Yorkshire and Humberside Strategic Clinical Networks: Regional Leads Meeting 12 May 2015 Raphael...
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Transcript of Yorkshire and Humberside Strategic Clinical Networks: Regional Leads Meeting 12 May 2015 Raphael...
Yorkshire and Humberside Strategic Clinical Networks: Regional Leads Meeting
12 May 2015
Raphael WittenbergPersonal Social Services Research Unit
London School of Economics and Political Science
The evidence and economic case for post diagnostic support for people with dementia
The evidence and economic case for post diagnostic support for people with dementia
The work I am presenting was conducted by colleagues at the Personal Social Services Research Unit (PSSRU) at LSE
Some of it was supported by:•the Department of Health (DH) for England•NHS England •the National Institute for Health Research (NIHR) •the Economic and Social Research Council•the Alzheimer’s Society.
All views expressed in this presentation are those of the presenter, and are not necessarily those of the DH, NHSE, NIHR, ESRC or Alzheimer’s Society.
Acknowledgements and Disclaimer Acknowledgements and Disclaimer
•Dementia scenarios study for G7 Dementia Event, June 2014•Cost of Illness Study for Dementia UK second edition report, funded by the Alzheimer’s Society, September 2014•Alzheimer’s disease scenarios modelling for the Office for Life Sciences, November 2014•Economic analyses for a range of trials of different interventions•Economic case for dementia care, funded by NHS England, started this month•Comprehensive approach to modelling outcome and cost impacts of interventions for dementia(Modem), funded by the ESRC and NIHR, 2014 to 2018
PSSRU Studies of DementiaPSSRU Studies of Dementia
Estimates by PSSRU for Dementia UK: 2nd edition published by the Alzheimer’s Society Sept 2014
Annual cost of dementia in the UKAnnual cost of dementia in the UK
Total cost = £26.3 billionAverage cost per person (for the 816,000 people
with dementia) = £32,250
This is a 24% real terms increase in just 7 years
Average annual cost per person - depends on severity and care setting
Average annual cost per person - depends on severity and care setting
£25,723
£42,841£55,197
£36,738
Prince, Knapp et al Dementia UK 2nd Edition, 2014
These are just aggregate costs (not cost-effectiveness findings) – some are good and some bad:
‘Good costs’ – appropriate (evidence-based) treatment and care responses to assessed needs; and responding to individual preferences.
‘Bad costs’ – result from late or no diagnosis, unavailability of effective care, crisis admissions to hospital, unnecessarily long inpatient stays etc.
We must shift the balance from ‘bad’ to ‘good’ – by making evidence-based treatment & care much more widely available.
Good and bad costsGood and bad costs
o Risk reduction
o Screening & diagnosis
o Carer support
o Staff skills training
o Medications
o Psychosocial treatments
o Home-based care
o Case management
o Awareness and attitudes
Responding to the challenge: what works?
Responding to the challenge: what works?
For each area there is (some) international
evidence on effectiveness; not
much on cost-effectiveness.
+++++++++++Many trials underway
+++++++++++Review of evidence
now underway (MODEM)
Knapp et al Int J Geriatric Psychiatry 2013; Lombard et al In prep’n
Individual programme (8 sessions over 8-14 weeks, delivered by psychology graduates + manual); carers given techniques to:
ounderstand behaviours of person they care for
omanage behaviour
ochange unhelpful thoughts
opromote acceptance
oimprove communication
oplan for the future
orelax
oengage in meaningful, enjoyable activities.
START: a manual-based coping strategy
START: a manual-based coping strategy
Livingston et al BMJ 2013; Knapp et al BMJ 2013; Livingston et al submitted
Pragmatic, multicentre RCT – START vs usual support.
n=260 family carers of people with dementia, North London area.
Analyses 8 & 24 months after end of intervention
Carers with usual support were 4 times more likely to have clinically significant depression than carers with START; HADS-total = 2.10 (95% CI 0.51 to 3.75).Small incremental QALY gain for START group; mean 0.042 (95% CI 0.015 to 0.071). (QALY = quality-adjusted life year)
Livingston et al BMJ 2013
START improved carer mental health and
health-related quality of life over 8 months.
START: outcomes at 8 months
START: outcomes at 8 months
Carers getting START had slightly but not significantly higher costs (£252; 95% CI -28 to +565), adjusting for baseline.Cost-effectiveness: £118 (€201) per 1-point change on HADS-total; and £6000 (€7620) per additional QALY (quality-adjusted life year) … measuring carer service use only.
Cost of START was offset by reduced use of
other services by carers over 8
months. START is cost-effective.
Cost-effectiveness at 8 months
Cost-effectiveness at 8 months
Knapp et al BMJ 2013
Effects on carers:oBetter mental health: carers with usual support were 7 times more likely to have clinically significant depressionoSignificantly better quality of life
Outcomes & cost-effectiveness at 24 months
Outcomes & cost-effectiveness at 24 months
Livingston et al Lancet Psych 2014
Effects on people with dementia:oNo differences in health status or quality of lifeoSome delay to care home admission (not (yet?) significant)
Service costs go up in both groups over time; but care home costs go up more for people in the usual care group.Cost-effectiveness: START has better outcomes and doesn’t cost any more … It is clearly cost-effective.
CST is a group intervention in care homes & day centres for people with mild-to-moderate dementia: themed activities to stimulate cognitive function.Effective and cost-effective if delivered bi-weekly over 7 weeks.Maintenance CST (weekly for 24 weeks) improves QOL; in combination with ACHEI meds it improves cognition.Also cost-effective over 24 weeks, especially with ACHEIs.
Cognitive stimulation therapy (CST)Cognitive stimulation therapy (CST)
Woods et al Cochrane 2012; Orrell et al BJPsychiatry 2014; D’Amico et al, submitted
Home-based care Home-based care
Worringly little evidence on what works in home care.Patterns of home support provided to people with dementia and their carers - study led by David Challis (reporting 2015)Reablement home care – no direct evidence for people with dementia, but Glendinning et al (2010) report some success.
Glendinning et al SPRU/PSSRU report 2010; Hirani et al Age & Ageing 2014; Henderson et al Age & Ageing 2014
What evidence there is suggests quality of care is highly variable, and often very poor (e.g. see recent report from group chaired by Paul Burstow).
Home-based care Home-based care
Surprisingly little evidence on what works in home care.Patterns of home support provided to people with dementia and their carers - study led by David Challis (reporting 2015)Reablement home care – no direct evidence for people with dementia, but Glendinning et al (2010) report some success.
Glendinning et al SPRU/PSSRU report 2010; Hirani et al Age & Ageing 2014; Henderson et al Age & Ageing 2014
Telecare is widely seen as long-term solution. However, today’s evidence is not encouraging: oWSD trial telecare for (all) older people offers ‘small relative benefits’ over usual care, but is not cost-effective (cost per QALY = £297,000).
So, are robots the future?
• Summarise and update the existing evidence base on the cost-effectiveness of treatments and care arrangements;
• Identify those interventions that are consistent with both national policy frameworks and practice guidance, and for which an economic case might be developed;
• Summarise, update or generate (e.g. through simulation modelling) a corpus of up-to-date economic evidence on those interventions that is relevant to the English context;
• Prepare an accessible summary of that evidence that could potentially be useful to commissioners as they make their decisions.
Dementia treatment and care: making the economic case: new study
Dementia treatment and care: making the economic case: new study
o How many people with dementia between now and 2040?
o What will be the costs and outcomes of their treatment, care and support under present arrangements?
o How do these costs and outcomes vary with individual characteristics and circumstances?
o How could costs and cost-effectiveness change if better interventions were more widely available and accessed?
Methods – data-heavy modelling:
o Micro-simulation, macro-simulation, care pathways
MODEM: a projections study (2014-18)MODEM: a projections study (2014-18)
Team: Martin Knapp, Mauricio Avendano, Sally-Marie Bamford, Sube Banerjee, Ann Bowling, Adelina Comas, Margaret Dangoor, Josie Dixon, Emily Grundy, Bo Hu, Carol Jagger, Maria Karagiannidou, Derek King, Daniel Lombard, David McDaid, Jitka Pikhartova, Amritpal Rehill, Raphael Wittenberg,