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Integrated palliative homecare in advanced dementia: reduced healthcare utilisation and costs
  1. Michelle Jessica Pereira1,
  2. Ri Yin Tay2,3,
  3. Woan Shin Tan1,3,
  4. Joseph Antonio De Castro Molina1,
  5. Noorhazlina Binte Ali4,
  6. Ian Yi Onn Leong5,
  7. Huei Yaw Wu3,6,
  8. Jing Jih Chin4,5,
  9. Angel Onn Kei Lee7,
  10. Mervyn Yong Hwang Koh3,6 and
  11. Allyn Y M Hum3,6
  1. 1Health Services and Outcomes Research, National Healthcare Group, Singapore
  2. 2Research, Dover Park Hospice, Singapore
  3. 3Palliative Care Centre for Excellence in Research and Education, Singapore
  4. 4Geriatric Medicine, Tan Tock Seng Hospital, Singapore
  5. 5Integrative and Community Care, Tan Tock Seng Hospital, Singapore
  6. 6Palliative Medicine, Tan Tock Seng Hospital, Singapore
  7. 7Palliative Medicine, St. Andrew's Community Hospital, Singapore
  1. Correspondence to Ms Ri Yin Tay, Dover Park Hospice, Singapore 308436, Singapore; riyin_tay{at}


Objectives To determine the economic benefit of an integrated home-based palliative care programme for advanced dementia (Programme Dignity), evaluation is required. This study aimed to estimate Programme Dignity’s average monthly cost from a provider’s perspective; and compare healthcare utilisation and costs of programme patients with controls, accounting for enrolment duration.

Methods This was a retrospective cohort study. Home-dwelling patients with advanced dementia (stage 7 on the functional assessment staging in Alzheimer’s disease) with a history of pneumonia, albumin <35 g/L or tube-feeding and known to be deceased were analysed (Programme Dignity=184, controls=139). One-year programme operational costs were apportioned on a per patient-month basis. Cumulative healthcare utilisation and costs were examined at 1, 3 and 6 months look-back from death. Between-group comparisons used Poisson, zero-inflated Poisson regressions and generalised linear models.

Results The average monthly programme cost was SGD$1311 (SGD-Pounds exchange rate: 0.481) per patient. Fully enrolled programme patients were less likely to visit the emergency department (incidence rate ratios (IRRs): 1 month=0.56; 3 months=0.19; 6 months=0.10; all p<0.001), be admitted to hospital (IRRs: 1 month=0.60; 3 months=0.19; 6 months=0.15; all p<0.001), had a lower cumulative length of stay (IRRs: 1 month=0.78; 3 months=0.49; 6 months=0.24; all p<0.001) and incurred lesser healthcare utilisation costs (β-coefficients: 1 month=0.70; 3 months=0.40; 6 months=0.43; all p<0.01) at all time-points examined.

Conclusion Programme Dignity for advanced dementia reduces healthcare utilisation and costs. If scalable, it may benefit more patients wishing to remain at home at the end-of-life, allowing for a potentially sustainable care model to cope with rapid population ageing. It contributes to the evidence base of advanced dementia palliative care and informs healthcare policy making. Future studies should estimate informal caregiving costs for comprehensive economic evaluation.

  • home care
  • neurological conditions
  • service evaluation

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  • Contributors MJP, WST, NBA, IYOL, HYW, JJC, MYHK, AOKL and AYMH designed and conceptualised the study. MJP, RYT and AYMH acquired the data. MJP, RYT and JADCM analysed and interpreted the data. MJP and RYT drafted the manuscript. WST, JADCM, AOKL and AYMH critically revised the manuscript for important intellectual content.

  • Funding This work was supported by Temasek Foundation Cares CLG Limited (Grant number: TC-APP-3-39) and the Ministry of Health of Singapore (Agreement number: MH 70: 65/7).

  • Disclaimer The sponsors had no role in the study design, methods, subject recruitment, data collection and analysis and preparation of the manuscript.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the ethics review board of the National Healthcare Group Singapore (2014/00577) and was conducted from October 2014 to August 2017.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. De-identified participant data may be requested from the corresponding author and it may be made available whenever reasonably and practically possible.

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