Evaluation of an integrated primary care-led dementia shared care program in Singapore: An effectiveness and cost-effectiveness study

Collaborative Care Models of Primary Care Clinics for People with Early-Stage Dementia: A Cross-Sectional Survey of Primary Care Physicians in Japan

Objectives

This study explored collaboration models between primary care physicians (PCPs) and care managers (CMs) and assessed each model's potential in meeting the support needs of individuals with early-stage dementia.

Methods

In 2022, a cross-sectional survey was conducted among the PCPs in Tokyo. The data regarding the participant and clinic characteristics and daily practices for individuals with early-stage dementia were collected. The clinical collaborative practice was classified using a latent class analysis; comparisons were made between the identified classes based on 14 items in seven domains of support.

Results

Two collaborative and one stand-alone models were identified. The former varied in the professionals' roles, with one led by PCPs and the other by CMs. We named them PCP-led, CM-led, and stand-alone models, accounting for 46.4%, 32.8%, and 20.6% of the clinics, respectively. The PCP-led clinics were significantly more likely to provide support than the stand-alone ones across five domains: cognitive function, care planning, carers' support, information, and social health. The CM-led model clinics generally fell between those of the other two models.

Conclusion

Different leadership styles exist in the PCP-CM collaborations in care delivery for people with early-stage dementia. This collaboration offers distinct advantages for clinics in addressing their needs.

Cost-Effectiveness of Non-pharmacological Interventions for Mild Cognitive Impairment and Dementia: A Systematic Review of Economic Evaluations and a Review of Reviews

BACKGROUND

Dementia prevalence is increasing, with no cure at present. Drug therapies have potential side effects and risk of mortality. People with dementia are frequently offered non-pharmacological interventions to improve quality of life and relieve symptoms. Identifying which interventions are cost-effective is important due to finite resources in healthcare services.

AIMS

The aims were to review published economic evaluations of community and nursing home non-pharmacological interventions for people with mild cognitive impairment or dementia and assess the usefulness of these evaluations for decision making in health services, for use by policy and local and national decision makers.

METHODS

We conducted a systematic review (PROSPERO CRD42021252999) of economic evaluations of non-pharmacological interventions for dementia or mild cognitive impairment with a narrative approach to data synthesis.

EXCLUSIONS

interventions for dementia prevention/early detection/end of life care. Databases searched: Academic Search Premier, MEDLINE, Web of Science, EMBASE, Google Scholar, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, Psychology and Behavioural Sciences Collection, PsycArticles, Cochrane Database of Systematic Reviews, Business Source Premier and Regional Business News; timeframe 1 January 2011-11 May 2023. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).

RESULTS

The review included 37 economic evaluations and four reviews worldwide across several distinct forms of care: physical activity, cognition, training, multicomponent, assistive technology and other (specialist dementia care, group living, home care vs care home). The intervention with the strongest evidence of cost-effectiveness was maintenance cognitive stimulation therapy. Case management, occupational therapy and dementia care management also showed good evidence of cost-effectiveness.

CONCLUSION

More economic evidence on the cost-effectiveness of specific dementia care interventions is needed, with consistency of methods and outcome measures. This could improve local and national decision makers' confidence to promote future cost-effective dementia interventions.

A qualitative research study of primary care physicians' views of telehealth in delivering postnatal care to women

BACKGROUND

The postpartum period is a critical time for women to optimise their physical and mental health. Primary care physicians (PCP) often manage postpartum women in the community setting after uneventful births. However, women encounter difficulties accessing care before and after their conventional 6-week physical review. Telehealth-based interventional studies have demonstrated their successful applications in several areas of postpartum care but is not widely adopted. The study aimed to explore the PCPs' views on their acceptability and perceived barriers of telehealth in delivering postpartum care to women in primary care.

METHODS

Twenty-nine PCPs participated in eleven in-depth interviews and four focus group discussions for this qualitative study conducted in Singapore. The purposively sampled PCPs had varied demographic background and medical training. Two investigators independently coded the audited transcripts. Thematic content analysis was performed using the codes to identify issues in the pertaining to the perceived usefulness, ease of use and attitudes towards telehealth in postpartum care as described in the "Telehealth Acceptance Model" framework.

RESULTS

Most PCPs perceived usefulness and ease of use of video consultation in delivering postpartum care. They recognised telehealth service to complement and support the current face-to-face postpartum care amidst the pandemic. However, training, leadership support, organizational infrastructure, healthcare financial policy and personal demographic profile influence their acceptance of a new care model for postnatal mothers.

CONCLUSION

Addressing the barriers and strengthening the facilitators will enhance PCPs' acceptance and utilisation of the proposed hybrid (telehealth and in-person) postnatal care model for mothers.

Improving Care for Older Prisoners Living With Dementia in Australian Prisons: Perspectives of External Organizations

BACKGROUND AND OBJECTIVES

The care and well-being of an increasing number of older prisoners living with dementia require an adequate care continuum. Longstanding barriers, including limited resources and relevant expertise, necessitate an interdisciplinary approach and incorporation of external organizations in supporting prisoners with dementia. However, little is known about their perspectives and experiences. This study aimed to explore the role of external organizations in providing care for prisoners with dementia in Australia.

RESEARCH DESIGN AND METHODS

In this qualitative descriptive study, 27 participants from legal, health, and social services rendering services in Australian prisons were recruited. Qualitative data were generated by applying the Nominal Group Technique in research group discussions. Demographic/background data were used to generate descriptive statistics through Qualtrics.

RESULTS

Inductive thematic analysis of qualitative data revealed challenges and opportunities for future dementia care in Australian prisons. Six research discussion groups represented participants from Victoria, Queensland, New South Wales, Western Australia, and Tasmania. Identified themes included (a) possible models of care for prisoners with dementia, (b) uncovering the invisible issues of dementia care in prisons, and (c) proposed next steps for improved care of prisoners with dementia.

DISCUSSION AND IMPLICATIONS

This study provided recommendations for multiple stakeholders to overcome barriers in providing dementia care to prisoners. Increased collaboration between corrective services and external organizations was recommended, with a clear delineation of custodial and care priorities. External organizations highlighted the wider community's responsibility to care for older prisoners and the need to explore emerging areas of practice in this regard.

Implementing post diagnostic dementia care in primary care: a mixed-methods systematic review

OBJECTIVES

Concentrating post-diagnostic dementia care in primary care may lead to better and more cost-effective care closer to home. We aimed to assess which intervention components and contextual factors may contribute to the successful delivery and implementation of primary care-led post-diagnostic dementia care.

METHODS

Mixed-methods systematic review. We searched five databases (inception-March 2019) with reference list screening and citation tracking. We included studies evaluating post-diagnostic dementia care interventions where primary care had a significant role in dementia care, which assessed one or more implementation elements (acceptability, feasibility, adoption, sustainability, reach, costs, appropriateness or fidelity). Two authors independently critically appraised studies.

RESULTS

Out of 4528 unique references, we screened 380 full texts and included 49 evaluations of services collecting implementation process data. Most services had high acceptability ratings. The most acceptable components were information provision, social and emotional support and links to community organisations. Feasibility was chiefly influenced by provider engagement and leadership, building dementia care capacity, sufficient resources/funding and collaboration. Care quality was maximised through adding capacity from a dementia-specific health professional. On the basis of limited data, costs for various primary care-led models did not substantially differ from each other.

CONCLUSION

A range of primary care-led dementia care models appear feasible and acceptable. Future services should: add dementia-focussed health professionals into primary care, develop primary care leadership and provide sufficient funding and collaboration opportunities. Information, community service links and social and ongoing support should be part of services. Further exploration of service reach and formalised fidelity assessment are needed.

Experiences of primary care physicians managing postpartum care: a qualitative research study

BACKGROUND

The postpartum period is redefined as 12 weeks following childbirth. Primary care physicians (PCP) often manage postpartum women in the community after uneventful childbirths. Postpartum care significantly impacts on the maternal and neonatal physical and mental health. However, evidence has revealed unmet needs in postpartum maternal care.

AIM

The study aimed to explore the experiences of PCPs in managing postpartum mothers.

METHODS

Four focus group discussions and eleven in-depth interviews with twenty-nine PCPs were conducted in this qualitative research study in urban Singapore. PCPs of both gender and variable postgraduate training background were purposively enrolled. Audited transcripts were independently coded by two investigators. Thematic content analysis was performed using the codes to identify issues in the "clinician", "mother", "postpartum care" and "healthcare system & policy" domains stipulated in "The Generalists' Wheel of Knowledge, Understanding and Inquiry" framework.

FINDINGS

PCPs' personal attributes such as gender and knowledge influenced their postpartum care delivery. Prior training, child caring experience and access to resource materials contributed to their information mastery of postpartum care. Their professional relationship with local multi-ethic and multi-lingual Asian mothers was impacted by their mutual communication, language compatibility and understanding of local confinement practices. Consultation time constraint, awareness of community postnatal services and inadequate handover of care from the specialists hindered PCPs in the healthcare system.

DISCUSSION

Personal, maternal and healthcare system barriers currently prevent PCPs from delivering optimal postpartum care.

CONCLUSION

Interventions to overcome the barriers to improve postpartum care will likely be multi-faceted across domains discussed.

Elements and Performance Indicators of Integrated Healthcare Programmes on Chronic Diseases in Six Countries in the Asia-Pacific Region: A Scoping Review

Background and Aims:

Globally, hospital-based healthcare models targeting acute care, are not effective in addressing chronic conditions. Integrated care programmes for chronic diseases have been widely developed and implemented in Europe and North America and to a much lesser extent in the Asia-Pacific region to meet such challenges. We completed a scoping review aiming to examine the elements of programmes identified in the literature from select study countries in the Asia-Pacific, and discuss important facilitators and barriers for design and implementation.

Methods:

The study design adopted a scoping review approach. Integrated care programmes in the study countries were searched in electronic databases using a developed search strategy and key words. Elements of care integration, barriers and facilitators were identified and charted following the Chronic Care Model (CCM).

Results:

Overall the study found a total of 87 integrated care programmes for chronic diseases in all countries, with 44 in China, 21 in Singapore, 12 in India, 5 in Vietnam, 4 in the Philippines and 1 in Fiji. Financial incentives were found to play a crucial role in facilitating integrated care and ensuring the sustainability of programmes. In many cases, the performance of programmes was found not to have been adequately assessed.

Conclusion:

Integrated care is important for addressing the challenges surrounding the delivery of long-term care and there is an increasing trend of integrated care programmes for chronic diseases in the Asia-Pacific. Evaluating the performance of integrated care programmes is crucial for developing strategies for implementing future programmes and improving already existing programmes.

Effectiveness of different post-diagnostic dementia care models delivered by primary care: a systematic review

BACKGROUND

Global policy recommendations suggest a task-shifted model of post-diagnostic dementia care, moving towards primary and community-based care. It is unclear how this may best be delivered.

AIM

To assess the effectiveness and cost-effectiveness of primary care-based models of post-diagnostic dementia care.

DESIGN AND SETTING

A systematic review of trials and economic evaluations of post-diagnostic dementia care interventions where primary care was substantially involved in care plan decision making.

METHOD

Searches were undertaken of MEDLINE, PsychINFO, EMBASE, Web of Science, and CINAHL (from inception to March 2019). Two authors independently critically appraised studies and inductively classified interventions into types of care models. Random effects meta-analysis or narrative synthesis was conducted for each model where appropriate.

RESULTS

From 4506 unique references and 357 full texts, 23 papers were included from 10 trials of nine interventions, delivered in four countries. Four types of care models were identified. Primary care provider (PCP)-led care (n = 1) led to better caregiver mental health and reduced hospital and memory clinic costs compared with memory clinics. PCP-led care with specialist consulting support (n = 2) did not have additional effects on clinical outcomes or costs over usual primary care. PCP-case management partnership models (n = 6) offered the most promise, with impact on neuropsychiatric symptoms, caregiver burden, distress and mastery, and healthcare costs. Integrated primary care memory clinics (n = 1) had limited evidence for improved quality of life and cost-effectiveness compared with memory clinics.

CONCLUSION

Partnership models may impact on some clinical outcomes and healthcare costs. More rigorous evaluation of promising primary care-led care models is needed.

Commissioning social care for people with dementia living at home: Findings from a national survey

OBJECTIVE

To explore the complexities, circumstances, and range of services commissioned for people with dementia living at home.

METHODS

A national survey was used to collect data from English local authorities in 2015. Commissioners of services for older adults were invited to complete a questionnaire. An exploratory cluster analysis of nominal data was conducted using a TwoStep procedure to identify distinct groups.

RESULTS

A total of 122 authorities (83%) responded to the request. Four approaches to commissioning were identified, reflecting commissioning practices at the organisational, strategic, and individual service user levels. Commissioning at the service user level was most apparent. Bivariate analysis found that these configurations were not associated with the types of dementia specific services provided but were related to the number available. Authorities delivered a greater range of specialist services when joint commissioning between social care and health partners was undertaken. However, the joint commissioning of services was less observed in services specifically for people with dementia than in generic services for all older people. There was limited evidence that local circumstances (population configuration and deprivation levels) were associated with this approach to commissioning.

CONCLUSIONS

The significant role of health partners in the delivery of social care services to support older people living with dementia in their own homes is evident. As the population with dementia ages and physical health needs increase, how dementia specific services differ from and complement those services available to all older people warrants further investigation.

Family and Caregiver Spillover Effects in Cost-Utility Analyses of Alzheimer's Disease Interventions

BACKGROUND AND OBJECTIVE

Alzheimer's disease or dementia can impose a significant burden on family and other informal caregivers. This study investigated how the inclusion of family/informal caregiver spillover effects in a cost-utility analysis may influence the reported value of Alzheimer's disease/dementia interventions.

METHODS

We used PubMed to identify Alzheimer's disease or dementia cost-utility analyses published from 1 January, 2000 to 31 March, 2018. We reviewed and abstracted information from each study using a two-reader consensus process. We investigated the frequency and methods in which family/caregiver spillover costs and health effects were incorporated into cost-utility analyses, and examined how their inclusion may influence the reported incremental cost-effectiveness ratios.

RESULTS

Of 63 Alzheimer's disease/dementia cost-utility analyses meeting inclusion criteria, 44 (70%) considered at least some family/caregiver spillover costs or health effects. Thirty-two studies incorporated spillover costs only, two incorporated spillover health effects only, and ten incorporated both. The most common approach for accounting for spillover was adding informal caregiving time costs to patient costs (n = 36) and adding informal caregiver quality-adjusted life-years to patient values (n = 7). In a subset of 33 incremental cost-effectiveness ratio pairs from 19 studies, incorporating spillover outcomes made incremental cost-effectiveness ratios more favorable (n = 15; 45%) or kept the intervention cost saving (n = 13; 39%) in most cases. In fewer cases, including spillover increased incremental cost-effectiveness ratios (n = 2; 6%), kept the intervention dominated [more costs/less quality-adjusted life-years] (n = 2; 6%), or changed incremental cost-effectiveness ratio from dominated to less cost/less quality-adjusted life-years (n = 1; 3%). In 11 cases (33%), adding spillover effects into analyses resulted in a lower incremental cost-effectiveness ratio that crossed a common cost-effectiveness threshold, which could have downstream implications for programs or policies that are adopted based on cost-effectiveness analysis results.

DISCUSSION

Most Alzheimer's disease/dementia cost-utility analyses incorporated spillover costs, often as caregiver time costs, but considered spillover health impacts less often. In about 85% of the analyses, including Alzheimer's disease/dementia spillover cost or health effects decreased incremental cost-effectiveness ratios or kept the intervention cost saving. The broader value of an Alzheimer's disease/dementia intervention to society may in some cases be underestimated without considering these spillover effects on family and informal caregivers.

Integrated health care systems in Asia: an urgent necessity

A rapidly aging population along with the increasing burden of patients with chronic conditions in Asia requires efficient health systems with integrated care. Although some efforts to integrate primary care and hospital care in Asia are underway, overall care delivery remains fragmented and diverse, eg, in terms of medical electronic record sharing and availability, patient registries, and empowerment of primary health care providers to handle chronic illnesses. The primary care sector requires more robust and effective initiatives targeted at specific diseases, particularly chronic conditions such as diabetes, hypertension, depression, and dementia. This can be achieved through integrated care - a health care model of collaborative care provision. For successful implementation of integrated care policy, key stakeholders need a thorough understanding of the high-risk patient population and relevant resources to tackle the imminent population demographic shift due to the extremely rapid rate of increase in the aging population in Asia.

Integrated care for adults with dementia and other cognitive disorders

The importance of better care integration is emphasized in many national dementia plans. The inherent complexity of organizing care for people with dementia provides both the justification for improving care integration and the challenges to achieving it. The prevention, detection, and early diagnosis of cognitive disorders mainly resides in primary care, but how this is best integrated within the range of disorders that primary care clinicians are expected to screen is unclear. Models of integrated community dementia assessment and management have varying degrees of involvement of primary and specialist care, but share an emphasis on improving care coordination, interdisciplinary teamwork, and personalized care. Integrated care strategies in acute care are still in early development, but have been a focus of investigation in the past decade. Integrated care outreach strategies to reduce transfers from long-term residential care to acute care have been consistently effective. Integrated long-term residential care includes considerations of end-of-life care. Future directions should include strategies for training and education, early detection in anticipation of disease modifying treatments, integration of technological developments into dementia care, integration of dementia care into general health and social care, and the encouragement of a dementia-friendly society.