Title: Optimising acute care for people with dementia: a mixed-methods study
Funder: Department of Health and Social Care

Abstract: 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.

Lay abstract: The number of people living with dementia is increasing. It is expected that over a million people in the UK will have this condition by 2021. Numbers of people with dementia who are admitted to general hospitals are also increasing with as many as one in four beds now occupied by people with dementia. Concerns have repeatedly been raised about the quality of inpatient care that people with dementia receive. Enquiries into poorly performing hospitals have highlighted the mismanagement of frail elderly people with dementia. A recent national audit of inpatient care for people with dementia found that many people do not receive a comprehensive assessment of their needs and that carers are not sufficiently involved during the admission or in planning for discharge from hospital. As a result, people with dementia often spend longer in hospital than those without this condition and are more likely to be readmitted to hospital following their discharge. In recent years efforts have been made to improve the quality of inpatient care that people with dementia receive. These efforts include better training for staff, use of specialist nurses and expansion of mental health liaison teams. Changes have also been made to the design of wards and some units have been set up that specialise in treating people with dementia. While studies based in single wards or hospitals have shown that it is possible to improve the quality of inpatient care for people with dementia, we have very little understanding of the impact of these changes at a national level and there is a pressing need to understand why some hospitals deliver more effective care to people with dementia than others. The National Audit of Dementia will be repeated in 2015/16 and we believe that this provides an ideal opportunity to address these issues. While the aim of the audit is to highlight differences in quality of inpatient care across hospitals, we believe that the data provide an important opportunity to examine which aspects of the organisation and delivery of services have an impact on the quality of care that people receive. Audit information will identify the best and worst performing hospitals and we will then interview front-line staff, managers and people with dementia and their carers in these hospitals to understand how systems and resources can be used to deliver high quality care. Plans for this project have been developed in collaboration with those who use and provide acute care for people with dementia. We will set up a project advisory group and a patient and carer reference group that will help make sure that future stages of the project also take the views of managers, clinicians, patient and carers into account. This will help ensure that our results can have a direct bearing on the way that services are managed and improved in the future. We will publicise the results of this research through papers published in journals that clinicians and service managers read. We will also send summaries of the project findings to service commissioners and representatives of Strategic Clinical Networks. The results of the study will also be used to strengthen the design of future rounds of the National Audit of Dementia and will feed into practice guidelines through the strong links we have with professional bodies and NHS England via the National Clinical Director for Dementia (who is a co-applicant on the study).

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: NEUROLOGICAL