Tailored educational intervention for primary care to improve the management of dementia: the EVIDEM-ED cluster randomized controlled trial

Trials

David Rapp¹  Frances Lefford¹  Ingela Thuné-Boyle¹  Priya Jain¹  Mark Griffin¹  Steve Iliffe¹  Jane Wilcock¹ 

[1] Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK

关键词: UK;    RCT;    Information management;    Family medicine;    Primary care;    General practice;    Memory disorders;    Dementia;   

Others  :  807893
DOI  :  10.1186/1745-6215-14-397

 received in 2013-07-11, accepted in 2013-11-07,  发布年份 2013

【 摘 要 】

Background

Early diagnosis of dementia is important because this allows those with dementia and their families to engage support and plan ahead. However, dementia remains underdetected and suboptimally managed in general practice. Our objective was to test the effect of a workplace-based tailored educational intervention developed for general practice on the clinical management of people with dementia.

Methods

The tailored educational intervention was tested in an unblinded cluster randomized controlled trial with a pre/post-intervention design, with two arms: usual/normal care control versus educational intervention. The primary outcome measure was an increase in the proportion of patients with dementia who received at least two documented dementia-specific management reviews per year. Case identification was a secondary outcome measure.

Results

23 practices in South-East England participated. A total of 1,072 patients with dementia (intervention: 512, control: 560) had information in their medical records showing the number of reviews within 12 months (or a proportion of) before intervention or randomization and within 12 months (or a proportion of) after. The mean total number of dementia management reviews after the educational intervention for people with dementia was 0.89 (SD 1.09; minimum 0; median 1; maximum 8) compared with 0.89 (SD 0.92; minimum 0; median 1; maximum 4) before intervention. In the control group prior to randomization the mean total number of dementia management reviews was 1.66 (SD 1.87; minimum 0; median 1; maximum 12) and in the period after randomization it was 1.56 (SD 1.79; minimum 0; median 1; maximum 11). Case detection rates were unaffected. The estimated incidence rate ratio for intervention versus control group was 1.03 (P = 0.927, 95% CI 0.57 to 1.86).

Conclusions

The trial was timely, coinciding with financial incentives for dementia management in general practice (through the Quality Outcomes Framework); legal imperatives (in the form of the Mental Capacity Act 2005); policy pressure (The National Dementia Strategy 2009); and new resources (such as dementia advisors) that increased the salience of dementia for general practitioners. Despite this the intervention did not alter the documentation of clinical management of patients with dementia in volunteer practices, nor did it increase case identification.

Trial registration

NCT00866099/Clinical Trials

【 授权许可】

   
2013 Wilcock et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 2.

【 参考文献 】

• [1]Bamford C, Lamont S, Eccles M, Robinson L, May C, Bond J: Disclosing a diagnosis of dementia: a systematic review. Int J Geriatr Psychiatry 2004, 19:151-169.
• [2]Pratt R, Wilkinson H: A psychosocial model of understanding the experience of receiving a diagnosis of dementia. Dementia 2003, 2:181-199.
• [3]Husband HJ: The psychological consequences of learning a diagnosis of dementia: three case examples. Aging Ment Health 1999, 3:179-183.
• [4]Smith AP, Beattie BL: Disclosing a diagnosis of Alzheimer’s disease: patients and families’ experiences. Can J Neurol Sci 2001, 28(Suppl 1):67-71.
• [5]Pucci E, Angeleri F, Borsetti G, Brizioli E, Cartechini E, Giuliani G, Solari A: General practitioners facing dementia: are they fully prepared? Neurol Sci 2004, 24:384-389.
• [6]Vernooij-Dassen M, Moniz-Cook E, Woods R, De Lepeleire J, Leuschner A, Zanetti O, de Rotrou J, Kenny J, Franco M, Peters V, Iliffe S: INTERDEM group: Factors affecting the timely recognition and diagnosis of dementia in primary care across eight European states: a modified focus group study. Int J Geriatr Psychiatry 2005, 20:1-10.
• [7]Boustani M, Peterson B, Hanson L, Harris R, Lohr KN, U.S. Preventive Services Task Force: Screening for dementia in primary care: a summary of the evidence for the US preventive services task force. Ann Int med 2003, 138:927-937.
• [8]NICE: NICE clinical guideline 42: Dementia. Supporting people with dementia and their carers in health and social care. [http://guidance.nice.org.uk/CG42/NICEGuidance/pdf/English webcite]
• [9]Turner S, Iliffe S, Downs M, Wilcock J, Bryans M, Levin E, Keady J, O'Carroll R: General practitioners’ knowledge, confidence and attitudes in the diagnosis and management of dementia. Age Ageing 2004, 33:461-467.
• [10]Iliffe S, Wilcock J: The identification of barriers to the recognition of and response to dementia in primary care using a modified focus group method. Dementia 2005, 4:73-85.
• [11]Perry M, Drascovic I, Lucassen P, Vernooij-Dassen M, van Achterberg T, Rikkert M: Effects of educational interventions on primary dementia care: systematic review. Int J Geriatr Psychiatry 2011, 26:1-11.
• [12]Department of Health: National Dementia Strategy. London, UK: DoH; 2009.
• [13]BMA: Quality and Outcomes Framework guidance for GMS contract 2011/12: Delivering investment in general practice. [http://www.nhsemployers.org/Aboutus/Publications/Documents/QOF_guidance_GMS_contract_2011_12.pdf webcite]
• [14]BMA: Quality and Outcomes Framework guidance for GMS contract 2009/10. [http://www.hscic.gov.uk/qof webcite]
• [15]Downs M, Turner S, Iliffe S, Bryans M, Wilcock J, Keady J, Levin E, O’Carroll RE, Howie K, Iliffe S: Effectiveness of educational interventions in improving detection and management of dementia in primary care: cluster randomized controlled study. BMJ 2006, 332:692-696.
• [16]Iliffe S, Jain P, Wong G, Lefford F, Gupta S, Warner A, Kennedy H: Dementia diagnosis in primary care: thinking outside the educational box. Aging Health 2009, 5:51-59.
• [17]Jordan ME, Lanham HJ, Crabtree BF, Nutting PA, Miller WL, Stange KC, McDaniel RR: The role of conversation in health care interventions: enabling sensemaking and learning Implementation. Science 2009, 4:15.
• [18]Grant J: Learning needs assessment: assessing the need. BMJ 2002, 324:156-159.
• [19]Green M: Evaluating evidence based practice performance. Evid Based Med 2006, 11:99-100.
• [20]Sackett D, Straus S: Finding and applying evidence during clinical rounds. JAMA 1998, 280:1336-1338.
• [21]Khunti K: Teaching evidence-based medicine using educational prescriptions in general practice. Med Teach 1998, 20:380-381.
• [22]Leykum LK, Palmer R, Lanham H, Jordan M, McDaniel RR, Noel PH, Parchman M: Reciprocal learning and chronic care model implementation in primary care. BMC Health Serv Res 2011, 11:44. BioMed Central Full Text
• [23]Nowlem PM: A New Approach to Continuing Education for Business and the Professions. New York, NY: MacMillan; 1988.
• [24]Grant J, Stanton F: The effectiveness of continuing professional development. Edinburgh, UK: The Association for the Study of Medical Education; 2000.
• [25]Iliffe S, Koch T, Jain P, Lefford F, Wong G, Warner A, Wilcock J: Developing an educational intervention on dementia diagnosis and management in primary care for the EVIDEM-ED trial. Trials 2012, 13:142. BioMed Central Full Text
• [26]Iliffe S, Wilcock J, Griffin M, Jain P, Thuné-Boyle I, Koch T, Lefford F: Evidence-based interventions in dementia: a pragmatic cluster-randomised trial of an educational intervention to promote earlier recognition and response to dementia in primary care (EVIDEM-ED). Trials 2010, 11:13. BioMed Central Full Text
• [27]Ukoumunne OC, Gulliford MC, Chinn S, Sterne JAC, Burney PCJ: Methods for evaluating area-wide and organisation-based interventions in health and health care: a systematic review. Health Technol Assess 1999, 3:5.
• [28]Research Randomizer: Research Randomizer, a free online tool available for researchers. [http://www.randomizer.org webcite]
• [29]Medical Research Council: Good Clinical Practice (GCP) in Clinical Trials. London, UK: MRC; 1998.
• [30]IBM: SPSS Statistics. [http://www-01.ibm.com/software/uk/analytics/spss/ webcite]
• [31]British Department for Communities and Local Government: The indices of deprivation 2010 (ID 2010) (DCLG). [https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/6871/1871208.pdf webcite]
• [32]Medical Research Council: A Framework for Development and Evaluation of RCTs for Complex Interventions to Improve Health. London, UK: MRC; 2000.
• [33]Kaulio M: Customer, consumer and user involvement in product development: a framework and a review of selected methods. Total Qual Manag Bus Excell 1998, 9:141-149.
• [34]Paton N, Callander R, Cavill M, Ning L, Weavell W: Collaborative quality improvement: consumers, carers and mental health service providers working together in service co-design. Australas Psychiatry 2013, 21:78-79.
• [35]Piper D, Ledema R, Gray J, Verma R, Holmes L, Manning N: Utilizing experience-based co-design to improve the experience of patients accessing emergency departments in New South Wales public hospitals: an evaluation study. Health Serv Manage Res 2012, 25:162-172.
• [36]Boyd H, McKernon S, Mullin B, Old A: Improving healthcare through the use of co-design. N Z Med J 2012, 125:76-87.
• [37]Bate P, Robert G: Experience-based design: from redesigning the system around the patient to co-designing services with the patient. Qual Saf Health Care 2006, 15:307-310.
• [38]Rubinstein L, Pugh J: Strategies for promoting organizational practice change by advancing implementation research. J Gen Intern Med 2006, 21:S58-S64.
• [39]Davis D, Mazmanian P, Fordis M, van Harrison R, Thorpe K, Perrier L: Accuracy of physician self-assessment compared with observed measures of competence. JAMA 2006, 296:1094-1102.