Investigating the impact of primary care payments on underdiagnosis in dementia: A difference-in-differences analysis.

OBJECTIVE: In England, two primary care incentive schemes were introduced to increase dementia diagnosis rates to two-thirds of expected levels. This study assesses the effectiveness of these schemes. METHODS: We used a difference-in-differences framework to analyse the individual and collective impacts of the incentive schemes: (1) Directed Enhanced Service 18 (DES18: facilitating timely diagnosis of and support for dementia) and (2) the Dementia Identification Scheme (DIS). The dataset included 7529 English general practices, of which 7142 were active throughout the 10-year study period (April 2006 to March 2016). We controlled for a range of factors, including a contemporaneous hospital incentive scheme for dementia. Our dependent variable was the percentage of expected cases that was recorded on practice dementia registers (the "rate"). RESULTS: From March 2013 to March 2016, the mean rate rose from 51.8% to 68.6%. Both DES18 and DIS had positive and significant effects. In practices participating in the DES18 scheme, the rate increased by 1.44 percentage points more than the rate for non-participants; DIS had a larger effect, with an increase of 3.59 percentage points. These combined effects increased dementia registers nationally by an estimated 40 767 individuals. Had all practices fully participated in both schemes, the corresponding number would have been 48 685. CONCLUSION: The primary care incentive schemes appear to have been effective in closing the gap between recorded and expected prevalence of dementia, but the hospital scheme had no additional discernible effect. This study contributes additional evidence that financial incentives can motivate improved performance in primary care.

A randomized controlled trial to assess the psychosocial effects of early exercise engagement in patients diagnosed with transient ischaemic attack and mild, non-disabling stroke.

OBJECTIVE: To examine the effect of an early exercise and education programme on psychosocial health of transient ischaemic attack (TIA) and mild, non-disabling stroke patients. DESIGN: Randomized, parallel-group, clinical trial. SETTING: Hospital and academic institution. PARTICIPANTS: A total of 55 newly diagnosed transient ischaemic attack/mild stroke patients (Mean[SD]; 69[11]y). INTERVENTION: Participants were randomized to either an eight-week, twice weekly, 90-minute exercise and education programme (experimental group) or to a usual care control group. MAIN MEASURES: Psychosocial measures (SF-36, Hospital Anxiety and Depression Scale, Profile of Mood States, International Physical Activity Questionnaire, Stroke Awareness Questionnaire) were assessed at baseline and eight-week and 12-month follow-up. RESULTS: The experimental group demonstrated improvements in the Physical Component Score (Mean[SD]; 44.1[11.7] to 47.4[11.3]%), Vitality (46.5[12.4] to 54.2[14.2]%), Physical Functioning (45.6[10.7] to 51.9[14.7]%), Role Physical (38.7[10.8] to 43.1[13.6]%) and Global Health (49.1[10.3] to 54.4[13.6]%) from the SF-36, at the eight-week follow-up assessment (P < 0.05). There were no further changes in these measures between the eight-week and 12-month follow-up assessment (P > 0.05). The experimental group demonstrated a greater awareness of the signs and symptoms associated with stroke (P < 0.05). There were no differences in the Mental Component Score (SF-36), the Hospital Anxiety and Depression Scale or the International Physical Activity Questionnaire between treatment groups (P > 0.05). CONCLUSION: Early engagement in an exercise and education programme may improve physical health perceptions in transient ischaemic attack/mild stroke patients. However, secondary prevention exercise and education programmes warrant further research with regards to their effects on perceptions of mental health in this population group.

Effects of early exercise engagement on vascular risk in patients with transient ischemic attack and nondisabling stroke.

The objective of this study was to conduct a randomized, parallel-group clinical trial assessed the efficacy of a health-enhancing physical activity program (exercise and education) on vascular risk factors and aerobic fitness in patients who have experienced a transient ischemic attack (TIA) or nondisabling stroke. Sixty patients (69±11 years) completed a baseline (BL) vascular risk stratification and aerobic fitness examination (cycle test) within 2 weeks of symptom onset. Subjects were then randomized to either an 8-week, twice weekly exercise program or to a usual-care control (CON) group. Postintervention (PI) assessments were completed immediately after the intervention and at 3-month follow-up. A series of primary (systolic blood pressure [SBP]) and secondary (vascular risk factors like total cholesterol [TC], high-density lipoproteins, etc.; Framingham risk score; peak oxygen uptake) outcome measures were assessed. Significantly greater reductions in SBP (mean change±SD; -10.4±9.2 mm Hg) and TC (-.53±.90 mmol/L) were observed between BL and PI assessments for the exercise group compared with the CON group (-1.9±15.4 mm Hg and -.08±.59 mmol/L, respectively) (P<.05). These improvements were maintained between the PI and the 3-month follow-up assessment (P>.05). Significant improvements in aerobic fitness were also observed and maintained at the 3-month follow-up assessment after regular exercise participation (P<.05). The early engagement in exercise resulted in significant improvements in vascular risk factors and fitness in those diagnosed with TIA. As these beneficial effects were maintained up to 3 months after completing the exercise program, exercise should be considered a useful additive treatment strategy for newly diagnosed TIA patients. Future research should examine the long-term efficacy of such programs.

Risk of Care Home Placement following Acute Hospital Admission: Effects of a Pay-for-Performance Scheme for Dementia.

INTRODUCTION: The Quality and Outcomes Framework, or QOF, rewards primary care doctors (GPs) in the UK for providing certain types of care. Since 2006, GPs have been paid to identify patients with dementia and to conduct an annual review of their mental and physical health. During the review, the GP also assesses the carer's support needs, including impact of caring, and ensures that services are co-ordinated across care settings. In principle, this type of care should reduce the risk of admission to long-term residential care directly from an acute hospital ward, a phenomenon considered to be indicative of poor quality care. However, this potential effect has not previously been tested. METHODS: Using English data from 2006/07 to 2010/11, we ran multilevel logit models to assess the impact of the QOF review on the risk of care home placement following emergency admission to acute hospital. Emergency admissions were defined for (a) people with a primary diagnosis of dementia and (b) people with dementia admitted for treatment of an ambulatory care sensitive condition. We adjusted for a wide range of potential confounding factors. RESULTS: Over the study period, 19% of individuals admitted to hospital with a primary diagnosis of dementia (N = 31,120) were discharged to a care home; of those admitted for an ambulatory care sensitive condition (N = 139,267), the corresponding figure was 14%. Risk factors for subsequent care home placement included older age, female gender, vascular dementia, incontinence, fall, hip fracture, and number of comorbidities. Better performance on the QOF review was associated with a lower risk of care home placement but only when the admission was for an ambulatory care sensitive condition. CONCLUSIONS: The QOF dementia review may help to reduce the risk of long-term care home placement following acute hospital admission.

The influence of primary care quality on hospital admissions for people with dementia in England: a regression analysis.

OBJECTIVES: To test the impact of a UK pay-for-performance indicator, the Quality and Outcomes Framework (QOF) dementia review, on three types of hospital admission for people with dementia: emergency admissions where dementia was the primary diagnosis; emergency admissions for ambulatory care sensitive conditions (ACSCs); and elective admissions for cataract, hip replacement, hernia, prostate disease, or hearing loss. METHODS: Count data regression analyses of hospital admissions from 8,304 English general practices from 2006/7 to 2010/11. We identified relevant admissions from national Hospital Episode Statistics and aggregated them to practice level. We merged these with practice-level data on the QOF dementia review. In the base case, the exposure measure was the reported QOF register. As dementia is commonly under-diagnosed, we tested a predicted practice register based on consensus estimates. We adjusted for practice characteristics including measures of deprivation and uptake of a social benefit to purchase care services (Attendance Allowance). RESULTS: In the base case analysis, higher QOF achievement had no significant effect on any type of hospital admission. However, when the predicted register was used to account for under-diagnosis, a one-percentage point improvement in QOF achievement was associated with a small reduction in emergency admissions for both dementia (-0.1%; P=0.011) and ACSCs (-0.1%; P=0.001). In areas of greater deprivation, uptake of Attendance Allowance was consistently associated with significantly lower emergency admissions. In all analyses, practices with a higher proportion of nursing home patients had significantly lower admission rates for elective and emergency care. CONCLUSION: In one of three analyses at practice level, the QOF review for dementia was associated with a small but significant reduction in unplanned hospital admissions. Given the rising prevalence of dementia, increasing pressures on acute hospital beds and poor outcomes associated with hospital stays for this patient group, this small change may be clinically and economically relevant.

The long-term effect of exercise on vascular risk factors and aerobic fitness in those with transient ischaemic attack: a randomized controlled trial.

OBJECTIVE: Exercise has beneficial effects on vascular risk factors in transient ischaemic attack (TIA) patients within the sub-acute phase. This study examined whether TIA patients randomized to an early exercise and education programme within 2 weeks of TIA diagnosis would demonstrate improvements in cardiovascular risk factors and aerobic fitness 12 months post-diagnosis compared with control patients. METHODS: A single-centre, randomized, parallel-group clinical trial. Sixty TIA patients (69 ±â€Š11 years) completed a vascular risk stratification baseline assessment and a physical fitness examination. Individuals were randomized to either an 8-week early exercise and education group or control group. Fifty-one patients attended post-intervention assessments that were completed immediately (post-intervention) and 12 months after (12PI). RESULTS: A significantly greater improvement in resting SBP was observed between baseline and post-intervention for EX than for CON (-11 mmHg cf. -1 mmHg, respectively; P < 0.05). The improvement in SBP was maintained between post-intervention and 12PI (P > 0.05). Similar findings were demonstrated for BMI, bodyweight and peak oxygen uptake (P < 0.05). Exercise blood pressure, pulse pressure and double product (SBP x heart rate; an indication of myocardial workload) were significantly lower at post-intervention and 12PI for EX than for CON (all P < 0.05). CONCLUSION: An 8-week exercise programme soon after TIA resulted in beneficial changes in resting and exercise blood pressure that were maintained for 12 months. CLINICAL TRIAL REGISTRATION: http://www.anzctr.org.au/ TRIAL REGISTRATION NUMBER: ACTRN12611000630910.

Clinical audit of stroke thrombolysis in Wellington, New Zealand: disparity between in-hours and out-of-hours treatment time.

AIMS: To report on the safety and efficiency of a comprehensive stroke thrombolysis service and look for evidence of disparity between in-hours and out-of-hours treatment times. METHOD: Clinical audit of patients treated with tissue plasminogen activator, alteplase (rt-PA) for stroke at Wellington Hospital between 1 November 2009 and 31 October 2010. RESULTS: Thirty-one patients were treated with rt-PA. All were treated within agreed clinical eligibility criteria. The median NIHSS score pre-treatment was 10; post treatment 5. Two patients died, both from intracranial haemorrhage. Overall the average time to treatment from symptom onset was 168 minutes. Those treated out-of-hours had an additional delay of 33 minutes compared to in-hours treatment (p=0.03). CONCLUSIONS: Patients admitted out-of-hours had significantly longer delays to rt-PA treatment. Those planning Stroke Services should ensure this source of inequity is addressed within their localities.

Health-enhancing physical activity programme (HEPAP) for transient ischaemic attack and non-disabling stroke: recruitment and compliance.

AIM: To assess the feasibility of recruiting and retaining patients newly diagnosed with a Transient Ischaemic Attack (TIA) into an 8-week exercise programme. METHODS: The study was a single-centre, randomised-controlled trial. TIA was confirmed by a specialist stroke physician within 7 days of symptom onset. Following baseline assessment, participants were randomised to either an 8-week exercise intervention or control group (usual care). Participants completed a further assessment 2 months after baseline. RESULTS: Of the 285 individuals diagnosed with TIA, 97 patients were invited to participate in the trial, of which 60 were successfully recruited (62%). Of those invited, 89% were identified within outpatient care. Individuals were typically of European descent (87%) and lived within 20 km of the study site (81%). Distance to travel was considered the primary barrier for non-participation (46%). Three participants (5%) did not attend the follow-up assessment. CONCLUSION: Individuals with TIA were successfully recruited and retained into a RCT. A different approach is required to study interventions in Maori, Pacific Islanders, Asian and Indian populations. If the exercise intervention improves vascular risk factors and reduces recurrent vascular events, it could be applied to a large number of people who suffer a TIA or non-disabling stroke.