Geriatric assessment with management for older patients with cancer receiving radiotherapy: a cluster-randomised controlled pilot study.

BACKGROUND: Geriatric assessment and management (GAM) improve outcomes in older patients with cancer treated with surgery or chemotherapy. It is unclear whether GAM may provide better function and quality of life (QoL), or be cost-effective, in a radiotherapy (RT) setting. METHODS: In this Norwegian cluster-randomised controlled pilot study, we assessed the impact of a GAM intervention involving specialist and primary health services. It was initiated in-hospital at the start of RT by assessing somatic and mental health, function, and social situation, followed by individually adapted management plans and systematic follow-up in the municipalities until 8 weeks after the end of RT, managed by municipal nurses as patients' care coordinators. Thirty-two municipal/city districts were 1:1 randomised to intervention or conventional care. Patients with cancer ≥ 65 years, referred for RT, were enrolled irrespective of cancer type, treatment intent, and frailty status, and followed the allocation of their residential district. The primary outcome was physical function measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (QLQ-C30). Secondary outcomes were overall quality of life (QoL), physical performance, use and costs of health services. Analyses followed the intention-to-treat principle. Study registration at ClinicalTrials.gov ID NCT03881137. RESULTS: We included 178 patients, 89 in each group with comparable age (mean 74.1), sex (female 38.2%), and Edmonton Frail Scale scores (mean 3.4 [scale 0-17], scores 0-3 [fit] in 57%). More intervention patients received curative RT (76.4 vs 61.8%), had higher irradiation doses (mean 54.1 vs 45.5 Gy), and longer lasting RT (mean 4.4 vs 3.6 weeks). The primary outcome was completed by 91% (intervention) vs 88% (control) of patients. No significant differences between groups on predefined outcomes were observed. GAM costs represented 3% of health service costs for the intervention group during the study period. CONCLUSIONS: In this heterogeneous cohort of older patients receiving RT, the majority was fit. We found no impact of the intervention on patient-centred outcomes or the cost of health services. Targeting a more homogeneous group of only pre-frail and frail patients is strongly recommended in future studies needed to clarify the role and organisation of GAM in RT settings.

Mortality in nursing home residents stratified according to subtype of dementia: a longitudinal study over three years.

BACKGROUND: There are several subtypes of dementia caused by different pathophysiology and with different clinical characteristics. Irrespective subtype, the disease is progressive, eventually leading to the need for care and supervision on a 24/7 basis, often provided in nursing homes (NH). The progression rate and course of the disease might vary according to subtype. The aim of this study was to explore whether the mortality rate for NH residents varied according to the subtype of dementia. METHODS: NH residents were followed from admission to NH over a period of 36 months or until death with annual follow-up examinations. Demographic and clinical data were collected. The diagnosis of dementia and its subtype at baseline (BL) were set according to international accepted criteria. Kaplan-Meier analysis was performed to estimate median survival time. A Cox regression model was estimated to assess the impact of dementia diagnosis and demographic and clinical variables on mortality. RESULTS: A total of 1349 participants were included. When compared to persons with Alzheimer's disease (AD), persons with frontotemporal dementia (FTD) and dementia with Lewy bodies or Parkinson's disease dementia (DLB/PDD) were younger and had more neuropsychiatric symptoms. Median survival for the total sample was 2.3 years (95% confidence interval: 2.2-2.5). When compared to persons with AD, having no dementia or unspecified dementia was associated with higher mortality, while we found similar mortality in other subtypes of dementia. Higher age, male gender, poorer general health, higher dependency in activities of daily living, and more affective symptoms were associated with higher mortality. CONCLUSION: Mortality did not differ across the subtypes of dementia, except in persons with unspecified dementia or without dementia, where we found a higher mortality. With a median survival of 2.3 years, NH residents are in the last stage of their lives and care and medical follow-up should focus on a palliative approach. However, identifying the subtype of dementia might help carers to better understand and address neuropsychiatric symptoms and to customize medical treatment.

Cause and place of death in Norwegian nursing home residents.

BACKGROUND: Nursing home (NH) residents are in their last phase of life, and two aims of the NH's medical care in Norway is to prevent unnecessary hospital admissions that would not benefit the resident and to facilitate a peaceful death in familiar surroundings when the time comes. However, little is known about the share of residents dying in NHs and the causes of death. We therefore evaluated the cause and place of death in a cohort of NH residents followed from the time of NH admission until death. METHODS: NH residents were followed from admission to the NH and over the entire course of their NH stay. Demographic and clinical data were collected. Cause and place of death were retrieved from the Norwegian Cause of Death Registry. RESULTS: Of 1283 residents, 6.2% died in hospital and 91.2% in a NH. Those who died in hospitals were more often male, died sooner after NH admission, had a less severe degree of dementia and had poorer general health. Dementia was the most common underlying cause of death, followed by cardiovascular disease. CONCLUSIONS: Dementia is one of the main causes of death in NH residents. In addition, our findings indicate a low number of inappropriate referrals to hospital during the last stage of life. However, further research should explore whether the terminal phase of NH residents is formed in accordance with their preferences and whether appropriate palliative care is offered.

The impact of introducing ambulance and delivery fees in a rural hospital in Tanzania.

BACKGROUND: Access to health care facilities is a key requirement to enhance safety for mothers and newborns during labour and delivery. Haydom Lutheran Hospital (HLH) is a regional hospital in rural Tanzania with a catchment area of about two million inhabitants. Up to June 2013 ambulance transport and delivery at HLH were free of charge, while a user fee for both services was introduced from January 2014. We aimed to explore the impact of introducing user fees on the population of women giving birth at HLH in order to document potentially unwanted consequences in the period after introduction of fees. METHODS: Retrospective analysis of data from a prospective observational study. Data was compared between the period before introduction of fees from February 2010 through June 2013 and the period after from January 2014 through January 2017. Logistic regression modelling was used to construct risk-adjusted variable-life adjusted display (VLAD) and cumulative sum (CUSUM) plots to monitor changes. RESULTS: A total of 28,601 births were observed. The monthly number of births was reduced by 17.3% during the post-introduction period. Spontaneous vaginal deliveries were registered less frequently with a decrease of about 17/1000 births in non-cephalic presentations. Labour complications and caesarean sections increased with about 80/1000 births. There was a reduction in newborns with birth weight less than 2500 g. The observed changes were stable over time. For most variables, a significant change could be detected after a few weeks. CONCLUSION: After the introduction of ambulance and delivery fees, an increase in labour complications and caesarean sections and a decrease in newborns with low birthweight were observed. This might indicate that women delay the decision to seek skilled birth attendance or do not seek help at all, possibly due to financial reasons. Lower rates of births in a safe health care facility like HLH is of great concern, as access to skilled birth attendance is a key requirement in order to further reduce perinatal mortality. Therefore, free delivery care should be a high priority.

Informal and formal care among persons with dementia immediately before nursing home admission.

BACKGROUND: Dementia is a care intensive disease, especially in the later stages, implying in many cases a substantial carer burden. This study assesses the use of formal and informal care resources among persons with dementia during the last month before nursing home admission. It also describes main providers of informal care and assesses the extent of informal care rendered by the extended social network. METHODS: In this cross-sectional study, we collected data about persons with dementia that were newly admitted to a nursing home in Norway. Information about the amount of formal and informal care during the last 4 weeks preceding nursing home admission was collected from the primary caregivers. Clinical data were collected by examining the patients, while sociodemographic data was collected from the patients' files. RESULTS: A total of 395 persons with dementia were included. The amount of informal care provided by the family caregiver was 141.9 h per month SD = 227.4. Co-resident patients received five times more informal care than non-co-residents. Informal care from the extended social network was provided to 212 patients (53.7%) with a mean of 5.6 (SD = 11.2) hours per month and represented 3.8% of the total informal care rendered to the patients. Formal care was provided to 52.7% of the patients with a mean of 18.0 (SD = 50.1) hours per month. Co-residency was significantly associated with more informal care, and the associations varied with respect to age, relation to the caregiver, and the caregiver's working situation. Good/excellent general health was associated with less formal care. CONCLUSION: Persons with dementia on the verge of admission to a nursing home are mainly supported by the family caregiver, and the use of informal care is particularly high among co-residents. In order to delay nursing home admission, future research should explore the unrealized care potential in extended social networks, as well as the potential for increasing the number of recipients of formal care services.

The use of direct care in nursing home residents: A longitudinal cohort study over 3 years.

OBJECTIVES: To evaluate the trend in the use of direct care in a cohort of nursing home (NH) residents and explore its association with resident characteristics and organizational factors. METHODS/DESIGN: A total of 696 NH residents from 47 Norwegian NHs were included at admissions at NH. In 537 residents, the use of direct care was assessed every 6 months over a course of 3 years. A multiple model was estimated to identify demographic, clinical, and organizational characteristics associated with the use of direct care time. RESULTS: Six months after admission, on average, 76.2 hours of direct care were rendered to each resident per month, while this number was reduced to 50.3 hours per month at the end of the study period. Most residents (92%) showed a stable use of direct care time, while a small group of residents displayed a much higher and varying use of direct care time. Increasing dementia, neuropsychiatric symptoms, and decreasing function in activities of daily living were associated with higher use of direct care time. Direct care time constituted about 50% of the staff's working time. CONCLUSION: In Norwegian NHs, high use of direct care time was associated with younger age, more severe dementia, and severe neuropsychiatric symptoms. By identifying factors that impact on direct care time, preventive measures might be put in place to the benefit of the residents and possibly to improve resource use. Further research should explore the association between direct care time, quality of care, and the residents' quality of life.

The use and costs of formal care in newly diagnosed dementia: a three-year prospective follow-up study.

OBJECTIVE: To investigate the use of formal care during the first three years after diagnosis of mild dementia and identify cost-predicting factors. DESIGN: Prospective longitudinal study over three years. SETTING: An incidence-based bottom-up cost-of-illness study where information about formal health care services was drawn from the municipalities' registers during the first three years after the diagnosis of mild dementia. PARTICIPANTS: 109 patients with mild dementia at baseline, diagnosed according to consensus criteria based on standardized assessments. MEASUREMENT: The use of formal care as registered by the municipalities' registration systems. Costs were estimated by applying unit costs, including municipal expenses and out-of-pocket contributions. Clinical data were collected at baseline to identify cost-predicting factors. RESULTS: Costs for formal care were increasing from € 535 per month of survival (MOS) at baseline to € 3,611 per MOS during the third year, with a mean of € 2,420 during the whole observation period. The major cost driver (74%) was institutional care. The costs for people with dementia with Lewy bodies (€ 3,247 per MOS) were significantly higher than for people with Alzheimer disease (€ 1,855 per MOS). The most important cost-predicting factors we identified were the living situation, a diagnosis of non-Alzheimer disease, comorbidity, and daily living functioning. The use of cholinesterase inhibitors was related to lower costs. CONCLUSION: Formal care costs increased significantly over time with institutional care being the heaviest cost driver. Studies with longer observation periods will be necessary to evaluate the complete socioeconomic impact of the course of dementia.

Long-term mortality in a cohort of home-dwelling elderly with mild Alzheimer's disease and Lewy body dementia.

OBJECTIVE: To study mortality in subjects with mild dementia in Norway with a special focus on patients with Lewy body dementia (LBD) compared to Alzheimer's disease (AD). METHODS: All referrals of mild dementia patients to dementia clinics in western Norway from March 2005 to March 2007 were included and followed until December 2012. Diagnoses were based on a comprehensive standardized assessment program. RESULTS: Of 209 patients, 137 (66%) had AD and 53 (25%) had LBD. Dementia was associated with increased mortality (standardized mortality ratio = 1.8, AD 1.5, LBD 2.6). The median survival time was 6.2 years (95% CI 5.4-6.9). Predictors of mortality were age at diagnosis (HR 1.1 per year) and LBD diagnosis (HR 2.4). CONCLUSION: Dementia patients had an increased mortality, particularly those with LBD.

Time until nursing home admission in people with mild dementia: comparison of dementia with Lewy bodies and Alzheimer's dementia.

OBJECTIVE: We studied time until nursing home admission (NHA) in mild dementia and predictors for NHA in people with Dementia with Lewy bodies (DLB) and how it compares to Alzheimer's dementia (AD). METHODS: Kaplan-Meier survival analysis and Cox proportional hazards were applied. RESULTS: Median time until NHA was 1114 days (95% confidence interval [CI] [932, 1296]). In DLB median time until NHA was 663 days [472, 998]) as compared with 1336 days (1068, 1606) in AD, p < 0.0005. Predictors of shorter time to NHA in the DLB and AD groups in unadjusted analyses were a DLB diagnosis, the use of antipsychotic medication, more advanced age, longer duration of dementia symptoms prior to diagnosis, living alone, higher reported caregiver distress, and more neuropsychiatric symptoms. The use of cholinesterase inhibitors was associated with halved risk of NHA in the combined DLB/AD group in the unadjusted Cox regression. In adjusted Cox regression in the DLB group, we found the use of cholinesterase inhibitors to be associated with reduced risk of NHA (HR = 0.24) and the use of antipsychotic medication to be associated with increased risk of NHA (HR = 37) during the study period. CONCLUSION: Patients diagnosed with DLB had nearly 2 years shorter time to NHA than those diagnosed with AD. In the DLB group, the use of cholinesterase inhibitors was associated with reduced and the use of antipsychotics with increased risk of NHA. Future studies should explore whether better identification and management of the variety of clinical problems in patients diagnosed with DLB can delay NHA.

Referrals from nursing home to hospital: reasons, appropriateness and costs.

BACKGROUND: Nursing home residents represent a frail and multimorbid group of patients. The rationality of the hospitalisation of nursing home patients has therefore been questioned. OBJECTIVE: To investigate hospital referrals of nursing home patients in the municipality of Stavanger, Norway and identify the number of inappropriate referrals and costs. METHODS: The number of referrals was retrospectively identified by the emergency dispatch centre in the 18 municipalities of South Rogaland in 2011. For the municipality of Stavanger, referring instance, reason for referral, purpose of referral, the existence of an advance care plan, and appropriateness were assessed. Total costs and costs for inappropriate referrals were estimated. RESULTS: In Stavanger there were 0.38 hospital referrals per nursing home bed per year as compared to 0.60 in the surrounding municipalities. Of 359 referrals, 78.6% resulted in an in-hospital stay, in-hospital mortality rate was 7.8%, and 7% were assessed as being inappropriate. The costs per referral were estimated to be €6198. CONCLUSION: Stavanger had a lower referral rate than the surrounding municipalities. The results also show that the in-hospital mortality rate and the share of inappropriate referrals were low compared to other studies in the field. Further research is needed in order to evaluate which interventions are effective in improving medical care at nursing homes and thus reduce referral rates.

The use and costs of health and social services in patients with longstanding substance abuse.

BACKGROUND: Persons with longstanding substance abuse might become increasingly dependent on help by the public, eventually requiring permanent care. In 2006 the municipality of Stavanger established a so-called addiction ward for these clients, comprising 17 beds at the largest municipal nursing home. We assumed that the residents of this ward were high consumers of health care and social services during the last months preceding their admission. The aim of the study was to register the type and extent of services that were claimed by this client group during the last six months prior to admission, and to calculate the costs that were caused. Further, we estimated the incremental costs for nursing home placement. METHODS: In 15 residents from the addiction ward the use of all welfare services during the six months prior to admission were registered. Costs were calculated by unit costs from a municipal, national and societal perspective. RESULTS: Mean total costs during this period were €32 474. Approximately half of these costs were borne by state-funded institutions, and half were borne by the municipality. The clients used a great variety of services aimed at subsistence, health care and support in independent living, while services aimed at drug withdrawal were not claimed. There was no correlation between costs and the level of functioning. The incremental costs for nursing home admission were borne by the municipalities. CONCLUSION: Persons with longstanding substance abuse represent a group with a high use of welfare resources and hence cause high costs. However, our findings do not indicate any correlation between the amount of services rendered and the level of functioning. Further research should focus on the identification of the clients' need for support in order to facilitate targeted interventions that might prevent further deterioration and, finally, the need for permanent care.

Body mass index in nursing home residents during the first year after admission.

BACKGROUND: Malnutrition - comprising both undernutrition and overweight - has to be addressed in the medical follow-up of older adults due to the negative consequences for the functional state and general health. Still, little is known about the nutritional state of nursing home (NH) residents, especially with respect to weight gain or weight loss after NH admission. Therefore, this study aims to evaluate changes in the body mass index (BMI) during the first year following NH admission, and to explore demographic and clinical characteristics related to BMI changes. METHODS: Data from two prospective studies that recruited participants at NH admission were combined. Demographic and clinical characteristics including the BMI were assessed at baseline and after one year. A linear regression model was estimated to explore the impact of demographic and clinical characteristics on the change in BMI. RESULTS: The study cohort consisted of 1,044 participants with a mean age of 84.3 years (SD7.6) at baseline; 64.2% were female. At baseline, 33% of the NH residents had severe to moderate undernutrition, while 10% were obese. During the first year of their NH stay, residents with severe to moderate undernutrition had an average increase in BMI of 1.3 kg/m2 (SD 2.2; p < 0.001), while weight changes were either very small or not significant in the other BMI groups. Characteristics related to weight gain were younger age and less agitation. CONCLUSION: Malnutrition is a common health challenge at NH admission, with one third of NH residents being moderately to severely underweight and 10% being obese. However, during the first year of NH stay, there was a favourable development for underweight NH residents, as they increased their BMI, and 43.6% changed to a higher weight classification, while we observed no changes in the BMI in residents with obesity. As NH residents are in the last phase of their lives, interventions to prevent malnutrition or overweight should be initiated while still home-dwelling, and then continued in the nursing homes.

Cost-effectiveness of a quality improvement project, including simulation-based training, on reducing door-to-needle times in stroke thrombolysis.

BACKGROUND: Rapid revascularisation in acute ischaemic stroke is crucial to reduce its total burden including societal costs. A quality improvement (QI) project that included streamlining the stroke care pathway and simulation-based training was followed by a significant reduction in median door-to-needle time (27 to 13 min) and improved patient outcomes after stroke thrombolysis at our centre. Here, we present a retrospective cost-effectiveness analysis of the QI project. METHODS: Costs for implementing and sustaining QI were assessed using recognised frameworks for economic evaluations. Effectiveness was calculated from previously published outcome measures. Cost-effectiveness was presented as incremental cost-effectiveness ratios including costs per minute door-to-needle time reduction per patient, and costs per averted death in the 13-month post-intervention period. We also estimated incremental cost-effectiveness ratios for a projected 5-year post-intervention period and for varying numbers of patients treated with thrombolysis. Furthermore, we performed a sensitivity analysis including and excluding costs of unpaid time. RESULTS: All costs including fixed costs for implementing the QI project totalled US$44 802, while monthly costs were US$2141. We calculated a mean reduction in door-to-needle time of 13.1 min per patient and 6.36 annual averted deaths. Across different scenarios, the estimated costs per minute reduction in door-to-needle time per patient ranged from US$13 to US$29, and the estimated costs per averted death ranged from US$4679 to US$10 543. CONCLUSIONS: We have shown that a QI project aiming to improve stroke thrombolysis treatment at our centre can be implemented and sustained at a relatively low cost with increasing cost-effectiveness over time. Our work builds on the emerging theory and practice for economic evaluations in QI projects and simulation-based training. The presented cost-effectiveness data might help guide healthcare leaders planning similar interventions.

The economic impact of cognitive impairment in Parkinson's disease.

BACKGROUND: We investigated to what extent cognitive impairment and dementia were related to the direct medical and nonmedical costs in Parkinson's disease. METHODS: Sixty-one patients with Parkinson's disease from a population-based cohort were assessed for motor and cognitive symptoms in 1993, 1997, and 2001. Data on use of health care and social services were collected. RESULTS: The costs of patients with dementia were 3.3 times higher (€34,980) than those of nondemented patients (€10,626) per year of survival. Institutional care was the largest cost factor, representing 67% of the costs. Cognitive functioning predicted direct costs by 29.4%. Cognitive decline was associated with increased costs, even in nondemented subjects. CONCLUSIONS: Our findings suggest that dementia has a substantial impact on direct costs in Parkinson's disease, mainly due to high costs for institutional care. In addition, there were indications that even patients with mild cognitive impairment have higher nonmedical costs.

Mortality in nursing home residents: A longitudinal study over three years.

OBJECTIVE: Nursing home (NH) stay is the highest level of formal care. With the expected demographic changes ahead, the need for NH placement will put an increasing socioeconomic strain on the society. Survival in NHs and factors predicting survival are important knowledge in order to evaluate NH admission policies and plan future NH capacity. METHODS: We followed 690 NH residents included at admission to NH over a period of three years. Participants were examined at baseline (BL) and every six months. Demographic and clinical data were collected, including comorbidity, severity of cognitive impairment, dependency in activities of daily living (ADL) and neuropsychiatric symptoms. Median survival was calculated by the Kaplan-Meier analysis, and factors associated with mortality were identified by Cox models with baseline and time-dependent covariates. RESULTS: Median survival in NH was 2.2 years (95% confidence interval [CI]: 1.9-2.4). Yearly mortality rate throughout the three-year observation period was 31.8%. Mortality was associated with higher age and comorbidity at BL, and more severe dementia, higher ADL-dependency, less severe psychotic symptoms, and a lower BMI throughout the study period. Of the organizational variables, living on a ward with more residents resulted in a higher risk of mortality. CONCLUSION: In conclusion, the NH mortality rate remained stable throughout the three-year study period with about one third of the residents deceasing each year. Individual resident characteristics appeared to be more important than organizational variables for predicting mortality risk. The finding of an association between ward size and mortality risk deserves further investigation in future studies.

Cost-effectiveness of the "helping babies breathe" program in a missionary hospital in rural Tanzania.

OBJECTIVE: The Helping Babies Breathe" (HBB) program is an evidence-based curriculum in basic neonatal care and resuscitation, utilizing simulation-based training to educate large numbers of birth attendants in low-resource countries. We analyzed its cost-effectiveness at a faith-based Haydom Lutheran Hospital (HLH) in rural Tanzania. METHODS: Data about early neonatal mortality and fresh stillbirth rates were drawn from a linked observational study during one year before and one year after full implementation of the HBB program. Cost data were provided by the Tanzanian Ministry of Health and Social Welfare (MOHSW), the research department at HLH, and the manufacturer of the training material Lærdal Global Health. FINDINGS: Costs per life saved were USD 233, while they were USD 4.21 per life year gained. Costs for maintaining the program were USD 80 per life saved and USD 1.44 per life year gained. Costs per disease adjusted life year (DALY) averted ranged from International Dollars (ID; a virtual valuta corrected for purchasing power world-wide) 12 to 23, according to how DALYs were calculated. CONCLUSION: The HBB program is a low-cost intervention. Implementation in a very rural faith-based hospital like HLH has been highly cost-effective. To facilitate further global implementation of HBB a cost-effectiveness analysis including government owned institutions, urban hospitals and district facilities is desirable for a more diverse analysis to explore cost-driving factors and predictors of enhanced cost-effectiveness.

Health state values during the first year of drug treatment in early-stage Parkinson's disease: a prospective, population-based, cohort study.

BACKGROUND: Parkinson's disease (PD) is a common neurodegenerative disorder in the elderly that may lead to both motor and non-motor symptoms with consequent severe impairment of quality of life. PD also represents a substantial economic burden on society because of the patient's decreased ability to work, increased need for care and need for costly treatment. Evaluation of quality-adjusted life-years (QALYs) is an important tool in cost-effectiveness analyses. To date, however, few data have become available about the utility gains or losses associated with the disease and its management. OBJECTIVES: To evaluate the changes in health state values in patients with newly diagnosed PD during their first year of drug treatment, and to calculate the gain in QALYs and the incremental cost-effectiveness ratio (ICER) for this patient group. METHODS: In this prospective, population-based, cohort study, 199 patients with incident PD and 172 controls were followed over 1 year. Clinical data, drug use and utility scores obtained from the Short Form 6D (SF-6D) health state questionnaire were documented. RESULTS: Patients with PD had lower SF-6D utility scores than controls at baseline. Patients started on antiparkinsonian drugs had an improvement in mean utility scores of 0.039 from 0.667 to 0.706 (p < 0.05). The ICER was euros 45,259 (2007 values) per QALY, of which two-thirds consisted of the costs of drugs and one-third represented the costs of clinical consultations. CONCLUSION: Drug treatment in patients with early-stage PD increases health state values, but the ICER is high. Further investigations will be necessary to capture the full consequences of treatment of PD and to evaluate the efficacy of disease management in this setting.