Volume 55, Issue 8 p. 1260-1268

Caring for Patients with Dementia: How Good Is the Quality of Care? Results from Three Health Systems

Joshua Chodosh MD, MSHS

Joshua Chodosh MD, MSHS

From the * Department of Veterans Affairs, Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California Department of Veterans Affairs, Greater Los Angeles Health Services Research and Development Service Center of Excellence, Sepulveda, California Multicampus Program in Geriatric Medicine and Gerontology § Department of Medicine, Division of Geriatrics, David Geffen School of Medicine Department of Neurology # Department of Biostatistics, School of Public Health, University of California at Los Angeles, Los Angeles, California VA Greater Los Angeles Healthcare System, Los Angeles, California ** Scripps Clinic †† Department of Family and Preventive Medicine, University of California at San Diego, San Diego, California ‡‡ Kaiser Permanente Medical Center, San Diego, California §§ Care Management Institute, The Permanente Federation, Oakland, California.

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Brian S. Mittman PhD

Brian S. Mittman PhD

From the * Department of Veterans Affairs, Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California Department of Veterans Affairs, Greater Los Angeles Health Services Research and Development Service Center of Excellence, Sepulveda, California Multicampus Program in Geriatric Medicine and Gerontology § Department of Medicine, Division of Geriatrics, David Geffen School of Medicine Department of Neurology # Department of Biostatistics, School of Public Health, University of California at Los Angeles, Los Angeles, California VA Greater Los Angeles Healthcare System, Los Angeles, California ** Scripps Clinic †† Department of Family and Preventive Medicine, University of California at San Diego, San Diego, California ‡‡ Kaiser Permanente Medical Center, San Diego, California §§ Care Management Institute, The Permanente Federation, Oakland, California.

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Karen I. Connor RN, MBA

Karen I. Connor RN, MBA

From the * Department of Veterans Affairs, Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California Department of Veterans Affairs, Greater Los Angeles Health Services Research and Development Service Center of Excellence, Sepulveda, California Multicampus Program in Geriatric Medicine and Gerontology § Department of Medicine, Division of Geriatrics, David Geffen School of Medicine Department of Neurology # Department of Biostatistics, School of Public Health, University of California at Los Angeles, Los Angeles, California VA Greater Los Angeles Healthcare System, Los Angeles, California ** Scripps Clinic †† Department of Family and Preventive Medicine, University of California at San Diego, San Diego, California ‡‡ Kaiser Permanente Medical Center, San Diego, California §§ Care Management Institute, The Permanente Federation, Oakland, California.

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Stefanie D. Vassar MS

Stefanie D. Vassar MS

From the * Department of Veterans Affairs, Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California Department of Veterans Affairs, Greater Los Angeles Health Services Research and Development Service Center of Excellence, Sepulveda, California Multicampus Program in Geriatric Medicine and Gerontology § Department of Medicine, Division of Geriatrics, David Geffen School of Medicine Department of Neurology # Department of Biostatistics, School of Public Health, University of California at Los Angeles, Los Angeles, California VA Greater Los Angeles Healthcare System, Los Angeles, California ** Scripps Clinic †† Department of Family and Preventive Medicine, University of California at San Diego, San Diego, California ‡‡ Kaiser Permanente Medical Center, San Diego, California §§ Care Management Institute, The Permanente Federation, Oakland, California.

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Martin L. Lee PhD

Martin L. Lee PhD

From the * Department of Veterans Affairs, Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California Department of Veterans Affairs, Greater Los Angeles Health Services Research and Development Service Center of Excellence, Sepulveda, California Multicampus Program in Geriatric Medicine and Gerontology § Department of Medicine, Division of Geriatrics, David Geffen School of Medicine Department of Neurology # Department of Biostatistics, School of Public Health, University of California at Los Angeles, Los Angeles, California VA Greater Los Angeles Healthcare System, Los Angeles, California ** Scripps Clinic †† Department of Family and Preventive Medicine, University of California at San Diego, San Diego, California ‡‡ Kaiser Permanente Medical Center, San Diego, California §§ Care Management Institute, The Permanente Federation, Oakland, California.

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Robert W. DeMonte MD

Robert W. DeMonte MD

From the * Department of Veterans Affairs, Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California Department of Veterans Affairs, Greater Los Angeles Health Services Research and Development Service Center of Excellence, Sepulveda, California Multicampus Program in Geriatric Medicine and Gerontology § Department of Medicine, Division of Geriatrics, David Geffen School of Medicine Department of Neurology # Department of Biostatistics, School of Public Health, University of California at Los Angeles, Los Angeles, California VA Greater Los Angeles Healthcare System, Los Angeles, California ** Scripps Clinic †† Department of Family and Preventive Medicine, University of California at San Diego, San Diego, California ‡‡ Kaiser Permanente Medical Center, San Diego, California §§ Care Management Institute, The Permanente Federation, Oakland, California.

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Theodore G. Ganiats MD

Theodore G. Ganiats MD

From the * Department of Veterans Affairs, Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California Department of Veterans Affairs, Greater Los Angeles Health Services Research and Development Service Center of Excellence, Sepulveda, California Multicampus Program in Geriatric Medicine and Gerontology § Department of Medicine, Division of Geriatrics, David Geffen School of Medicine Department of Neurology # Department of Biostatistics, School of Public Health, University of California at Los Angeles, Los Angeles, California VA Greater Los Angeles Healthcare System, Los Angeles, California ** Scripps Clinic †† Department of Family and Preventive Medicine, University of California at San Diego, San Diego, California ‡‡ Kaiser Permanente Medical Center, San Diego, California §§ Care Management Institute, The Permanente Federation, Oakland, California.

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Lisa E. Heikoff MD

Lisa E. Heikoff MD

From the * Department of Veterans Affairs, Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California Department of Veterans Affairs, Greater Los Angeles Health Services Research and Development Service Center of Excellence, Sepulveda, California Multicampus Program in Geriatric Medicine and Gerontology § Department of Medicine, Division of Geriatrics, David Geffen School of Medicine Department of Neurology # Department of Biostatistics, School of Public Health, University of California at Los Angeles, Los Angeles, California VA Greater Los Angeles Healthcare System, Los Angeles, California ** Scripps Clinic †† Department of Family and Preventive Medicine, University of California at San Diego, San Diego, California ‡‡ Kaiser Permanente Medical Center, San Diego, California §§ Care Management Institute, The Permanente Federation, Oakland, California.

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Laurence Z. Rubenstein MD, MPH

Laurence Z. Rubenstein MD, MPH

From the * Department of Veterans Affairs, Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California Department of Veterans Affairs, Greater Los Angeles Health Services Research and Development Service Center of Excellence, Sepulveda, California Multicampus Program in Geriatric Medicine and Gerontology § Department of Medicine, Division of Geriatrics, David Geffen School of Medicine Department of Neurology # Department of Biostatistics, School of Public Health, University of California at Los Angeles, Los Angeles, California VA Greater Los Angeles Healthcare System, Los Angeles, California ** Scripps Clinic †† Department of Family and Preventive Medicine, University of California at San Diego, San Diego, California ‡‡ Kaiser Permanente Medical Center, San Diego, California §§ Care Management Institute, The Permanente Federation, Oakland, California.

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Richard D. Della Penna MD

Richard D. Della Penna MD

From the * Department of Veterans Affairs, Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California Department of Veterans Affairs, Greater Los Angeles Health Services Research and Development Service Center of Excellence, Sepulveda, California Multicampus Program in Geriatric Medicine and Gerontology § Department of Medicine, Division of Geriatrics, David Geffen School of Medicine Department of Neurology # Department of Biostatistics, School of Public Health, University of California at Los Angeles, Los Angeles, California VA Greater Los Angeles Healthcare System, Los Angeles, California ** Scripps Clinic †† Department of Family and Preventive Medicine, University of California at San Diego, San Diego, California ‡‡ Kaiser Permanente Medical Center, San Diego, California §§ Care Management Institute, The Permanente Federation, Oakland, California.

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Barbara G. Vickrey MD, MPH

Barbara G. Vickrey MD, MPH

From the * Department of Veterans Affairs, Greater Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, California Department of Veterans Affairs, Greater Los Angeles Health Services Research and Development Service Center of Excellence, Sepulveda, California Multicampus Program in Geriatric Medicine and Gerontology § Department of Medicine, Division of Geriatrics, David Geffen School of Medicine Department of Neurology # Department of Biostatistics, School of Public Health, University of California at Los Angeles, Los Angeles, California VA Greater Los Angeles Healthcare System, Los Angeles, California ** Scripps Clinic †† Department of Family and Preventive Medicine, University of California at San Diego, San Diego, California ‡‡ Kaiser Permanente Medical Center, San Diego, California §§ Care Management Institute, The Permanente Federation, Oakland, California.

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First published: 07 June 2007
Citations: 58
Address correspondence to Joshua Chodosh, MD, MSHS, 11301 Wilshire Blvd/GRECC (11G), Los Angeles, CA 90073. E-mail: [email protected]

Abstract

OBJECTIVES: To describe the quality of dementia care within one U.S. metropolitan area and to investigate associations between variations in quality and patient, caregiver, and health system characteristics.

DESIGN: Observational, cross-sectional.

SETTING AND PARTICIPANTS: Three hundred eighty-seven patient–caregiver pairs from three healthcare organizations

MEASUREMENTS: Using caregiver surveys and medical record abstraction to assess 18 dementia care processes drawn from existing guidelines, the proportion adherent to each care process was calculated, as well as mean percentages of adherence aggregated within four care dimensions: assessment (6 processes), treatment (6 processes), education and support (3 processes), and safety (3 processes). For each dimension, associations between adherence and patient, caregiver, and health system characteristics were investigated using multivariable models.

RESULTS: Adherence ranged from 9% to 79% for the 18 individual care processes; 11 processes had less than 40% adherence. Mean percentage adherence across the four care dimensions was 37% for assessment, 33% for treatment, 52% for education and support, and 21% for safety. Higher comorbidity was associated with greater adherence across all four dimensions, whereas greater caregiver knowledge (in particular, one item) was associated with higher care quality in three of four care dimensions. For selected dimensions, greater adherence was also associated with greater dementia severity and with more geriatrics or neurologist visits.

CONCLUSION: In general, dementia care quality has considerable room for improvement. Although greater comorbidity and dementia severity were associated with better quality, caregiver knowledge was the most consistent caregiver characteristic associated with better adherence. These findings offer opportunities for targeting low quality and suggest potential focused interventions.