key: cord-0933993-0mrut8ln authors: Henein, Mary; Arsenault‐Lapierre, Geneviève; Sourial, Nadia; Godard‐Sebillotte, Claire; Vedel, Isabelle title: The association between the level of institutional support for dementia care in primary care practices and the quality of dementia primary care: A retrospective chart review date: 2022-02-01 journal: Alzheimers Dement (N Y) DOI: 10.1002/trc2.12233 sha: bbcb9ee588551f2132797902bcae5c4cee0fb0b9 doc_id: 933993 cord_uid: 0mrut8ln INTRODUCTION: Institutional support, encompassing financial and training support, as well as interdisciplinary teams, may be important for the quality of dementia primary care for persons living with dementia. The aim of this study was to measure the association between the level of institutional support provided to primary care practices and the quality of dementia care. METHODS: This was a cross‐sectional chart review in 33 Canadian primary care practices to measure the quality of dementia primary care using a quality of follow‐up score. The score was based on the assessment of 10 indicators. Practices were chosen using a purposeful sampling method with varying levels of institutional support for dementia primary care (e.g., financial support, training, interdisciplinary team). A linear mixed‐effect model was used to measure the association between the level of institutional support and the quality of dementia care. RESULTS: There was a significant association between the level of institutional support and the quality of dementia care (mean difference = 23.5, 95% confidence interval: 16.4, 30.6). DISCUSSION: Providing more institutional support for primary care practices could be a promising avenue to improve the care of persons living with dementia. There has been considerable effort in Canada to improve dementia care. There have been several Canadian dementia strategies that have been introduced provincially 8-12 and nationally, 13 which among other elements, intend to improve dementia care by increasing financial support and training and are based on current Canadian guidelines. 14 As such, these strategies recommend dementia management to be rooted in primary care and many take advantage of existing interdisciplinary care team structures, allowing for an integrated approach to dementia primary care. 2 However, whether this effort is associated with better quality of care is unclear. Financial support, training, and interdisciplinary teams are potential elements for implementing appropriate practices for improving dementia care. The WHO 15 has indicated the importance of funding or financial commitment to a dementia strategy, such as investing in the health system and services and in implementing and sustaining dementia care strategy. Training the workforce to be equipped to handle dementia care was also identified as a priority for strategies to address. 15 In addition, interdisciplinary teams may be an ideal environment to implement good quality dementia care practices. Specifically, existing and established primary care teams and funding were instrumental in implementing new targeted programs for dementia in three Canadian provinces. 16 Thus, institutional support, when defined as financial and training resources provided by varying levels of health authorities to interdisciplinary primary care teams, could contribute to improving the quality of dementia primary care. Our study sought to measure the association between the level of institutional support for dementia care in primary care practices and the quality of dementia primary care for persons living with dementia in Canada. We conducted a cross-sectional retrospective chart review in 33 purposefully sampled primary care practices across various Canadian regions in the three Canadian provinces of Ontario, Quebec, and New Brunswick. These practices received various levels of institutional support for dementia primary care by regional health authorities. [17] [18] [19] The level of institutional support of each region was categorized by (1) consulting with primary care clinicians in the practices and with experts in the field (11 physicians, five managers and decision-makers, three patient and caregiver representatives) and (2) examining documentation of regional health authorities' policies. Specifically, institutional support was defined by whether the practice was in a region that provided financial support for dementia care (yes or no), training for dementia care (yes, to some extent, no), and/or interdisciplinary care teams (yes or no). We categorized the level of institutional support received in three levels: intensive, moderate, and none (Table 1 ). An intensive level of institutional support for dementia care had extensive training to all primary care clinicians, and funding incentive to hire more nurses and social workers into existing comprehensive interdis- For each practice, we conducted a retrospective cross-sectional chart review of randomly selected patients age 75+ years living with dementia who had a visit at the primary care practice during a 9-month observation period (between October 1, 2014 and July 1, 2016). The quality of dementia primary care was measured using a quality of follow-up score. The quality of follow-up score was based on validated tools, current recommendations, and consensus guidelines. 9, 14, 20, 21 The score was calculated with 10 indicators: documentation in the patient's chart for the assessment of their cognitive status, functional status, presence or absence of behavioral and psychological symptoms of dementia, weight, caregiver needs, aptitude to drive, home care needs, community service needs (e.g., Alzheimer's Society), the absence of anticholinergic medication, and the discussion to introduce dementia-specific medications. The score was calculated as the percentage of indicators assessed in the observation period over the total number of eligible indicators. Therefore, each 10-point increase in the quality of followup score is equivalent to an additional indicator assessed. The quality of follow-up score has been described elsewhere. 22 Patients' age and sex were also collected. The mean and standard deviations (SD) of continuous variables (age, quality of follow-up score) and frequency with proportions for categorical data (sex, level of institutional support) were calculated. A linear mixed model was used to measure the association between the main explanatory variable, the level of institutional support, and The mean quality of follow-up score of patients (N = 734) in each institutional support group. The quality of follow-up score was calculated as a percentage documented completion of ten indicators in the patient's chart: cognitive status, functional status, presence, or absence of behavioral and psychological symptoms of dementia, weight, caregiver needs, aptitude to drive, home care needs, community service needs (eg, Alzheimer's Society), absence of anticholinergic medication, and discussion to introduce dementia-specific medications. Intensive institutional support included training, financial support, and interdisciplinary teams; moderate institutional support included some training to interested physicians and interdisciplinary teams; no institutional support did not include financial support, training, or interdisciplinary care. Means are unadjusted the quality of dementia follow-up score. Additional explanatory variables were patient age and sex. To account for the clustering of patients within a practice, a practice number was included as a random effect. We assessed the homogeneity of variances using a Levene's test with the dependent variable (quality of follow-up score) according to the group (institutional support). Estimates and associated 95% confidence intervals (CIs) were derived for each variable in the model. R statistical software was used. 23 In addition, a bar plot of the unadjusted mean quality of follow-up score of each institutional support group was produced. In showed that the variances between groups were not significantly different. The unadjusted mean quality of follow-up score of the 734 patients was 48.6 (SD = 22.0). Figure 1 shows the unadjusted mean quality of follow-up scores across patients at each level of institutional support. The intensive institutional support group had a higher mean Table 3 ). Our study found that a higher level of institutional support for demen- Our results align with a growing literature on the need for improving our health-care systems for persons living with dementia. [26] [27] [28] [29] Other research has found that multi-faceted support from policymakers is essential for complex populations. 30 Institutional support is an important factor for effectively supporting dementia care within primary care practices and sustaining programs for dementia. 16 Our results continue to highlight the need for institutional support for dementia primary care for delivering better quality of primary care for persons living with dementia. Our study had several strengths and some limitations. The quality of dementia primary care was measured using a quality of follow-up score, which measured the adherence to dementia care guidelines. 22, 32 Process measures, such as follow-up care, are an aspect of quality of care. 31 Furthermore, the chart reflects not only physician, but also nurse and other health-care professionals' activities. While the crosssectional design and unbalanced samples from each region (i.e., there were more patients and sites in intensive institutional support than the other support levels) does not allow us to measure causation, this is a large study with the collaboration from 33 practices across Canada, offering a diversity of institutional support structures. In addition, the unbalanced samples generally widen the confidence intervals and thus, give more conservative results. Although the measure of institutional support was not a continuous variable, the categories were collaboratively defined by consulting clinicians and experts and analyzing regional policies. Close monitoring of the data collection of the patient's chart yielded no missing data. Our study has not considered organizational culture or clinician attitudes, which could also impact quality of dementia primary care. As the development and implementation of dementia initiatives and strategies continues in Canada with a focus on strengthening primary dementia care, this study suggests that institutional support is a valuable aspect for the quality of dementia primary care. Without such support, primary care practices might not be able to provide appropriate dementia care. A coordinated national and subnational effort to provide financial, training, and interdisciplinary care teams to all primary care practices and clinicians would help provide high quality of care in primary care practices for a growing population of persons with dementia. We would like to recognize the contributions of the clinicians, managers, and staff of the primary care practices that participated in this study. World Health Organization. The Epidemiology and Impact of Dementia: Current State and Future Trends Canadian Academy of Health Sciences. 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