Private equity investment in health care delivery, Australia, 2008-2022.

OBJECTIVES: To examine the scale of private equity investment in Australian health care delivery assets (clinics, hospitals, imaging facilities, other doctor-led health care services). STUDY DESIGN, SETTING: Extraction of information about private equity acquisitions of hospitals, clinics, imaging centres and in vitro fertilisation facilities in Australia, 2008-2022, from a commercial database (PitchBook), supplemented by information from publicly available online media sources. MAIN OUTCOME MEASURES: Number and value of private equity acquisitions of health care assets, 2008-2022; numbers of clinic parent company and clinic acquisitions, 2017-2022. RESULTS: A total of 75 private equity acquisitions of health care delivery assets in Australia during 2008-2022 were identified; the annual number rose from three acquisitions in 2008 to eighteen in 2022. During 2008-2010, five of seven acquisitions were of in vitro fertilisation providers; during 2020-2022, 22 of 39 acquisitions were of clinics or clinic groups, including eleven of eighteen in 2022. The total value of the 39 acquisitions for which purchase price could be ascertained (52%) was $24.1 billion. During 2017-2022, the clinic specialty with the greatest number of private equity acquisitions was general practice (256 of 446 clinics purchased within acquisitions). Seven companies owning ophthalmology clinics (24 clinics) were acquired by private equity. Four private equity acquisitions during 2017-2022 included 60 oncology clinics, all related to a single clinic group. CONCLUSIONS: The number of private equity acquisitions of Australian health care delivery assets increased during 2008-2022. Doctors should be aware of the motivations and dynamics of private equity companies, as they are increasingly likely to interact with these firms and assets owned by these firms.

Reimbursement of interventional oncology in Australia: How it works and how it does not.

The practice of interventional oncology (IO) embodies all the qualities that one would expect to find in a modern, value-based healthcare system. A dynamic, cutting-edge specialty like IO uses highly-targeted, minimally-invasive, image-guided techniques to deliver cost-effective, personalised medicine for cancer patients. Unfortunately, the technical and clinical sophistication of IO is not matched by the reimbursement models and funding arrangements in Australia to fully support this critical component of patient care. Differences between state and federal funding lead to inequity of access to 'standard of care' interventions for patients across public and private hospitals. IO procedures are poorly represented in the Medicare Benefits Schedule and often inadequately funded to cover the true costs of providing care. Complex private health fund reimbursements and inconsistent rebates for prostheses and essential equipment result in inconsistent access to important services and widely variable out-of-pocket costs for patients. IO techniques must be supported by fair, consistent and equitable funding arrangements at all levels to allow for integrated contemporary patient care; only then will the full clinical and economic benefits of IO  be realised.

The value of maternity care in Queensland, 2012-18, based on an analysis of administrative data: a retrospective observational study.

OBJECTIVE: To quantify the value of maternity health care - the relationship of outcomes to costs - in Queensland during 2012-18. STUDY DESIGN: Retrospective observational study; analysis of Queensland Perinatal Data Collection data linked with the Queensland Health Admitted Patient, Non-Admitted Patient, and Emergency Data Collections, and with the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) databases. SETTING, PARTICIPANTS: All births in Queensland during 1 July 2012 - 30 June 2018. MAIN OUTCOME MEASURES: Maternity care costs per birth (reported in 2021-22 Australian dollars), both overall and by funder type (public hospital funders, MBS, PBS, private health insurers, out-of-pocket costs); value of care, defined as total cost per positive birth outcome (composite measure). RESULTS: The mean cost per birth (all funders) increased from $20 471 (standard deviation [SD], $17 513) during the second half of 2012 to $30 000 (SD, $22 323) during the first half of 2018; the annual total costs for all births increased from $1.31 billion to $1.84 billion, despite a slight decline in the total number of births. In a mixed effects linear analysis adjusted for demographic, clinical, and birth characteristics, the mean total cost per birth in the second half of 2018 was $9493 higher (99.9% confidence interval, $8930-10 056) than during the first half of 2012. The proportion of births that did not satisfy our criteria for a positive birth outcome increased from 27.1% (8404 births) during the second half of 2012 to 30.5% (9041 births) during the first half of 2018. CONCLUSION: The costs of maternity care have increased in Queensland, and many adverse birth outcomes have become more frequent. Broad clinical collaboration, effective prevention and treatment strategies, as well as maternal health services focused on all dimensions of value, are needed to ensure the quality and viability of maternity care in Australia.

The cost-effectiveness of universal hepatitis B screening for reaching WHO diagnosis targets in Australia by 2030.

OBJECTIVES: To assess the impact on diagnosis targets, cost, and cost-effectiveness of universal hepatitis B screening in Australia. DESIGN: Markov model simulation of disease and care cascade progression for people with chronic hepatitis B in Australia. SETTING: Three scenarios were compared: 1. no change to current hepatitis B virus (HBV) testing practice; 2. universal screening strategy, with the aim of achieving the WHO diagnosis target by 2030 (90% of people with chronic hepatitis B diagnosed), based on opportunistic (general practitioner-initiated) screening for HBsAg; 3. universal screening strategy, and also ensuring that 50% of people with chronic hepatitis B are receiving appropriate clinical management by 2030. MAIN OUTCOME MEASURES: Projected care cascade for people with chronic hepatitis B, cumulative number of HBV-related deaths, intervention costs, and health utility (quality-adjusted life-years [QALYs] gained during 2020-2030). An incremental cost-effectiveness ratio (ICER) threshold (v scenario 1) of $50 000 per QALY gained was applied. RESULTS: Compared with scenario 1, 80 HBV-related deaths (interquartile range [IQR], 41-127 deaths) were averted during 2020-2030 in scenario 2, 315 HBV-related deaths (IQR, 211-454 deaths) in scenario 3. Scenario 2 cost $84 million (IQR, $41-106 million) more than scenario 1 during 2020-2030 (+8%), yielding an ICER of $104 921 (IQR, $49 587-107 952) per QALY gained. Scenario 3 cost $263 million (IQR, $214-316 million) more than scenario 1 during 2020-2030 (+24%), yielding an ICER of $47 341 (IQR, $32 643-58 200) per QALY gained. Scenario 3 remained cost-effective if the test positivity rate was higher than 0.35% or the additional costs per person tested did not exceed $4.02. CONCLUSIONS: Universal screening for hepatitis B will be cost-effective only if the cost of testing is kept low and people receive appropriate clinical management.

[Analysis on disease burden and trend of occupational lung disease in Tianjin from 2010 to 2019 based on disability adjusted life years].

Objective: To analyze the level and trend of occupational pneumoconiosis disease burden in Tianjin from 2010 to 2019, and to provide scientific basis for making prevention and control countermeasures and suggestions. Methods: In June 2021, the data of occupational pneumoconiosis cases in Tianjin from 2010 to 2019 were selected from Follow-up survey of occupational pneumoconiosis patients in Tianjin and occupational "Health Hazardous Surveillance Information System", the subsystem of China Disease Control and Prevention Information System. Disability-adjusted life year (DALY) , years of life lost (YLL) and years lost due to disability (YLD) were used to comprehensively measure the disease burden of occupational pneumoconiosis by region, year, disease type, industry, sex and age; Kruskal-wallis H test was used for univariate analysis of DALY loss in pneumdo-niosis occupational. Results: A total of 43089 person-years of DALY due to pneumoconiosis in Tianjin from 2010 to 2019, of which the YLD accounted for about 2/3 (28277 person-years) , the YLL accounted for about 1/3 (14812 person-years) , and the average DALY was 7.34 person-years. The industrial distribution of pneumoconiosis burden in Tianjin was mainly concentrated in the manufacturing industry accounting for 90.6% of the whole industry. The disease types were mainly concentrated in silicosis, foundry pneumoconiosis, asbestosis and cement pneumoconiosis accounting for 34.4%, 16.9%, 13.3% and 10.5%, and the age distribution was mainly concentrated in the 50~<85 years old age group, accouling for 83.6%. The median DALY of occupational pneumoconiosis patients with different pneumoconiosis stages, disability grades and years of service exposed to dust were statistically significant (P<0.05) . Conclusion: The disease burden of occupational pneumoconiosis in Tianjin was still serious. It is necessary to take targeted intervention measures for key industries and population.

[Analysis on the rationality of input and output of occupational health funds in an iron and steel enterprise].

Objective: To analyzes the various occupational health investment and occupational health output of a steel enterprise, and propose a reasonable occupational health investment plan for this enterprise. Methods: In march 2016, various occupational health input and output data of various branches of an iron and steel company in 2015 were collected, and the efficiency of occupational health inputs and outputs of each branch was evaluated using data envelopment analysis (DEA) , and the branches with non-optimal efficiency were adjusted to propose a reasonable occupational health investment plan. Results: Among the branch plants investigated by this steel company, the occupational health input-output efficiency values of ironmaking north plant, power plant, hot rolling plant and stainless steel plant were 1, while the occupational health input-output efficiency of gas making plant, cold rolling plant, metallurgical furnace charge plant, coking plant, ironmaking south plant and long product plant were not the best, and the cold rolling plant has the lowest efficiency value of 0.759. For the cold rolling plant, only the parameters of acid rolling plant satisfy α=1 and s(-)=0, s(+)=0, while the remaining four workshops do not meet. After adjusting the inputs of each part according to the parameters, the occupational health output of the remaining four workshops can reach 1.7044, 2.0238, 1.3152 and 1.2136 times of the current workshop, respectively. Adjustment plans for other branch factories with unreasonable investment structures are also presented in the corresponding tables. Conclusion: The occupational health investment structure of the ironmaking south plant and other branches in this steel enterprise is unreasonable, and the adjustment using data envelopment analysis can maximize the benefits of its occupational health output.

Análisis de costos de la atención hospitalaria en un paciente con fibrilación auricular no valvular y accidente cerebrovascular a repetición / Cost analysis of in hospital attention in a non-valvular atrial fibrillation patient and recurrent stroke

RESUMEN INTRODUCCIÓN: Paciente de 71 años con diagnóstico de fibrilación auricular y ataques cerebrovasculares recurrentes, tratada con varios anticoagulantes. El costo del tratamiento del ictus en Colombia para el año 2008 fue de $450.000 millones de pesos colombianos. OBJETIVO: Estimar el costo hospitalario de la atención de un paciente con ictus a repetición secundario a fibrilación auricular. MÉTODOS: Estudio económico parcial de microcosteo de la atención intrahospitalaria para un caso de espectro severo recurrente, que no necesariamente refleja el caso promedio. El consumo de recursos se valoró mediante el uso de tarifas de referencia nacionales. Los resultados se presentan en precios actuales del 2019 (peso colombiano y dólar americano). RESULTADOS: Paciente con 3 eventos hospitalarios, que estuvo 31 días hospitalizada. Las hospitalizaciones tuvieron unos costos de: $53.883.490 (USD 16.141,1), $6.343.096 (USD 1.900,1) y $15.719.443 (USD 4.708,9) respectivamente, con un precio promedio por cada hospitalización de $25.315.343 (USD 7.583,4), costo total de $75.946.029 (USD 22.750,1) costo día de $2.449.872 (USD 729,5). El rubro que aumentó consistentemente los costos fueron los procedimientos (35,7 %). CONCLUSIONES: El ictus recurrente causado por fibrilación auricular no valvular se asocia con un incremento significativo de los costos directos, con un impacto de casi dos veces el PIB per cápita. Un diagnóstico oportuno y una selección adecuada pueden reducirlo.

ABSTRACT INTRODUCTION: A 71-year-old patient with a diagnosis of atrial fibrillation and recurrent strokes, treated with various anticoagulants, the stroke treatment in Colombia for 2008 was $ 450 billion Colombian pesos. OBJECTIVE: To estimate the hospital cost of caring for a patient with recurrent stroke secondary to atrial fibrillation. METHODS: Partial economic study of micro costing of in-hospital care for a case of recurrent severe spectrum stroke, which does not necessarily reflect the average case. Resource consumption was valued using national reference rates. The results are presented in current 2019 prices (Colombian pesos and US dollars). RESULTS: Patient with 3 hospital events, who was hospitalized for 31 days. Hospitalizations had costs of $ 53,883,490 (USD 16,141.1), $ 6,343,096 (USD 1,900.1) and $ 15,719,443 (USD 4,708.9) respectively, with an average price for each hospitalization of $ 25,315,343 (USD 7,583.4), total cost of $ 75,946,029 (USD 22,750.1) daily cost of $ 2,449,872 (USD 729.5). The item that consistently increased costs was procedures (35.7 %). CONCLUSIONS: Recurrent stroke caused by nonvalvular atrial fibrillation is associated with a significant increase in direct costs, with an impact of almost twice the GDP per capita. A timely diagnosis and proper selection can reduce it.

Physicians' income in Brazil: a study on information sources

SUMMARY OBJECTIVE: Data on physicians' income are relevant for well-informed health policies, both due to their strategic role and the volume of resources that their activities represent to health systems. In Brazil, multiple sources of data measure the income of these professionals, each one with singularities that generate a complex and heterogeneous picture. This study explores the methodological aspects of different data sources, pointing to potentials and limitations to measuring the income of physicians. METHODS: We use the sources' documentation and data on the average monthly income in 2019, by gender and macro region, from four distinct surveys: Continuous Pnad (National Household Sample Survey), RAIS (Annual Listing of Social Information), Medical Demographics, and IRPF (Personal Income Tax). RESULTS: The results confirm the heterogeneity of definitions, variables, and methodologies. The data set can evidence phenomena such as the income difference between men and women. Regional inequalities are evident; however, the data interpretation is less assertive. CONCLUSIONS: Although eventual gaps and discrepancies among sources can limit some strong conclusions, the analysis of different methodologies employed can suggest relevant hypotheses for in-depth studies.

Cost-utility analysis of breast reduction surgery for women with symptomatic breast hypertrophy.

OBJECTIVE: To assess the cost-effectiveness of breast reduction surgery for women with symptomatic breast hypertrophy in Australia. DESIGN: Cost-utility analysis of data from a prospective cohort study. SETTING, PARTICIPANTS: Adult women with symptomatic breast hypertrophy assessed for bilateral breast reduction at the Flinders Medical Centre, a public tertiary hospital in Adelaide, April 2007 - February 2018. The control group included women with breast hypertrophy who had not undergone surgery. MAIN OUTCOME MEASURES: Health care costs (for the surgical admission and other related hospital costs within 12 months of surgery) and SF-6D utility scores (measure of health-related quality of life) were used to calculate incremental costs per quality-adjusted life-year (QALY) gained over 12 months, extrapolated to a 10-year time horizon. RESULTS: Of 251 women who underwent breast reduction, 209 completed the baseline and at least one post-operation assessment (83%; intervention group); 124 of 350 invited women waiting for breast reduction surgery completed the baseline and 12-month assessments (35%; control group). In the intervention group, the mean SF-6D utility score increased from 0.313 (SD, 0.263) at baseline to 0.626 (SD, 0.277) at 12 months; in the control group, it declined from 0.296 (SD, 0.267) to 0.270 (SD, 0.257). The mean QALY gain was consequently greater for the intervention group (adjusted difference, 1.519; 95% CI, 1.362-1.675). The mean hospital cost per patient was $11 857 (SD, $4322), and the incremental cost-effectiveness ratio (ICER) for the intervention was $7808 per QALY gained. The probability of breast reduction surgery being cost-effective was 100% at a willingness-to-pay threshold of $50 000 per QALY and 88% at $28 033 per QALY. CONCLUSIONS: Breast reduction surgery for women with symptomatic breast hypertrophy is cost-effective and should be available to women through the Australian public healthcare system.

Effectiveness, safety and cost of urinary follicle stimulating hormone in controlled ovarian stimulation in China: multi-center retrospective cohort study of 102 061 in vitro fertilization cycles / 中华妇产科杂志

Objective:To explore the effectiveness, safety and cost between urinary follicle stimulating hormone (uFSH) and recombinant follicle stimulating hormone (rFSH) in controlled ovarian stimulation (COS) in China.Methods:Data were collected from 16 reproductive centers in China covering oocytes collection time from May 1, 2015 to June 30, 2018. Eligible patients were over 18 years old, adopting COS with uFSH (uFSH group) or rFSH (rFSH group) as start gonadotropins (Gn), and using in vitro fertilization (IVF) and (or) intracytoplasmic sperm injection for fertilisation, excluding frozen embryo recovery cycle. Generalised estimating equation was used to address the violation of independency assumption between cycles due to multiple IVF cycles for one person and clustering nature of cycles carried out within one center. Controlling variables included age, body mass index, anti-Müllerian hormone level, cause of infertility, ovulation protocol, type of fertilisation, number of embryos transferred, number of days of Gn use.Results:Totally 102 061 cycles met eligibility criteria and were included in the analyses. In terms of effectiveness, after controlling relevant unbalanced baseline characteristics, compared with rFSH group, the high oocyte retrieval (>15 oocytes was considered high retrieval) rate of uFSH group significantly decreased in gonadotropin-releasing hormone agonist protocol ( OR=0.642, P<0.01) and in gonadotropin-releasing hormone antagonist protocol ( OR=0.556, P=0.001), but the clinical pregnancy rate per transfer cycle and the live birth rate per transfer cycle significantly increased ( OR=1.179, OR=1.169, both P<0.01) in both agonist and antagonist protocols. For safety, multiple analysis result demonstrated that in the agonist protocol, compared with rFSH group, the incidence of moderate to severe ovarian hyperstimulation syndrome of uFSH group significantly decreased ( OR=0.644, P=0.002). The differences in ectopic pregnancy rate and multiple pregnancy rate between the uFSH and rFSH groups were not significant ( P=0.890, P=0.470) in all patients. In terms of cost, compared with rFSH group, the uFSH group had lower total Gn costs for each patient ( P<0.01). Conclusion:For patients who underwent COS, uFSH has better safety, and economic profiles over rFSH in China.

Trends in Total and Out-of-Pocket Expenditures for Visits to Primary Care Physicians, by Insurance Type, 2002-2017.

PURPOSE: Total and out-of-pocket visit expenditures for primary care physician visits may affect how primary care is delivered. We determined trends in these expenditures for visits to US primary care physicians. METHODS: Using the 2002-2017 Medical Expenditure Panel Survey, we ascertained changes in total and out-of-pocket visit expenditures for primary care visits for Medicare, Medicaid, and private insurance. We calculated mean values for each insurer using a generalized linear model and a 2-part model, respectively. RESULTS: Analyses were based on 750,837 primary care visits during 2002-2017. Over time, the proportion of primary care visits associated with private insurance or no insurance decreased, while Medicare- or Medicaid-associated visits increased. The proportion of visits with $0 out-of-pocket expenditure increased, primarily from an increase in $0 private insurance visits. Total expenditure per visit increased for private insurance and Medicare visits, but did not notably change for Medicaid visits. Out-of-pocket expenditures rose primarily from increases in private insurance visits with higher expenditures of this type. Medicare and Medicaid had minimal change in out-of-pocket expenditure per visit. CONCLUSIONS: Between 2002 and 2017, mean total expenditures and out-of-pocket expenditures increased for primary care visits, but at notably lower rates than those previously documented for emergency department visits. A rise in total expenditure per visit was identified for private insurance and Medicare, but not for Medicaid. Out-of-pocket expenditures increased marginally related to changes in out-of-pocket expenditures for private insurance visits. We would expect increasing difficulty with primary care physician access, particularly for Medicaid patients, if the current trends continue.

Conflicting Perspectives on the Value of Neprilysin Inhibition in Heart Failure Revealed During Development of a Decision Aid Focusing on Patient Costs for Sacubitril/Valsartan.

BACKGROUND: Despite concerns about rising costs in health care, cost is rarely an issue discussed by patients and clinicians when making treatment decisions in a clinical setting. This study aimed to understand stakeholder perspectives on a patient decision aid (PtDA) meant to help patients with heart failure choose between a generic and relatively low-cost heart failure medication (ACE [angiotensin-converting enzyme] inhibitor or angiotensin II receptor blocker) and a newer, but more expensive, heart failure medication (angiotensin II receptor blocker neprilysin inhibitor). METHODS AND RESULTS: Feedback on the PtDA was solicited from 26 stakeholders including patients, clinicians, and the manufacturer. Feedback was recorded and discussed among development team members until consensus regarding both the interpretation of the data and the appropriate changes to the PtDA was reached. Stakeholders found the PtDA sufficient in clarifying the different treatment options for heart failure. However, patients, physicians, and the manufacturer had different opinions on the importance of highlighting cost in a PtDA. Patients indicated issues of cost were crucial to the decision while physicians and manufacturers expressed that the cost issue was secondary and should be de-emphasized. CONCLUSIONS: The stratified perspectives on the role of cost in medical decision-making expressed by our participants underscore the importance and challenge of having clear, frank discussions during clinic visits about treatment cost and perceived value.

Dementia Care Mapping™ to reduce agitation in care home residents with dementia: the EPIC cluster RCT.

BACKGROUND: The quality of care for people with dementia in care homes is of concern. Interventions that can improve care outcomes are required. OBJECTIVE: To investigate the clinical effectiveness and cost-effectiveness of Dementia Care Mapping™ (DCM) for reducing agitation and improving care outcomes for people living with dementia in care homes, versus usual care. DESIGN: A pragmatic, cluster randomised controlled trial with an open-cohort design, follow-up at 6 and 16 months, integrated cost-effectiveness analysis and process evaluation. Clusters were not blinded to allocation. The primary end point was completed by staff proxy and independent assessors. SETTING: Stratified randomisation of 50 care homes to the intervention and control groups on a 3 : 2 ratio by type, size, staff exposure to dementia training and recruiting hub. PARTICIPANTS: Fifty care homes were randomised (intervention, n = 31; control, n = 19), with 726 residents recruited at baseline and a further 261 recruited after 16 months. Care homes were eligible if they recruited a minimum of 10 residents, were not subject to improvement notices, had not used DCM in the previous 18 months and were not participating in conflicting research. Residents were eligible if they lived there permanently, had a formal diagnosis of dementia or a score of 4+ on the Functional Assessment Staging Test of Alzheimer's Disease, were proficient in English and were not terminally ill or permanently cared for in bed. All homes were audited on the delivery of dementia and person-centred care awareness training. Those not reaching a minimum standard were provided training ahead of randomisation. Eighteen homes took part in the process evaluation. INTERVENTION: Two staff members from each intervention home were trained to use DCM and were asked to carry out three DCM cycles; the first was supported by an external expert. MAIN OUTCOME MEASURES: The primary outcome was agitation (Cohen-Mansfield Agitation Inventory), measured at 16 months. Secondary outcomes included resident behaviours and quality of life. RESULTS: There were 675 residents in the final analysis (intervention, n = 388; control, n = 287). There was no evidence of a difference in agitation levels between the treatment arms. The adjusted mean difference in Cohen-Mansfield Agitation Inventory score was -2.11 points, being lower in the intervention group than in the control (95% confidence interval -4.66 to 0.44; p = 0.104; adjusted intracluster correlation coefficient: control = 0, intervention = 0.001). The sensitivity analyses results supported the primary analysis. No differences were detected in any of the secondary outcomes. The health economic analyses indicated that DCM was not cost-effective. Intervention adherence was problematic; only 26% of homes completed more than their first DCM cycle. Impacts, barriers to and facilitators of DCM implementation were identified. LIMITATIONS: The primary completion of resident outcomes was by staff proxy, owing to self-report difficulties for residents with advanced dementia. Clusters were not blinded to allocation, although supportive analyses suggested that any reporting bias was not clinically important. CONCLUSIONS: There was no benefit of DCM over control for any outcomes. The implementation of DCM by care home staff was suboptimal compared with the protocol in the majority of homes. FUTURE WORK: Alternative models of DCM implementation should be considered that do not rely solely on leadership by care home staff. TRIAL REGISTRATION: Current Controlled Trials ISRCTN82288852. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 16. See the NIHR Journals Library website for further project information.

Agitation is common in care home residents and may result from care that does not meet individual needs. Dementia Care Mapping™ (DCM) is a tool used within care homes to improve the delivery of person-centred care, which may help reduce agitation. This randomised controlled trial aimed to understand whether or not DCM is better than usual care at reducing resident agitation, behaviours that staff may find difficult to support and the use of antipsychotic medicines, as well as at improving residents' quality of life and staff communication. It also assessed its value for money. We recruited 726 residents with dementia from 50 care homes. After initial data collection, care homes were randomly assigned to DCM (31/50) or told to continue with usual care (19/50) and data were collected again after 6 and 16 months. A further 261 residents were recruited after 16 months. We also interviewed staff, relatives and residents about the use of DCM after the final data collection had taken place. Two staff members in each DCM home were trained to use DCM and were helped by an expert to use it for the first time. They were asked to use it again a further two times without support. Results showed that DCM was no better than usual care in relation to any of the outcomes. It was also not shown to be value for money. Only one-quarter of care homes used DCM more than once. The care staff who were interviewed said that the benefits of using DCM included reduced resident boredom and increased staff confidence. There were also many challenges, including the time needed to complete DCM, a lack of managerial support and problems with staffing levels. Putting DCM into practice in care homes was difficult, even with expert support, and most care homes did not complete three DCM cycles. Future research should explore models of implementing DCM that do not rely on care home staff to lead them.