has consumer directed care improved the quality of … consumer directed care improved the quality...
TRANSCRIPT
Has Consumer Directed Care improved the quality of life of older
Australians?
Professor Julie RatcliffeSchool of MedicineFlinders University
Acknowledgments: ARC Linkage Project – A Health Economics Model
for Evaluating CDC in CACS
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What is CDC• Consumer Directed Care: underlying philosophy is to
promote consumer choice and autonomy in decision‐making in relation to their care needs
• In reality CDC models of care internationally have ranged along a continuum from self‐directed care to cash for care schemes
• In Australia CACS currently characterized by self‐directed care whereby financial control and accountability is retained by the service provider
Process: Consumer Directed Care
Outcome: Quality of life(health status, HrQoL, wellness, wellbeing)
Quality of life: the ultimate outcome for consumers
Objectives• To assess the impact of CDC on the quality of life (QoL) of older
Australians
• Internationally limited evidence and mixed findings.
• Largest study to date of CDC approach ‐ personalised budgets in UK found no improvement in quality of life and increased anxiety levels for older people [Glendenning 2008].
• Evidence from the US to assess the effectiveness of cash and counselling indicated positive wellbeing benefits for older people [Carlsson et al 2007]
MethodsStudy samples: • Eligibility: 60+ years, capable of providing informed consent and
responding to survey, living in the community, in receipt of a HCP from our aged care partners
Timing: • Sept 2015‐ Jan 2016. Snap shot assessment, variation in length of
exposure to CDC (less than and more than 12 months)
Quality of life instruments: • For economic evaluation generic & preference based is preferred:
EQ‐5D is currently the most widely used instrument internationally
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EuroQol-5D Tick one answer in each group below to indicate your health state today. Mobility: I have no problems in walking around
I have some problems in walking around I am confined to bed
Self-Care: I have no problems with self-care
I have some problems washing or dressing myself I am unable to wash or dress myself
Usual Activities: I have no problems with performing my usual activities
I have some problems with performing my usual activities I am unable to perform my usual activities
Pain/Discomfort: I have no pain or discomfort
I have moderate pain or discomfort I have extreme pain or discomfort
Anxiety/Depression: I am not anxious or depressed
I am moderately anxious or depressed I am extremely anxious or depressed
Please go to http://www.euroqol.org/ for registration and permission to use details
Comparison of Aus./UK EQ‐5D Values
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Health state Aus. Value UK value11111 1 111112 0.798 0.84811113 0.498 0.41421133 0.166 ‐0.04121211 0.774 0.81421212 0.677 0.74321213 0.377 0.30931223 0.017 ‐0.05931231 0.111 ‐0.08633313 ‐0.137 ‐0.20833333 ‐0.217 ‐0.594
EQ‐5D‐5L descriptive systemUnder each heading, please tick the ONE box that best describes your health TODAY MOBILITY I have no problems in walking about ・
I have slight problems in walking about ・
I have moderate problems in walking about ・
I have severe problems in walking about ・
I am unable to walk about ・
SELF-CARE I have no problems washing or dressing myself ・
I have slight problems washing or dressing myself ・
I have moderate problems washing or dressing myself ・
I have severe problems washing or dressing myself ・
I am unable to wash or dress myself ・
USUAL ACTIVITIES (e.g. work, study, housework, family or leisure activities) I have no problems doing my usual activities ・
I have slight problems doing my usual activities ・
I have moderate problems doing my usual activities ・
I have severe problems doing my usual activities ・
I am unable to do my usual activities ・
PAIN / DISCOMFORT I have no pain or discomfort ・
I have slight pain or discomfort ・
I have moderate pain or discomfort ・
I have severe pain or discomfort ・
I have extreme pain or discomfort ・
ANXIETY / DEPRESSION I am not anxious or depressed ・
I am slightly anxious or depressed ・
I am moderately anxious or depressed ・
I am severely anxious or depressed ・
I am extremely anxious or depressed ・
Please go to http://www.euroqol.org/ for registration and permission to use details
Defining quality of life for older people [1][Ref: Milte C, Walker R, Luszcz M, Lancsar E, Kaambwa B, Ratcliffe J (2014). How important is health status in defining quality of life for older people? An exploratory study of the views of
older South Australians. Applied Health Economics and Health Policy.12(1):73‐84]
Quality of life domainsHealth
“I am healthy enough to get out and about”Social relationships“My family, friends or neighbours would help me if needed”Independence, control over life, freedom
“I am healthy enough to have my independence”“I can please myself what I do”
Home and neighbourhood“I feel safe where I live”“I can please myself what I do”
Psychological and emotional well‐being“I take life as it comes and make the best of things”“I feel lucky compared to most people”
Financial circumstances“I have enough money to pay household bills”
Leisure and activities“I have social or leisure activities/hobbies that I enjoy doing”
“I try to stay involved with things”
Defining quality of life for older people [2][Ref: Ratcliffe J, Lancsar E, Flint T et al (2016). Does one size fit all? Assessing the preferences of older and younger
people for attributes of quality of life. Quality of Life Research Forthcoming]
SLEEP Being able to sleep without difficulty most of the
time
PAINHaving no pain or discomfort
INDEPENDENCE Being able to spend your time as you want, doing
thing you value and enjoy
VISIONBeing able to see normally
PHYSICAL MOBILITYBeing able to get around your home and community
by yourself without any difficulty
HEARINGBeing able to hear normally
MENTAL HEALTHNot feeling anxious, worried or depressed
SAFETYFeeling as safe as you want
CONTROLHaving as much control over your daily life as you
would want
SOCIAL‐RELATIONSHIPSHaving as much social contact as you want with
people you like
SELF‐CAREFeeling clean and being able to present yourself in
the way you like
DIGNITYHaving help which makes you think and feel better
about yourself
Defining quality of life for older people [2][Ref: Ratcliffe J, Lancsar E, Flint T, Kaambwa B, Walker R, Lewin G, Luszcz M, Cameron I (2016). Does one size fit
all? Assessing the preferences of older and younger people for attributes of quality of life. Quality of Life Research Forthcoming]
Figure 1: Relative importance of quality of life dimensions by ranking task (WB= well‐being, HS = health status)
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
Domain Younger Domain Older
Alternatives to the EQ‐5D• Several older person specific quality of life indicators exist – however
relatively few are preference based and therefore amenable for economic evaluation
• ASCOT: social care related quality of life [Netten et al 2012]
• ASCOT and healthy ageing: ASCOT is focused on care related attributes – insensitive to physical health for HrQoL (reablement, restorative care, wellness interventions)
• Increasingly many interventions in aged care are designed to impact upon HrQoL
• New instrument: the OVQOL Older People’s Values in Quality of Life – developed from its inception with older Australians and incorporating their values into QALY’s for economic evaluation
The Capability paradigm • Offers an alternative paradigm to the QALY for assessing quality of life
• ICECAP‐O instrument (Coast et al 2008) Based on Sen’stheory of capability
• ICECAP has five dimensions (attachment, security, role, enjoyment, control) with four levels in each dimension
• Scored using 0=no capability to 1=full capability scale
ICECAP‐O descriptive systemAttachmentI can have all of the love and friendship that I wantI can have some of the love and friendship that I wantI can have a little of the love and friendship that I wantI cannot have any of the love and friendship that I wantSecurityI can think about the future without any concernI can think about the future with only a little concernI can only think about the future with some concernI can only think about the future with a lot of concernRoleI am able to do all of the things that make me feel valuedI am able to do many of the things that make me feel valuedI am able to do a few of the things that make me feel valuedI am unable to do any of the things that make me feel valuedEnjoymentI can have all of the enjoyment and pleasure that I wantI can have a lot of the enjoyment and pleasure that I wantI can have a little of the enjoyment and pleasure that I want I cannot have any of the enjoyment and pleasure that I wantControlI am able to be completely independentI am able to be independent in many thingsI am able to be independent in a few thingsI am unable to be at all independent
Please go to http://www.birmingham.ac.uk/research/activity/mds/projects/HaPS/HE/ICECAP/index.aspxfor registration and permission to use details
Results: Socio‐demographicsCharacteristic CDC < 12 months
(n=101)CDC > 12 months
(n=49)Total (N=150) p-value
Age [Mean(sd§); Median(range)] 83.57 (7.28);(80,88)
80.82 (7.12);(78,87)
82.67 (7.32);83.50 (78,87)
0.01
Age category0.0165-79 years 25(25%) 22(45%) 47(31%)
80+ years 76(75%) 27(55%) 108(69%)Gender 0.85Male 29(35%) 17(36%) 50(34%)Female 55(65%) 30(64%) 95(66%)Birthplace 0.71Australia 60(71%) 35(74%) 107(74%)Other 24(29%) 12(26%) 38(26%)
Living arrangement 0.10On your own 58(70%) 26(55%) 95(66%)With spouse or other family 25(30%) 21(45%) 49(34%)
Have informal carer 0.75Yes 68(83%) 40(85%) 121(85%)No 14(17%) 7(15%) 22(15%)Hours of support [Mean(sd§);Median(range)]
6.45 (4.47);(4,7.5)
6.70 (2.96);(4.5,8.5)
6.53(4.03);(4,8)
0.21
Education level 0.11Up to secondary school 57(70%) 39(83%) 106(75%)Beyond secondary school 24(30%) 8(17%) 35(25%)
Quality of Life ScoresInstrument n Mean (SD) 95% CI
EQ‐5D‐5L 140 0.56 (0.26) 0.52, 0.60
ICECAP‐O 141 0.76 (0.17) 0.73, 0.79
QoL and Length of time on CDC
Time on
CDC
n EQ‐5D‐5L ICECAP‐O
Mean
(SD)
95% CI p‐value Mean
(SD)
95% CI p‐value
< 12 months 101 0.57
(0.25)
0.52, 0.62 0.427 0.78
(0.15)
0.75, 0.81 0.052
> 12 months 49 0.54
(0.25)
0.47, 0.62 0.72
(0.18)
0.67, 0.77
Study 2: Tests of association between ICECAP‐O attributes and time spent on CDC
Capability attribute
0‐12 Months >12 months Test of difference
Mean(SD)
95% CI Mean(SD)
95% CI z‐statistic p‐value
Attachment(love and friendship)
3.20 (0.78) 3.04, 3.36 2.92 (0.87) 2.66, 3.17 ‐1.925 0.054
Security 2.84 (0.97) 2.65, 3.04 2.72 (0.97) 2.44, 3.01 ‐0.646 0.518
Role(doing things that make you feel valued)
2.72 (0.79) 2.56, 2.88 2.33 (0.88) 2.08, 2.58 ‐2.744 0.006
Enjoyment (enjoyment and pleasure)
2.79 (0.74) 2.64, 2.94 2.52 (0.80) 2.29, 2.75 ‐1.836 0.066
Control 2.62 (0.70) 2.48, 2.76 2.47 (0.68) 2.27, 2.66 ‐1.158 0.246
Discussion [1]• Findings indicate no statistically significant differences in quality of
life overall although ICECAP‐O scores trend towards statistical significance for the newly transitioned CDC group
• Some support for quality of life improvements in specific dimensions of the ICECAP‐O commensurate with development of CDC in the sector and the main policy objectives: promotion of choice and control.
• Limitations: relatively small sample sizes, timing – QoL assessment undertaken during unprecedented period of transition for the sector, limited number of provider organisations
Discussion [2]• Future directions: How to definitively answer the question as to whether
CDC has improved the quality of life of older Australians?
• We need the best instrument so please join me! OVQoL ‐ developed from its inception with older Australians and suitable for application in an economic evaluation framework
• Extended longitudinal follow up in larger samples is needed to facilitate a more detailed examination of the relationship between the evolution of CDC and its longer term influences on quality of life.
• Routine assessment similar to PROMs movement in the UK NHS? Consumer Reported Outcome Measures to assess QoL longitudinally –change over time – critical for the sector in demonstrating cost effectiveness of new interventions/service innovations
