Imperial College London
Optimising acute care for people with dementia: a mixed-methods study
Alzheimer's disease & other dementias
Background Concerns have been repeatedly expressed about the poor quality of inpatient care that people with dementia receive which can lead to longer length of admission and increased morbidity and mortality. Various attempts are being made to improve the quality of care that people with dementia receive, but their impact is unclear. Aims To identify which aspects of the organisation and delivery of acute inpatient care for people with dementia are associated with better quality care and shorter length of stay and to find out how hospitals can successfully implement changes that deliver better quality care to people with dementia. Setting Quantitative data will be collected from all general hospitals in England and Wales as part of the National Audit of Dementia. Additional qualitative data will be collected from a sub-sample of up to eight general hospitals in England and Wales. Methods A mixed methods study with two work packages (WPs). It will combine a secondary analysis of data from the third round of the National Audit of Dementia (WP1) with a series of comparative case studies of hospitals with better or worse performance against audit standards (WP2). In work-package 1, we will conduct a secondary analysis of data from over 10,000 patients admitted to over 1000 wards in 215 hospitals. We will examine associations between key components of the organisation and delivery of services, (including – staffing levels, staff training, access to liaison mental health services, and other specialist services) and three main outcomes: quality of assessment of needs, length of admission, and carer-rated experience of quality of care. In work-package 2, we will purposively select up to 15 hospitals with better/ worse performance based on audit results. We will select hospitals with marked differences in length of stay and carer-rated experience of care and which use different approaches to trying to improve quality of care for people with dementia. In-depth qualitative interviews will be conducted with managers, front-line staff, and service users and carers to examine if and how interventions aimed at improving quality of care for people with dementia impact on length of stay and experience of care received. We will also examine why certain quality improvements impact on length of stay and experience of care received, for whom and in what circumstances. Analysis Quality of assessment, length of stay and carer-rated experience of quality of care delivered will be compared between hospitals and wards using multilevel models adjusted for age, sex, and presenting complaint. We will also use multi-level modelling to identify aspects of the organisation and delivery of care that operate at the level of the hospital and ward where patients are admitted to examine their impact on patient outcomes. The analysis will then be repeated in sub-samples of patients presenting with one of the three prevalent tracer conditions. Qualitative data will be transcribed and analysed from a realistic perspective. Realistic evaluation involves evaluating how interventions bring about change, by examining their nature, and how the context in which they are delivered impacts on outcomes. Through theory testing and refinement, this approach will enable us to develop and test our understanding of the mechanisms of action and impact of interventions aimed at improving the quality of inpatient care for people with dementia.