The Effect of a Disease Management Intervention on Quality and Outcomes of Dementia Care

A Randomized, Controlled Trial

  1. Barbara G. Vickrey, MD, MPH;
  2. Brian S. Mittman, PhD;
  3. Karen I. Connor, RN, MBA;
  4. Marjorie L. Pearson, PhD;
  5. Richard D. Della Penna, MD;
  6. Theodore G. Ganiats, MD;
  7. Robert W. DeMonte, Jr., MD;
  8. Joshua Chodosh, MD, MSHS;
  9. Xinping Cui, PhD;
  10. Stefanie Vassar, MS;
  11. Naihua Duan, PhD; and
  12. Martin Lee, PhD
  1. From University of California, Los Angeles, VA Greater Los Angeles Healthcare System, Los Angeles, California; RAND Corporation, Santa Monica, California; Kaiser Permanente Federation and University of California, San Diego, San Diego, California; University of California, Riverside, Riverside, California; and Scripps Clinic, La Jolla, California.

    Abstract

    Background: Adherence to dementia guidelines is poor despite evidence that some guideline recommendations can improve symptoms and delay institutionalization of patients.

    Objective: To test the effectiveness of a dementia guideline–based disease management program on quality of care and outcomes for patients with dementia.

    Design: Clinic-level, cluster randomized, controlled trial.

    Setting: 3 health care organizations collaborating with 3 community agencies in southern California.

    Participants: 18 primary care clinics and 408 patients with dementia age 65 years or older paired with 408 informal caregivers.

    Intervention: Disease management program led by care managers and provided to 238 patient–caregiver pairs at 9 intervention clinics for more than 12 months.

    Measurements: Adherence to 23 guideline recommendations (primary outcome) and receipt of community resources and patient and caregiver health and quality-of-care measures (secondary outcomes).

    Results: The mean percentage of per-patient guideline recommendations to which care was adherent was significantly higher in the intervention group than in the usual care group (63.9% vs. 32.9%, respectively; adjusted difference, 30.1% [95% CI, 25.2% to 34.9%]; P < 0.001). Participants who received the intervention had higher care quality on 21 of 23 guidelines (P ≤ 0.013 for all), and higher proportions received community agency assistance (P ≤ 0.03) than those who received usual care. Patient health-related quality of life, overall quality of patient care, caregiving quality, social support, and level of unmet caregiving assistance needs were better for participants in the intervention group than for those in the usual care group (P < 0.05 for all). Caregiver health-related quality of life did not differ between the 2 groups.

    Limitations: Participants were well-educated, were predominantly white, had a usual source of care, and were not institutionalized. Generalizability to other patients and geographic regions is unknown. Also, costs of a care management program under fee-for-service reimbursement may impede adoption.

    Conclusions: A dementia guideline–based disease management program led to substantial improvements in quality of care for patients with dementia.

    Current Controlled Trials identifier: ISRCTN72577751.

    Article and Author Information

    • 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, bvickrey{at}ucla.edu.

    • 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.

    Responses to this article

    • In Response
      • Barbara G. Vickrey and
      • Brian S. Mittman and Joshua Chodosh
      Ann Intern Med published online October 26, 2009
    • Response
      • Abid Iraqi
      Ann Intern Med published online October 26, 2009

    Summary for Patients

    • Summaries for Patients:Can a Coordinated System of Care Improve the Quality of Care for People With Dementia? Ann Intern Med November 21, 2006 145:I-31
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