Claims data-based analysis of the influence of individual and regional characteristics on the utilisation of long-term care by people with dementia in Baden-Wurttemberg, Germany

Regional variations in healthcare in people living with dementia in Germany: protocol for a mixed-methods study

INTRODUCTION

Care for people living with dementia is both important and complex, and there is evidence of large regional variations in the quality of care. This study protocol describes design, methods and objectives of an investigation of regional variations in the utilisation, the quality and the costs of care for people living with dementia in Germany.

METHODS AND ANALYSIS

An exploratory, naturalistic, mixed-methods study is being conducted with three modules: Module A: A quantitative analysis of claims data of statutory health insurance will be conducted to investigate regional variations in the utilisation and costs of care. Module B: In selected regions of interest that deviate significantly from the average in terms of utilisation in Module A, the quality of care and patient characteristics, variations and possible causes of these variations in care will be examined in more detail using quantitative and qualitative assessments. Module C: The claims and primary data from modules A and B will be combined, synthesised and evaluated to elicit recommendations for regional healthcare using a participatory consensus method.

ETHICS AND DISSEMINATION

The study is overseen by the German Alzheimer's Association. The study's ethics and data protection plan was approved by the data and ethics committee of the leading university, Brandenburg Medical School Theodor Fontane (reference number: 152092023-BO-E) as well as the data committee of the three participating health insurances. Dissemination plans include dissemination of our main results to the general public, people affected, the scientific community and funding-, policy- and decision makers. Study outcomes and conclusions will be published on our own and the funder's websites, through presentations at conferences and in scientific journals. The funder ensures dissemination of main study results and recommendations for action to relevant organisations and institutions. Publication of the study's main results is planned within 6 months of the study's conclusion.

TRIAL REGISTRATION NUMBER

DRKS00031944 (https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00031944).

Rural and urban differences in quality of dementia care of persons with dementia and caregivers across all domains: a systematic review

BACKGROUND

There are challenges in healthcare service delivery in rural areas, and this may be especially true for persons with dementia, who have higher needs to access to the healthcare system, and may have difficulties to commute easily and safely to these services. There is a growing body of literature regarding geographical disparities, but there is no comprehensive systematic review of geographical differences in persons with dementia across all domains of care quality. Therefore, the objective of this study is to conduct a systematic review of the literature on rural and urban differences in quality of dementia care outcomes of persons with dementia across all quality-of-care domains.

METHODS

We performed a digital search in Ovid MEDLINE on July 16, 2019, updated on May 3, 2021, for French or English records. We selected studies that reported outcome from at least one domain of quality of dementia care (Access, Integration, Effective Care, Efficient Care, Population Health, Safety, and Patient-Centered) in both rural and urban persons with dementia or caregivers. We used rigorous, systematic methods for screening, selection, data extraction and we analyzed outcomes reported by at least two studies using vote counting and appraised the certainty of evidence. Finally, we explored sources of heterogeneity.

RESULTS

From the 38 included studies, we found differences in many dementia care domains. Rural persons with dementia had higher mortality rates (Population Health), lower visits to any physicians (Access), more hospitalizations but shorter stays (Integration), higher antipsychotic medications (Safety), lower use of home care services and higher use of nursing home (Patient-Centered Care) compared to urban persons with dementia.

CONCLUSIONS

This comprehensive portrait of rural-urban differences in dementia care highlights possible geographically based inequities and can be used by researchers and decision makers to guide development of more equitable dementia care policies.

Clustering 5-Year Multidimensional Health Care Trajectory Patterns in Alzheimer's Disease and Related Syndromes

OBJECTIVE

After diagnosis of Alzheimer's disease and related syndromes (ADRS), personalized care adapted to each patient's needs is recommended to provide a care plan and start symptomatic treatments according to guidelines. Over the past decade, dedicated structures and care have been implemented in various settings. Equal access to ADRS care, health care providers and services is crucial to ensure potential health benefits for everyone. However, the extent of use of recommended services and favorable health care utilization trajectories (HUT) may vary according to individual and contextual characteristics. The aim of this article was to (1) describe HUT patterns after multidimensional clustering of similar trajectories, (2) assess the proportion of individuals presenting favorable HUTs, and (3) identify factors associated with favorable HUTs.

DESIGN

Cohort study.

SETTING AND PARTICIPANTS

A cohort of 103,317 people newly diagnosed with ADRS identified in the French health reimbursement system (SNDS) was followed for 5 years with their monthly utilization on 11 health care dimensions.

METHODS

For 3 age groups (65-74, 75-84, ≥85 years), 15 clusters of patients were identified using partitioning around medoids applied to Levenshtein distances. They were qualitatively assessed by pluridisciplinary experts. Individual and contextual determinants of clusters denoting favorable trajectories were identified using mixed random effects multivariable logistic regression models.

RESULTS

Clusters with favorable HUTs denoting slow, progressive trajectories centered on at-home care, represented approximatively 25% of the patients. Determinants of favorable HUTs were mostly individual (age, female gender, absence of certain comorbidities, circumstances of ADRS identification, lower deprivation). Contextual determinants were also identified, in particular accessibility to nurses and nursing homes. Inter-territories variance was small but significant in all age groups (from 0.9% to 1.8%).

CONCLUSION AND IMPLICATIONS

Favorable HUTs remain the minority and many efforts can still be made to improve HUTs. Qualitative studies could help understanding underlying barriers to favorable HUTs.