Effect of Collaborative Dementia Care via Telephone and Internet on Quality of Life, Caregiver Well-being, and Health Care Use The Care Ecosystem Randomized Clinical Trial
Effect of Collaborative Dementia Care via Telephone and Internet on Quality of Life, Caregiver Well-being, and Health Care Use The Care Ecosystem Randomized Clinical Trial
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DOI：
10.1001/jamainternmed.2019.4101
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发表时间：
2019-12-01
影响因子：
39
通讯作者：
Miller, Bruce L.
中科院分区：
文献类型：
--
作者：
Possin, Katherine L.;Merrilees, Jennifer J.;Miller, Bruce L.
问题：护理生态系统，一个通过电话和互联网提供的痴呆症协作性护理计划，是否改善了对痴呆症患者、他们的照顾者和付款人重要的结果？在这项对3个州的城乡1560名参与者进行的随机临床试验中，关怀生态系统改善了痴呆症患者的生活质量，减少了急诊科就诊，并减少了照顾者的抑郁和负担。这项研究的结果表明，通过电话和互联网提供的集中枢纽提供的痴呆症护理管理可以减轻痴呆症日益增长的社会和经济负担。这项随机临床试验评估了通过电话和互联网提供痴呆症护理服务对3个州的城乡地区痴呆症患者及其照顾者与常规护理的关键结果的影响。重要的是，很少有卫生系统采用有效的痴呆症护理管理计划。护理生态系统是从广泛地理区域的集中枢纽向照顾者和痴呆症患者提供护理的模式，独立于他们的医疗系统附属关系。目的确定护理生态系统是否有效地改善了对残疾人、他们的照顾者和付款人来说重要的结果，而不是常规护理所取得的效果。设计、设置和参与者在残疾人及其照顾者中进行了一项务实设计的单盲、随机临床试验。每个PWD照顾者二人组在2015年3月20日至2017年2月28日期间注册了12个月。数据收集一直持续到2018年3月5日。加州旧金山和内布拉斯加州奥马哈的临床和研究团队通过电话和互联网进行研究干预和评估。在加利福尼亚州、爱荷华州或内布拉斯加州的2585名转介或志愿残疾照顾者二人组中，780人符合资格标准并被登记。共有512名PWD照顾者双亲被随机分配到通过关怀生态系统接受护理，268名双亲接受常规护理。所有符合条件的残疾人都有痴呆症的诊断；参加或有资格参加联邦医疗保险或医疗补助；会说英语、西班牙语或广东话。分析是意向治疗。干预电话协作痴呆症护理由训练有素的护理团队导航员提供，他们与痴呆症专家团队(高级执业护士、社会工作者和药剂师)一起提供教育、支持和护理协调。主要结果和测量主要结果衡量：阿尔茨海默病的生活质量基于照顾者对PWD幸福感的13个方面(包括身体健康、精力水平、情绪、生活状况、记忆力、人际关系和财务状况)的评分，满分为4分(从差到优)。次要结果：残疾人使用急诊科、住院和救护车服务的频率；照顾者抑郁(9项患者健康问卷得分；得分越高，表明抑郁越严重)；照顾者负担(12项Zarit Burden访谈得分；得分越高，表明照顾者负担越重)。结果780名残疾人(56.3%女性，平均年龄78.1[9.9]岁)和780名照顾者(70.9%女性，平均年龄64.7[12.0]岁)生活在加利福尼亚州(n=452)、内布拉斯加州(n=284)或爱荷华州(n=44)。在780个二元体中，655个在12个月时仍然活跃，571个完成了12个月的调查。与常规护理相比，护理生态系统改善了PWD生活质量(B，0.53；95%CI，0.25-1.30；P=0.04)，减少了急诊科就诊(B，-0.14；95%CI，-0.29至-0.01；P=0.04)，并减少了照顾者抑郁(B，-1.14；95%CI，-2.15至-0.13；P=0.03)和照顾者负担(B，-1.90；95%CI，-3.89至-0.08；P=.046)。结论和相关性可以从集中式中心提供有效的痴呆症护理管理，以补充通常的护理，并减轻痴呆症日益增长的社会和经济负担。
Question Does the Care Ecosystem, a program for collaborative dementia care delivered over the telephone and internet, improve outcomes important to persons with dementia, their caregivers, and payers? Findings In this randomized clinical trial of 1560 participants in rural and urban regions of 3 states, the Care Ecosystem improved quality of life of persons with dementia, reduced emergency department visits, and decreased caregiver depression and burden. Meaning This study's findings show that dementia care management delivered from centralized hubs over the telephone and internet could mitigate the growing societal and economic burdens of dementia.This randomized clinical trial assesses the effects of dementia care provision via telephone and internet on key outcomes for persons with dementia and their caregivers in rural and urban regions of 3 states compared with usual care.Importance Few health systems have adopted effective dementia care management programs. The Care Ecosystem is a model for delivering care from centralized hubs across broad geographic areas to caregivers and persons with dementia (PWDs) independently of their health system affiliations. Objective To determine whether the Care Ecosystem is effective in improving outcomes important to PWDs, their caregivers, and payers beyond those achieved with usual care. Design, Setting, and Participants A single-blind, randomized clinical trial with a pragmatic design was conducted among PWDs and their caregivers. Each PWD-caregiver dyad was enrolled for 12 months between March 20, 2015, and February 28, 2017. Data were collected until March 5, 2018. Study interventions and assessments were administered over the telephone and internet by clinical and research teams in San Francisco, California, and Omaha, Nebraska. Of 2585 referred or volunteer PWD-caregiver dyads in California, Iowa, or Nebraska, 780 met eligibility criteria and were enrolled. A total of 512 PWD-caregiver dyads were randomized to receive care through the Care Ecosystem and 268 dyads to receive usual care. All eligible PWDs had a dementia diagnosis; were enrolled or eligible for enrollment in Medicare or Medicaid; and spoke English, Spanish, or Cantonese. Analyses were intention-to-treat. Intervention Telephone-based collaborative dementia care was delivered by a trained care team navigator, who provided education, support and care coordination with a team of dementia specialists (advanced practice nurse, social worker, and pharmacist). Main Outcomes and Measures Primary outcome measure: Quality of Life in Alzheimer's Disease based on caregiver's rating of 13 aspects of PWD's well-being (including physical health, energy level, mood, living situation, memory, relationships, and finances) on a 4-point scale (poor to excellent). Secondary outcomes: frequencies of PWDs' use of emergency department, hospitalization, and ambulance services; caregiver depression (score on 9-Item Patient Health Questionnaire; higher scores indicate more severe depression); and caregiver burden (score on 12-Item Zarit Burden Interview; higher scores indicate more severe caregiver burden). Results The 780 PWDs (56.3% female; mean [SD] age, 78.1 [9.9] years) and 780 caregivers (70.9% female; mean [SD] age, 64.7 [12.0] years) lived in California (n = 452), Nebraska (n = 284), or Iowa (n = 44). Of 780 dyads, 655 were still active at 12 months, and 571 completed the 12-month survey. Compared with usual care, the Care Ecosystem improved PWD quality of life (B, 0.53; 95% CI, 0.25-1.30; P = .04), reduced emergency department visits (B, -0.14; 95% CI, -0.29 to -0.01; P = .04), and decreased caregiver depression (B, -1.14; 95% CI, -2.15 to -0.13; P = .03) and caregiver burden (B, -1.90; 95% CI, -3.89 to -0.08; P = .046). Conclusions and Relevance Effective care management for dementia can be delivered from centralized hubs to supplement usual care and mitigate the growing societal and economic burdens of dementia.