of life.

OBJECTIVE

The objective of this study was to examine whether the Drug Burden Index and potentially inappropriate medications were associated with quality of life in older adults living in residential care with a high prevalence of cognitive impairment and dementia.

METHODS

We conducted cross-sectional analyses of 541 individuals recruited from 17 residential aged care facilities in Australia in the Investigating Services Provided in the Residential Environment for Dementia (INSPIRED) study. Quality of life was measured using the EuroQol Five Dimensions Questionnaire (a measure of generic quality of life) and the Dementia Quality of Life Questionnaire completed by the participant or a proxy.

RESULTS

In the 100 days prior to recruitment, 83.1% of the participants received at least one anticholinergic or sedative medication included in the Drug Burden Index and 73.0% received at least one potentially inappropriate medication according to the Beers Criteria. Multi-level linear models showed there was a significant association between a higher Drug Burden Index and lower quality of life according to the EuroQol Five Dimensions Questionnaire [β (standard error): - 0.034 (0.012), p = 0.006] after adjustment for potential confounding factors. Increasing numbers of potentially inappropriate medications were also associated with lower EuroQol Five Dimensions Questionnaire scores [- 0.030 (0.010), p = 0.003] and Dementia Quality of Life Questionnaire-Self-Report-Utility scores [- 0.020 (0.009), p = 0.029]. Exposure to both Drug Burden Index-associated medications and potentially inappropriate medications was associated with lower Dementia Quality of Life Questionnaire-Self-Report-Utility scores [- 0.034 (0.017), p = 0.049].

CONCLUSION

Exposure to anticholinergic and sedative medications and potentially inappropriate medications occurred in over three-quarters of a population of older adults in residential care and was associated with a lower quality of life.

An empirical comparison of the measurement properties of the EQ-5D-5L, DEMQOL-U and DEMQOL-Proxy-U for older people in residential care

PURPOSE

This study aimed to empirically compare the measurement properties of self-reported and proxy-reported (in cases of severe cognitive impairment) generic (EQ-5D-5L) and condition-specific (DEMQOL-U and DEMQOL-Proxy-U) preference-based HRQoL instruments in residential care, where the population is characterised by older people with high rates of cognitive impairment, dementia and disability.

METHODS

Participants were recruited from seventeen residential care facilities across four Australian states. One hundred and forty-three participants self-completed the EQ-5D-5L and the DEMQOL-U while three hundred and eight-seven proxy completed (due to the presence of severe dementia) the EQ-5D-5L and DEMQOL-Proxy-U. The convergent validity of the outcome measures and known group validity relative to a series of clinical outcome measures were assessed.

RESULTS

Results satisfy convergent validity among the outcome measures. EQ-5D-5L and DEMQOL-U utilities were found to be significantly correlated with each other (p < 0.01) as were EQ-5D-5L and DEMQOL-Proxy-U utilities (p < 0.01). Both self-reported and proxy-reported EQ-5D-5L utilities demonstrated strong known group validity in relation to clinically recognised thresholds of cognition and physical functioning, while in contrast neither DEMQOL-U nor DEMQOL-Proxy-U demonstrated this association.

CONCLUSIONS

The findings suggest that the EQ-5D-5L, DEMQOL-U and DEMQOL-Proxy-U capture distinct aspects of HRQoL for this population. The measurement and valuation of HRQoL form an essential component of economic evaluation in residential care. However, high levels of cognitive impairment may preclude self-completion for a majority. Further research is needed to determine cognition thresholds beyond which an individual is unable to reliably self-report their own health-related quality of life.

Psychotropic medications in older people in residential care facilities and associations with quality of life: a cross-sectional study

BACKGROUND

Psychotropic medications have been associated with many adverse outcomes in older people living in residential care. Home-like models of residential care may be preferable to traditional models of care and we hypothesized that this model may impact on the prevalence of psychotropic medications. The objectives were to: 1) examine associations between psychotropic medications and quality of life in older adults living in residential care facilities with a high prevalence of cognitive impairment and dementia and 2) determine if there was a difference in prevalence of psychotropic medications in facilities which provide a small group home-like model of residential care compared to a 'standard model' of care.

METHODS

Participants included 541 residents from 17 residential aged care facilities in the Investigating Services Provided in the Residential Environment for Dementia (INSPIRED) study. Cross-sectional analyses were completed to examine the above objectives. Quality of life was measured with the dementia quality of life questionnaire (DEMQOL) and the EQ-5D-5L completed by the resident or a proxy.

RESULTS

Overall, 70.8% (n = 380) of the population had been prescribed/dispensed at least one psychotropic medication in the 100 days prior to recruitment. An increased number of psychotropic medications was associated with lower quality of life according to DEMQOL-Proxy-Utility scores (β (SE): - 0.012 (0.006), p = 0.04) and EQ-5D-5L scores (- 0.024 (0.011), p = 0.03) after adjustment for resident-level and facility-level characteristics. Analysis of the individual classes of psychotropic medications showed antipsychotics were associated with lower DEMQOL-Proxy-Utility scores (- 0.030 (0.014), p = 0.03) and benzodiazepines were associated with lower EQ-5D-5L scores (- 0.059 (0.024), p = 0.01). Participants residing in facilities which had a home-like model of residential care were less likely to be prescribed psychotropic medications (OR (95% CI): 0.24 (0.12, 0.46), p < 0.001).

CONCLUSIONS

An increased number of psychotropic medications were associated with lower quality of life scores. These medications have many associated adverse effects and the use of these medications should be re-examined when investigating approaches to improve quality of life for older people in residential care. Home-like models of residential care may help to reduce the need for psychotropic medications, but further research is needed to validate these findings.

A development study and randomised feasibility trial of a tailored intervention to improve activity and reduce falls in older adults with mild cognitive impairment and mild dementia

BACKGROUND

People with dementia progressively lose abilities and are prone to falling. Exercise- and activity-based interventions hold the prospect of increasing abilities, reducing falls, and slowing decline in cognition. Current falls prevention approaches are poorly suited to people with dementia, however, and are of uncertain effectiveness. We used multiple sources, and a co-production approach, to develop a new intervention, which we will evaluate in a feasibility randomised controlled trial (RCT), with embedded adherence, process and economic analyses.

METHODS

We will recruit people with mild cognitive impairment or mild dementia from memory assessment clinics, and a family member or carer. We will randomise participants between a therapy programme with high intensity supervision over 12 months, a therapy programme with moderate intensity supervision over 3 months, and brief falls assessment and advice as a control intervention. The therapy programmes will be delivered at home by mental health specialist therapists and therapy assistants. We will measure activities of daily living, falls and a battery of intermediate and distal health status outcomes, including activity, balance, cognition, mood and quality of life. The main aim is to test recruitment and retention, intervention delivery, data collection and other trial processes in advance of a planned definitive RCT. We will also study motivation and adherence, and conduct a process evaluation to help understand why results occurred using mixed methods, including a qualitative interview study and scales measuring psychological, motivation and communication variables. We will undertake an economic study, including modelling of future impact and cost to end-of-life, and a social return on investment analysis.

DISCUSSION

In this study, we aim to better understand the practicalities of both intervention and research delivery, and to generate substantial new knowledge on motivation, adherence and the approach to economic analysis. This will enable us to refine a novel intervention to promote activity and safety after a diagnosis of dementia, which will be evaluated in a definitive randomised controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02874300; ISRCTN 10550694.

Measurement tools of resource use and quality of life in clinical trials for dementia or cognitive impairment interventions: A systematically conducted narrative review

OBJECTIVE

Knowledge is limited about the standardised instruments used to collect resource use and quality of life data alongside trials of dementia interventions. This review aimed to identify the trials using such instruments in order to guide the design of future trial-based cost-effectiveness studies.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement, this review examined all original, peer-reviewed research in major databases and general searches published until June 2017, including randomised clinical trials, pilot studies, or feasibility studies about interventions for older adults with dementia or cognitive impairment.

RESULTS

Forty-one studies were identified. Only 8 collected the resource use data using adapted Client Service Receipt Inventory (CSRI), Resource Use Inventory (RUI), cost diary, or study-specific questionnaire. Quality of life was assessed using a wide range of instruments. The most frequently used dementia-specific instrument was Quality of Life in Alzheimer's Disease (QOL-AD) and Dementia Quality of Life questionnaire (DEMQOL). Among the generic measures, EuroQol 5-dimentison (EQ-5D) was mostly used to collect health utility data, and Short Form surveys (SF-36 or SF-12) were widely to measure general health.

CONCLUSIONS

Several useful resource use and quality of life measurement instruments have been identified by this review. For resource use, CSRI was mostly used, but no studies have used Resource Utilisation in Dementia (RUD); for quality of life, we recommend the inclusion of dementia-specific DEMQOL, generic SF-12, and health utility EQ-5D-5L, based on both self-report and proxy-report.

Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: A cluster-randomised controlled trial

BACKGROUND

Agitation is a common, challenging symptom affecting large numbers of people with dementia and impacting on quality of life (QoL). There is an urgent need for evidence-based, cost-effective psychosocial interventions to improve these outcomes, particularly in the absence of safe, effective pharmacological therapies. This study aimed to evaluate the efficacy of a person-centred care and psychosocial intervention incorporating an antipsychotic review, WHELD, on QoL, agitation, and antipsychotic use in people with dementia living in nursing homes, and to determine its cost.

METHODS AND FINDINGS

This was a randomised controlled cluster trial conducted between 1 January 2013 and 30 September 2015 that compared the WHELD intervention with treatment as usual (TAU) in people with dementia living in 69 UK nursing homes, using an intention to treat analysis. All nursing homes allocated to the intervention received staff training in person-centred care and social interaction and education regarding antipsychotic medications (antipsychotic review), followed by ongoing delivery through a care staff champion model. The primary outcome measure was QoL (DEMQOL-Proxy). Secondary outcomes were agitation (Cohen-Mansfield Agitation Inventory [CMAI]), neuropsychiatric symptoms (Neuropsychiatric Inventory-Nursing Home Version [NPI-NH]), antipsychotic use, global deterioration (Clinical Dementia Rating), mood (Cornell Scale for Depression in Dementia), unmet needs (Camberwell Assessment of Need for the Elderly), mortality, quality of interactions (Quality of Interactions Scale [QUIS]), pain (Abbey Pain Scale), and cost. Costs were calculated using cost function figures compared with usual costs. In all, 847 people were randomised to WHELD or TAU, of whom 553 completed the 9-month randomised controlled trial. The intervention conferred a statistically significant improvement in QoL (DEMQOL-Proxy Z score 2.82, p = 0.0042; mean difference 2.54, SEM 0.88; 95% CI 0.81, 4.28; Cohen's D effect size 0.24). There were also statistically significant benefits in agitation (CMAI Z score 2.68, p = 0.0076; mean difference 4.27, SEM 1.59; 95% CI -7.39, -1.15; Cohen's D 0.23) and overall neuropsychiatric symptoms (NPI-NH Z score 3.52, p < 0.001; mean difference 4.55, SEM 1.28; 95% CI -7.07,-2.02; Cohen's D 0.30). Benefits were greatest in people with moderately severe dementia. There was a statistically significant benefit in positive care interactions as measured by QUIS (19.7% increase, SEM 8.94; 95% CI 2.12, 37.16, p = 0.03; Cohen's D 0.55). There were no statistically significant differences between WHELD and TAU for the other outcomes. A sensitivity analysis using a pre-specified imputation model confirmed statistically significant benefits in DEMQOL-Proxy, CMAI, and NPI-NH outcomes with the WHELD intervention. Antipsychotic drug use was at a low stable level in both treatment groups, and the intervention did not reduce use. The WHELD intervention reduced cost compared to TAU, and the benefits achieved were therefore associated with a cost saving. The main limitation was that antipsychotic review was based on augmenting processes within care homes to trigger medical review and did not in this study involve proactive primary care education. An additional limitation was the inherent challenge of assessing QoL in this patient group.

CONCLUSIONS

These findings suggest that the WHELD intervention confers benefits in terms of QoL, agitation, and neuropsychiatric symptoms, albeit with relatively small effect sizes, as well as cost saving in a model that can readily be implemented in nursing homes. Future work should consider how to facilitate sustainability of the intervention in this setting.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN62237498.

Developing a dementia-specific preference--based quality of life measure (AD-5D) in Australia: a valuation study protocol

INTRODUCTION

Generic instruments for assessing health-related quality of life may lack the sensitivity to detect changes in health specific to certain conditions, such as dementia. The Quality of Life in Alzheimer's Disease (QOL-AD) is a widely used and well-validated condition-specific instrument for assessing health-related quality of life for people living with dementia, but it does not enable the calculation of quality-adjusted life years, the basis of cost utility analysis. This study will generate a preference-based scoring algorithm for a health state classification system -the Alzheimer's Disease Five Dimensions (AD-5D) derived from the QOL-AD.

METHODS AND ANALYSIS

Discrete choice experiments with duration (DCE_TTO) and best-worst scaling health state valuation tasks will be administered to a representative sample of 2000 members of the Australian general population via an online survey and to 250 dementia dyads (250 people with dementia and their carers) via face-to-face interview. A multinomial (conditional) logistic framework will be used to analyse responses and produce the utility algorithm for the AD-5D.

ETHICS AND DISSEMINATION

The algorithms developed will enable prospective and retrospective economic evaluation of any treatment or intervention targeting people with dementia where the QOL-AD has been administered and will be available online. Results will be disseminated through journals that publish health economics articles and through professional conferences. This study has ethical approval.

The Role of Condition-Specific Preference-Based Measures in Health Technology Assessment

A condition-specific preference-based measure (CSPBM) is a measure of health-related quality of life (HRQOL) that is specific to a certain condition or disease and that can be used to obtain the quality adjustment weight of the quality-adjusted life-year (QALY) for use in economic models. This article provides an overview of the role and the development of CSPBMs, and presents a description of existing CSPBMs in the literature. The article also provides an overview of the psychometric properties of CSPBMs in comparison with generic preference-based measures (generic PBMs), and considers the advantages and disadvantages of CSPBMs in comparison with generic PBMs. CSPBMs typically include dimensions that are important for that condition but may not be important across all patient groups. There are a large number of CSPBMs across a wide range of conditions, and these vary from covering a wide range of dimensions to more symptomatic or uni-dimensional measures. Psychometric evidence is limited but suggests that CSPBMs offer an advantage in more accurate measurement of milder health states. The mean change and standard deviation can differ for CSPBMs and generic PBMs, and this may impact on incremental cost-effectiveness ratios. CSPBMs have a useful role in HTA where a generic PBM is not appropriate, sensitive or responsive. However, due to issues of comparability across different patient groups and interventions, their usage in health technology assessment is often limited to conditions where it is inappropriate to use a generic PBM or sensitivity analyses.

Trial of Acute Femoral Fracture Fixation (TrAFFix): study protocol for a randomised controlled feasibility trial

BACKGROUND

Distal femoral fractures are a source of considerable morbidity and best treatment is currently uncertain. The Trial of Acute Femoral Fracture Fixation (TrAFFix) is a randomised, parallel-group feasibility study designed to inform the design of a later, definitive clinical trial comparing intramedullary nails and locking plates for the treatment of distal femoral fractures.

METHODS/DESIGN

Patients aged 50 years and older with a femoral fracture within the distal two Müller squares are potentially eligible for inclusion. Participants are randomly allocated to receive fixation with either an intramedullary nail or a distal locking plate. Measurements (EuroQol 5 Dimensions, Dementia Quality of Life, Disability Rating Index) are collected at baseline, 6 weeks and 4 months. The recruitment rate will be assessed across seven participating centres over a total of 52 centre-months which is expected after 10 months of recruitment. Objectives are - feasibility phase, to assess recruitment rate and completion rate of the primary outcome measure; process evaluation, to assess the generalisability and likely success of a future trial; definitive trial, quantify and draw inferences on observed differences in health-related quality of life at 4 months between the study intervention groups (nail versus plate). A favourable opinion was granted by the Wales Research Ethics Committee (16/WA/0225), study-wide NHS approval was given by the Health Research Authority (IRAS 206745), and participating NHS trusts provided local approvals. This study was funded by the National Institute for Health Research Health Technology Assessment (HTA 15/59/22).

DISCUSSION

This is the protocol for a feasibility study conducted prior to any future definitive trial. The estimates of participant recruitment rate and proportion of data completion will be coupled with outputs from the process evaluation to make a final decision regarding feasibility TRIAL REGISTRATIONS: The study is registered with the National Institute for Health Research Portfolio (CPMS ID: 32536) and the ISRCTN registry ( ISRCTN92089567 ) on 26 May 2016.

Impact of antipsychotic review and non-pharmacological intervention on health-related quality of life in people with dementia living in care homes: WHELD-a factorial cluster randomised controlled trial

BACKGROUND

Very few interventional studies have directly examined the impact of treatment approaches on health-related quality of life (HRQL) in people with dementia. This is of particular importance in therapies to address behavioural symptoms, where HRQL is often severely affected.

METHODS

Analysis within the WHELD cluster randomised factorial study in 16 UK care homes examining the impact of person-centred care in combination with antipsychotic review, social interaction and exercise interventions. This study analysed impact on HRQL through the DEMQOL-Proxy.

RESULTS

Data on HRQL were available for 187 participants. People receiving antipsychotic review showed a significant worsening in two DEMQOL-Proxy domains (negative emotion: p = 0.02; appearance: p = 0.04). A best-case scenario analysis showed significant worsening for total DEMQOL-Proxy score. Social interaction intervention resulted in a significant benefit to HRQL (p = 0.04). There was no deterioration in HRQL in groups receiving both antipsychotic review and social interaction (p = 0.62).

CONCLUSIONS

This demonstrates an important detrimental impact of discontinuation of antipsychotics in dementia on HRQL, highlighting the need for careful review of best practice guidelines regarding antipsychotic use and emphasising the importance of providing evidence-based non-pharmacological interventions in conjunction with antipsychotic review. Copyright © 2016 John Wiley & Sons, Ltd.

Evaluating the quality of care received in long-term care facilities from a consumer perspective: development and construct validity of the Consumer Choice Index – Six Dimension instrument

The Consumer Choice Index – Six Dimension (CCI-6D) is a new instrument designed specifically to evaluate the quality of care received in long-term care from a consumer perspective. This study aims to demonstrate the construct validity of the CCI-6D. Older residents living in long-term care facilities and proxy family carers (where severely impaired cognition precluded resident consent) participated as consumers of long-term care. Data collected included the CCI-6D instrument, quality of life, physical function and characteristics of the care facility. Relationships between these variables and the CCI-6D dimensions were assessed and analysed through chi-squared and Kruskal–Wallis tests to assess the construct validity of each dimension. Of 430 eligible consumers, a total of 253 completed the questionnaire, of whom 68 (27%) were residents and 185 (73%) were informal carer proxy participants. There was strong evidence of construct validity of the dimensions relating to adequacy of individual care time, access to outside and gardens, access to meaningful activities and flexibility of care. There was more moderate evidence of validity of the home-like own room and shared spaces items, which may be in part due to difficulty in identifying strong discriminatory variables for comparison with these items. The results also indicate a strong association between ‘processes’ of care delivery (as measured by the CCI-6D) and quality of life of care recipients.

DEMQOL and DEMQOL-Proxy: a Rasch analysis

Background

DEMQOL and DEMQOL-Proxy are widely used patient reported outcome measures (PROMs) of health related quality of life in people with dementia (PWD). Growing interest in routine use of PROMs in health care calls for more robust instruments that are potentially fit for reliable and valid comparisons at the micro-level (patients) and meso-level (clinics, hospitals, care homes).

Methods

We used modern psychometric methods (based on the Rasch model) to re-evaluate DEMQOL (1428 PWDs) and DEMQOL-Proxy (1022 carers) to ensure they are fit for purpose. We evaluated scale to sample targeting, ordering of item thresholds, item fit to the model, and differential item functioning (sex, age, relationship), local independence, unidimensionality and reliability on the full set of items and a smaller item set.

Results

For both DEMQOL and DEMQOL-Proxy the smaller item set performed better than the original item set. We developed revised scores using the items from the smaller set.

Conclusions

We have improved the scoring of DEMQOL and DEMQOL-Proxy using the Rasch measurement model. Future work should focus on the problems identified with content and response options.

Evaluating the effectiveness of different approaches to home support for people in later stage dementia: a protocol for an observational study

BACKGROUND

Dementia is a major health problem with a growing number of people affected by the condition, both directly and indirectly through caring for someone with dementia. Many live at home but little is known about the range and intensity of the support they receive. Previous studies have mainly reported on discrete services within a single geographical area. This paper presents a protocol for study of different services across several sites in England. The aim is to explore the presence, effects, and cost-effectiveness of approaches to home support for people in later stage dementia and their carers.

METHODS

This is a prospective observational study employing mixed methods. At least 300 participants (people with dementia and their carers) from geographical areas with demonstrably different ranges of services available for people with dementia will be selected. Within each area, participants will be recruited from a range of services. Participants will be interviewed on two occasions and data will be collected on their characteristics and circumstances, quality of life, carer health and burden, and informal and formal support for the person with dementia. The structured interviews will also collect qualitative data to explore the perceptions of older people and carers.

CONCLUSIONS

This national study will explore the components of appropriate and effective home support for people with late stage dementia and their carers. It aims to inform commissioners and service providers across health and social care.

Reliability and validity of a self-administration version of DEMQOL-Proxy

OBJECTIVE

This study aimed to investigate the reliability and validity of a self-administered version of DEMQOL-Proxy, a disease-specific instrument that measures health-related quality of life in people with dementia.

METHODS

The sample consisted of 173 informal carers of people with dementia, aged 29 to 89 years old. Carers were mostly female, White/White British and closely related to the patient. They completed DEMQOL-Proxy (self-administered), EQ-5D-3L (proxy reported about the person with dementia), EQ-5D-3L (self-reported about their own health) and the Zarit Burden Interview. Using well-established methods from classical test theory, we evaluated scale level acceptability, reliability and convergent, discriminant and known-groups validity of DEMQOL-Proxy.

RESULTS

DEMQOL-Proxy (self-administered) showed high acceptability (3.5% missing data and 0% scores at floor or ceiling), high internal consistency reliability (α = 0.93) and good convergent and discriminant validity. Amongst others, we found a moderately high correlation with EQ-5D-3L proxy reported (r = 0.52) and low to essentially zero correlations with EQ-5D-3L self-reported (r = 0.20) and carer and patient background variables (r ≤ 0.20). As predicted, DEMQOL-Proxy (self-administered) showed a modest correlation with DEMQOL (r = 0.32). Known-groups differences on health-related quality of life (comparing people with versus people without cognitive impairment) were of moderate effect size (d = 0.38) and in the expected direction.

CONCLUSIONS

DEMQOL-Proxy (self-administered) has comparable acceptability, reliability and validity with DEMQOL-Proxy (interviewer administered). DEMQOL-Proxy (self-administered) can be used in a wider variety of contexts than its interviewer-administered version, including routine use in busy clinics. Copyright © 2016 John Wiley & Sons, Ltd.

Cost-effectiveness of Memory Assessment Services for the diagnosis and early support of patients with dementia in England

Background Policy makers in England advocate referral of patients with suspected dementia to Memory Assessment Services (MAS), but it is unclear how any improvement in patients' health-related quality of life (HRQL) compares with the associated costs. Aims To evaluate the cost-effectiveness of MAS for the diagnosis and follow-up care of patients with suspected dementia. Method We analysed observational data from 1318 patients referred to 69 MAS, and their lay carers (n = 944), who completed resource use and HRQL questionnaires at baseline, three and six months. We reported mean differences in HRQL (disease-specific DEMQOL and generic EQ-5D-3L), quality-adjusted life years (QALYs) and costs between baseline and six months after referral to MAS. We also assessed the cost-effectiveness of MAS across different patient subgroups and clinic characteristics. Results Referral to MAS was associated with gains in DEMQOL (mean gain: 3.48, 95% confidence interval: 2.84 to 4.12), EQ-5D-3L (0.023, 0.008 to 0.038) and QALYs (0.006, 0.002 to 0.01). Mean total cost over six months, assuming a societal perspective, was £1899 (£1277 to £2539). This yielded a negative incremental net monetary benefit of -£1724 (-£2388 to -£1085), assuming NICE's recommended willingness-to-pay threshold (£30,000 per QALY). These base case results were relatively robust to alternative assumptions about costs and HRQL. There was some evidence that patients aged 80 or older benefitted more from referral to MAS (p < 0.01 from adjusted mean differences in net benefits) compared to younger patients. MAS with over 75 new patients a month or cost per patient less than £2500 over six months were relatively more cost-effective (p < 0.01) than MAS with fewer new monthly patients or higher cost per patient. Conclusions Diagnosis, treatment and follow-up care provided by MAS to patients with suspected dementia appears to be effective, but not cost-effective, in the six months after diagnosis. Longer term evidence is required before drawing conclusions about the cost-effectiveness of MAS.

Defining health-related quality of life for young wheelchair users: A qualitative health economics study

BACKGROUND

Wheelchairs for children with impaired mobility provide health, developmental and psychosocial benefits, however there is limited understanding of how mobility aids affect the health-related quality of life of children with impaired mobility. Preference-based health-related quality of life outcome measures are used to calculate quality-adjusted life years; an important concept in health economics. The aim of this research was to understand how young wheelchair users and their parents define health-related quality of life in relation to mobility impairment and wheelchair use.

METHODS

The sampling frame was children with impaired mobility (≤18 years) who use a wheelchair and their parents. Data were collected through semi-structured face-to-face interviews conducted in participants' homes. Qualitative framework analysis was used to analyse the interview transcripts. An a priori thematic coding framework was developed. Emerging codes were grouped into categories, and refined into analytical themes. The data were used to build an understanding of how children with impaired mobility define health-related quality of life in relation to mobility impairment, and to assess the applicability of two standard measures of health-related quality of life.

RESULTS

Eleven children with impaired mobility and 24 parents were interviewed across 27 interviews. Participants defined mobility-related quality of life through three distinct but interrelated concepts: 1) participation and positive experiences; 2) self-worth and feeling fulfilled; 3) health and functioning. A good degree of consensus was found between child and parent responses, although there was some evidence to suggest a shift in perception of mobility-related quality of life with child age.

CONCLUSIONS

Young wheelchair users define health-related quality of life in a distinct way as a result of their mobility impairment and adaptation use. Generic, preference-based measures of health-related quality of life lack sensitivity in this population. Development of a mobility-related quality of life outcome measure for children is recommended.

An Empirical Comparison of the EQ-5D-5L, DEMQOL-U and DEMQOL-Proxy-U in a Post-Hospitalisation Population of Frail Older People Living in Residential Aged Care

OBJECTIVE

To empirically compare the measurement properties of the DEMQOL-U and DEMQOL-Proxy-U instruments to the EQ-5D-5L and its proxy version (CEQ-5D-5L) in a population of frail older people living in residential aged care in the post-hospitalisation period following a hip fracture.

METHODS

A battery of instruments to measure health-related quality of life (HRQoL), cognition, and clinical indicators of depression, pain and functioning were administered at baseline and repeated at 4 weeks' follow-up. Descriptive summary statistics were produced and psychometric analyses were conducted to assess the levels of agreement, convergent validity and known group validity between clinical indicators and HRQoL measures.

RESULTS

There was a large divergence in mean (SD) utility scores at baseline for the EQ-5D-5L and DEMQOL-U [EQ-5D-5L mean 0.21 (0.19); DEMQOL-U mean 0.79 (0.14)]. At 4 weeks' follow-up, there was a marked improvement in EQ-5D-5L scores whereas DEMQOL-U scores had deteriorated. [EQ-5D-5L mean 0.45 (0.38); DEMQOL-U mean 0.58 (0.38)]. The EQ-5D and CEQ-5D-5L were more responsive to the physical recovery trajectory experienced by frail older people following surgery to repair a fractured hip, whereas the DEMQOL-U and DEMQOL-Proxy-U appeared more responsive to the changes in delirium and dementia symptoms often experienced by frail older people in this period.

CONCLUSIONS

This study presents important insights into the HRQoL of a relatively under-researched population of post-hospitalisation frail older people in residential care. Further research should investigate the implications for economic evaluation of self-complete versus proxy assessment of HRQoL and the choice of preference-based instrument for the measurement and valuation of HRQoL in older people exhibiting cognitive decline, dementia and other co-morbidities.

"Naming and Framing": The Impact of Labeling on Health State Values for Multiple Sclerosis

INTRODUCTION

Health state valuation is a key input in many economic evaluations that inform resource allocation across competing healthcare interventions. Empirical evidence has shown that, in preference elicitation surveys, respondents may value a health state differently if they are aware of the condition causing it ('labeling effects'). This study investigates the impact of including a multiple sclerosis (MS) label for valuation of MS health states.

METHODS

Health state values for MS were elicited using two internet-based surveys in representative samples of the UK population ( n = 1702; n = 1788). In one survey respondents were not informed that health states were caused by MS. The second survey included a condition label for MS. Surveys were identical in all other ways. Health states were described using a MS-specific eight-dimensional classification system (MSIS-8D), and the time trade-off valuation technique was used. Differences between values for labeled and unlabeled states were assessed using descriptive statistics and multivariate regression methods.

RESULTS

Adding a MS condition label had a statistically significant effect on mean health state values, resulting in lower values for labeled MS states v. unlabeled states. The data suggest that the MS label had a more significant effect on values for less severe states, and no significant effect on values for the most severe states. The inclusion of the MS label had a differential impact across the dimensions of the MSIS-8D. Across the MSIS-8D, predicted values ranged from 0.079 to 0.883 for unlabeled states, and 0.066 to 0.861 for labeled states.

CONCLUSION

Differences reported in health state values, using labeled and unlabeled states, demonstrate that condition labels affect the results of valuation studies, and can have important implications in decision-analytic modelling and in economic evaluations.

Development of a core outcome set for disease modification trials in mild to moderate dementia: a systematic review, patient and public consultation and consensus recommendations

BACKGROUND

There is currently no disease-modifying treatment available to halt or delay the progression of the disease pathology in dementia. An agreed core set of the best-available and most appropriate outcomes for disease modification would facilitate the design of trials and ensure consistency across disease modification trials, as well as making results comparable and meta-analysable in future trials.

OBJECTIVES

To agree a set of core outcomes for disease modification trials for mild to moderate dementia with the UK dementia research community and patient and public involvement (PPI).

DATA SOURCES

We included disease modification trials with quantitative outcomes of efficacy from (1) references from related systematic reviews in workstream 1; (2) searches of the Cochrane Dementia and Cognitive Improvement Group study register, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Latin American and Caribbean Health Sciences Literature and PsycINFO on 11 December 2015, and clinical trial registries [International Standard Randomised Controlled Trial Number (ISRCTN) and clinicaltrials.gov] on 22 and 29 January 2016; and (3) hand-searches of reference lists of relevant systematic reviews from database searches.

REVIEW METHODS

The project consisted of four workstreams. (1) We obtained related core outcome sets and work from co-applicants. (2) We systematically reviewed published and ongoing disease modification trials to identify the outcomes used in different domains. We extracted outcomes used in each trial, recording how many used each outcome and with how many participants. We divided outcomes into the domains measured and searched for validation data. (3) We consulted with PPI participants about recommended outcomes. (4) We presented all the synthesised information at a conference attended by the wider body of National Institute for Health Research (NIHR) dementia researchers to reach consensus on a core set of outcomes.

RESULTS

We included 149 papers from the 22,918 papers screened, referring to 125 individual trials. Eighty-one outcomes were used across trials, including 72 scales [31 cognitive, 12 activities of daily living (ADLs), 10 global, 16 neuropsychiatric and three quality of life] and nine biological techniques. We consulted with 18 people for PPI. The conference decided that only cognition and biological markers are core measures of disease modification. Cognition should be measured by the Mini Mental State Examination (MMSE) or the Alzheimer's Disease Assessment Scale - Cognitive subscale (ADAS-Cog), and brain changes through structural magnetic resonance imaging (MRI) in a subset of participants. All other domains are important but not core. We recommend using the Neuropsychiatric Inventory for neuropsychiatric symptoms: the Disability Assessment for Dementia for ADLs, the Dementia Quality of Life Measure for quality of life and the Clinical Dementia Rating scale to measure dementia globally.

LIMITATIONS

Most of the trials included participants with Alzheimer's disease, so recommendations may not apply to other types of dementia. We did not conduct economic analyses. The PPI consultation was limited to members of the Alzheimer's Society Research Network.

CONCLUSIONS

Cognitive outcomes and biological markers form the core outcome set for future disease modification trials, measured by the MMSE or ADAS-Cog, and structural MRI in a subset of participants.

FUTURE WORK

We envisage that the core set may be superseded in the future, particularly for other types of dementia. There is a need to develop an algorithm to compare scores on the MMSE and ADAS-Cog.

STUDY REGISTRATION

The project was registered with Core Outcome Measures in Effectiveness Trials [ www.comet-initiative.org/studies/details/819?result=true (accessed 7 April 2016)]. The systematic review protocol is registered as PROSPERO CRD42015027346.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Comparing Generic and Condition-Specific Preference-Based Measures in Epilepsy: EQ-5D-3L and NEWQOL-6D

BACKGROUND

There is debate about the psychometric characteristics of the three-level EuroQol five-dimensional questionnaire (EQ-5D-3L) for use in epilepsy. In response to the concerns, an epilepsy-specific preference-based measure (NEWQOL-6D) was developed. The psychometric characteristics of the NEWQOL-6D, however, have not been assessed.

OBJECTIVES

To investigate the validity and responsiveness of the EQ-5D-3L and the Quality of Life in Newly Diagnosed Epilepsy Instrument-six dimensions (NEWQOL-6D) for use in the assessment of treatments for newly diagnosed focal epilepsy.

METHODS

The analysis used data from the Standard And New Antiepileptic Drugs trial including patients with focal epilepsy. We assessed convergent validity using correlations, and known-group validity across different epilepsy and general health severity indicators using analysis of variance and effect sizes. The responsiveness of the measures to change over time was assessed using standardized response means. We also assessed agreement between the measures.

RESULTS

There was some level of convergence and agreement between the measures in terms of utility score but divergence in the concepts measured by the descriptive systems. Both instruments displayed known-group validity, with significant differences between severity groups, and generally slightly larger effect sizes for the NEWQOL-6D across the epilepsy-specific indicators. Evidence for responsiveness was less clear, with small to moderate standardized response means demonstrating different levels of change across different indicators.

CONCLUSIONS

There was an overall tendency for the NEWQOL-6D to better reflect differences across groups, but this does not translate into large absolute utility differences. Both the EQ-5D-3L and the NEWQOL-6D show some evidence of validity for providing utility values for economic evaluations in newly diagnosed focal epilepsy.

A Comprehensive Review of the Quality and Feasibility of Dementia Assessment Measures: The Dementia Outcomes Measurement Suite

The diagnosis of dementia and the management of its associated symptoms are aided by high-quality assessment tools. However, there is disagreement on the optimal tools among abundant alternatives and lack of consistent quality standards across the different domains of dementia-related change (ie, cognition, severity, function, behavioral and psychological symptoms, delirium, quality of life). Standardization is difficult because the relevance of a measurement tool for health professionals may depend on the clinical setting and on the dementia type and severity. To address this need, we conducted a comprehensive and clinically relevant evidence-based review of dementia-related tools and present a set of recommended tools, the Dementia Outcomes Measurement Suite. The review revealed that considerable development has occurred in terms of assessment of persons with mild cognitive impairment, executive dysfunction, cognitively mediated functional change, and apathy. More research is needed to develop and validate tools to assess health-related quality of life and specific symptoms of dementia including anxiety, wandering, and repetitive vocalizations. This extensive overview of the quality of different measures may serve as a guide for health professionals clinically and for researchers developing new or improved dementia assessment tools.

Developing a dementia-specific health state classification system for a new preference-based instrument AD-5D

Background

With an ageing population, the number of people with dementia is rising. The economic impact on the health care system is considerable and new treatment methods and approaches to dementia care must be cost effective. Economic evaluation requires valid patient reported outcome measures, and this study aims to develop a dementia-specific health state classification system based on the Quality of Life for Alzheimer’s disease (QOL-AD) instrument (nursing home version). This classification system will subsequently be valued to generate a preference-based measure for use in the economic evaluation of interventions for people with dementia.

Methods

We assessed the dimensionality of the QOL-AD to develop a new classification system. This was done using exploratory and confirmatory factor analysis and further assessment of the structure of the measure to ensure coverage of the key areas of quality of life. Secondly, we used Rasch analysis to test the psychometric performance of the items, and select item(s) to describe each dimension. This was done on 13 items of the QOL-AD (excluding two general health items) using a sample of 284 residents living in long-term care facilities in Australia who had a diagnosis of dementia.

Results

A five dimension classification system is proposed resulting from the three factor structure (defined as ‘interpersonal environment’, ‘physical health’ and ‘self-functioning’) derived from the factor analysis and two factors (‘memory’ and ‘mood’) from the accompanying review. For the first three dimensions, Rasch analysis selected three questions of the QOL-AD (‘living situation’, ‘physical health’, and ‘do fun things’) with memory and mood questions representing their own dimensions. The resulting classification system (AD-5D) includes many of the health-related quality of life dimensions considered important to people with dementia, including mood, global function and skill in daily living.

Conclusions

The development of the AD-5D classification system is an important step in the future application of the widely used QOL-AD in economic evaluations. Future valuation studies will enable this tool to be used to calculate quality adjusted life years to evaluate treatments and interventions for people diagnosed with mild to moderate dementia.

Quality-of-life assessment in dementia: the use of DEMQOL and DEMQOL-Proxy total scores

PURPOSE

There is a need to determine whether health-related quality-of-life (HRQL) assessments in dementia capture what is important, to form a coherent basis for guiding research and clinical and policy decisions. This study investigated structural validity of HRQL assessments made using the DEMQOL system, with particular interest in studying domains that might be central to HRQL, and the external validity of these HRQL measurements.

METHODS

HRQL of people with dementia was evaluated by 868 self-reports (DEMQOL) and 909 proxy reports (DEMQOL-Proxy) at a community memory service. Exploratory and confirmatory factor analyses (EFA and CFA) were conducted using bifactor models to investigate domains that might be central to general HRQL. Reliability of the general and specific factors measured by the bifactor models was examined using omega (ω) and omega hierarchical (ω h) coefficients. Multiple-indicators multiple-causes models were used to explore the external validity of these HRQL measurements in terms of their associations with other clinical assessments.

RESULTS

Bifactor models showed adequate goodness of fit, supporting HRQL in dementia as a general construct that underlies a diverse range of health indicators. At the same time, additional factors were necessary to explain residual covariation of items within specific health domains identified from the literature. Based on these models, DEMQOL and DEMQOL-Proxy overall total scores showed excellent reliability (ω h > 0.8). After accounting for common variance due to a general factor, subscale scores were less reliable (ω h < 0.7) for informing on individual differences in specific HRQL domains. Depression was more strongly associated with general HRQL based on DEMQOL than on DEMQOL-Proxy (-0.55 vs -0.22). Cognitive impairment had no reliable association with general HRQL based on DEMQOL or DEMQOL-Proxy.

CONCLUSIONS

The tenability of a bifactor model of HRQL in dementia suggests that it is possible to retain theoretical focus on the assessment of a general phenomenon, while exploring variation in specific HRQL domains for insights on what may lie at the 'heart' of HRQL for people with dementia. These data suggest that DEMQOL and DEMQOL-Proxy total scores are likely to be accurate measures of individual differences in HRQL, but that subscale scores should not be used. No specific domain was solely responsible for general HRQL at dementia diagnosis. Better HRQL was moderately associated with less depressive symptoms, but this was less apparent based on informant reports. HRQL was not associated with severity of cognitive impairment.

Dementia-specific quality of life instruments: a conceptual analysis

BACKGROUND

Over the past 20 years, many researchers have worked in developing various methods for measuring quality of life (QoL) of people with dementia. The aim of this review is to develop the conceptual frameworks of the dementia-specific QoL instruments, to identify their evolution over time and to provide elements of reflection on the QoL concept in dementia and its evaluation.

METHODS

An electronic search was conducted on PsycINFO and MEDLINE databases, from January 1985 to June 2015 using a combination of key words that include QoL, dementia, and review.

RESULTS

The analysis of the conceptual frameworks of the 18 selected dementia-specific QoL tools shows a great diversity in: (1) the QoL definitions (e.g. health-related QoL definitions, QoL definitions based on Lawton's work, or similar to this latter); (2) the theoretical QoL models (e.g. Lawton' work and modified Lawton, adaptation, personhood); (3) the domains and dimensions; (4) the way to construct the instrument (e.g. development based on literature, opinion of the experts), and (5) the items' formulation (e.g. use of criterion of intensity or frequency).

CONCLUSIONS

There are different conceptual frameworks in the dementia-specific QoL measures with improvements over time (e.g. inclusion of interesting concepts such as adaptation, taking into account the views of patients themselves). Each of the conceptual parameters (definitions, models, domains, and dimensions) is discussed to identify the scales that are conceptually the strongest. Through their review, recommendations for future instrument refinement and development are discussed and a new QoL definition is proposed.

Evaluating the effectiveness and cost-effectiveness of Dementia Care Mapping™ to enable person-centred care for people with dementia and their carers (DCM-EPIC) in care homes: study protocol for a randomised controlled trial

BACKGROUND

Up to 90 % of people living with dementia in care homes experience one or more behaviours that staff may describe as challenging to support (BSC). Of these agitation is the most common and difficult to manage. The presence of agitation is associated with fewer visits from relatives, poorer quality of life and social isolation. It is recommended that agitation is treated through psychosocial interventions. Dementia Care Mapping™ (DCM™) is an established, widely used observational tool and practice development cycle, for ensuring a systematic approach to providing person-centred care. There is a body of practice-based literature and experience to suggests that DCM™ is potentially effective but limited robust evidence for its effectiveness, and no examination of its cost-effectiveness, as a UK health care intervention. Therefore, a definitive randomised controlled trial (RCT) of DCM™ in the UK is urgently needed.

METHODS/DESIGN

A pragmatic, multi-centre, cluster-randomised controlled trial of Dementia Care Mapping (DCM™) plus Usual Care (UC) versus UC alone, where UC is the normal care delivered within the care home following a minimum level of dementia awareness training. The trial will take place in residential, nursing and dementia-specialist care homes across West Yorkshire, Oxfordshire and London, with residents with dementia. A random sample of 50 care homes will be selected within which a minimum of 750 residents will be registered. Care homes will be randomised in an allocation ratio of 3:2 to receive either intervention or control. Outcome measures will be obtained at 6 and 16 months following randomisation. The primary outcome is agitation as measured by the Cohen-Mansfield Agitation Inventory, at 16 months post randomisation. Key secondary outcomes are other BSC and quality of life. There will be an integral cost-effectiveness analysis and a process evaluation.

DISCUSSION

The protocol was refined following a pilot of trial procedures. Changes include replacement of a questionnaire, whose wording caused some residents distress, to an adapted version specifically designed for use in care homes, a change to the randomisation stratification factors, adaption in how the staff measures are collected to encourage greater compliance, and additional reminders to intervention homes of when mapping cycles are due, via text message.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN82288852 . Registered on 16 January 2014. Full protocol version and date: v7.1: 18 December 2015.

An evaluation of shared reading groups for adults living with dementia: preliminary findings

Purpose

– Although there is a growing evidence base for the value of psychosocial and arts-based strategies for enhancing well-being amongst adults living with dementia, relatively little attention has been paid to literature-based interventions. The purpose of this paper is to assess the impact of shared reading (SR) groups, a programme developed and implemented by The Reader Organisation, on quality of life for care home residents with mild/moderate dementia.

Design/methodology/approach

– In total, 31 individuals were recruited from four care homes, which were randomly assigned to either reading-waiting groups (three months reading, followed by three months no reading) or waiting-reading groups (three months no reading, followed by three months reading). Quality of life was assessed by the DEMQOL-Proxy and psychopathological symptoms were assessed by the Neuropsychiatric Inventory Questionnaire.

Findings

– Compared to the waiting condition, the positive effects of SR on quality of life were demonstrated at the commencement of the reading groups and were maintained once the activity ended. Low levels of baseline symptoms prevented analyses on whether the intervention impacted on the clinical signs of dementia.

Research limitations/implications

– Limitations included the small sample and lack of control for confounding variables.

Originality/value

– The therapeutic potential of reading groups is discussed as a positive and practical intervention for older adults living with dementia.

Cost-effectiveness of exercise as a therapy for behavioural and psychological symptoms of dementia within the EVIDEM-E randomised controlled trial

OBJECTIVE

Although available evidence is modest, exercise could be beneficial in reducing behavioural and psychological symptoms of dementia. We aim to evaluate the cost-effectiveness of a dyadic exercise regimen for individuals with dementia and their main carer as therapy for behavioural and psychological symptoms of dementia.

METHODS

Cost-effectiveness analysis within a two-arm, pragmatic, randomised, controlled, single-blind, parallel-group trial of a dyadic exercise regimen (individually tailored, for 20-30 min at least five times per week). The study randomised 131 community-dwelling individuals with dementia and clinically significant behavioural and psychological symptoms with a carer willing and able to participate in the exercise regimen; 52 dyads provided sufficient cost data for analyses.

RESULTS

Mean intervention cost was £284 per dyad. For the subsample of 52 dyads, the intervention group had significantly higher mean cost from a societal perspective (mean difference £2728.60, p = 0.05), but costs were not significantly different from a health and social care perspective. The exercise intervention was more cost-effective than treatment as usual from both societal and health and social care perspectives for the measure of behavioural and psychological symptoms (Neuropsychiatric Inventory). It does not appear cost-effective in terms of cost per quality-adjusted life year gain.

CONCLUSIONS

The exercise intervention has the potential to be seen as cost-effective when considering behavioural and psychological symptoms but did not appear cost-effective when considering quality-adjusted life year gains.

A Systematic Review of the Literature on the Development of Condition-Specific Preference-Based Measures of Health

BACKGROUND

Health state utility values (HSUVs) are required to calculate quality-adjusted life-years (QALYs). They are frequently derived from generic preference-based measures of health. However, such generic measures may not capture health attributes of relevance to specific conditions. In such cases, a condition-specific preference-based measure (CSPBM) may be more appropriate.

OBJECTIVE

This systematic review aimed to identify all published accounts of developing CSPBMs to describe and appraise the methods used.

METHOD

We undertook a systematic search (of Embase, MEDLINE, PsycINFO, Web of Science, the Cochrane Library, CINAHL, EconLit, ASSIA and the Health Management Information Consortium database) to identify published accounts of CSPBM development up to July 2015. Studies were reviewed to investigate the methods used to design classification systems, estimate HSUVs, and validate the measures.

RESULTS

A total of 86 publications were identified, describing 51 CSPBMs. Around two-thirds of these were QALY measures; the remainder were designed for clinical decision making only. Classification systems for 33 CSPBMs were derived from existing instruments; 18 were developed de novo. HSUVs for 34 instruments were estimated using a 'composite' approach, involving statistical modelling; the remainder used a 'decomposed' approach based on multi-attribute utility theory. Half of the papers that described the estimation of HSUVs did not report validating their measures.

CONCLUSION

Various methods have been used at all stages of CSPBM development. The choice between developing a classification system de novo or from an existing instrument may depend on the availability of a suitable existing measure, while the choice between a decomposed or composite approach appears to be determined primarily by the purpose for which the instrument is designed. The validation of CSPBMs remains an area for further development.

Economic Evaluation of a General Hospital Unit for Older People with Delirium and Dementia (TEAM Randomised Controlled Trial)

BACKGROUND

One in three hospital acute medical admissions is of an older person with cognitive impairment. Their outcomes are poor and the quality of their care in hospital has been criticised. A specialist unit to care for older people with delirium and dementia (the Medical and Mental Health Unit, MMHU) was developed and then tested in a randomised controlled trial where it delivered significantly higher quality of, and satisfaction with, care, but no significant benefits in terms of health status outcomes at three months.

OBJECTIVE

To examine the cost-effectiveness of the MMHU for older people with delirium and dementia in general hospitals, compared with standard care.

METHODS

Six hundred participants aged over 65 admitted for acute medical care, identified on admission as cognitively impaired, were randomised to the MMHU or to standard care on acute geriatric or general medical wards. Cost per quality adjusted life year (QALY) gained, at 3-month follow-up, was assessed in trial-based economic evaluation (599/600 participants, intervention: 309). Multiple imputation and complete-case sample analyses were employed to deal with missing QALY data (55%).

RESULTS

The total adjusted health and social care costs, including direct costs of the intervention, at 3 months was £7714 and £7862 for MMHU and standard care groups, respectively (difference -£149 (95% confidence interval [CI]: -298, 4)). The difference in QALYs gained was 0.001 (95% CI: -0.006, 0.008). The probability that the intervention was dominant was 58%, and the probability that it was cost-saving with QALY loss was 39%. At £20,000/QALY threshold, the probability of cost-effectiveness was 94%, falling to 59% when cost-saving QALY loss cases were excluded.

CONCLUSIONS

The MMHU was strongly cost-effective using usual criteria, although considerably less so when the less acceptable situation with QALY loss and cost savings were excluded. Nevertheless, this model of care is worthy of further evaluation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01136148.

A Quality-Adjusted Life-Year Measure for Multiple Sclerosis: Developing a Patient-Reported Health State Classification System for a Multiple Sclerosis-Specific Preference-Based Measure

BACKGROUND

Increasingly, generic preference-based measures of health-related quality of life (HRQOL) are used to estimate quality-adjusted life-years to inform resource allocation decisions. Evidence suggests that generic measures may not be appropriate for multiple sclerosis (MS).

OBJECTIVES

To report the first stage in the development of an MS-specific preference-based measure to quantify the impact of MS and its treatment: deriving a health state classification system, which is amenable to valuation, from the 29-item Multiple Sclerosis Impact Scale (MSIS-29), a widely used patient-reported outcome measure in MS.

METHODS

The dimensional structure of the MSIS-29 was determined using factor analysis and a conceptual framework of HRQOL in MS. Item performance was assessed, using Rasch analysis and psychometric criteria, to enable the selection of one item to represent each dimension of HRQOL covered by the MSIS-29. Analysis was undertaken using a sample (N = 529) from a longitudinal study of people with MS. Results were validated by repeating the analysis with a second sample (N = 528).

RESULTS

Factor analysis confirmed the two-subscale structure of the MSIS-29. Both subscales covered several conceptually independent dimensions of HRQOL. Following Rasch and psychometric analysis, an eight-dimensional classification system named the MSIS-8D was developed. Each dimension was represented by one item with four response levels.

CONCLUSIONS

Combining factor analysis with conceptual mapping, and Rasch analysis with psychometric criteria, provides a valid method of constructing a classification system for an MS-specific preference-based measure. The next stage is to obtain preference weights so that the measure can be used in studies investigating MS.

Estimating a Preference-Based Index for an Eight-Dimensional Health State Classification System for Multiple Sclerosis

BACKGROUND

Condition-specific measures are frequently used to assess the health-related quality of life of people with multiple sclerosis (MS). Such measures are unsuitable for use in economic evaluations that require estimates of cost per quality-adjusted life-year because they are not based on preferences.

OBJECTIVES

To report the estimation of a preference-based single index for an eight-dimensional instrument for MS, the Multiple Sclerosis Impact Scale - Eight Dimensions (MSIS-8D), derived from an MS-specific measure of health-related quality of life, the 29-item Multiple Sclerosis Impact Scale (MSIS-29).

METHODS

We elicited preferences for a sample of MSIS-8D states (n = 169) from a sample (n = 1702) of the UK general population. Preferences were elicited using the time trade-off technique via an Internet-based survey. We fitted regression models to these data to estimate values for all health states described by the MSIS-8D. Estimated values were assessed against MSIS-29 scores and values derived from generic preference-based measures in a large, representative sample of people with MS.

RESULTS

Participants reported that the time trade-off questions were easy to understand. Observed health state values ranged from 0.08 to 0.89. The best-performing model was a main effects, random effects model (mean absolute error = 0.04). Validation analyses support the performance of the MSIS-8D index: it correlated more strongly than did generic measures with MSIS-29 scores, and it discriminated effectively between subgroups of people with MS.

CONCLUSIONS

The MSIS-8D enables health state values to be estimated from the MSIS-29, adding to the methods available to assess health outcomes and to estimate quality-adjusted life-years for MS for use in health technology assessment and decision-making contexts.

Journeying through Dementia, a community-based self-management intervention for people aged 65 years and over: a feasibility study to inform a future trial

BACKGROUND

A study to determine the feasibility of conducting a future population-based trial into a self-management intervention for community-living adults with early stage dementia included evaluation of intervention content and modes of delivery, staffing requirements, recruitment methods and the utility and usability of patient reported outcomes.

METHODS

Participants identified through memory clinics in one city took part in an intervention called 'Journeying through Dementia'. The 12-week programme incorporating four individual sessions with one of the facilitators encourages participants to engage in discussion and activities related to health and well-being positioning them as the expert enabling long-term behavioural change. Participants (n = 10) and their nominated carers (n = 7) were all asked to complete selected outcomes at baseline, 8 weeks (participants only) and post intervention and invited to comment on their usability. All participants and carers were qualitatively interviewed before intervention delivery about their expectations and participants; nominated carers and facilitators were all interviewed after cessation about their experiences.

RESULTS

The manualised intervention and modes of delivery proved acceptable to participants and carers. Reported benefits included increased confidence and self-efficacy, engagement in new or lapsed activities and re-engagement in fun and friendships. People with dementia and carers were able to self-complete all outcome measures, but time required to complete the measures is a key factor. Strategies for recruitment need to include direct contact within 24-48 h post invitation to the study. Analysis of data on the primary outcome did not reveal any trends. Facilitators found the training and support to be appropriate and helpful.

CONCLUSIONS

The tailored intervention reportedly met the needs of all participants. The study confirmed the need for careful identification and application of patient-reported outcome measures. Outcomes to measure some dimensions of reported benefit are not available.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN67209155.