A systematic review of the economic evidence for home support interventions in dementia

Paul Clarkson1*, PhD, MSc, BA (Hons)

Linda Davies2, MSc, BA (Hons)

Rowan Jasper1, MPhil, BSc (Hons)

Niklas Loynes1, MA, BA (Hons)

David Challis1, PhD, MSc, BA (Hons)

and members of the HoSt-D (Home Support in Dementia) Programme Management Group.

1 PSSRU, Division of Population Health, Health Services Research and Primary Care, 2nd Floor,

Crawford House, University of Manchester, M13 9PL, UK.

2 Centre for Health Economics, Division of Population Health, Health Services Research and Primary

Care, Oxford Road, University of Manchester, M13 9PL, UK.

* Corresponding author: Dr Paul Clarkson, PSSRU, Division of Population Health, Health Services

Research and Primary Care, 2nd Floor, Crawford House, University of Manchester, M13 9PL, UK;

email: paul.clarkson@manchester.ac.uk; tel: 44(0)161 275 5674.

Key words: Dementia, home support, economic review, cost measurement

Acknowledgements

This research was funded by the National Institute for Health Research (NIHR) in England under its

Programme Grants for Applied Research (Grant Reference Number: DTC-RP-PG-0311-12003). The

views expressed in this paper are those of the authors and not necessarily those of the NHS, the

NIHR or the Department of Health in England.

Members of the Programme Management Group include: Dr Jane Hughes, Professor David Jolley,

Professor Chris Roberts (University of Manchester); Professor Martin Orrell, Narinder Kapur

(University College London); Professor Brenda Roe (Edge Hill University); Professor Fiona Poland

(University of East Anglia); Professor Ian Russell (Swansea University); Jean Tottie (Together in

Dementia Everyday); and Reagan Blyth (Pennine Care NHS Foundation Trust). We would like to

thank Rebecca Hays for initial help in developing the search strategies. We thank staff of the UK

Centre for Reviews and Dissemination at the University of York for making available critical appraisals

of the papers arising from the review.

ABSTRACT

Objectives: Recent evidence signals the need for effective forms of home support to people with

dementia and their carers. The cost-effectiveness evidence of different approaches to support is

scant. This review aimed to appraise economic evidence on the cost-effectiveness of home support

interventions for dementia to inform future evaluation.

Methods: A systematic literature review of full and partial economic evaluations was performed using

the British National Health Service Economic Evaluation Database (NHS EED) supplemented by

additional references. Study characteristics and findings, including Incremental Cost Effectiveness

Ratios (ICERs), where available, were summarised narratively. Study quality was appraised using the

NHS EED critical appraisal criteria and independent ratings, agreed by two reviewers. Studies were

located on a permutation matrix describing their mix of incremental costs/effects to aid decision-

making.

Results: Of 151 articles retrieved, 14 studies met the inclusion criteria: 8 concerning support to

people with dementia and 6 to carers. Five studies were incremental Cost Utility Analyses, 7 cost-

effectiveness analyses, and 2 cost consequences analyses. Five studies expressed ICERs as

cost/QALY (£6,696 to £207,942/QALY). In 4 studies, interventions were dominant over usual care.

Two interventions were more costly but more beneficial and were favourable against current

acceptability thresholds.

Conclusions: Occupational therapy, home-based exercise, and a carers’ coping intervention

emerged as cost-effective approaches for which there was better evidence. These interventions used

environmental modifications, behaviour management, physical activity, and emotional support as

active components. More robust evidence is needed to judge the value of these and other

interventions across the dementia care pathway.

Introduction

With population ageing, dementia is a significant public health and care challenge. In 2015, 9.9

million new cases of dementia were estimated each year worldwide, one case every 3.2 seconds [1].

Worldwide it is estimated that 46.8 million people were living with dementia in 2015, reaching 74.7

million in 2050 [1]. At the current rate of prevalence, there were 850,000 people with dementia in the

UK in 2015, which is forecast to increase to over 1 million people by 2025 and over 2 million by 2051

[2]. In 2015, the total estimated worldwide cost of dementia reached US$ 818 billion, and will become

a trillion dollar condition by 2018 [1]. At present, the cost of dementia in the UK is estimated at £26.3

billion per annum [2], leading commentators to term the search for cost-effective ways to improve the

care of people with dementia and their families the ‘£20 billion question’ [3]. Currently there is no

evidence-based method of preventing or curing dementia as it is a chronic, long-term condition

associated with high levels of physical as well as cognitive problems and increased risk of death.

However, the immediate priority remains helping people to live well with dementia [4], through

developing interventions likely to ameliorate difficulties and enhance well-being, so-called tertiary

prevention [5].

About 60 per cent of people with dementia live at home. Helping them to live well requires

home support from a variety of agencies. A range of home support interventions are available, with

little clear evidence of effectiveness and cost-effectiveness [6, 9]. There is evidence that psychosocial

interventions, broad-based approaches offering different ways of supporting people with dementia and

their carers to overcome challenges and maintain health, are potentially effective [7,8]. Whether and

how these approaches can be effectively translated into routine home support is uncertain [9]. The

evidence about how particular components (‘active ingredients’) of these interventions could be

combined into different models of support is relatively weak. There is uncertainty about the likely costs

and effects and value for money of adopting such care and support models for people with dementia.

This systematic review therefore critically assesses economic evaluations of home support

interventions in dementia, as part of a wider research programme to appraise evidence and conduct

primary research into the most cost-effective home and personal support arrangements for people

with dementia and their carers (National Institute for Health Research (NIHR) in England, Programme

Grant for Applied Research no. DTC-RP-PG-0311-12003).

Methods

Searches and study selection

The British National Health Service Economic Evaluation Database (NHS EED)

(www.crd.york.ac.uk/CRDWeb//) was searched for full (where both cost and effectiveness data are

available to compare two or more interventions) and partial (that where no comparator is employed)

economic analyses (PC, RJ). The NHS EED, commissioned through the English Research and

Development programme, has been providing access to cost-effectiveness information from studies

since 1994, through the Centre for Reviews and Dissemination (CRD) at the University of York. It

provided one of the most extensive, specialist repositories of studies where an economic evaluation of

technologies had taken place. The NHS EED contained economic evaluations of healthcare

interventions, along with critical appraisals containing a summary of the effectiveness information on

which the economic evidence was based and details of the key elements of the evaluation,

summarizing the overall reliability and generalizability of each study. The appraisals were written and

independently checked by health economists with in-depth knowledge and experience of economic

evaluation methods.

Until the end of March 2015, when central government funding to produce the NHS EED

ceased, the database was updated weekly by CRD staff using a robust, sensitive search to identify

published economic evaluations [10,11]. Our search, using this database, was not restricted by

publication date, so as to increase the pool of economic evaluations of home support interventions to

be appraised. The full search was completed by 15.01.2015.

The search terms used to identify economic evaluations included in the NHS EED database

were:

((dementia OR Alzheimer) AND (therapy OR treatment OR intervention OR non

pharmacological OR psychosocial) OR (home care))

The search strategy was developed and tested by an experienced systematic reviewer (RH)

prior to deciding on the final search terms and this process was informed by the search strategy of a

wider evidence synthesis, including a systematic review of non-economic studies of home support in

dementia, from the parent research programme [12].

Owing to the imminent, planned withdrawal of funding for the NHS EED, searches of the

database were supplemented by other searches to identify studies that may not have been included.

The electronic search was supplemented by a search of the INTERDEM (Early detection and timely

INTERvention in DEMentia) website (http://www.interdem.org) and a hand search (PC, RJ).

INTERDEM is a pan-European network of researchers collaborating in research on and dissemination

of early, timely and quality psychosocial interventions in dementia aimed at improving the quality of

life of people with dementia and their supporters, across Europe. The reference lists of publications

identified in NHS EED and INTERDEM were also searched (PC, RJ) and experts in the field who had

previously published economic evaluations in social care and dementia were consulted (PC). These

additional search strategies were used to identify studies published between January 2014 and

January 2015 and any previous or recent systematic reviews of economic evaluations of non-drug

interventions for dementia.

Inclusion and exclusion criteria

Table 1 shows the inclusion/exclusion criteria, using the PICOS (Population, Interventions,

Comparators, Outcomes and Study Designs) framework [13]. Only English language sources were

consulted. The main purpose of the review was to discern the cost-effective evidence with respect to

the components of several different approaches to dementia home support that had been evaluated.

Therefore, studies assessing only resource use, for example effects on numbers of hospital

admissions, were excluded unless unit costs were employed to fully cost an intervention.

Data extraction

One researcher (PC) screened the titles and abstracts of all citations retrieved against the inclusion

criteria, with a second (RJ) confirming the inclusion or exclusion of each study. The full-texts of these

studies were then retrieved and screened against the inclusion criteria (PC, RJ), with uncertainties

and disagreements resolved through discussion.

After screening, one researcher (RJ) extracted data using a standardised form [13], with

these data checked by a second reviewer (PC). The fields included: author, year; country; study

objective; intervention and comparator descriptions; methods (analytical approach, measure of health

benefit, cost data, analysis of uncertainty); results (participant numbers in intervention/control groups;

reported costs and outcomes of the intervention/comparator; Incremental Cost-Effectiveness Ratio

(ICER)); and conclusions.

Quality assessment

Two researchers (PC, RJ) together determined the extent to which the reported studies complied with

criteria of good practice in economic evaluation by summarizing them against their NHS EED critical

appraisals. These criteria were those set out in the CRD NHS EED Database Handbook [14], which

was used to guide those staff undertaking the critical appraisals. The criteria were: whether a clear

rationale was given for the choice of comparator; whether the methods of modelling techniques and/or

statistical analysis were clearly reported and appropriate; whether the estimates of effectiveness,

health benefit and costs were likely to be valid and any sources of bias; and other issues

(generalizability, comparison with other studies, selective presentation of results, and whether

conclusions were justified).

However, as the NHS EED critical appraisals, undertaken by multiple CRD staff, may

themselves have been variable in quality, two reviewers (PC, RJ) also rated the studies independently

using the Consensus on Health Economic Criteria checklist of Evers and colleagues [15,16], a tool

recommended in a systematic review of tools [17], with disagreements between the reviewers

resolved through discussion. The two assessments share some criteria in common, although the

NHS EED critical appraisals were structured narratively whereas the Evers checklist [15] simply

signals whether each of nineteen criteria are satisfied. Thus, the results of each rating were

compared side-by-side, across the studies, highlighting agreements and discrepancies, to draw

conclusions concerning the overall quality of each study.

Data synthesis

Two methods were used to synthesise the results. Firstly, a narrative synthesis was used to

summarise, compare and contrast the aims, methods and results of the studies reviewed. This

illustrates the heterogeneity of the studies in terms of characteristics and settings [13]. Where

possible, information was summarised across studies about the cost perspective (e.g. public agency

costs only, societal costs), the interventions themselves, the measures of benefit used and ICERs.

For ICERs, net costs were converted to a common currency (both $US and £Sterling) and price year

(2014) using the CCEMG–EPPI-Centre Cost Converter (v.1.4) [18]. As part of this synthesis, the

interventions evaluated in each study were also mapped to a range of intervention ‘components’,

which described the essential ingredients of each intervention in a way that would permit their

translation into routine practice. These components were defined as “common and distinctive

techniques across evaluated interventions” (p.379) [19], and were derived from an overview of

systematic reviews of non-pharmacological interventions for dementia [12], by extracting descriptive

data from the reviews, regarding particularly the foci of interventions and their outcomes. Each study

was also reviewed to determine its location on the care pathway for the United Kingdom (UK). This

was necessary to inform policy on dementia home support and future implementation. Evidence

about usual care pathways was based on material in national reports [2, 9].

Secondly, where data permitted, a permutation index [20] was used as a framework to

present the outcomes of the evaluations from the review, in terms of their relative costs versus effects.

This index ranks all possible permutations of costs and health outcomes, providing an instant visual

summary of findings and their likely implications for the decision maker. This matrix was used to

guide potential decisions as to whether an intervention may be deemed acceptable in terms of its

relative cost-effectiveness if it were adopted in routine practice.

Results

Literature search: Identification of studies

Overall, our search identified 151 potentially relevant studies, 14 of which were included in the review.

The selection process is shown in Figure 1. One systematic economic review for dementia care

(including pharmacological treatments and non-home based interventions) was identified [21]. This

was consulted to identify other potentially relevant studies not available from the searches of the NHS

EED.

Study descriptions

Table 2 summarises the characteristics of the economic analyses that were selected. There were

eight studies directed towards supporting people with dementia and six specifically for carers. Five

studies were incremental Cost Utility Analyses [24,25,27,31,35], seven cost-effectiveness analyses

[22,23,26,28,29,30,35], and two were cost consequences analyses [32,34].

The studies differed quite markedly in terms of their design, the cost elements included and choice of

outcome measures. One study [25], synthesised data from secondary sources in a Markov model to

estimate the cost utility of the intervention. Fifteen studies used primary cost and outcome data

collected in prospective evaluations. Of these, eight studies [22,26,27,28,30,32,34,35] used a

randomised controlled trial design, four [23,25,29,33] were non-randomised comparisons and one [31]

used a pre/post-test design.

Five studies [24,25,27,31,35] used the QALY as the measure of health benefit. Four studies

used a health benefit measure related to the impact on carers [22, 23, 26, 33]; measures of health

benefit differed in the remaining studies. Two studies [32,34] did not report a measure of

effectiveness or health benefit.

Quality assessment

Each study was summarized against the two sources of quality appraisal to raise key issues

(Appendix A). Overall, few studies met all our combined quality criteria. For some, there was

insufficient detail of comparators [22,27,28,29] and/or of measures of health benefit [22,23,25,27,29].

For others, the cost perspective [22,29,30] or price year [23,26,28,29] was not stated. In some

studies, incremental analysis of costs and outcomes of alternatives was not undertaken [22,29,32,34]

and in most studies there was no sensitivity analysis [22,23,24,29,30,31,32,33,34].

For most studies, the NHS EED and our independent ratings concurred, notable exceptions being

those of Roberts et al. [22], Challis et al. [23], Drummond et al. [24], and Gitlin et al. [28], where NHS

EED appraisals did not provide sufficient information to rate against several items on the Evers

checklist [15]. NHS EED critical appraisals were unavailable for four studies [31,32,33,34], but our

independent ratings identified weaknesses for these in terms of: poor description of competing

alternatives [31,33]; the lack of comprehensive costs measurement [31,33]; not identifying all

important and relevant outcomes [31,32,33,34]; and lack of sensitivity analyses [31,32,33,34].

Four studies emerged as being well reported and of high quality [26,27,30,35], although these

were still subject to limitations. The study by Graff et al. [26], for example, did not state the price year

and that by Pitkala et al. [30] did not state the cost perspective. The NHS EED critical appraisals for

some, otherwise well reported, studies did not rate against the criteria of generalizability, conflicts of

interest and ethics/distributional issues; an example being the study by Wilson et al. [27]. It was not

necessarily the case that more recent studies, published after systematic guidelines for reporting

economic evaluations, were of higher quality.

Data synthesis results

A range of potential intervention components were present across the studies (Table 3). Half (N=7) of

the interventions [22,24,26,28,31,33,35] were multicomponent; a tailored activity programme [28], for

example, included elements of physical activity for people with dementia but also education/advice

and behaviour management for carers. The most common component across interventions was

behaviour management for carers – education on techniques to identify and modify beliefs and

develop new repertoires of behaviour to deal with behavioural challenges of the person with dementia

– occurring in five studies. Care co-ordination – connecting and bringing together different services

around the person with dementia or caregiver or advising on and negotiating delivery of services from

multiple providers to provide benefit – was present in three of the studies. Of potential components of

interventions identified in the literature [8] three – sensory stimulation or relaxation, cognitive training

and emotional support for the person with dementia – were not present in any of the interventions

reviewed.

The interventions described in the studies were located on the care pathway for dementia

[1,9]. Two of the studies, a care management approach in primary care [34] and a community

occupational therapy intervention from memory clinics [26], were located earlier along the care

pathway, where dementia is likely to be in its mild to moderate stages, where people are beginning to

experience early symptoms, such as decline in short-term memory and difficulties following a

conversation [24]. Two other studies, a more intensive care management intervention [23] and an

exercise programme for the person with dementia [30] were located at a later stage, where dementia

is likely to be in its moderate to severe stages, where completing everyday activities becomes more of

a concern [24]. All interventions with primary benefits for carers [22,24,27,28,32,33,35] were located

at the moderate to severe stages. There were no interventions, such as for example palliative care

approaches [37], at the final or severe stage.

Results from each study on the permutation index, showing where each sits in relation to its

relative incremental costs versus benefits, are shown in Table 4. There were no studies occupying six

out of the nine cells of the matrix, either because the intervention over comparator was more costly for

the same or lower effects (dominated); had similar costs for a net gain, no difference or lower effects;

or was less costly but for lower effects. However, in four studies [26,30,32,34] the intervention was

dominant (less costly and more effective) (cell g, Table 4) with one study finding similar effects at

lower cost (cell h, Table 4). Here the evidence would indicate acceptance of these interventions.

However, for most (N=9) studies, the interventions were more effective but more costly (cell

a, Table 4), justifying incremental analysis as to whether there is a willingness to pay this additional

cost. For these studies where requisite data were available (N=5), the range of incremental costs per

QALY gained (converted to £/$ at 2014 prices) ranged from £6,696 ($9,790) [35] to £207,942

($304,010) [25]. Two of these interventions, a specialist dementia day care service [31] and a carers’

coping intervention [35], had values under the revised (2015) threshold value of acceptable cost per

QALY gained recommended to the UK National Institute for Health and Care Excellence (NICE) of

£12,936 per QALY [38].

Discussion

Main findings

This systematic review of economic evaluations of home support approaches for dementia revealed a

relatively small number of studies reporting both the costs and effects of these interventions. Studies

varied in quality and their inclusion of relevant costs and effectiveness measures. Differences in

design and in particular, the non-reporting of key parameters and estimates of variability in some,

makes it difficult to draw firm conclusions about which approaches could be considered most cost-

effective. However, against this, the better quality studies provided some useful findings on the value

of specific forms of home support, which could be taken forward by policymakers.

Four studies [26,30,32,34] found the intervention to be dominant with a further two studies

[31,35] finding home support approaches cost-effective under current recommended willingness to

pay thresholds. Thus, from these studies, there is some positive evidence of cost-effectiveness from

approaches that focus on occupational therapy [26], home-based exercise [30], specialist day care

[31], a social service intervention [32], care management [34], and a carers’ coping intervention [35].

However, study quality was variable with only three of these studies [26,30,35] well reported and of

higher quality. Thus, occupational therapy, home-based exercise, and a carers’ coping intervention

emerging as cost-effective approaches for which there was better evidence. These interventions

used environmental modifications, behaviour management, physical activity, and emotional support

as active components.

Strengths and limitations of review methods

This review adds to the literature by providing critical evaluation of the cost-effectiveness evidence in

a developing area, where there is a paucity of well-conducted studies. The methodology used broad

search terms within a comprehensive, regularly updated database (NHS EED) and the resultant

retrieved studies were quality appraised, using both the NHS EED quality appraisal process and our

own independent ratings, using a recommended checklist [15]. The data synthesis not only described

the studies, as an aid to comparability, but also mapped the location of each intervention on the

dementia care pathway and additionally, elicited the components of each intervention. The latter

element is particularly worthwhile as it may assist policymakers, who require knowledge of how and

why particular interventions may work [39] to benefit people with dementia or their carers.

Our review has several limitations. Heterogeneity in terms of study designs, methods, interventions

and outcome measures meant that a narrative summary was used and a formal meta-analysis of

studies was not possible. In terms of quality assessment, there were discrepancies in results for

particular studies, between the two instruments chosen. This arose because rating systems used to

measure quality vary in their comprehensiveness and there is a lack of agreement on what an ideal

instrument for quality assessment would be [40].

Some studies reviewed [24,25,31,32] were also published before the development of

guidelines for reporting economic evaluations and so their quality may have been compromised.

However, these studies did evaluate forms of home support not covered by more recent studies, so

their inclusion was warranted on the basis of examining a fuller range of possible interventions.

Furthermore, the permutation index used to summarise the potential acceptability of interventions was

limited in comparison to the approach adopted by NICE, which assesses the ICER in the context of

the uncertainty that surrounds it. Nevertheless, this was thought to be useful in providing an easily

discernible summary for the policymaker. In five studies ICERs were expressed in terms of £/QALY,

enabling direct comparisons as to cost-effectiveness. Comparison of the ICER from interventions with

a threshold value of £/QALY indicates whether or not the health benefit gained from their use exceeds

the health expected to be lost elsewhere in the health system [38]. The UK NICE recommended

threshold value (£12,936/QALY) [38] was chosen as an estimate, based on current UK data, of the

scale of opportunity costs faced by the public health agency (the NHS). However, its use has been

debated [41].

Further research

There was a lack of sufficient data on both costs and relevant comparable effects (such as utility

values to construct QALYs) for the full range of potential home support interventions. Predominantly,

this paucity of data was due to a lack of mean per person costs, and indications of variability in costs

for particular interventions. On the effects side, however, only 5 studies provided data in terms of

QALYs, permitting comparable ICERs to be calculated. Thus, additional data, particularly on a

comprehensive array of costs, potentially arising from these interventions, is necessary to guide future

evaluation. These data could be collected from national reports [1,9,]. Alternatively, special data

collections, for example on utilities for people with dementia [42] at different stages, appropriately

inflated or deflated according to their receipt of specific interventions, could be used. To improve this

situation, there is a need for well-designed and reported integrated clinical and economic trials of

dementia home support that can offer robust evidence of costs and effects.

There was a relative lack of studies investigating cost-effectiveness for specific interventions

at particular stages of dementia. Most of the interventions occurred at moderate to severe stages of

dementia, later in the care pathway. Only two [26,34] were undertaken with people in the early stages

of dementia. It is here that interventions may offer sustainable benefits to people in terms of them

‘living well’ with the condition. One type of intervention with potential benefit at this stage may be one

with a cognitive training component [43], addressing memory deficits by stimulating cognitive

functions through guided practice, reflecting memory, attention or problem solving. More robust

evidence, from well-conducted trials, is needed to judge the value of such an intervention. The

criterion ‘delivered at home’, meant that some economic studies with favourable outcomes, but in

other settings, reported in the literature were excluded from this review. Interventions such as

cognitive stimulation therapy [44], delivered in nursing homes or day centres, may potentially be

useful but further studies are necessary to adapt its principles and methods for delivery to patients or

carers in their own homes. There were no studies at end-stage dementia, such as palliative care

approaches, which is an area of topical interest [45].

Conclusions and implications

This review identifies three approaches for which there is positive cost-effectiveness evidence:

occupational therapy, home-based exercise, and a carers’ coping intervention. In particular, the

approaches rely on the active components of: environmental modifications, behaviour management,

physical activity, and emotional support. Decision makers should seek to configure home support

services for dementia building on these approaches. Policy makers should also align such cost-

effectiveness evidence with patient and carer preferences about what combinations of these

ingredients are most valued as part of packages of home support [46]. However, future studies are

necessary since the economic evidence around these home support interventions is far from robust.

Better quality data is needed to judge the value of these and other interventions at particular points

along the dementia care pathway. In particular, economic evidence of new approaches in early stage

dementia, such as home-based cognitive training, and in late stage, such as palliative care, is

required.

Acknowledgements

This research was funded by the National Institute for Health Research (NIHR) in England under its

Programme Grants for Applied Research (Grant Reference Number: DTC-RP-PG-0311-12003). The

views expressed in this paper are those of the authors and not necessarily those of the NHS, the

NIHR or the Department of Health in England.

Members of the Programme Management Group include: Dr Jane Hughes, Professor David Jolley,

Professor Chris Roberts (University of Manchester); Professor Martin Orrell, Narinder Kapur

(University College London); Professor Brenda Roe (Edge Hill University); Professor Fiona Poland

(University of East Anglia); Professor Ian Russell (Swansea University); Jean Tottie (Together in

Dementia Everyday); and Reagan Blyth (Pennine Care NHS Foundation Trust). We would like to

thank Rebecca Hays for initial help in developing the search strategies. We thank staff of the UK

Centre for Reviews and Dissemination at the University of York for making available critical appraisals

of the papers arising from the review.

References

[1] Alzheimer’s Disease International. World Alzheimer’s Report. The Global Impact of

Dementia. London: Alzheimer’s Disease International, 2015.

[2] Alzheimer’s Society. Dementia UK: 2014 edition. London: Alzheimer’s Society, 2014.

[3] House of Commons All-Party Parliamentary Group on Dementia. The £20 Billion Question:

An Enquiry into Improving Lives through Cost-effective Dementia Services. London: House of

Commons, 2011.

[4] Department of Health. Living Well with Dementia: A National Dementia Strategy. London:

Department of Health, 2009.

[5] Cooper B. Thinking preventively about dementia: a review. Int J Geriatr Psychiatry 2002; 17:

895–906.

[6] Comas-Herrera A, Wittenberg R, Pickard L, Knapp M. Cognitive impairment in older people:

the implications for future demand for long-term care services and their costs. Int J Geriatr

Psychiatry 2007; 22(10): 1037-45.

[7] Olazaran J, Reisberg B, Clare L, Orrell M. et al. Non-pharmacological therapies in

Alzheimer’s disease: a systematic review of efficacy. Dementia and Geriatric Cognitive

Disorders 2010; 30: 161-78.

[8] Elvish R, Lever S-J, Johnstone J, Cawley R, Keady J. Psychological interventions for

carers of people with dementia: A systematic review of quantitative and qualitative evidence.

Counselling and Psychotherapy Research 2013; 13(2): 106-25.

[9] NICE-SCIE. Dementia: supporting people with dementia and their carers in health and

social care. Care guideline (amended March 2011). London: National Institute for

Health and Clinical Excellence (NICE) and Social Care Institute for Excellence, 2011.

[10] United Kingdom National Health Service Centre for Reviews and Dissemination DARE and

NHS EED. Available from: http://www.crd.york.ac.uk/CRDWeb//AboutPage.asp. [Accessed

September 1, 2016].

[11] Glanville J, Kaunelis D, Mensinkai S. How well do search filters perform in identifying

economic evaluations in MEDLINE and EMBASE. Int J Technol Assess Health Care 2009;

25(4): 522-9.

[12] Clarkson P, Giebel CM, Larbey M. et al. A protocol for a systematic review of effective home

support to people with dementia and their carers: components and impacts. Journal of

Advanced Nursing 2016; 72: 186-96.

[13] United Kingdom National Health Service Centre for Reviews and Dissemination. Systematic

Reviews: CRD’s Guidance for Undertaking Reviews in Health Care. York: Centre for Reviews

and Dissemination, University of York, 2009.

[14] United Kingdom National Health Service Centre for Reviews and Dissemination. NHS

Economic Evaluation Database Handbook, April 2007. York: University of York, 2007.

[15] Evers S, Goossens M, de Vet H, van Tulder M, Ament A. Criteria list for assessment of

methodological quality of economic evaluations: Consensus on Health Economic Criteria. Int

J Technol Assess Health Care 2005; 21(2): 240-5.

[16] Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the

Economic Evaluation of Health Care Programmes (4th ed). New York: Oxford University

Press, 2015.

[17] National Collaborating Centre for Methods and Tools. Critically Appraising Economic

Evaluations: A Systematic Review of Tools. Hamilton, ON: McMaster University, 2013.

[18] Shemilt I, Thomas J, Morciano M. A web-based tool for adjusting costs to a specific

target currency and price year. Evidence & Policy 2010; 6: 51-59.

[19] Abraham C, Michie S. A taxonomy of behaviour change techniques used in interventions.

Health Psychology 2008; 27: 379–87.

[20] Nixon J, Khan KS, Kleijnen J. Summarising economic evaluations in systematic reviews: a

new approach. BMJ 2001; 322: 1596–98.

[21] Knapp M, Iemmi V, Romeo R. Dementia care costs and outcomes: a systematic review. Int J

Geriatr Psychiatry 2013; 28: 551–61.

[22] Roberts J, Browne G, Milne C. et al. Problem-solving counseling for caregivers of the

cognitively impaired: effective for whom?. Nursing Research 1999; 48(3): 162-72.

[23] Challis D, von Abendorff R, Brown P, Chesterman J, Hughes J. Care management,

dementia care and specialist mental health services: an evaluation. Int J Geriatr Psychiatry

2002; 17(4): 315-325.

[24] Drummond MF, Mohide EA, Tew M. et al. Economic evaluation of a support program for

caregivers of demented elderly. Int J Technol Assess Health Care 1991; 7(2): 209-19.

[25] Wimo A, Mattson B, Krakau I. et al. Cost-utility analysis of group living in dementia care. Int J

Technol Assess Health Care 1995; 11(1): 49-65.

[26] Graff M J, Adang EM, Vernooij-Dassen MJ. Et al. Community occupational therapy for older

patients with dementia and their caregivers: cost effectiveness study. BMJ 2008: 336(7636):

134-38.

[27] Wilson E, Thalanany M, Shepstone L. Befriending carers of people with dementia: a cost

utility analysis. Int J Geriatr Psychiatry 2009; 24(6): 610-23.

[28] Gitlin LN, Hodgson N, Jutkowitz E, Pizzi L. The cost-effectiveness of a nonpharmacologic

intervention for individuals with dementia and family caregivers: the Tailored Activity Program.

American Journal of Geriatric Psychiatry 2010; 18(6): 510-19.

[29] Kuo YC, Lan CF, Chen LK, Lan VM. Dementia care costs and the patient's quality of life

(QoL) in Taiwan: home versus institutional care services. Archives of Gerontology and

Geriatrics 2010; 51(2):159-63.

[30] Pitkala KH, Poysti MM, Laakkonen ML. et al. TE Effects of the Finnish Alzheimer Disease

Exercise Trial (FINALEX): a randomized controlled trial. JAMA Internal Medicine 2013;

173(10): 894-901.

[31] Wimo A, Wallin J, Lundgren K. et al. Impact of day care on dementia patients – costs, well-

being and relatives’ views. Family Practice 1990; 7: 279–87.

[32] Weinberger M, Gold DT, Divine GW. et al. Social service interventions for caregivers of

patients with dementia: impact on health care utilization and expenditures. J Am Geriatr Soc

1993; 41: 153-6.

[33] McGuire RC. A case study in cost-effectiveness analysis for computer technology used in

support of caregivers with Alzheimers disease patients. In: Moorhead S and Delaney C eds,

Information Systems Innovations for Nursing: New Visions and Ventures, Thousand Oaks,

CA: Sage Publications, 1998.

[34] Duru OK, Ettner SL, Vassar SD, Chodosh J, Vickrey BG. Cost evaluation of a coordinated

care management intervention for dementia. Am J Manag Care 2009; 15(8): 521–28.

[35] Knapp M, King D, Romeo R. et al. Cost effectiveness of a manual based coping strategy

programme in promoting the mental health of family carers of people with dementia (the

START (STrAtegies for RelaTives) study): a pragmatic randomised controlled trial BMJ 2013;

347: f6342.

[36] Vickrey BG, Mittman BS, Connor KI. et al. The effect of a disease management intervention

on quality and outcomes of dementia care: a randomized controlled trial. Ann Intern Med

2006; 145: 713–26.

[37] Treloar A, Crugel M, Adamis D. Palliative and end of life care of dementia at home is feasible

and rewarding: Results from the `Hope for Home' study. Dementia 2009; 8: 335-47.

[38] Claxton K, Martin S, Soares M. et al. Methods for the estimation of the National Institute for

Health and Care Excellence cost-effectiveness threshold. Health Technol Assess 2015;

19(14).

[39] Burgener S, Jao Y-L, Anderson JG, Bossen AL. Mechanism of action for nonpharmacological

therapies for individuals with dementia: implications for practice and research. Research in

Gerontological Nursing 2015, 8, 240-259.

[40] Walker DG, Wilson RF, Sharma R, et al. Best Practices for Conducting Economic

Evaluations in Health care: A Systematic review of Quality Assessment tools. Rockville, MD:

Agency for Healthcare Research and Quality, 2012.

[41] Raftery JP. NICE’s cost-effectiveness range: Should it be lowered? PharmacoEconomics

2014; 32: 613–15.

[42] Jonsson L, Andreasen N, Kilander L. et al. Patient and proxy-reported utility in Alzheimer

Disease using the EuroQol. Alzheimer Dis Assoc Disord 2006; 20: 49–55.

[43] Moniz-Cook E, Agar S, Gibson G, Win T, Wang M. A preliminary study of the effects of early

intervention with people with dementia and their families in a memory clinic. Aging & Mental

Health 1998; 2: 199-211.

[44] Knapp M, Thorgrimsen L, Patel A. et al. Cognitive stimulation therapy for people with

dementia: cost-effectiveness analysis. British Journal of Psychiatry 2006; 188: 574-80.

[45] Jolley D, Hughes J, Greaves I, Jordan A, Sampson E. Seeing patients with dementia through

to the end of life. Geriatric Medicine 2008; 38(9): 461-64.

[46] Chester H, Clarkson P, Davies L, Sutcliffe C, Davies S, Feast A., Hughes J, Challis, D.

People with dementia and carer preferences for home support services in early-stage

dementia. Aging & Mental Health 2016; 16: 1-10.

Table 1 Inclusion and exclusion criteria for the review

Population. At least 80% of the population must have a diagnosis of dementia, only including: Alzheimer’s Disease, vascular dementia, fronto-temporal

dementia and dementia with Lewy bodies. The dementia may be mild, moderate or severe. Populations with mild cognitive impairment (MCI) or

cognitive impairment as a result of an acquired brain injury or other rarer dementias (e.g. AIDS acquired dementia) were excluded.

Interventions. Included were interventions that were non-pharmacological and non-invasive and delivered at home to the person with dementia and/or their

carer. Invasive interventions, involving the consumption or application of a substance (including drugs, vitamins and food supplements, herbal

medicines and homeopathic remedies, oxygen and acupuncture) were excluded but assistance with activities of daily living, including feeding, was

included. Interventions, providing formal support (i.e. not purely through informal and family channels) may be categorised, according to their

expressed purpose, as Supportive, Informational, Therapeutic, or Educative (SITE). Supportive approaches rely on both an emotional component

and one that assists in the maintenance of both basic and instrumental activities of daily living; Informational approaches include general

information about dementia and its consequences; Therapeutic approaches include structured involvement to meet emotional needs such as

counselling and psychotherapy; and Educative approaches include skills training for both carers and people with dementia to help in managing

behaviour. Support involving Assistive Technology was included, if this was set up or delivered by people (e.g. a nurse visiting at home to set up a

computer system and/or train a carer in how to use it), and the expressed purpose of this could be included in the above categories of support.

Interventions containing a day care element were included, as this was interpreted to be providing a respite component for carers. Interventions

delivered exclusively in residential, nursing homes or clinics were excluded but those provided to tenants of extra-care housing were included.

Comparators. Usual care or treatment as usual; this may include pharmacological treatment. In some settings, usual support may mean the absence of formal

care services or care only by informal carers (relatives and friends). Partial economic evaluations, where no formal comparator was employed,

were included.

Outcomes Included: For the person with dementia (PWD): Time to care home admission; hospital admissions; quality of life (including Quality Adjusted Life

Years); activities of daily living (ADLs); behavior; cognition; mood. For the caregiver (CG): Quality of life; Burden / stress / anxiety.

Study designs Full and partial economic analyses from studies where the designs were: randomised controlled trials (RCTs), non-randomised controlled studies,

cohort studies, modelling studies. Editorials or other descriptive studies (e.g. historical discussion, single case reports) were excluded.

General Included were studies conducted anywhere in the world; but English language sources only were consulted. No date restrictions were applied:

sources were searched from inception up to 15.01.2015.

Table 2 Summary of economic analyses of home support interventions for people with dementia/carers

Reference (year) Country Study objective Intervention

description

Methods Results/conclusions

Roberts et al. (1999) [22] Canada To determine

effectiveness of

individualised

problem-solving

counselling by

nurses for

caregivers and

expenditure of

health care

utilisation

Nurse counselling. A

problem solving

manual was used plus

10 individual sessions

with a nurse

counsellor over a 6-

month period

Cost-effectiveness analysis.

Measure of benefit:

Psychosocial Adjustment to

Relatives Illness.

Cost data: public agency and

caregiver perspectives.

Source of data: single study.

Analysis of uncertainty:

Statistical comparisons only.

There were greater costs to the

intervention as against a small

(non-significant) improvement in

carers’ psychosocial adjustment

after 1 year.

ICER Not reported.

Challis et al. (2002) [23] England, UK To evaluate a

model of intensive

care management

for people with

dementia/carers

based in a

CMHTOP

Intensive care

management service -

case managers

deployed flexible

budgets and

maintained structured

care plans which were

completed at regular

intervals

Cost-effectiveness analysis.

Measure of benefit: carer

malaise.

Cost data: public agency and

societal.

Source of data: Single study.

Analysis of uncertainty:

Statistical comparisons only.

Increased costs from the

intervention as against beneficial

effects in terms of people with

dementia remaining at home

and a decrease in carer stress.

The setting of the intervention

(Community Mental Health

Team) was crucial in targeting

resources on a specific frail

group of older people.

ICER Not reported.

Drummond et al. (1991) [24] Canada Economic

evaluation of a

support

programme for

caregivers of

people with

dementia

Caregiver Support

Programme (CSP) -

Caregiver support

nurses (CSN) first

made regular home

visits providing

information and

advice, then

scheduled weekly in-

home respite, and

self-help support

groups

Cost-utility analysis.

Measure of benefit: QALY.

Cost data: public agency

perspective.

Source of data: Single study.

Analysis of uncertainty: none.

Increased costs of the

intervention as against a (non-

significant) enhancement in

caregivers’ quality of life.

$CDN 20,036/QALY reported.

Net cost of adding intervention:

ICER= $CDN 12,090/QALY

(£19,373/QALY)a.

Wimo et al. (1995) [25] Sweden To perform a cost

utility analysis on

group living in

order to calculate

the costs per

QALY gained

Group living - in

comparison with

controls at home or

controls in institutions

Cost-utility analysis.

Measure of benefit: QALY.

Cost data: public agency

perspective.

Source of data: secondary

sources – decision analytic

model.

Analysis of uncertainty: One

way sensitivity analyses

undertaken using: alternative

discount rates for costs and

benefits, utility values,

survival times, transition

Increased costs of intervention

as against enhanced quality of

life for people with dementia.

Cost/QALY < $0 for 8 year

model extrapolation.

ICER= $US 211,900/QALY

(£207,942/QALY)a

probabilities, and costs of

institutional care.

Graff et al. (2008) [26] Netherlands To assess the cost

effectiveness of

community based

occupational

therapy compared

with usual care in

older people with

dementia and their

caregivers from a

societal viewpoint

Community based

occupational therapy -

10 one hour sessions

administered by

occupational

therapists in own

home to improve

meaningful activities

Cost-effectiveness analysis.

Measure of benefit: No. of

successful treatments:

(significant improvement in

three outcomes: process

scale, performance scale,

competence scale).

Cost data: societal

perspective.

Source of data: Trial based

analysis.

Analysis of uncertainty: One-

way and probabilistic

sensitivity analyses

(bootstrapping) undertaken.

Decreased costs from

intervention with main cost

saving arising from informal

care; this against an increase in

successful treatments.

ICER not reported

Wilson et al. (2009) [27] England, UK To evaluate the

cost-effectiveness

of a structured

befriending service

for carers of

people with

dementia in terms

of improving their

quality of life

Carers had access to

a Befriender

Facilitator (BF), and

offer of contact with a

trained volunteer for

the duration of the

scheme. Weekly

home visits for at least

six months from

Cost-utility analysis.

Measure of benefit: QALY.

Cost data: societal

perspective.

Source of data: Trial based

analysis.

Analysis of uncertainty:

confidence intervals for

outcomes and costs

Increased costs from

intervention as against improved

carer quality of life.

ICER= £105,954/QALY

(£118,261/QALY) a.

£28,848/QALY (£32,198/QALY)

a, if patients also included

volunteer overseen by

the BF (flexible

around the carer)

generated using

nonparametric bootstrapping;

scenario analyses performed

from statutory, voluntary and

household sectors, and from

societal perspective including

both carer and patient

QALYs.

Gitlin et al. (2010) [28] Philadelphia, US To evaluate the

cost-effectiveness

of a Tailored

Activity Program

(TAP) for

individuals with

dementia and

family care givers,

delivered by

occupational

therapists

Eight sessions of

activities over 4

months (identifying

patients' preserved

capabilities, previous

roles, habits and

interests) to develop

customised activities

and train families in

their use. Delivered by

occupational

therapists

Cost-effectiveness analysis.

Measure of benefit: average

carer hours "doing

things"/“on duty” per day.

Cost data: public agency

perspective cost of

intervention only.

Source of data: Single study.

Analysis of uncertainty:

analysis of covariance

conducted to test differences

between groups; probabilistic

sensitivity analysis

Conducted; one-way

sensitivity analyses varied

costs between minimum and

maximum values for therapist

time and travel expenses.

Increased costs from

intervention as against savings

for carers ‘doing things’ and

‘being on duty’.

ICER not reported.

Kuo et al. (2010) [29] Taipei, Taiwan To explore the

optimal model of

dementia care in

Taiwan by

evaluating care

costs, Quality of

Life and healthcare

settings of people

with dementia

living in home care

versus institutional

care settings

Usual home /

community care was

the intervention in

comparison with

institutional care

settings for people

with dementia

Cost-effectiveness analysis.

Measure of benefit: Quality of

life/utility.

Cost data: public agency and

caregiver perspectives.

Source of data: Single study.

Analysis of uncertainty: Only

statistical comparisons used

for between-group

differences.

Lower costs from intervention

(home care) but costs were

higher when indirect (carer)

costs were included.

ICER not reported.

Pitkala et al. (2013) [30] Finland To investigate the

effects of intense

and long-term

exercise on the

physical

functioning/mobility

of home-dwelling

patients with

dementia and to

explore its effects

on the use and

costs of health and

social services

Exercise with a

home-based group

performing physical

exercise for 1 hour

twice a week for 12

months under the

guidance of

physiotherapists

Cost-effectiveness analysis.

Measure of benefit: patient

functional independence.

Cost data: public agency

perspective.

Source of data: Trial based

analysis.

Analysis of uncertainty:

Standard deviations or 95%

confidence intervals

reported; bootstrapping used

to derive confidence intervals

for costs.

Increased costs of a home

based exercise intervention as

against beneficial effects on

physical functioning of people

with dementia.

ICER not reported.

Wimo et al. (1990) [31] Sweden To evaluate the

use of resources,

costs and effects

on the well-being

of people with

dementia in day

care/undertake a

cost utility analysis

comparing costs

and effects on

wellbeing

Specialist dementia

day care in three day

care units, with social

workers, activity

assistants, home aid

and assistant nurse.

All staff had

approximately a

month of dementia

training prior to the

start

Cost-utility analysis.

Measure of benefit: Quality of

life/utility.

Cost data: public agency

perspective.

Source of data: Single study.

Analysis of uncertainty: none.

Overall increased costs arising

from the intervention as against

improvements in the quality of

life of people with dementia.

SEK48,076/year translates to

ICER=£4293/QALY

(£7565/QALY) a.

Weinberger et al. (1993) [32] Philadelphia, US To evaluate the

impact of a social

service

intervention

(compliance to

social work

recommendations)

on 6-month health

services utilization

and expenditures

Social workers

devised an

individualised service

plan for caregivers

tailored for them and

followed this up with

contacts to enhance

compliance to the

plan's

recommendations

Cost consequences analysis.

Measure of benefit:

compliance to social work

intervention (no data

reported).

Cost data: public agency

perspective.

Source of data: Trial based

analysis.

Analysis of uncertainty: none.

Lower costs arising from

intervention group as against a

high rate of compliance to social

work intervention elicited.

ICER not reported.

McGuire (1998) [33] US To evaluate the

effectiveness of a

computer system,

ComputerLink, in

A computer

programme with three

sections to enhance

caregivers’ confidence

Cost-effectiveness analysis.

Measure of benefit: carers’

decision competence.

Cost data: public agency

Increased costs arising from the

intervention as against

increased decision confidence

reducing

caregiver's social

isolation and

increasing decision

making confidence

and improve their

decision making skills

perspective.

Source of data: Single study.

Analysis of uncertainty:

Statistical comparisons only.

amongst carers.

ICER not reported.

Duru et al. (2009) [34] California, US To calculate

intervention costs

and the potential

cost offset of a

care management

intervention to

subsequently

improve the quality

of care

People with dementia

and their caregivers

assigned a care

manager who

performed structured

home assessments,

care plans and

followed up as needed

plus at home re-

assessment every six

months

Cost consequences analysis.

Measure of benefit: not

reported but evidence of

improved patient/carer

outcomes from Vickrey et al.

2006 [36], including patient

health related quality of

life/utility.

Cost data: public agency and

societal perspectives.

Source of data: Trial based

analysis.

Analysis of uncertainty:

Statistical comparisons only

used for between-group

differences (with 95%

confidence intervals

reported).

Lower costs arising from the

intervention as against

improvements in the quality of

life of people with dementia.

ICER not reported.

Knapp et al. (2013) [35] England, UK To assess whether

the START

Manual based coping

intervention of eight

Cost utility analysis. Increased costs arising from the

intervention as against

(Strategies for

Relatives)

intervention added

to treatment as

usual was cost

effective compared

with usual

treatment alone

sessions delivered in

own home to carers of

people with dementia

by supervised

psychology graduates

Measure of benefit: QALY.

Cost data: public agency

perspective.

Source of data: Trial based

analysis.

Analysis of uncertainty:

Bootstrapping used to

estimate 95% confidence

intervals around cost

estimates. Cost-effectiveness

acceptability curves for

likelihood that intervention

was cost-effective over a

range of values for

willingness to pay for

additional QALY/HADS unit

change. Sensitivity analyses

to assess effects of missing

data, and to adjust outcomes

for initial imbalances.

improvements in the quality of

life of carers.

ICER = £6000/QALY

(£6696/QALY) a

a Converted to £ Sterling at 2014 prices

Table 3 Data synthesis, components of interventions

Components Studies [reference]

Primarily for person with dementia

Sensory stimulation/relaxation*

Social engagement† [31]

Cognitive training‡

Emotional support§

Physical activity a [28,30]

Environmental modifications b [25,26]

Behaviour management c [26]

Daily living activities d [29]

Care coordination e [23,32,34]

Primarily for caregiver

Education/advice f [24,28,33]

Social support g [24,27]

Behaviour management h [22,26,28,33,34]

Emotional support i [22,35]

Respite care j [24,31]

* To increase or relax the overall level of sensory stimulation in the environment to counterbalance the negative impact of sensory deprivation/stimulation common in dementia.

† To provide access to different forms of social contact to counterbalance the limited contact with others that may be characteristic of the experience of dementia. This social contact may be real or simulated.‡ To provide enhancement and stimulation of cognitive functions through guided practice on a set of standard tasks, reflecting memory, attention or problem solving.§ To address feelings and emotional needs through prompts, discussion or by stimulating memories and enabling the person to share their experiences; undertaken to counterbalance and help people manage difficult feelings and emotions.a To provide structured activities and/or exercise to provide meaningful and engaging experiences that can be a useful counterbalance to difficult behaviours.b To modify the living environment, including the visual environment, in order to lessen agitation and/or wandering and promote safety.c To increase pleasant events and/or to identify and modify factors which lead to difficult behaviours or their consequences through distraction or communication.d To assist with basic care, e.g. provision of laundry services, basic nutrition and help with activities of daily living.e Connecting and bringing together different services around the person; advising on and negotiating the delivery of services from multiple providers on behalf of the person to provide benefit.f Structured presentation of information concerning the condition and carer-related issues (e.g. legal issues, carer’s health), including an active role for carers, e.g. role-playing.g The opportunity to share personal feelings and concerns and overcome feelings of social isolation.h Education on techniques to identify and modify beliefs and develop new repertoires of behaviour to deal with behavioural challenges of the person with dementia.i To resolve pre-existing personal problems that can complicate caregiving and that can reduce conflicts between caregiver and person with dementia.j Planned, temporary relief through the provision of substitute care, e.g. day care, in-home sitting, residential care for the person with dementia.

Table 4 Data synthesis, results of the studies on the permutation matrix: number [reference] of studiesIn

crem

enta

l cos

ts

(inte

rven

tion

vs. c

ompa

rato

r)Incremental effects (intervention vs. comparator)

Net gain (+) No difference (0) Net loss (-)

Increased (+) a

9 [22,23,24,25,27,28,31,33,35]

c

none

c

none

Same (0) d

none

e

none

f

none

Reduced (-) g

4 [26,30,32,34]

h

1 [29]

j

none

Key:

Decision strongly favoured

g=accept intervention

c=reject intervention

Decision less favoured

d=accept intervention

b=reject intervention

f=reject intervention

h=accept intervention

No obvious decision

a=is added effect worth additional cost? Incremental analysis required.

j=is reduced effect acceptable given reduced cost? Incremental analysis required.

e=neutral cost and effect. Other reasons to adopt intervention?

Figure 1 Flow chart of the study selection process

Additional references from other sources:5 INTERDEM; 19 Systematic review, Knapp et al. 2013 [21]; 1 Known recent study

126 Potentially relevant references identified from NHS EED

151 Total retrieved references

12 Duplicates

139 Title/Abstracts reviewed

38 excluded (not dementia population)

57 excluded (invasive or drug technology

6 excluded (not delivered at home

38 full papers retrieved

6 excluded (not dementia population

3 excluded (invasive/drug technology

1 excluded (editorial/descriptive study)

12 excluded (not delivered at home)

2 excluded (non-English language)

14 Studies Included

Highlights

i. What is already known about the topic?

A range of dementia support interventions have been implemented and their costs and benefits have been evaluated. However, cost-effectiveness evidence is limited. A systematic appraisal of these interventions, in terms of costs versus benefits, has not yet taken place.

ii. What does the paper add to existing knowledge?

The better quality evidence suggests that three approaches: occupational therapy, home-based exercise, and a coping intervention for carers may be cost-effective, judged against current thresholds. The paper also adds to existing knowledge in delineating the components of evaluated interventions across the dementia pathway, an important element for those, such as local policymakers, wishing to devise possible interventions in routine practice.

iii. What insights does the paper provide for informing health care-related decision making? (optional)

The paper highlights what may be acceptable interventions, in terms of costs versus benefits but more detailed evidence is needed to inform policy makers, particularly for interventions in the early and very late stages of the condition.

Appendix A

Table A1 – Quality rating of studies1

Evers et al. checklist items Roberts et al. [22]

Challis et al.[23]

Drummond et al.[24]

Wimo et al.

(1995) [25]

Graff et al. [26]

Wilson et al. [27]

Gitlin et al. [28]

Kuo et al.

[29]

Pitkala et al. [30]

Wimo et al.

(1990) [31]

Weinberger et al.[32]

McGuire [33]

Duru et al. [34]

Knapp et al. [35]

1. Study population clearly described?

a b a b a b a b a b a b a b a b a b a* a* * a* a b

2. Competing alternatives clearly described?

a a b a b a b a b a b a b * a* * a* a b

3. Well-defined research question in answerable form?

a a b a b a b a b a a b a* a* * a* a b

4. Economic study design appropriate to stated objective?

a a b a a b a b a b a a b a* a* * a* a b

5. Chosen time horizon appropriate to include relevant costs and consequences?

a a b a a b a b a b a b a* a* a* a*

6. Actual perspective chosen appropriate?

a a b a a b a b a b * a* * a* a b

7. All important and relevant costs for each alternative identified?

a a b a b a b a b a b a b * a* * a* a b

8. All costs measured appropriately in physical units?

a b a b a b a b a b a b a b a b a b a* a* a* a* a b

9. Costs valued appropriately?

a b a a b a b a b a b a a* a* a* a* a b

10. All important and relevant outcomes for each alternative identified?

a a b a b a b a b a b a b a b * * * * a b

11. All outcomes measured appropriately?

a b a b a b a b a b a b a a b * * a* * a b

12. Outcomes valued a b a a b a b a b a a b a b * * a* * a b

appropriately?13. Incremental analysis of costs and outcomes of alternatives performed?

a a b a b a b a b a b a b a* * a* * a b

14. All future costs and outcomes discounted appropriately?

NA NA NA a b NA a b NA NA NA* * NA* NA* NA

15. All important variables, whose values are uncertain, appropriately subjected to sensitivity analysis?

a b a b a b a * * * * a b

16. Do conclusions follow from the data reported?

a a b a b a a b a b a b a b a* a* a* a* a b

17. Study discusses generalizability of results to other settings and patient/client groups?

a b a a b a a a b * a* a* a* a b

18. Article indicates that there is no potential conflict of interest of study researcher(s) and funder(s)?

a b a a a * * * a* a

19. Ethical and distributional issues discussed appropriately?

a b a a a * * * * a

1 Rated against checklist of Evers et al. [15] and NHS EED critical appraisals: a Satisfies criteria of Evers et al. [15]; b satisfies criteria of NHS EED critical appraisal.NA = not appropriate to discount as intervention lasted < 1 year.* No NHS EED critical appraisals were available for studies [31,32,33,34].Criteria used in NHS EED critical appraisals followed the United Kingdom National Health Service Centre for Reviews and Dissemination. NHS Economic Evaluation Database Handbook, April 2007 [14].