Health-related quality of life in Parkinson's disease: systematic review and meta-analysis of EuroQol (EQ-5D) utility scores

INTRODUCTION

Evaluating the Health-related quality of life (HRQoL) of individuals with Parkinson's disease (PD) holds significant importance in clinical and research settings. The EQ-5D is a widely recognized tool for comprehensive measurement of HRQoL using utility values. This study aims to systematically review and synthesize EQ-5D utility values from existing literature on patients with PD and their caregivers.

METHODS

We conducted a systematic search for studies that provided EQ-5D utility scores for patients with PD, using PubMed-Medline, Scopus, and Embase and selected the studies. The selected studies underwent systematic review, including an assessment of their quality. We performed a meta-analysis using a random-effect model and conducted a meta-regression analysis to investigate sources of heterogeneity among the studies.

RESULTS

The search result of 13,417 articles that were reviewed, 130 studies with 33,914 participants were selected for systematic review, and 79 studies were included for meta-analysis. The pooled EQ-5D utility values and visual analog score (VAS) among PD were 62.72% (60.53-64.93, I2 = 99.56%) and 0.60 (0.55-0.65, I2 = 99.81%), respectively. The pooled scores for caregivers' EQ-VAS and EQ-5D utility were 70.10% (63.99-76.20, I2 = 98.25%) and 0.71 (0.61-0.81, I2 = 94.88%), respectively. Disease duration (P < 0.05) showed a negative correlation with EQ-5D utility values on meta-regression.

CONCLUSION

The pooled utility values of PD and their caregivers help to understand their HRQoL and aid in conducting health economics research. The negative association between disease duration and utility values highlights the evolving nature of HRQoL challenges, suggesting the need for appropriate long-term disease management.

Stemming the Tide: The Proactive Role of Allied Health Therapy in Parkinson's Disease

Motor and nonmotor symptoms occur in early Parkinson's disease (PD), or even in the prodromal stage. Many of these symptoms can be addressed by allied health therapies, including physical therapy, occupational therapy, speech therapy, and psychological therapies. However, referrals to these services early in the disease are low. We provide a review summarizing the efficacy of proactive allied health interventions on motor and nonmotor symptoms and daily function in prodromal and early disease. We also highlight areas for additional research and provide recommendations to improve care for individuals with early PD within each discipline. We recognize the overlapping roles of the allied health disciplines and support integrated or transdisciplinary care beginning soon after diagnosis to help stem the tide in the progression of PD symptoms and disability.

Cost-Effectiveness Analyses of Non-Pharmacological and Non-Surgical Interventions in Idiopathic Parkinson's Disease: A Systematic Review

Background

Interest in non-pharmacological/non-surgical interventions to treat Parkinson's disease (PD) has substantially increased. Although a few health-economic studies have been conducted, summary information on the cost-effectiveness is still scarce.

Objective

To give an overview of cost-effectiveness analyses (CEA) focusing on non-pharmacological/non-surgical interventions in PD patients.

Methods

A systematic literature search was conducted in five databases. Studies were included that provided cost-effectiveness analysis (CEA) or cost-utility analysis (CUA) of non-pharmacological/non-surgical interventions in PD patients. Study quality was assessed with the Drummond and CHEERS 2022 checklists respectively, for economic evaluation.

Results

N = 9 studies published between 2012-2023 were identified. Most studies undertook a CUA (n = 5); n = 3 reported a combination of CEA and CUA, and n = 1 a pure CEA. Most studies (n = 6) examined physical exercise. The CEA studies identified additional costs of 170€ -660€  for the improvement of one single unit of a clinical outcome and savings of 18.40€ -22.80€  per score gained as measured with established instruments. The four studies that found significant quality of life benefits show large variations in the incremental cost effectiveness ratio (ICER) of 3,220€ -214,226€  per quality-adjusted life year (QALY); notably interventions were heterogenous regarding content and intensity.

Conclusions

Despite increasing numbers of non-pharmacological/non-surgical intervention trials in PD patients, health-economic evaluations are rare. The examined intervention types and health-economic results vary greatly. Together with the heterogeneity of the health-economic studies these factors limit the conclusions that can be drawn. Further research and a standardization of methods is needed to allow decision makers to make meaningful interpretations, and to allocate scarce resources.

Cost-effectiveness of occupational therapy for older adults: a protocol for an updated systematic review

INTRODUCTION

The ageing populations in developed countries are a global concern, with increasing numbers of older adults facing physical, cognitive and psychological challenges, resulting in reduced quality of life and higher healthcare costs. Healthcare expenditure worldwide has been on the rise, especially among older adults, emphasising the importance of enabling independent living while reducing healthcare costs. Occupational therapy holds promising outcomes in promoting functional independence and enhancing the quality of life for older adults, but research on its cost-effectiveness remains limited. This systematic review aims to evaluate the recent evidence on the cost-effectiveness of occupational therapy interventions for older adults from a pragmatic perspective.

METHODS AND ANALYSIS

This systematic review will cover full economic evaluations, including cost-effectiveness, cost-utility and cost-benefit analyses, by reviewing randomised and cluster randomised controlled trials. The participants will be aged over 65 years without disease or disability restrictions. Primary outcomes will be assessed using functional status and quality-of-life assessments. Studies published before July 2023 will be searched in PubMed, Web of Science and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, with no language restrictions.

ETHICS AND DISSEMINATION

Ethical approval is not required for this literature-based systematic review. The study's findings will update the evaluation of occupational therapy's cost-effectiveness in older adults and will be made public by publishing them in scholarly journals.

PROSPERO REGISTRATION NUMBER

CRD42023453558.

Cost-effectiveness of occupational therapy return-to-work interventions for people with mental health disorders: A systematic review

BACKGROUND

Return-to-work (RTW) resources for persons with mental health disorders are limited and costs are typically shared by several stakeholders in society. Occupational therapists (OT) provide RTW interventions for this target group, however, increased knowledge of health, and employment effects, as well as costs are needed to better inform decision makers in their prioritisations.

AIMS/OBJECTIVES

To identify and summarise evidence of cost-effectiveness of RTW interventions for persons with mental health disorders which OTs provide.

MATERIALS AND METHODS

A systematic search was applied and resulted in 358 articles. After screening, nine articles met inclusion criteria and were reviewed. Quality assessment was conducted using the economic evaluation tool by Joanna Briggs Institute.

RESULTS

Supported employment, Individual Placement and Support was cost-effective in several contexts while three studies showed larger effects and higher costs. An OT intervention added to treatment for major depression was indicated to be cost-beneficial and an advanced supported employment was cost-saving. The methodological quality varied considerably between studies.

CONCLUSIONS AND SIGNIFICANCE

The results of the included studies are promising, however, to further strengthen the economic perspective in OT RTW interventions, the need for conducting more and methodologically robust economic evaluations is crucial in future studies.

Systematic Review of Cost-Utility Analyses That Have Included Carer and Family Member Health-Related Quality of Life

OBJECTIVES

Health interventions for patients can also affect the health of their informal carers and family members. These changes in carer or family member health could be reflected in cost-utility analyses (CUAs) through the inclusion of their quality-adjusted life-years (QALYs). We conducted a systematic review to identify and describe all CUAs that have included family member health-related QALYs.

METHODS

A total of 4 bibliographic databases were searched from inception to July 2021. A 2-stage sifting process for inclusion of studies was undertaken. We performed data extraction using a standardized data extraction form and performed a narrative synthesis of the evidence.

RESULTS

A total of 40 CUAs published between 1999 and 2021 were identified. CUAs were conducted in 15 different countries. CUAs examined 13 different conditions including 15 CUAs on vaccination, 5 on Alzheimer's disease, 2 on Parkinson's disease, 3 on dementia, and 2 on terminal illness. The EQ-5D was the most commonly used measure of family member health. Generally, including carer QALYs resulted in lower incremental cost-effectiveness ratios.

CONCLUSIONS

When considering the total number of economic evaluations published, few have included family member QALYs and the methods for doing so are often inconsistent and data sources often limited. Estimation of family member QALYs in patient CUAs was regularly uncertain and often substantial in magnitude. The findings highlight the variation among methods and call for greater consistency in methods for incorporating family member QALYs in patient CUAs.

The Architecture of Contemporary Care Networks for Rare Movement Disorders: Leveraging the ParkinsonNet Experience

In this paper, we present a universal model for implementing network care for persons living with chronic diseases, specifically those with rare movement disorders. Building on our longstanding experience with ParkinsonNet, an integrated care network for persons living with Parkinson's disease or a form of atypical parkinsonism, we provide a series of generic, supportive building blocks to (re)design comparable care networks. We discuss the specific challenges related to rare movement disorders and how these challenges can inform a tailored implementation strategy, using the basic building blocks to offer practical guidance. Lastly, we identify three main priorities to facilitate network development for these rare diseases. These include the clustering of different types of rare movement disorders at the network level, the implementation of supportive technology, and the development of interdisciplinary guidelines.

From trials to clinical practice: Temporal trends in the coverage of specialized allied health services for Parkinson's disease

BACKGROUND AND PURPOSE

To determine how the coverage of specialized allied health services for patients with Parkinson's disease (PD) has developed in the Netherlands since the publication of trials that demonstrated cost-effectiveness.

METHODS

We used healthcare expenditure-based data on all insured individuals in the Netherlands to determine the annual proportion of patients with PD who received either specialized or generic allied health services (physiotherapy, occupational therapy, speech-language therapy) in 2 calendar years separated by a 5-year interval (2012 and 2017). Specialized allied health services were delivered through the ParkinsonNet approach, which encompassed professional training and concentration of care among specifically trained professionals.

RESULTS

Between 2012 and 2017, there was an increase in the number of patients with any physiotherapy (from 17,843 [62% of all patients with PD that year] to 22,282 [68%]), speech-language therapy (from 2171 [8%] to 3378 [10%]), and occupational therapy (from 2813 [10%] to 5939 [18%]). Among therapy-requiring patients, the percentage who were treated by a specialized therapist rose substantially for physiotherapy (from 36% in 2012 to 62% in 2017; χ²  = 2460.2; p < 0.001), speech-language therapy (from 59% to 85%; χ²  = 445.4; p < 0.001), and occupational therapy (from 61% to 77%; χ²  = 231.6; p < 0.001). By contrast, the number of patients with generic therapists did not change meaningfully. By 2017, specialized care delivery had extended to regions that had been poorly covered in 2012, essentially achieving nationwide coverage.

CONCLUSIONS

Following the publication of positive trials, specialized allied healthcare delivery was successfully scaled for patients with PD in the Netherlands, potentially serving as a template for other healthcare innovations for patients with PD elsewhere.

Activities of Daily Living and Associated Costs in the Most Widespread Neurodegenerative Diseases: A Systematic Review

Nowadays, the population is rapidly ageing because of increasing life expectancy and decreasing birth rates. Thus, the purpose of this systematic review is to prepare a comprehensive overview which identifies the activities of daily living (ADLs) that are gradually reduced among patients with dementia, as well as explore the therapies applied in relation to dementia and how they effectively improve the quality of life (QoL) of patients and caregivers. Furthermore, we aim to summarise the ADL activities influenced by therapies and examine the treatment costs and care for patients so that recommendations for research and development (R&D) can be made to improve both the QoL of people with dementia and cost-saving measures. The research focuses on four selected neurodegenerative diseases: Alzheimer, Parkinson, vascular dementia, and amyotrophic lateral sclerosis. Therefore, the peer-reviewed English written articles from 2014 to 2019 were searched between September 1 and December 13, 2019. Twenty-seven papers were included in the analysis. The results show that essential assistance occurs in connection with activities: eating, drinking, dressing, bathing, personal hygiene, use of the toilet, and transport. By contrast, shopping or cleaning is not addressed as much. A lower ability to take care of oneself is connected with poor patient health and higher social care costs because the patient requires care from external sources, such as home aid or nurse visits. The challenge that remains is to shift new knowledge from scientific disciplines and connect it with the needs of patients to remove legitimate barriers and increase the acceptance of new solutions by popularisation. Additionally, regarding the burden on caregivers, it would be appropriate to promote this area of education and employment so that family members can use formal caregivers, ensuring them free time and much-needed rest.

Parkinson Network Eastern Saxony (PANOS): Reaching Consensus for a Regional Intersectoral Integrated Care Concept for Patients with Parkinson's Disease in the Region of Eastern Saxony, Germany

As integrated care is recognized as crucial to meet the challenges of chronic conditions such as Parkinson's disease (PD), integrated care networks have emerged internationally and throughout Germany. One of these networks is the Parkinson Network Eastern Saxony (PANOS). PANOS aims to deliver timely and equal care to PD patients with a collaborative intersectoral structured care pathway. Additional components encompass personalized case management, an electronic health record, and communicative and educative measures. To reach an intersectoral consensus of the future collaboration in PANOS, a structured consensus process was conducted in three sequential workshops. Community-based physicians, PD specialists, therapists, scientists and representatives of regulatory authorities and statutory health insurances were asked to rate core pathway-elements and supporting technological, personal and communicative measures. For the majority of core elements/planned measures, a consensus was reached, defined as an agreement by >75% of participants. Additionally, six representatives from all partners involved in the network-design independently assessed PANOS based on the Development Model for Integrated Care (DMIC), a validated model addressing the comprehensiveness and maturity of integrated care concepts. The results show that PANOS is currently in an early maturation state but has the potential to comprehensively represent the DMIC if all planned activities are implemented successfully. Despite the favorable high level of consensus regarding the PANOS concept and despite its potential to become a balanced integrated care concept according to the DMIC, its full implementation remains a considerable challenge.

Cost-Utility Analyses of Interventions for Informal Carers: A Systematic and Critical Review

BACKGROUND

Demographic and epidemiological changes place an increasing reliance on informal carers. Some support programmes exist, but funding is often limited. There is a need for economic evaluation of interventions for carers to assist policymakers in prioritizing carer support.

OBJECTIVE

Our aim was to systematically review and critically appraise cost-utility analyses of interventions for informal carers, in order to assess the methods employed and the quality of the reporting.

METHODS

A systematic review of databases was conducted using MEDLINE, Embase, PsycINFO, and EconLit of items published between 1950 and February 2019. Published studies were selected if they involved a cost-utility analysis of an intervention mainly or jointly targeting informal carers. The reporting quality of economic analyses was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement.

RESULTS

An initial set of 1364 potentially relevant studies was identified. The titles and the abstracts were then screened, resulting in the identification of 62 full-text articles that warranted further assessment of their eligibility. Of these, 20 economic evaluations of informal carer interventions met the inclusion criteria. The main geographical area was the UK (n = 11). These studies were conducted in mental and/or behavioural (n = 15), cardiovascular (n = 3) or cancer (n = 2) clinical fields. These cost-utility analyses were based on randomized clinical trials (n = 16) and on observational studies (n = 4), of which only one presented a Markov model-based economic evaluation. Four of the six psychological interventions were deemed to be cost effective versus two of the four education/support interventions, and four of the nine training/support interventions. Two articles achieved a CHEERS score of 100% and nine of the economic evaluations achieved a score of 85% in terms of the CHEERS criteria for high-quality economic studies.

CONCLUSIONS

Our critical review highlights the lack of cost-utility analyses of interventions to support informal carers. However, it also shows the relative prominence of good reporting practices in these analyses that other studies might be able to build on.

Using Medical Claims Analyses to Understand Interventions for Parkinson Patients

The scientific evidence to support the value of a range of non-pharmacological interventions for people with Parkinson’s disease (PD) is increasing. However, showing unequivocally that specific interventions are better than usual care is not straightforward because of generic drawbacks of clinical trials. Here, we address these challenges, specifically related to the context of evaluating complex non-pharmacological interventions for people with PD. Moreover, we discuss the potential merits of undertaking “real world” analyses using medical claims data. We illustrate this approach by discussing an interesting recent publication in The Lancet Neurology, which used such an approach to demonstrate the value of specialized physiotherapy for PD patients, over and above usual care physiotherapy.

Multidisciplinary Care to Optimize Functional Mobility in Parkinson Disease

This review elaborates on multidisciplinary care for persons living with Parkinson disease by using gait and balance impairments as an example of a treatable target that typically necessitates an integrated approach by a range of different and complementary professional disciplines. Using the International Classification of Functioning, Disability, and Health model as a framework, the authors discuss the assessment and multidisciplinary management of reduced functional mobility due to gait and balance impairments. By doing so, they highlight the complex interplay between motor and nonmotor symptoms, and their influence on rehabilitation. They outline how multidisciplinary care for Parkinson disease can be organized.

Incorporating Household Spillovers in Cost Utility Analysis: A Case Study Using Behavior Change in COPD

OBJECTIVES

It is important to capture all health effects of interventions in cost-utility analyses conducted under a societal or healthcare perspective. However, this is rarely done. Household spillovers (health effects on patients' other household members) may be particularly likely in the context of technologies and interventions to change behaviors that are interdependent in the household. Our objective was to prospectively collect outcome data from household members and illustrate how these can be included in a cost-utility analysis of a behavior change intervention in chronic obstructive pulmonary disease (COPD).

METHODS

Data were collected from patients' household members (n = 153) alongside a randomized controlled trial of a COPD self-management intervention. The impact of the intervention on household members' EQ-5D-5L scores (primary outcome), was evaluated. Analyses were then carried out to estimate household members' quality-adjusted life-years (QALYs) and assess the impact of including these QALYs on cost-effectiveness.

RESULTS

The intervention had a negligible spillover on household members' EQ-5D-5L scores (-0.007; p = .75). There were also no statistically significant spillovers at the 5 percent level in household member secondary outcomes. In the base-case model, the inclusion of household member QALYs in the incremental cost-effectiveness ratio (ICER) denominator marginally increased the ICER from GBP 10,271 (EUR 13,146) to GBP 10,991 (EUR 14,068) per QALY gained.

CONCLUSIONS

This study demonstrates it is feasible to prospectively collect and include household members' outcome data in cost utility analysis, although the study highlighted several methodological issues. In this case, the intervention did not impact significantly on household members' health or health behaviors, but inclusion of household spillovers may make a difference in other contexts.

Parental Health Spillover in Cost-Effectiveness Analysis: Evidence from Self-Harming Adolescents in England

OBJECTIVE

This article presents alternative parental health spillover quantification methods in the context of a randomised controlled trial comparing family therapy with treatment as usual as an intervention for self-harming adolescents, and discusses the practical limitations of those methods.

METHODS

The trial followed a sample of 754 participants aged 11-17 years. Health utilities are measured using answers to the EuroQoL 5 Dimensions 3 Levels (EQ-5D-3L) for the adolescent and the Health Utility Index (HUI2) for one parent at baseline, 6 and 12 months. We use regression analyses to evaluate the association between the parent's and adolescent's health utilities as part of an explanatory regression model including health-related and demographic characteristics of both the adolescent and the parent. We then measure cost-effectiveness over a 12-month period as mean incremental cost-effectiveness ratios using various spillover quantification methods. We propose an original quantification based on the use of a household welfare function along with an equivalence scale to generate a health gain within the family to be added to the adolescent's quality-adjusted life-year gain.

RESULTS

We find that the parent's health utility increased over the duration of the trial and is significantly and positively associated with adolescent's health utility at 6 and 12 months but not at baseline. When considering the adolescent's health gain only, the incremental cost-effectiveness ratio is £40,453 per quality-adjusted life-year. When including the health spillover to one parent, the incremental cost-effectiveness ratio estimates range from £27,167 per quality-adjusted life-year to £40,838 per quality-adjusted life-year and can be a dominated option depending on the quantification method used.

CONCLUSION

According to the health spillover quantification method considered, the incremental cost-effectiveness ratios vary from within the National Institute for Health and Care Excellence (NICE) cost-effectiveness threshold range to not being cost-effective.

Economic Evaluation of Interventions in Parkinson's Disease: A Systematic Literature Review

BACKGROUND

Parkinson's disease (PD) management comprises of drug treatments, surgery, and physical activity/occupational therapies to relieve PD's symptoms. The aim of this study is twofold; first, to appraise recent economic evaluation studies on PD management in order to update the existing knowledge; and second, to facilitate decision making on PD management by assessing the cost-effectiveness of all types of PD interventions.

METHODS

A systematic search for studies published between 2010 and 2018 was conducted. The inclusion and exclusion of the articles were based on criteria relevant to population, intervention, comparison, outcomes, and study design (PICO). The reporting quality of the articles was assessed according to Consolidated Health Economic Evaluation Reporting Standards.

RESULTS

Twenty-eight articles were included, 10 of which were evaluations of drug treatments, 10 deep brain stimulation (DBS), and eight physical/occupational therapies. Among early-stage treatments, Ti Ji dominated all physical activity interventions; however, its cost-effectiveness should be further explored in relation to its duration, intensity, and frequency. Multidisciplinary interventions of joint medical and nonmedical therapies provided slightly better health outcomes for the same costs. In advanced PD patients, adjunct drug treatments could become more cost-effective if introduced during early PD and, although DBS was more cost-effective than adjunct drug therapies, the results were time-bound.

CONCLUSIONS

Conditionally, certain PD interventions are cost-effective. However, PD progression differs in each patient; thus, the cost-effectiveness of individually tailored combinations of interventions that could provide more time in less severe disease states and improve patients' and caregivers' quality of life, should be further explored.

ParkinsonNet: A Low-Cost Health Care Innovation With A Systems Approach From The Netherlands

ParkinsonNet, a low-cost innovation to optimize care for patients with Parkinson disease, was developed in 2004 as a network of physical therapists in several regions in the Netherlands. Since that time, the network has achieved full national reach, with 70 regional networks and around 3,000 specifically trained professionals from 12 disciplines. Key elements include the empowerment of professionals who are highly trained and specialized in Parkinson disease, the empowerment of patients by education and consultation, and the empowerment of integrated multidisciplinary teams to better address and manage the disease. Studies have found that the ParkinsonNet approach leads to outcomes that are at least as good as, if not better than, outcomes from usual care. One study found a 50 percent reduction in hip fractures and fewer inpatient admissions. Other studies suggest that ParkinsonNet leads to modest but important cost savings (at least US$439 per patient annually). These cost savings outweigh the costs of building and maintaining the network. Because of ParkinsonNet's success, the program has now spread to several other countries and serves as a model of a successful and scalable frugal innovation.

Economic evaluations of occupational therapy approaches for people with cognitive and/or functional decline: A systematic review

With the ageing of the world's population comes significant implications for nearly all sectors of society, including health and aged care spending. Health and aged care systems need to respond to the increasing need for services for older people. Occupational therapy is concerned with maintaining a person's functional independence and well-being from preventative and treatment perspectives. The aim of this systematic review was to identify the costs and outcomes of occupational therapy for people with cognitive and/or functional decline. The searches for this review were conducted on 23 September 2016 and updated on 20 April 2017. Full economic evaluation studies, partial economic evaluations, randomised trials reporting estimates of resource use or costs associated with intervention(s) and comparator(s) and studies with pre- and post-intervention cost comparators were included. Thirteen studies met the inclusion criteria. The type and duration of occupational therapy intervention in the included studies varied, ranging from one-off assessments through to systematic multicomponent programmes. Results suggested that structured occupational therapy interventions which comprised of multiple consultations and engaged caregivers delivered better functional and economic outcomes.

Effectiveness and costs of specialised physiotherapy given via ParkinsonNet: a retrospective analysis of medical claims data

BACKGROUND

Parkinson's disease is a complex condition that is best managed by specialised professionals. Trials show that specialised allied health interventions are cost-effective, as compared with usual care. We aimed to study the long-term benefits of specialised physiotherapy using the ParkinsonNet approach in real-world practice.

METHODS

We did an observational study, retrospectively analysing a database of health insurance claims that included a representative population of Dutch patients with Parkinson's disease, who were followed for up to 3 years (Jan 1, 2013, to Dec 31, 2015). Eligibility criteria included having both a diagnosis of Parkinson's disease and having received physiotherapy for the disease. Allocation to specialised or usual care physiotherapy was based on the choices of patients and referring physicians. We used a mixed-effects model to compare health-care use and outcomes between patients treated by specialised or usual care physiotherapists. The primary outcome was the percentage of patients with a Parkinson's disease-related complication (ie, visit or admission to hospital because of fracture, other orthopaedic injuries, or pneumonia) adjusted for baseline variables. We compared physiotherapist caseload, the number of physiotherapy sessions, physiotherapy costs, and total health-care costs (including hospital care, but excluding community care, long-term care, and informal care) between the groups, and used a Cox's proportional hazard model for survival time to establish whether mortality was influenced by treatment by a specialised physiotherapist.

FINDINGS

We analysed 2129 patients (4649 observations) receiving specialised physiotherapy and 2252 patients (5353 observations) receiving usual care physiotherapy. Significantly fewer patients treated by a specialised physiotherapist had a Parkinson's disease-related complication (n=368 [17%]) than patients treated by a usual care physiotherapist (n=480 [21%]; odds ratio 0·67, 95% CI 0·56-0·81, p<0·0001). The annual caseload of patients per therapist was significantly higher for specialised physiotherapists (mean 3·89 patients per therapist [SD 3·91]) than usual care physiotherapists (1·48 [1·24]). Patients who saw specialised physiotherapists received fewer treatment sessions (mean 33·72 [SD 26·70]) than usual care physiotherapists (47·97 [32·11]). Consequently, expenditure was lower for specialised than usual care physiotherapists, both for direct costs (mean €933 [SD 843] vs €1329 [1021]; annual difference €395, 95% CI 358-432, p<0·0001) and total health-care expenditure (€2056 [3272] vs €2586 [3756]; €530, 391-669, p<0·0001). Mortality risk was lower for patients receiving specialised physiotherapy (134 [6%]) compared with patients receiving usual care physiotherapy (205 [9%], p=0·001) before correction for baseline variables, although Cox's survival model showed no significant difference between the two (hazard ratio 0·86, 95% CI 0·69-1·07, p=0·195).

INTERPRETATION

These results confirm the findings from controlled trials, and offer evidence that specialised physiotherapy as delivered through ParkinsonNet is associated with fewer Parkinson's disease-related complications and lower costs in real-world practice. Neurologists can facilitate specialised physiotherapy by specific referral to such experts.

FUNDING

None.

Palliative Care for Patients and Families With Parkinson's Disease

Parkinson's disease is the second most common neurodegenerative disease worldwide. There is widespread consensus that Parkinson patients, their carers, and clinicians involved in their care would benefit from a fully integrated, need-based provision of palliative care. However, the concept of palliative care in Parkinson's disease is still poorly defined and, consequently, poorly implemented into daily clinical practice. A particular challenge is the gradually progressive nature of Parkinson's disease-with insidiously increasing disability-making it challenging to clearly define the onset of palliative care needs for Parkinson patients. As people with Parkinson's disease are now living longer than in the past, future research needs to develop a more robust evidence-based approach to clarify the disease events associated with increased palliative care needs, and to examine these, prospectively, in an integrated palliative care service. The modern palliative care outlook, termed "simultaneous care,",is no longer restricted to the final stage of disease. It involves incorporating a continuity of care, effective management of the chronic-palliative interface, and a multidisciplinary network of professionals working both in the community and in specialized clinics, with active involvement of caregivers. Although promising, there is still a need to demonstrate the effectiveness of palliative care for patients with Parkinson's disease.

Living with Parkinson's and the Emerging Role of Occupational Therapy

Parkinson's disease is a chronic and increasingly complex condition, demanding multidisciplinary management. Over the last twenty years or so, alongside the growth of specialist services and healthcare teams specifically developed for people with Parkinson's, occupational therapy has grown in recognition as a treatment option, especially since evidence of its efficacy is now slowly emerging. The purpose of this work is to outline the role of occupational therapy clinical practice in the management of people living with Parkinson's disease and its emergent evidence base, combined with details of current occupational therapy philosophy and process, as applicable to occupational therapy practice for people with Parkinson's. The Canadian Practice Process Framework is used to structure this overview and was selected because it is a well-recognized, evidence-based tool used by occupational therapists and encompasses the core concepts of human occupation and person-centred practice. The framework employed allows the flexibility to reflect the pragmatic occupational therapy intervention process and so enables the illustration of the individually tailored approach required to accommodate to the complex pathology and personal, domestic, and social impacts, affecting the functioning of Parkinson's disease patients on a daily basis.

What is the evidence to support home environmental adaptation in Parkinson's disease? A call for multidisciplinary interventions

"Home" is where one has a sense of belonging and feels secure, but it can also be a risky place for people with Parkinson's disease (PD). PD patients need assistance making adjustments to their physical environment to maintain appropriate care and provide a safe environment. This relationship is called the "person-environmental fit" (P-E fit). While most PD patients remain in their own homes, little is known about the specific challenges that PD patients and their caregivers encounter in the routine activities of daily living. The aim of our study was to identify the existing evidence on the issue of housing environmental adaptation in PD by performing a systematic review with a proposal of development strategies to integrate a multidisciplinary team into a home environmental research. MEDLINE, and life science journals were searched by querying appropriate key words, but revealed very few publications in this area. However, early evidence suggested that PD patients do not enjoy an adequate P-E fit in their own homes and face more functional limitations compared to matched controls. We concluded that we need to develop research-based evaluation strategies that can provide us with a theoretical and conceptual basis as well as tools for analysis of the P-E fit for PD patients and caregivers. We recommend that individual members of the multidisciplinary team including patients, caregivers, physicians, rehabilitation specialists, and social workers use a team approach to identify the key indicators and solutions for the development of PD-specific solutions for improving the P-E fit.

Nonpharmacological treatments for patients with Parkinson's disease

Since 2013, a number of studies have enhanced the literature and have guided clinicians on viable treatment interventions outside of pharmacotherapy and surgery. Thirty-three randomized controlled trials and one large observational study on exercise and physiotherapy were published in this period. Four randomized controlled trials focused on dance interventions, eight on treatment of cognition and behavior, two on occupational therapy, and two on speech and language therapy (the latter two specifically addressed dysphagia). Three randomized controlled trials focused on multidisciplinary care models, one study on telemedicine, and four studies on alternative interventions, including music therapy and mindfulness. These studies attest to the marked interest in these therapeutic approaches and the increasing evidence base that places nonpharmacological treatments firmly within the integrated repertoire of treatment options in Parkinson's disease.