Abstract Background: Home care is an important care setting for those with Alzheimer’s disease (AD). It provides support that allows individuals with AD to remain at home and may delay the transition to long-term care homes. Many clients with AD receive medications that are used for managing the symptoms of AD: cholinesterase inhibitors (ChEIs) and memantine. Ontario’s provincial drug benefit plan (ODB) provides subsidies for some of these medications based on specific clinical criteria. These AD medications are costly and can have significant side effects, so it is important to understand how they are being used in practice. Objectives: The objectives of this study were to report the proportion taking AD medications and which types were taken, show the change in receipt of AD medications over time, and show the covariates that were independently associated with receiving AD medications. Methods: Analysis of secondary data was performed on the provincial home care dataset. All home care clients receiving long-term home care services were assessed using the RAI-Home Care (RAI-HC), which is a comprehensive and standardized assessment. One assessment from each individual over the age of 65 who was assessed between January 2004 and September 2008 was used, for a final sample size of 321,013. Results: Overall, 65% of clients with a diagnosis of AD were receiving an AD medication. Logistic regression analysis among those diagnosed with AD showed that increased physical impairment and clinical complexity were associated with decreased odds of receiving AD medication. Contraindicating diagnoses such as congestive heart failure, lack of medical oversight and needing to make economic tradeoffs were also associated with decreased odds of receiving AD medication. Conclusions: The multivariate model showed trends of rational prescribing, such as clients with contraindicating diagnoses or very high clinical complexity having decreased odds of receiving AD medications. At the same time, evidence of structural barriers to receiving the medications was shown. There is debate about the cost-effectiveness of these medications. The provincial government could consider expanding ODB guidelines to include all AD medications for those with all levels of cognitive impairment, but further analyses involving longitudinal outcomes available in this dataset should be performed to ensure it would be in the public interest.

Abstract Background: Home care is an important care setting for those with Alzheimer’s disease (AD). It provides support that allows individuals with AD to remain at home and may delay the transition to long-term care homes. Many clients with AD receive medications that are used for managing the symptoms of AD: cholinesterase inhibitors (ChEIs) and memantine. Ontario’s provincial drug benefit plan (ODB) provides subsidies for some of these medications based on specific clinical criteria. These AD medications are costly and can have significant side effects, so it is important to understand how they are being used in practice. Objectives: The objectives of this study were to report the proportion taking AD medications and which types were taken, show the change in receipt of AD medications over time, and show the covariates that were independently associated with receiving AD medications. Methods: Analysis of secondary data was performed on the provincial home care dataset. All home care clients receiving long-term home care services were assessed using the RAI-Home Care (RAI-HC), which is a comprehensive and standardized assessment. One assessment from each individual over the age of 65 who was assessed between January 2004 and September 2008 was used, for a final sample size of 321,013. Results: Overall, 65% of clients with a diagnosis of AD were receiving an AD medication. Logistic regression analysis among those diagnosed with AD showed that increased physical impairment and clinical complexity were associated with decreased odds of receiving AD medication. Contraindicating diagnoses such as congestive heart failure, lack of medical oversight and needing to make economic tradeoffs were also associated with decreased odds of receiving AD medication. Conclusions: The multivariate model showed trends of rational prescribing, such as clients with contraindicating diagnoses or very high clinical complexity having decreased odds of receiving AD medications. At the same time, evidence of structural barriers to receiving the medications was shown. There is debate about the cost-effectiveness of these medications. The provincial government could consider expanding ODB guidelines to include all AD medications for those with all levels of cognitive impairment, but further analyses involving longitudinal outcomes available in this dataset should be performed to ensure it would be in the public interest.

Several analytical techniques including use case diagrams, process flow diagrams (PFDs), hierarchical task analysis (HTA), failure mode and effects analysis (FMEA), systematic human error reduction and prediction approach (SHERPA), hazard analysis and critical control point (HACCP), heuristics, the Safe Living Guide and the Resident Assessment Instrument – Home Care (RAI-HC) are applied to data obtained from two pilot home visits to determine whether common failure modes, causes, effects and recommendations are yielded by the techniques. The time required to apply each analytical technique to processes uncovered from the pilot data was measured and outputs of the techniques were reviewed for commonality. Of the tools considered, SHERPA was found to return the most failure modes, effects and recommendations, while FMEA was the only human factors tool to yield causes. Additionally, FMEA and SHERPA provided a means of ranking potential failure modes based on severity and probability.

Several analytical techniques including use case diagrams, process flow diagrams (PFDs), hierarchical task analysis (HTA), failure mode and effects analysis (FMEA), systematic human error reduction and prediction approach (SHERPA), hazard analysis and critical control point (HACCP), heuristics, the Safe Living Guide and the Resident Assessment Instrument – Home Care (RAI-HC) are applied to data obtained from two pilot home visits to determine whether common failure modes, causes, effects and recommendations are yielded by the techniques. The time required to apply each analytical technique to processes uncovered from the pilot data was measured and outputs of the techniques were reviewed for commonality. Of the tools considered, SHERPA was found to return the most failure modes, effects and recommendations, while FMEA was the only human factors tool to yield causes. Additionally, FMEA and SHERPA provided a means of ranking potential failure modes based on severity and probability.