Costs of care trajectories of people with dementia compared with matched controls. Longitudinal analysis of linked health and administrative data.

OBJECTIVES: To provide insight into the health and social care costs during the disease trajectory in persons with dementia and the impact of institutionalization and death on healthcare costs compared with matched persons without dementia. METHODS: Electronic health record data from family physicians were linked with national administrative databases to estimate costs of primary care, medication, secondary care, mental care, home care and institutional care for people with dementia and matched persons from the year before the recorded dementia diagnosis until death or a maximum of 4 years after the diagnosis. RESULTS: Total mean health and social care costs among persons with dementia increased substantially during the disease trajectory, mainly due to institutional care costs. For people who remained living in the community, mean health and social care costs are higher for people with dementia than for those without dementia, while for those who are admitted to a long-term care facility, mean health and social care costs are higher for people without dementia than for those with dementia. CONCLUSIONS: The steep rise in health and social care costs across the dementia care trajectory is mainly due to increasing costs for institutional care. For those remaining in the community, home care costs and hospital care costs were the main cost drivers. Future research should adopt a societal perspective to investigate the influence of including social costs.

Hospital and Institutionalisation Care Costs after Limb and Visceral Ischaemia Benchmarked Against Stroke: Long-Term Results of a Population Based Cohort Study.

OBJECTIVE/BACKGROUND: There are few published data on the acute care or long-term costs after acute/critical limb or visceral ischaemia (ACLVI) events. Using data from patients with acute events in a population based incidence study (Oxford Vascular Study), the present study aimed to determine the long-term costs after an ACLVI event. METHODS: All patients with first ever incident ACLVI from 2002 to 2012 were included. Analysis was based on follow up until January 2017, with all patients having full 5 year follow up. Multivariate regressions were used to assess baseline and subsequent predictors of total 5 year hospital care costs. Overall costs after an ACLVI event were benchmarked against those after stroke in the same population, during the same period. RESULTS: Among 351 patients with an ACLVI event, mean 5 year total care costs were €35,211 (SD 50,500), of which €6443 (18%) were due to long-term institutionalisation. Costs differed by type of event (acute visceral ischaemia €16,476; acute limb ischaemia €24,437; critical limb ischaemia €46,281; p < 0.001). Results of the multivariate analyses showed that patients with diabetes and those undergoing above knee amputations incurred additional costs of €11,804 (p = 0.014) and €25,692 (p < 0.001), respectively. Five year hospital care costs after an ACLVI event were significantly higher than after stroke (€28,768 vs. €22,623; p = 0.004), but similar after including long-term costs of institutionalisation (€35,211 vs. €35,391; p = 0.957). CONCLUSION: Long-term care costs after an ACLVI event are considerable, especially after critical limb ischaemia. Hospital care costs were significantly higher than for stroke over the long term, and were similar after inclusion of costs of institutionalisation.

What Are the Determinants of Dental Care Expenditures in Institutions for Adults With Disabilities? Findings From a National Survey.

OBJECTIVE: To analyze the determinants of dental care expenditures in institutions for adults with disabilities. DESIGN: Health and disability survey and insurance database. SETTING: Institutional setting. PARTICIPANTS: Adults (N=2222) living in institutions for people with cognitive, sensory, and mobility disabilities. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We used a Heckman selection model to correct for potential sample selection bias due to the high percentage of non-dental care users. The Heckman selection model is a 2-step statistical approach based on the simultaneous estimation of 2 multiple regression models-a selection equation (step 1) and an outcome equation (step 2)-offering a means of correcting for nonrandomly selected samples. The selection equation modeled whether the individual had consulted a dentist at least once, whereas the outcome equation explained the dental care expenditures. Disability severity was assessed by scoring mobility and cognitive functional limitations. Regressions also included sociodemographic characteristics and other health-related variables. RESULTS: Individuals with the highest cognitive limitation scores, without family visits, without supplementary health insurance, and with poor oral health status were less likely to consult a dentist. After controlling for potential selection bias, the only variable that remained statistically significant in the outcome equation was the oral health status: when individuals with poor health status had consulted at least once, they had a higher level of dental care expenditure. CONCLUSIONS: Functional limitations were barriers to accessing dental care even in institutions for adult with disabilities. These barriers should be overcome because they may worsen their oral health status and well-being. Given the lack of literature on this specific topic, our results are important from a policy perspective. Health authorities should be alerted by these findings.

Is the level of institutionalisation found in psychiatric housing services associated with the severity of illness and the functional impairment of the patients? A patient record analysis.

BACKGROUND: In this cross-sectional study, we investigated whether clinical, social, financial, and care variables were associated with different accommodation settings for individuals suffering from severe and persistent mental disorders. METHOD: Electronic record data of 250 patients who fulfilled the criteria for persistent and severe mental illness were used. Multiple linear regression models were applied to analyse associations between the types and the costs of housing services and the patients' severity of illness, their functional impairment, and their socio-demographic characteristics. RESULTS: We identified 50 patients living at home without need for additional housing support who were receiving outpatient treatment, 41 patients living in the community with outpatient housing support, 23 patients living with foster families for adults, 45 patients living in group homes with 12-h staff cover, 10 patients living in group homes with 24-h staff, and 81 patients living in psychiatric nursing homes. While this housing differed largely in the level of institutionalisation and also in the costs of accommodation, these differences were not related to a patient's severity of disease or in their functional impairment. In particular, patients living in nursing homes had a slightly higher level of functioning compared to those living in the community without welfare housing services. Only where patients were subject to guardianship was there a significant association with an increased level of institutionalisation. CONCLUSIONS: Our study suggests that the level of institutionalisation and the associated costs of welfare housing services do not accurately reflect the severity of illness or the level of functional impairment of the patients there are designed to support. The limitations of the study design and the data do not allow for conclusions about causal relationships or generalisation of the findings to other regions. Therefore, further prospective studies are needed to assess the adequacy of the setting assignment of patients with persistent severe mental illness into different types of housing settings with appropriate (also welfare) services.

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.

Implications of early treatment among Medicaid patients with Alzheimer's disease.

OBJECTIVE: The objective of this study was to examine the effect of treatment timing on risk of institutionalization of Medicaid patients with Alzheimer's disease (AD) and to estimate the economic implications of earlier diagnosis and treatment initiation. METHODS: New Jersey Medicaid claims data (1997-2009) were used retrospectively to study the effect of treatment on time to institutionalization. Observed Medicaid payments were used to calculate savings from delayed institutionalization, adjusting for cost offsets resulting from concurrent changes in use of other medical services. RESULTS: Initiation of existing therapies at earliest symptomatic onset is predicted to delay institutionalization by 91 days, reducing Medicaid costs by $19,108/institutionalized patient. Incorporating an 18.5% cost offset from increased use of other medical services as well as drug costs associated with earlier treatment results in net savings of $12,687/patient. Projected annual Medicaid savings exceed $1 billion. CONCLUSION: Earlier treatment leads to a small delay in institutionalization among AD patients, resulting in significant costs savings to Medicaid.

[Prevention of frailty and dependency in older adults]. / Fragilité des personnes âgées et prévention de la dependence.

Aging is associated with the onset of frailty and chronic diseases, leading to physical and cognitive functional decline, reduced autonomy and, eventually, physical dependency. Persons aged 65 years or more should start to be screened in order to detect and prevent frailty, thus allowing the community to anticipate the consequences of aging rather than simply enduring them. According to the Trillard report commissioned by the French President, this could encourage economic growth and save up to 10 billion Euros per year: Fragile and pre-fragile elderly persons are not taken into account by our current healthcare system: it is only once they become truly dependent that they start to receive costly geriatric care Major medical advances could result from early detection of frailty and age-related diseases. In addition, development of specific medical, social and behavioural services could create new jobs and lead to greater economic efficiency. Our healthcare system will have to adapt rapidly to the growth in the elderly population. A pilot study conducted by the Toulouse Gerontopôle demonstrates the importance of screening, assessment and intervention for frail and pre-frail populations, who have previously been completely neglected by the French healthcare system.

Net costs of dementia in Sweden - an incidence based 10 year simulation study.

BACKGROUND: Aging of the population results in increasing number people suffering from dementia, and this will have a great impact on costs for the society. Because of the long duration of dementia disorders, it is difficult to collect empirical data for the whole survival period of incident cases. Therefore, modeling approaches are frequently used. The purpose of this study was to describe the costs of an incident dementia cohort with progression modeling. METHODS: Epidemiological data indicated that the incidence of dementia in Sweden was 24,000 people in 2005. Thus, incident cases were run in a Markov model for 10 cycles of 1 year each. Severity state specific costs were used and defined by Clinical Dementia Rating scale. RESULTS: Total cost for the cohort was 27.24 billion Swedish Krona (SEK). The mean cost per person and year was 269,558 SEK. Total cost for long-term institutional care was 21 billion SEK during the modeled period. CONCLUSION: Cost of long-term institutional care is the major cost driver, even in mild dementia.

North Carolina's institutional bias: enforcing the ADA's integration mandate.

Last year, the US Department of Justice determined that the state of North Carolina was violating the Americans with Disabilities Act by inappropriately institutionalizing people in adult care homes rather than providing them with housing and appropriate supports in the community. The state's long-standing institutional bias must now be corrected.

Institutional care versus home care for the elderly in a rural area: cost comparison in rural Japan.

INTRODUCTION: The rise in institutional care costs, such as that associated with care in chronic hospitals or nursing homes, is a serious social concern in Japan, and this is particularly so in rural areas which are more rapidly aging than others. This has led to a proposal to reduce costs by deinstitutionalizing the disabled elderly. However, the actual financial benefit of deinstitutionalizing the disabled elderly is unclear. OBJECTIVE: To examine the effectiveness of deinstitutionalizing the disabled elderly with the aim of cost reduction. METHODS: This study utilized a cross-sectional design and complete census survey. The participants were 139 residents of a rural town in Hokkaido who were institutionalized as of 1 July 2007, and whose Care Needs Levels were classified according to Long-Term Care Insurance (LTCI) in Japan. Of these, 87 participants were considered candidates for deinstitutionalization. Participants who were considered unable to stay alone at home, such as those with behavioral problems, at risk of falling, or in need of hospital medical care, were excluded. Data were collected on institutional care costs, and an original questionnaire was distributed asking institutional staff about participant characteristics and physical function levels. Existing costs were collected and costs were calculated if participants were discharged from institutions to their homes. RESULTS: Approximately 20% of participants lived alone, and 80% had a severe disability. The estimated costs of discharging patients to their homes were higher than existing institutional care costs for 98% of participants. The gap in cost tended to be greater in patients with higher care needs. CONCLUSION: The deinstitutionalization of disabled elderly is not an effective measure to help reduce healthcare costs in rural areas of Japan.

Assessing the cost-effectiveness of the rivastigmine transdermal patch for Alzheimer's disease in the UK using MMSE- and ADL-based models.

OBJECTIVE: Assess long-term cost-effectiveness of rivastigmine patch in Alzheimer's disease (AD) management in the UK, using cognitive and functional models based on clinical trial efficacy data. METHODS: Incremental costs and Quality Adjusted Life Years (QALYs) associated with rivastigmine patch and capsule treatment versus best supportive care (BSC) were calculated using two economic models, one based solely on Mini-Mental State Examination (MMSE) scores, and one also incorporating activities of daily living (ADL) scores. The clinical pathway was populated with data from a clinical trial of rivastigmine patch (9.5 mg/24 h) and capsules (12 mg/day) versus placebo. Costs were based on the UK health and social care costs and basic UK National Health Service (NHS) prices. Disease progression was modelled beyond the trial period over 5 years using published equations to predict natural decline in AD patients. Base case costing variables included drugs, clinical monitoring, and institutionalization. RESULTS: The MMSE model estimated incremental costs per QALY of £10 579 for rivastigmine patch and £15 154 for capsule versus BSC. The MMSE-ADL model estimated incremental costs per QALY of £9114 for rivastigmine patch and £13 758 for capsules. The main difference between the models was a greater number of institutionalized days avoided for rivastigmine versus BSC estimated by the MMSE-ADL model. CONCLUSIONS: Both the MMSE and MMSE-ADL models suggest that rivastigmine patch and capsules are cost-effective treatments versus BSC. Incorporating ADL evidence makes a marginal but important difference to estimates in this case. Future economic evaluations of AD treatment should include measures of both cognition and functioning.

Resource use and costs of end-of-Life/palliative care: Ontario adult cancer patients dying during 2002 and 2003.

The objective of this study is to estimate the direct medical cost of end-of-life and palliative (EOL/PAL) care for cancer patients during the last six months of their lives--or, during the period from diagnosis to death, if briefer--in 2002 and 2003, in Ontario, Canada. A linkage of cancer registry and administrative data is used to determine the costs of health care resources used during the EOL/PAL care period. Costs are analyzed by cancer diagnosis, location of death, and type of service. The total Ontario Ministry of Health-funded cost of EOL/PAL care for cancer patients is estimated to be about CAD$544 million per year, with an average per patient cost of about $25,000 in 2002-2003. Our results suggest that acute care consumes 75 percent of EOL/PAL funding and that only a small proportion of health care services used by EOL/PAL care cancer patients is likely to be formal palliative care.

A life-course approach to studying transitions among Canadian seniors in couple-only households.

This study tracked the occurrence of death, widowhood, institutionalization, and coresidence with others between 1994 and 2002 for a nationally representative sample of 1,580 Canadian respondents who, at initial interview, were aged 55 and older and living in a couple-only household. Although the majority of seniors remained in a couple-only household throughout the duration of the survey, nearly one in four who experienced a first transition underwent one or more subsequent transitions. Age, economic resources, and health were significant predictors of a specific first transition and multiple transitions. More work is needed to understand the dynamics of the aging process.

Impact of home and community-based services on hospitalisation and institutionalisation among individuals eligible for long-term care insurance in Japan.

BACKGROUND: This population-based retrospective cohort study aimed to clarify the impact of home and community-based services on the hospitalisation and institutionalisation of individuals certified as eligible for long-term care insurance (LTCI) benefits. METHODS: Health insurance data and LTCI data were combined into a database of 1,020 individuals in two farming communities in Hokkaido who were enrolled in Citizen's Health Insurance. They had not received long-term care services prior to April 1, 2000 and were newly certified as eligible for Long-Term Care Insurance benefits between April 1, 2000 and February 29, 2008. The analysis covered 565 subjects who had not been hospitalised or institutionalised at the time of first certification of LTCI benefits. The adjusted hazard ratios (HRs) of hospitalisation or institutionalisation or death after the initial certification were calculated using the Cox proportional hazard model. The predictors were age, sex, eligibility level, area of residence, income, year of initial certification and average monthly outpatient medical expenditures, in addition to average monthly total home and community-based services expenditures (analysis 1), the use or no use of each type of service (analysis 2), and average monthly expenditures for home-visit and day-care types of services, the use or no use of respite care, and the use or no use of rental services for assistive devices (analysis 3). RESULTS: Users of home and community-based services were less likely than non-users to be hospitalised or institutionalised. Among the types of services, users of respite care (HR: 0.71, 95% confidence interval [CI]: 0.55-0.93) and rental services for assistive devices (HR: 0.70, 95% CI: 0.54-0.92) were less likely to be hospitalised or institutionalised than non-users. For those with relatively light needs, users of day care were also less likely to be hospitalised or institutionalized than non-users (HR: 0.77, 95% CI: 0.61-0.98). CONCLUSIONS: Respite care, rental services for assistive devices and day care are effective in preventing hospitalisation and institutionalisation. Our results suggest that home and community-based services contribute to the goal of the LTCI system of encouraging individuals certified as needing long-term care to live independently at home for as long as possible.

Oral health care in private and small long-term care facilities: a qualitative study.

OBJECTIVE: Elderly people who are institutionalised receive qualified care. Among the services supplied, oral health care has not always been a priority. The aim of this study was to identify the characteristics of oral health care provided to the elderly residents in long-term care facilities (LTC) in Porto Alegre/RS city. METHODS: Twelve private and small-size LTCs (less than 20 residents) participated in this study. All supervisors and 36 carers were interviewed. The data obtained were organised according to the offer of oral health under the following categories: responsibility for oral care, oral care routines, difficulties carrying out oral care routines. RESULTS: The procedures used most often in order of frequency were tooth brushing, prostheses cleaning, use of mouthwashes, soaking of prostheses and cleaning of the tongue. Among the difficulties mentioned were the high cost of dental assistance, the lack of co-operation both by family members and by the elderly themselves, the oral and general health status of the elderly and the limited time available for carers to carry out the tasks. Oral care is conducted empirically, and the responsibility is left to the carers. CONCLUSIONS: Analysis of the statements given reveals that oral care does not follow any kind of protocol or standardisation. The persistence of this situation could lead to unsatisfactory oral health care in private and small LTC facilities.

Do Family Caregivers Offset Healthcare Costs for Older Adults? A Mapping Review on the Costs of Care for Older Adults With Versus Without Caregivers.

BACKGROUND AND OBJECTIVES: Older adults face significant long-term care and health care costs. But some of these costs can potentially be offset through family caregivers who may serve as substitutes for formal care or directly improve the care recipient's health and reduce health care utilization and expenditures. This article reviews the current literature to determine whether it is possible through existing work to compare the costs of care for individuals with versus without family caregivers and, if not, where the data, measurement, and other methodological challenges lie. RESEARCH DESIGN AND METHODS: A mapping review of published works containing information on health care utilization and expenditures and caregiving was conducted. A narrative approach was used to review and identify methodological challenges in the literature. RESULTS: Our review identified 47 articles that met our criteria and had information on caregiving and health care costs or utilization. Although findings were mixed, for the most part, having a family caregiver was associated with reduced health care utilization and a decreased risk of institutionalization however, the precise difference in health care expenditures for individuals with caregivers compared to those without was rarely examined, and findings were inconsistent across articles reviewed. DISCUSSION AND IMPLICATIONS: The number of family caregivers providing care to loved ones is expected to grow with the aging of the Baby Boomers. Various programs and policies have been proposed to support these caregivers, but they could be costly. These costs can potentially be offset if family caregivers reduce health care spending. More research is needed, however, to quantify the savings stemming from family caregiving.

Determinants of time to institutionalisation and related healthcare and societal costs in a community-based cohort of patients with Alzheimer's disease dementia.

OBJECTIVES: To examine the costs of caring for community-dwelling patients with Alzheimer's disease (AD) dementia in relation to the time to institutionalisation. METHODS: GERAS was a prospective, non-interventional cohort study in community-dwelling patients with AD dementia and their caregivers in three European countries. Using identified factors associated with time to institutionalisation, models were developed to estimate the time to institutionalisation for all patients. Estimates of monthly total societal costs, patient healthcare costs and total patient costs (healthcare and social care together) prior to institutionalisation were developed as a function of the time to institutionalisation. RESULTS: Of the 1495 patients assessed at baseline, 307 (20.5%) were institutionalised over 36 months. Disease severity at baseline [based on Mini-Mental State Examination (MMSE) scores] was associated with risk of being institutionalised during follow up (p < 0.001). Having a non-spousal informal caregiver was associated with a faster time to institutionalisation (944 fewer days versus having a spousal caregiver), as was each one-point worsening in baseline score of MMSE, instrumental activities of daily living and behavioural disturbance (67, 50 and 30 fewer days, respectively). Total societal costs, total patient costs and, to a lesser extent, patient healthcare-only costs were associated with time to institutionalisation. In the 5 years pre-institutionalisation, monthly total societal costs increased by more than £1000 (€1166 equivalent for 2010) from £1900 to £3160 and monthly total patient costs almost doubled from £770 to £1529. CONCLUSIONS: Total societal costs and total patient costs rise steeply as community-dwelling patients with AD dementia approach institutionalisation.

Time-varying effects of socio-demographic and economic factors on the use of institutional long-term care before dementia-related death: A Finnish register-based study.

OBJECTIVES: The effects of socio-demographic and economic factors on institutional long-term care (LTC) among people with dementia remain unclear. Inconsistent findings may relate to time-varying effects of these factors as dementia progresses. To clarify the question, we estimated institutional LTC trajectories by age, marital status and household income in the eight years preceding dementia-related and non-dementia-related deaths. METHODS: We assessed a population-representative sample of Finnish men and women for institutional LTC over an eight-year period before death. Deaths related to dementia and all other causes at the age of 70+ in 2001-2007 were identified from the Death Register. Dates in institutional LTC were obtained from national care registers. We calculated the average and time-varying marginal effects of age, marital status and household income on the estimated probability of institutional LTC use, employing repeated-measures logistic regression models with generalised estimating equations (GEE). RESULTS: The effects of age, marital status and household income on institutional LTC varied across the time before death, and the patterns differed between dementia-related and non-dementia-related deaths. Among people who died of dementia, being of older age, non-married and having a lower income predicted a higher probability of institutional LTC only until three to four years before death, after which the differences diminished or disappeared. Among women in particular, the probability of institutional LTC was nearly equal across age, marital status and income groups in the last year before dementia-related death. Among those who died from non-dementia-related causes, in contrast, the differences widened until death. CONCLUSIONS: We show that individuals with dementia require intensive professional care at the end of life, regardless of their socio-demographic or economic resources. The results imply that the potential for extending community living for people with dementia is likely to be difficult through modification of their socio-demographic and economic environments.

Medicare Part D and nursing home residents.

The objective of this study was to analyze national Part D formulary data to assess adequacy of coverage across seven drug classes commonly used by nursing home residents and older people, focusing on individuals dually eligible for Medicare and Medicaid and plans in which they enroll. Focusing at the molecule level, reasonably broad coverage across drug classes and minimal prior authorization overall was found. Of nonprotected classes, 69% of plans cover at least four of five Alzheimer's medications, 76% cover at least three of four bisphosphonates, 86% cover at least three of five proton pump inhibitors, and 61% cover at least four of six 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins). Nevertheless, a minority of plans are less generous, and some drug formulations important to nursing home residents are covered less well. For example, 11% of plans cover only one or two of the six statins. Of protected drug classes, plans generally cover all molecules, as expected. The majority of plans require no prior authorization for covered medications in six of seven classes reviewed (excepting bisphosphonates). A minority of plans once again are more stringent. For example, 22% and 9% of Part D Plans nationally require prior authorization for all covered Alzheimer's drugs and proton pump inhibitors, respectively. Random assignment of dually eligible patients to below-benchmark plans means that some residents initially will be enrolled in these more-restrictive plans. Part D allows nursing home residents to switch plans at any time, but there are important barriers to residents' self-advocacy. Finally, it is unclear how well nursing homes and the pharmacies they work with will work across Part D plans, and vigilance will be required as the benefit proceeds.

Independent sector mental health care: a 1-day census of private and voluntary sector placements in seven Strategic Health Authority areas in England.

The aims of this study were (i) to map the extent of all mental health placements in the independent sector, for adults of working age, and elderly people (excluding those with a diagnosis of dementia placed in Local Authority care homes), on a census date, across the areas in which the study was commissioned; (ii) to identify the characteristics of the population in placements; (iii) to explore some of the characteristics of the placements and the patterns of use within the private and voluntary sectors; and (iv) to identify the funding source of placements, and cost differences between the private and voluntary sector. The study took place in seven Strategic Health Authority areas, and information was sought from all Primary Care Trust and Social Services commissioners of mental health services, including regional secure commissioning teams, within those areas. A cross-sectional sample was used. Information was requested in relation to every individual meeting the inclusion criteria, placed in independent (private or voluntary) psychiatric hospitals, registered mental nursing homes and care homes on a specified study 'census date' of 28 June 2004 in six of the Strategic Health Authority areas, and 7 October 2004 in the seventh. Information was recorded on a standard questionnaire specifically designed for the study. Information was obtained on 3535 adults and 1623 elderly people in private or voluntary facilities. The largest groups of adults and elderly people had diagnoses of severe mental illnesses (42.1% and 30.5%, respectively), and placements were described as 'continuing care' or rehabilitation, with a 'niche' in specialist forensic care. Around four-fifths of units were in the private sector, which for adults was significantly more expensive than the voluntary sector. A large proportion of units (47.2% of adult placements and 59.3% of placements for elderly people) had only single placements from particular commissioning authorities, whilst others had large numbers, raising issues for effective commissioning. The distance of placements from patients' area of origin, is also an issue highlighted by the study. The study findings are discussed in relation to commissioning practice, and the development of the independent sector in mental health care.