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Rapid Responses to:
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Electronic letters published:
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In Response
Response
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Barbara G. Vickrey, MD, MPH UCLA, Brian S. Mittman and Joshua Chodosh
Send rapid response to journal:
bvickrey{at}ucla.edu Barbara G. Vickrey, et al.
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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. Conflict of Interest:None declared |
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Abid Iraqi, MD Syracuse VA Medical center
Send rapid response to journal:
abid.iraqi{at}va.gov Abid Iraqi
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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. References 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. Conflict of Interest:None declared |
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