Barbara G. Vickrey, MD, MPH; Brian S. Mittman, PhD; Karen I. Connor, RN, MBA; Marjorie L. Pearson, PhD; Richard D. Della Penna, MD; Theodore G. Ganiats, MD; Robert W. DeMonte, MD; Joshua Chodosh, MD, MSHS; Xinping Cui, PhD; Stefanie Vassar, MS; Naihua Duan, PhD; Martin Lee, PhD
Acknowledgments: The authors thank Kenneth Wells, MD, MPH, for feedback on drafts of the manuscript. They also thank leaders from the community agency partners, Lorie Van Tilburg, Roger Bailey, and Tom Pamilla, and caregiver community representatives Margo Fox Picou and Thomas L. Gillette for collaboration and support. They also acknowledge the collaboration and contributions of clinical and support staff and providers at all participating study sites: Kaiser Permanente San Diego, Scripps Clinic, University of California, San Diego HealthCare, Alzheimer's Association–San Diego Chapter, Meals on Wheels–Greater San Diego, and Southern Caregiver Resource Center.
Grant Support: This study was supported by the California HealthCare Foundation (99-3020), the State of California, Department of Aging (IG-0001-22), the State of California, Department of Health Services, Alzheimer's Disease Education Initiative (00-91316), and the Archstone Foundation (00-04-37), as well as the State of California, Department of Health Services (contract 013608-001) for the University of California, Los Angeles Alzheimer's Disease Research Center.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Barbara G. Vickrey, MD, MPH, Department of Neurology, University of California, Los Angeles, C-109 RNRC, Box 951769, Los Angeles, CA 90095-1769; e-mail, email@example.com.
Current Author Addresses: Dr. Vickrey, Ms. Connor, and Ms. Vassar: Department of Neurology, University of California, Los Angeles, C-109 RNRC, Box 951769, Los Angeles, CA 90095-1769.
Drs. Mittman and Lee: VA HSR&D Field Program, VA Medical Center (152), 16111 Plummer Street, Sepulveda, CA 91343-2036.
Dr. Pearson: RAND Corporation, 1776 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138.
Dr. Della Penna: Kaiser Permanente's Aging Network, 10990 San Diego Mission Road, San Diego, CA 92108.
Dr. Ganiats: University of California, San Diego, Stein Clinical Research Building, Room 240, 9500 Gilman Drive, Mail Code 0268, La Jolla, CA 92093-0622.
Dr. DeMonte: Division of Gerontology, Scripps Clinic, 10666 North Torrey Pines Road, Maildrop 201N, La Jolla, CA 92037.
Dr. Chodosh: Department of Medicine, Division of Geriatrics, University of California, Los Angeles, 10945 Le Conte Avenue, Suite 2339, Los Angeles, CA 90095-1687.
Dr. Cui: Department of Statistics, StatComp 2642, University of California, Riverside, Riverside, CA 92521-0138.
Dr. Duan: Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Box 957082, UCLA Wilshire Center, Suite 300, Los Angeles, CA 90095-7082.
Author Contributions: Conception and design: B.G. Vickrey, B.S. Mittman, K.I. Connor, M.L. Pearson, R.D. Della Penna, T.G. Ganiats, R.W. DeMonte, J. Chodosh.
Analysis and interpretation of the data: B.G. Vickrey, B.S. Mittman, K.I. Connor, M.L. Pearson, T.G. Ganiats, R.W. DeMonte, J. Chodosh, X. Cui, S. Vassar, M. Lee.
Drafting of the article: B.G. Vickrey, B.S. Mittman, M. Lee.
Critical revision of the article for important intellectual content: B.G. Vickrey, B.S. Mittman, K.I. Connor, M.L. Pearson, T.G. Ganiats, J. Chodosh, N. Duan.
Final approval of the article: B.G. Vickrey, B.S. Mittman, K.I. Connor, M.L. Pearson, R.D. Della Penna, T.G. Ganiats, R.W. DeMonte, J. Chodosh, X. Cui, S. Vassar, N. Duan, M. Lee.
Provision of study materials or patients: R.W. DeMonte.
Statistical expertise: X. Cui, N. Duan, M. Lee.
Obtaining of funding: B.G. Vickrey, B.S. Mittman.
Administrative, technical, or logistic support: B.G. Vickrey, K.I. Connor, R.D. Della Penna, T.G. Ganiats, R.W. DeMonte, J. Chodosh.
Collection and assembly of data: B.G. Vickrey, K.I. Connor, R.W. DeMonte, X. Cui, S. Vassar.
Vickrey B., Mittman B., Connor K., Pearson M., Della Penna R., Ganiats T., DeMonte R., Chodosh J., Cui X., Vassar S., Duan N., Lee M.; The Effect of a Disease Management Intervention on Quality and Outcomes of Dementia Care: A Randomized, Controlled Trial. Ann Intern Med. 2006;145:713-726. doi: 10.7326/0003-4819-145-10-200611210-00004
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Published: Ann Intern Med. 2006;145(10):713-726.
Dementia has enormous health and financial consequences for affected individuals, their family caregivers, and society (1-5). Although most dementia is currently neither preventable nor reversible, existing practice guidelines reflect evidence from randomized, controlled trials that caregiver assistance and support can delay institutionalization (6-8), and nonpharmacologic management of problem behaviors and depression can reduce symptom severity and improve patient health (9-10). Yet, adherence to published dementia care guidelines (11-14) is poor (15), including inappropriate use of psychoactive medications for initial management of agitation (16); low referral rates to community agencies (17-18); and underdetection of elder abuse, for which cognitive impairment is a risk factor (19), and of depression (20), a common comorbid condition (21).
Syracuse VA Medical center
December 13, 2006
To The Editor: Vickrey and colleagues (1) highlight the substantial difference in the adherence to dementia guideline-based diseased management in the intervention group due to care managers which in this study were social workers. However, they failed to mention the difference the physicians' role may have played in it. As outlined by Vickrey and colleagues, providers in the intervention group had better knowledge of assessing the patient's decision making capacity and a greater perception of the difficulty of dementia care management than those in the usual care group. These physicians who had greater perception in dementia management may have adhered more to the guidelines of dementia management as compared to their counter parts in the usual group. Furthermore, these physicians may have provided more education to the care givers about the natural course of dementia and what to anticipate and how to handle issues that may arise, and also encouraged and make early referral to the community agency resulting in higher utilization of services from community agency and utilization of services like respite and day care. Improvement in care giver outcome may also be related to higher social support in the intervention group as compared to the usual care group. Also the usual group patients had higher mean dementia severity score as well as mean duration of symptoms of dementia, both of which may adversely impact care giver stress and outcome. Dementia care management is an interdisciplinary team care approach, and emphasis on only one of its component "“care manager- may not achieve meaningful improvements in the quality of care for dementia care management.
1. Vickrey BG, Mittman BS, Connor KI, et al. The Effect of a Disease Management Intervention on Quality and Outcomes of Dementia Care. Ann Intern Med.2006; 713-26.
Barbara G. Vickrey
January 15, 2007
We thank Dr. Iraqi for his letter and welcome the opportunity to provide clarification. We conceptualized dementia care management as a re -engineering of traditional, physician visit-centered care ("usual care"). To create a new care model, we assembled a stakeholder group of physician champions from each participating healthcare organization and community agency leaders, who established common dementia care goals and designed protocols for achieving them. The group judged incorporation of dementia care managers as key for implementing care protocols, viewing many desired care management activities as better suited to providers with social work or nursing background. Care manager- designated tasks according to these protocols included not only actions to directly improve quality (for example, home safety evaluation), but also tasks to increase the likelihood that other providers would meet certain care quality goals, like referring a patient to his/her physician for formal decision-making capacity assessment and informing the physician of the patient's unmet care need. Our model's ultimate aim was to increase the likelihood that dementia care goals were achieved, irrespective of who actually executed the activity, anticipating that some goals would require interactions across physicians, care managers, and patient/caregiver dyads, while an individual (i.e., physician or care manager) could complete others.
This quality improvement intervention involved several components, including physician education on selected aspects of dementia care, deployment of trained care managers, and implementation of information systems to facilitate communication and referral. A near-universal question on finding that any multi-faceted intervention is effective is "Why?" Disentangling effects of different intervention components must be explored with caution (unless components were separately tested in different randomization arms). Nine months after the intervention began, we found that intervention and usual care physicians differed on two knowledge/attitude variables, as Dr. Iraqi notes. However, differences were modest, and the groups did not differ on 8 other knowledge/attitude measures(1). Thus, while we agree it is likely that some physicians modified their behavior in response to the intervention, existing literature(2), the nature of many of the care management activities, and our finding of few differences in knowledge/attitudes across intervention and usual care providers suggest that the broad, large effects on dementia care quality we observed are unlikely to be attributable primarily to changes in physician practices.
We previously reported and here reaffirm that intervention and usual care groups did not differ at baseline on dementia severity, dementia symptom duration, or caregiver social support (p-values=0.10, 0.25, and 0.58, respectively).
1. Chodosh J, Berry E, Connor K, DeMonte R, Ganiats T, Rubenstein L, Heikoff L, Vassar S, Vickrey BG. A quality of care intervention for dementia: Impact on provider knowledge, attitudes, and perceptions of dementia care quality. Journal of the American Geriatrics Society 2006;54:311-317.
2. Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor- Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? Journal of the American Medical Association 1999;282:867-74.
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