Cost-effectiveness of a telehealth intervention for in-home dementia care support: Findings from the FamTechCare clinical trial

Economic evaluations of technology-based interventions used to provide care support for people with mild dementia or mild cognitive impairment and their caregivers: A systematic review

BACKGROUND

The cost-effectiveness of interventions is a key issue owing to the limited resources of healthcare services.

OBJECTIVE

To conduct a systematic review of economic evaluations of technology-based healthcare interventions in care support for people with dementia or mild cognitive impairment (MCI) and their caregivers, and of the tools used to assess effectiveness and costs.

METHODS

The following databases were used: PubMed, National Health Service Economic Evaluation Database, and Health Technology Assessment. A total of 207 articles from 2012 to 2024 were identified and then screened.

RESULTS

Seventeen studies were included, of which nine were study protocols. Almost half (n = 8) the interventions were multicomponent. The most common components used in the interventions were cognitive stimulation, physical functioning and continuing support. Regarding the efficiency results of these interventions, only three studies provided a full economic evaluation. The most frequent tools in the economic evaluations used to measure effectiveness (measured in quality-adjusted life years) and costs were the European Quality of Life-5 Dimensions and Resource Utilization in Dementia instruments, respectively.

CONCLUSIONS

Most of the interventions evaluated were cost-effective. However, these results should be interpreted with caution, given the scarcity of the literature, and further economic evaluations of technology-based healthcare interventions for people with mild dementia or MCI care support and their caregivers are therefore needed. Additionally, a meta-analysis could not be performed due to the heterogeneity of the data.

Economics and dementia: Challenges and responses

Economics and dementia are interconnected in many ways. There is, for example, accumulating evidence of the ways in which dementia impacts on the economic status of individuals and families, on health and social care system budgets, and on national economies. An individual's economic status can affect their risk of dementia and their ability to respond to it. Governments and other strategic decision-makers are aware of the (growing, indeed urgent) need to take action - whether that is prevention, treatment or care - but also very aware of the limited resources available to them and to the general population. Research evidence can potentially inform the difficult decisions that government and others need to take. We briefly summarise some economic evaluation studies in the dementia area as a basis for identifying the main challenges of moving from evidence to better policy and practice. We then discuss some possible responses (from a range of stakeholders) to these challenges, and how the STRiDE study has sought to contribute to this fast-moving field.

Economic evaluations of electronic health interventions for people with age-related cognitive impairment and their caregivers: A systematic review

OBJECTS

Dementia has physical, social and economic impacts, causing considerable distress for people with age-related cognitive impairment (PWACI) and their caregivers. Electronic health (e-health) interventions can provide convenient education to improve the coping competence of caregivers and have become an important approach to supporting them. Understanding the economic evidence of e-health interventions will facilitate the decision making and implementation of integrating e-health into routine health services. The present review aimed to appraise economic evidence related to e-health interventions for PWACI and their caregivers.

METHODS

We systematically searched multiple cross-disciplinary databases from inception to February 28, 2023. Two reviewers independently selected the trials, assessed the quality, and checked the data. A descriptive-analytical narrative method was used to analyze the review findings.

RESULTS

Thirteen studies were analyzed, including 12 randomized controlled trials and one quasi-experimental study. All included studies were conducted in developed countries. The included studies reported limited economic information. There were six cost-effectiveness analysis, five cost-consequence analysis and one partial economic evaluation. The included studies were heterogeneous, and varied in quality. The results demonstrated that e-health multicomponent interventions can reduce the cost of health service utilization in short term (10-104 weeks).

CONCLUSIONS

Few studies calculated the incremental cost-effectiveness ratio to evaluate the cost-effectiveness of e-health interventions. Preliminary evidence indicates that e-health interventions can reduce the cost of health service utilization in the short term, but the cost-effectiveness of e-health interventions hasn't been identified. More robust evidence is needed to clarify the value of e-health interventions for PWACI and their caregivers.

Virtual Dementia-Friendly Communities (Verily Connect) Stepped-Wedge Cluster-Randomised Controlled Trial: Improving Dementia Caregiver Wellbeing in Rural Australia

Caring for people living with dementia often leads to social isolation and decreased support for caregivers. This study investigated the effect of a Virtual Dementia-Friendly Rural Communities (Verily Connect) model on social support and demand for caregivers of people living with dementia. The co-designed intervention entailed an integrated website and mobile application, peer-support videoconference, and technology learning hubs. This mixed-methods, stepped-wedge, cluster-randomised controlled trial was conducted with 113 participants from 12 rural communities in Australia. Caregiver data were collected using MOS-SSS and ZBI between 2018 and 2020. The relationship between post-intervention social support with age, years of caring, years since diagnosis, and duration of intervention were explored through correlation analysis and thin plate regression. Google Analytics were analysed for levels of engagement, and cost analysis was performed for implementation. Results showed that caregivers' perception of social support (MOS-SSS) increased over 32 weeks (p = 0.003) and there was a marginal trend of less care demand (ZBI) among caregivers. Better social support was observed with increasing caregiver age until 55 years. Younger caregivers (aged <55 years) experienced the greatest post-intervention improvement. The greatest engagement occurred early in the trial, declining sharply thereafter. The Verily Connect model improved caregivers' social support and appeared to ease caregiver demand.

The value of supportive care: A systematic review of cost-effectiveness of non-pharmacological interventions for dementia

BACKGROUND

Almost 44 million people are currently living with dementia worldwide. This number is set to increase threefold by 2050, posing a serious threat to the sustainability of healthcare systems. Overuse of antipsychotic drugs for the management of the symptoms of dementia carries negative consequences for patients while also increasing the health expenditures for society. Supportive care (SC) interventions could be considered a safer and potentially cost-saving option. In this paper we provide a systematic review of the existing evidence regarding the cost-effectiveness and cost-utility of SC interventions targeted towards persons living with dementia and their caregivers.

METHODS

A systematic literature review was performed between February 2019 and December 2021 through searches of the databases PubMed (MEDLINE), Cochrane Library, CENTRAL, Embase and PsycINFO. The search strategy was based on PRISMA 2020 recommendations. We considered studies published through December 2021 with no lower date limit. We distinguished between five categories of SC strategies: cognitive therapies, physical activity, indirect strategies (organisational and environmental changes), interventions primarily targeted towards family caregivers, and multicomponent interventions.

RESULTS

Of the 5,479 articles retrieved, 39 met the inclusion criteria. These studies analysed 35 SC programmes located at different stages of the dementia care pathway. Eleven studies provided evidence of high cost-effectiveness for seven interventions: two multicomponent interventions; two indirect interventions; two interventions aimed at caregivers of community-dwelling persons with dementia; one community-based cognitive stimulation and occupational programme.

CONCLUSION

We find that the most promising SC strategies in terms of cost-effectiveness are multicomponent interventions (targeted towards both nursing home residents and day-care service users), indirect strategies (group living and dementia care management at home), some forms of tailored occupational therapy, together with some psychosocial interventions for caregivers of community-dwelling persons with dementia. Our results suggest that the adoption of effective SC interventions may increase the economic sustainability of dementia care.

How Telemedicine Can Improve the Quality of Care for Patients with Alzheimer's Disease and Related Dementias? A Narrative Review

Background and Objectives: Dementia affects more than 55 million patients worldwide, with a significant societal, economic, and psychological impact. However, many patients with Alzheimer's disease (AD) and other related dementias have limited access to effective and individualized treatment. Care provision for dementia is often unequal, fragmented, and inefficient. The COVID-19 pandemic accelerated telemedicine use, which holds promising potential for addressing this important gap. In this narrative review, we aim to analyze and discuss how telemedicine can improve the quality of healthcare for AD and related dementias in a structured manner, based on the seven dimensions of healthcare quality defined by the World Health Organization (WHO), 2018: effectiveness, safety, people-centeredness, timeliness, equitability, integrated care, and efficiency. Materials and Methods: MEDLINE and Scopus databases were searched for peer-reviewed articles investigating the role of telemedicine in the quality of care for patients with dementia. A narrative synthesis was based on the seven WHO dimensions. Results: Most studies indicate that telemedicine is a valuable tool for AD and related dementias: it can improve effectiveness (better access to specialized care, accurate diagnosis, evidence-based treatment, avoidance of preventable hospitalizations), timeliness (reduction of waiting times and unnecessary transportation), patient-centeredness (personalized care for needs and values), safety (appropriate treatment, reduction of infection risk),integrated care (interdisciplinary approach through several dementia-related services), efficiency (mainly cost-effectiveness) and equitability (overcoming geographical barriers, cultural diversities). However, digital illiteracy, legal and organizational issues, as well as limited awareness, are significant potential barriers. Conclusions: Telemedicine may significantly improve all aspects of the quality of care for patients with dementia. However, future longitudinal studies with control groups including participants of a wide educational level spectrum will aid in our deeper understanding of the real impact of telemedicine in quality care for this population.

Effects of telehealth intervention for people with dementia and their carers: A systematic review and meta-analysis of randomized controlled studies

PURPOSE

Interventions delivered using telehealth modalities are becoming standard practice with patient populations around the world, partly because of innovation necessitated by the COVID-19 pandemic and partly due to improved infrastructure and comfort of providers, patients, and families, through technology. Though increasingly utilized, the effectiveness of telehealth interventions with families with dementia remains unclear. This gives rise to the need for investigation to develop telehealth interventions that are evidence based and not merely convenient tools. This current study is designed to systematically examine the impact and effectiveness of telehealth-delivered psychoeducational and behavioral interventions among persons with dementia and their caregivers.

DESIGN

The design combines systematic review and meta-analysis.

METHODS

A total of eight databases were electronically accessed and searched as of November 16, 2021. Experimental studies identifying the results of telehealth interventions for persons with dementia and associated caregivers published in English have been reviewed in this study. Standardized mean differences (SMD) offering 95% confidence intervals (CI) were developed to pool the effect size using a random effects model (in this case, Stata 16.0). The Revised Cochrane Risk-of-Bias Tool for Randomized Trials (RoB-2) was used to analyze the study's methodological soundness.

FINDINGS

Nineteen cases met the eligibility criteria (including 1379 persons with dementia and 1339 caregivers). Overall, telehealth interventions demonstrated effects in the expected directions on depression (SMD -0.63; 95% degree of confidence intervals (CI) -0.88 to -0.38, p < 0.001); and caregivers' perceived competency (SMD 0.27; 95% CI -0.05 to 0.50, p = 0.02). There were, however, no statistically significant effects observed on cognitive function or multiple aspects of quality of life for subjects.

CONCLUSIONS

Telehealth interventions appear to effect a reduction in depression among persons diagnosed with dementia while improving the perceived competency of caregivers.

CLINICAL RELEVANCE

The study's results could be used as evidence of the effectiveness of using telehealth for persons with dementia and their caregivers, including contextualizing where they are used (i.e., long-term care facilities, private homes, etc.), understanding the mechanisms in play (including intervention delivery and systems), and isolating and identifying mediating influences.

Behavioral Change Factors and Retention in Web-Based Interventions for Informal Caregivers of People Living With Dementia: Scoping Review

BACKGROUND

Web-based interventions aimed at supporting informal caregivers of people living with dementia have the potential to improve caregivers' well-being and psychological health. However, few interventions are widely implemented for this population, and none of the prior reviews have systematically examined the use of behavior change techniques (BCTs), theories, and agents in web-based interventions for informal caregivers of people living with dementia. To better understand this implementation gap, we reviewed the literature to map behavioral factors (BCTs, theories, and agents) deployed in the studies. Furthermore, because there is an emerging consensus that retention could be shaped by participant characteristics and behavioral factors, we explored relationships between these features and retention rates across studies.

OBJECTIVE

We pursued 3 objectives: to map behavioral factors involved in the web-based interventions for informal caregivers of people living with dementia; to examine the relationship between behavioral change elements and retention in the studies; and to examine the relationship between participant characteristics (gender, age, and spouse or adult children caregiver proportion) and study retention.

METHODS

We conducted a literature review using the following keywords and their corresponding Medical Subject Headings terms: dementia, caregivers, and web-based intervention. The time limits were January 1998 to March 2022. Using the BCTv1 taxonomy, which specifies active behavioral components in interventions, 2 coders collected, summarized, and analyzed the frequency distributions of BCTs. Similarly, they abstracted and analyzed participant characteristics, behavior change theories, behavior change agents, and retention rates in the studies.

RESULTS

The average age was 61.5 (SD 7.4) years, and the average proportion of spousal informal caregivers, adult children informal caregivers, and retention rates were 51.2% (SD 24.8%), 44.8% (SD 22%), and 70.4% (SD 17%), respectively. Only 53% (17/32) of the studies used behavior change theories, but 81% (26/32) included behavior change agents. The most common BCTv1 clusters were shaping knowledge and social support. The median number of BCTv1 clusters was 5 (IQR 3). We observed a negative correlation between the proportion of spousal informal caregivers and the retention rate (r=-0.45; P=.02) and between the number of BCTv1 clusters and retention rates (r=-0.47; P=.01). We also found that the proportion of adult children informal caregivers in the study was significantly and positively correlated with the retention rate (r=0.5; P=.03). No other participant characteristics or behavioral factors were associated with retention rates.

CONCLUSIONS

We found that almost half of the studies were not informed by behavior change theories. In addition, spousal involvement and a higher number of BCTs were each associated with lower retention rates, while the involvement of adult children caregivers in the study was associated with higher retention. In planning future studies, researchers should consider matching participant characteristics with their intended intervention as the alignment might improve their retention rates.

Smartphone applications for informal caregivers of chronically ill patients: a scoping review

Mobile-health applications can be used to deliver timely and personalized health information to family and friends of chronically ill adults living in the community. This scoping review aims to investigate the nature and extent of native smartphone applications for informal caregivers. Six databases were searched for articles on applications across ten chronic conditions, namely heart disease, stroke, cancer, chronic obstructive respiratory disease, asthma, diabetes, Alzheimer’s disease or other dementia, rheumatoid arthritis, hypertension, and mood or anxiety disorders. In total, 36 articles were included, encompassing 26 applications. Of these, smartphone applications were designed for use only by caregivers (n = 15), with a few applications also intended to be used with patients (n = 5), healthcare providers (n = 4), or all three roles (n = 2). Most applications targeted a single chronic condition (n = 25), with Alzheimer’s and other dementia being the most common (n = 18). Only one application was designed for management of multiple chronic conditions. Long-term evaluation methods are needed to continually assess the impact of applications on a range of process and health outcomes, such as usability, caregiver burden, and quality of life. Additional directions to advance native smartphone applications for caregivers are discussed, including personalization and expansion of eligibility criteria.

Impact of COVID-19 Pandemic on Research Participation Among Older African Americans

COVID-19 represents the newest health disparity faced by African Americans (AA). This study assessed the impact of COVID-19 on barriers and willingness to participate in research among older AAs. An online survey was sent to a nationwide sample of 65- to 85-year-old AAs between January and February 2021. Constant comparison analysis was used to extract themes. A total of 624 older AAs completed the survey. Approximately 40% of participants were willing to engage in virtual or in-person research. Of the individuals who were willing to participate in research, >50% were willing to engage in a spectrum of activities from group discussions to group exercise. Research participation themes related to logistics, technology, pandemic fears, and privacy or security. Older AAs face new research barriers that can be overcome through data use transparency and technology resources. This information can be used to encourage dementia research engagement among older AAs despite the pandemic.

Program Evaluation of My Life, My Story: Virtual Storytelling in the COVID-19 Age

OBJECTIVES

COVID-19 negatively affected older adults' well-being and quality of life, particularly individuals with dementia. My Life, My Story (MLMS) was developed at Veterans Health Administration as an opportunity for Veterans to interact and share life stories using guided interviews. This paper describes a program evaluation of MLMS delivered to Veterans with cognitive concerns and their caregivers using telehealth technology during COVID-19.

METHODS

Fourteen Veteran-caregiver dyads completed MLMS interviews with occupational therapy trainees using telehealth technology. Most (10 of 14) participating Veterans had mild-to-moderate dementia. Trainees ascertained Veteran and caregiver demographics such as age and recent cognitive evaluation scores via chart review. Trainees also gathered Veteran-caregiver technology and interview experience through post-interview program evaluation questionnaires.

RESULTS

Dyads reported generally positive interview and technological experience, despite technological glitches occurring in most (approximately 70%) interviews. Caregivers assisted with videoconferencing setup and participated in ten interviews.

CONCLUSIONS

Veterans with cognitive concerns successfully participated in virtual MLMS interviews during COVID-19. Caregivers enhanced Veteran engagement and often provided technological support.

CLINICAL IMPLICATIONS

Telehealth technology enabled participation in My Life, My Story by individuals with cognitive concerns and their caregivers. Post pandemic, clinicians may consider integrating telehealth technology with patients facing access challenges.

Supporting Informal Caregivers of People With Dementia in Cost-Effective Ways: A Systematic Review and Meta-Analysis

OBJECTIVES

Caring for persons with dementia is a heavy burden for informal caregivers. This study aimed to appraise the economic evidence of interventions supporting informal caregivers of people with dementia.

METHODS

Literature was searched, and trial-based studies evaluating the costs and effects of interventions supporting informal caregivers of people with dementia were included. Cost data were analyzed from both healthcare and societal perspectives. Random-effects models were used to synthesize cost and effect data, based on mean differences (MDs) or standardized MDs.

RESULTS

Of 33 eligible studies identified from 48 588 records, 14 (42.4%) showed net savings in total cost regardless of analytical perspectives. Among 22 studies included in meta-analyses, caregiver-focused psychosocial interventions showed improvements in caregivers' psychological health (n = 4; standardized MD 0.240; 95% confidence interval 0.094-0.387); nevertheless, the increases in societal cost were significant (n = 5; MD 3144; 95% confidence interval 922-5366). Psychological intervention and behavioral management engaging patient-caregiver dyads showed positive effects on caregivers' subjective burden, also with increases in total cost. Subgroup analyses indicated that the inclusion of different intervention components, the caregiver characteristics, and the follow-up periods could affect the costs and effects of interventions supporting informal caregivers.

CONCLUSIONS

Psychosocial interventions directed at informal caregivers and dyad-based psychological and behavioral interventions are effective but also expensive. The use of these interventions depends on the society's willingness to pay. More comprehensive economic evidence of interventions supporting informal caregivers is required, and the design of intervention should focus more on different intervention components, characteristics of patients and caregivers, and healthcare systems.

Satisfaction, utilization, and feasibility of a telehealth intervention for in-home dementia care support: A mixed methods study

BACKGROUND

Technology can enhance support for families caring for persons living with dementia but must be acceptable to be adopted. The FamTechCare clinical trial engaged caregivers in video recording care encounters that were reviewed by an expert panel who provided tailored feedback. The intervention reduced caregiver depression and improved caregiver competence. This mixed methods study reports on caregiver satisfaction and utilization of the intervention and expert panel evaluation of the intervention.

METHODS

A convergent parallel mixed methods design was used to evaluate the satisfaction, usability, and feasibility of the FamTechCare intervention. In the multisite randomized controlled trial, caregiver-person living with dementia dyads were randomized to the FamTechCare video support or attention control telephone support groups. Caregivers completed a satisfaction survey at the completion of the 3-month trial. Utilization was evaluated using the number and duration of videos submitted and calls received by caregivers. Relationships between participant characteristics and their satisfaction and utilization were evaluated. Feasibility of the intervention was assessed through content analysis of interviews with the expert panel.

RESULTS

The majority of caregivers in both groups reported benefits from participation. More FamTechCare caregivers found the interventionist support to be helpful (p = 0.001) and effective (p = 0.020) compared to attention control caregivers. FamTechCare caregivers of persons with more severe dementia were more likely to report that video recording intruded on their privacy (p = 0.050). Caregiver age, gender, education, dyad relationship, rural status, and type and severity of dementia were not associated with ratings of acceptability, ease of use, or intervention utilization. The expert panel described the FamTechCare intervention as useful and identified adaptations to enhance feasibility.

CONCLUSION

Regardless of age, gender, and relationship, caregivers found the intervention acceptable and easy to use and rated the expert feedback as effective in addressing care challenges. Further adaptation may be needed for FamTechCare to be readily implemented.

Ensuring full participation of people with disabilities in an era of telehealth

The widespread use of telehealth resulting from the COVID-19 pandemic has the potential to further exacerbate inequities faced by people with disabilities. Although, for some members of the disability community, the option to engage with telehealth may result in reduced barriers to care, for others, inadequate attention to the design, implementation, and policy dimensions may be detrimental. Addressing such considerations is imperative to mitigate health inequities faced by the disability community.