A valid instrument for measuring informal care time for people with dementia.

OBJECTIVE: An economic evaluation of dementia-related interventions from a societal perspective should take account of informal caregiving. We assessed informal caregiving time and report our findings on the validity and stability of our results. METHODS: Within the German IDA study ('Dementia Care Initiative in Primary Practice'), informal care time for people with dementia living at home is assessed. We applied a German adaptation of the Resource Utilization in Dementia (RUD) questions on informal care, which distinguishes three categories of informal care activities: Activities of Daily Living (ADL), Instrumental ADL (IADL), and supervision. In contrast to the original version, we included the time of all informal caregivers who are involved in caring for the patient. The questionnaire was completed as a computer-assisted telephone interview at baseline and after 1 year. To test the plausibility of the questionnaire, we proposed seven hypotheses about the reported informal care time. RESULTS: Nearly all results confirmed our hypotheses. Informal care time as well as changes over time correlated with the physical and mental health status of the patient. Considering the time of other informal caregivers led to slightly higher correlations (not significant). The results indicate that interviewees seem to underestimate particularly the time of supervision of other informal caregivers. CONCLUSION: In sum, the instrument gives plausible results and is suited for measuring informal care time, as well as changes over time. If it is not possible to directly interview each caregiver involved, it is of great importance to identify and interview the primary informal caregiver in order to prevent an underestimation of total informal care time.

Measurement of informal care time in a study of patients with dementia.

BACKGROUND: Previous assessments of informal care time have tended to consider only the amount of time spent with the patient by the primary informal caregiver; however, in many cases, more than one person is providing care for the patient. We assess total informal care time of people caring for patients with dementia, and estimate the bias that can arise if consideration is not made of the time spent by all participating informal caregivers. METHOD: We used an extended version of the questions on informal care time from the Resource Utilization in Dementia (RUD) instrument. Caregivers were asked to state the number of days and the number of hours on a typical day they had assisted the patient in activities of daily living (ADL), instrumental ADL (IADL), and supervision during the last four weeks. Multivariate regression analyses were conducted to identify factors that could account for the amount of informal care time. RESULTS: 357 informal caregivers took part. Values were missing from only 4.5% of all interviews. On average, the primary informal caregiver cared for the patient 1.5, 2.1 and 1.9 hours per day in ADL, IADL and supervision respectively. Fifty-seven percent of all patients had more than one informal caregiver. Total informal care time was underestimated by about 14% if the time of caregivers other than the primary caregiver was not taken into account. The informal care time was significantly higher if the caregiver was the patient's partner and the patient's health status was lower. CONCLUSION: Our results show that most previous studies probably underestimated costs of informal care because the time of informal caregivers other than the primary caregiver was not considered.

[Diagnostic procedure and antidementive therapy of dementia patients in primary care: an urban-rural comparison]. / Diagnostik und Therapie von Demenzerkrankungen in der hausärztlichen Praxis: ein Stadt-Land-Vergleich.

OBJECTIVES: The aim of this work was to investigate the diagnostic and therapeutic regime of general practitioners (GPs) of dementia patients in an urban-rural-comparison. METHODS: The cross-sectional analysis of 129 GPs and 390 patients is part of the three-arm cluster-randomized controlled follow-up-study Project IDA - Initiative dementia care in primary practice . The study was carried out in Middle Franconia, a typical urban-rural area in Southeastern Germany. The sample constitutes the baseline assessment. GPs had to document their diagnostic and therapeutic behaviour upon inclusion of dementia patients in the study. RESULTS: As expected, significant differences in imaging diagnostic procedures exist between urban (57.9 %) and rural (42.7 %) areas (p = 0.010). There are no differences in the referral quote to specialists (total 57.9 %), in the frequency of treatment with non-pharmacological therapies (total 13.3 %) as well as pharmacological therapies with evidence-based medication (18.7 %; AChE inhibitors and Memantine). CONCLUSIONS: Except for imaging diagnostic procedures, there were no differences in the regime of urban and rural GPs. Thus, an almost similar care for rural and urban dementia patients can be assumed.

Advertising bans as a means of tobacco control policy: a systematic literature review of time-series analyses.

OBJECTIVES: This paper reviews the international literature that employed time-series analysis to evaluate the effects of advertising bans on aggregate consumption of cigarettes or tobacco. METHODS: A systematic search of the literature was conducted. Three groups of studies representing analyses of advertising bans in the U.S.A., in other countries and in 22 OECD countries were defined. The estimated effects of advertising bans and their significance were analysed. RESULTS: 24 studies were identified. They used a wide array of explanatory variables, models, estimating methods and data sources. 18 studies found a negative effect of an advertising ban on aggregate consumption, but only ten of these studies found a significant effect. Two studies using data from 22 OECD countries suggested that partial bans would have little or no influence on aggregate consumption, whereas complete bans would significantly reduce consumption. CONCLUSIONS: The results imply that advertising bans have a negative but sometimes only narrow impact on consumption. Complete bans let expect a higher effectiveness. Because of methodological restrictions of analysing advertising bans' effects by time series approaches, also different approaches should be used in the future.

[IDA project--concept and implementation of a cluster-randomized trial on dementia management in a general practice setting]. / Projekt IDA - Konzept und Umsetzung einer cluster-randomisierten Studie zur Demenzver- sorgung im hausärztlichen Bereich.

Given the multiple deficits in dementia care IDA is a health services research project that addresses the key role of general practitioners in the early detection of dementia, patient and family education, therapy and referral to further counseling and supportive measures. Mid 2005 IDA was started by the AOK Bavaria as a pilot project targeting patients living at home. This three-armed cluster-randomized trial--currently including 180 participating general practitioners--is to compare two supportive measures of different intensity (counseling for care-giving relatives and care management) with the usual care in terms of time to nursing home placement. Additional outcomes investigated include the development of the patient's cognitive status and his abilities to perform activities of daily living, burden and quality of life of care-giving relatives as well as healthcare costs and costs of institutional care. Participating patients with initially mild to moderate disease will be observed for a period of two years. Data collection will proceed via general practitioners and caregivers and also utilize routine data of statutory health insurances and long-term care insurances. Keeping in mind that patient recruitment is ongoing throughout 2006 the initial analysis of 254 patients' data shows an average 80-year old patient in the early phase of moderate dementia. One third of the participants are cases with a first- time diagnosis obtained from their general practitioner. Final results for IDA are expected to be available in 2009.

[Multimodal training of general practitioners--evaluation and knowledge increase within the framework of the dementia management initiative in general medicine (IDA)]. / Multimodale Schulung von Hausärzten - Evaluation und Wissenszuwachs im Rahmen der Initiative Demenzversorgung in der Algemeinmedizin (IDA).

BACKGROUND AND OBJECTIVE: In many industrialized countries diagnostic and therapeutic deficits in the management of patients with dementia are well documented. Due to demographic trends the next years will see a further rise in the number of affected patients. Accordingly, the knowledge and competence of the physicians taking care of these patients need to be keep up-to-date. In the context of the three-armed cluster-randomized IDA trial (IDA = "Initiative Demenzversorgung in der Allgemeinmedizin"; Dementia Management Initiative in General Medicine), general practitioners (GPs) from the trial area (Bavaria, Germany) were trained in the diagnosis and treatment of dementia. METHODS: The educational training concept was based on the evidence-based guideline of Witten/Herdecke University (UWH). All participating GPs (n = 137, January 2006) received three hours training in the diagnosis of dementia. In addition, a subgroup was trained for two hours in dementia therapy (n = 90). Both groups obtained information about the study design. The didactic concept included screen and oral presentations by opinion leaders, video and interactive elements. At the beginning of the training sessions participants had to fill in a pilot-tested questionnaire with 20 multiple choice questions addressing the diagnosis and therapy of dementia (pretest). The same questionnaire was completed at the end of the training session (posttest) complemented by an evaluation sheet. Overall and intergroup differences between pre- and post-test results (increase in knowledge) were compared using the Chi-Square test. RESULTS: Overall, the quality of the training received a positive rating by the participants. By the end of January 2006, 137 doctors had been trained. The mean knowledge gain was 4.0+2.6 correctly answered questions (p<0.001; Cl 3.6 to 4.5) comparing pre- and posttest (n = 132). In the group trained on diagnosis alone (n = 45), the gain averaged 2.0+/-1.9 questions. The group with additional training on therapy (n = 87) achieved a difference of 5.1 -2.3 questions (p<0.001). DISCUSSION: Participants of the dementia training achieved a substantial gain of knowledge. The extent of this knowledge increase was associated with the attendance to respective training modules. An ongoing trial will add further information about knowledge translation in the field of dementia.

Mortality, morbidity and costs attributable to smoking in Germany: update and a 10-year comparison.

OBJECTIVE: To assess the negative health consequences and associated costs of cigarette smoking in Germany in 2003 and to compare them with the respective results from 1993. METHODS: The number of deaths, years of potential life lost (YPLL), direct medical and indirect costs caused by active cigarette smoking in Germany in 2003 is estimated from a societal perspective. The method is similar to that applied by Welte et al, who estimated the cost of smoking in Germany in 1993. Therefore, a direct comparison of the results was possible. Methodological and data differences between these two publications and their effect on the results are analysed. RESULTS: In 2003, 114,647 deaths and 1.6 million YPLL were attributable to smoking. Total costs were euro21.0 billion, with euro7.5 billion for acute hospital care, inpatient rehabilitation care, ambulatory care and prescribed drugs; euro4.7 billion for the indirect costs of mortality; and euro8.8 billion for costs due to work loss days and early retirement. From 1993 to 2003, the proportionate mortality attributable to smoking remained relatively stable, rising from 13.0% to 13.4%. The smoking-attributable deaths in men is lowered by 13.7% whereas that in women increased by 45.3%. Total real direct costs rose by 35.8%, and total real indirect costs declined by 7.1%, rendering an increase of 4.7% to real total costs. Accountable factors are changes in cigarette smoking prevalence and in disease-specific mortality and morbidity, as well as a rise in general healthcare expenditure. CONCLUSIONS: Despite the growing knowledge about the hazards of smoking, the smoking-attributable costs increased in Germany. Further, female mortality attributable to smoking is much higher than it was in 1993.