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Assistive technology and telecare to maintain independent living at home for people with dementia: the ATTILA RCT

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Rebecca Gathercole, Rosie Bradley, Emma Harper, Lucy Davies, Lynn Pank, Natalie Lam, Anna Davies, Emma Talbot, Emma Hooper, Rachel Winson, Bethany Scutt, Victoria Ordonez Montano, Samantha Nunn, Grace Lavelle, Matthew Lariviere, Shashivadan Hirani, Stefano Brini, Andrew Bateman, Peter Bentham, Alistair Burns & 12 more Barbara Dunk, Kirsty Forsyth, Chris Fox, Catherine Henderson, Martin Knapp, Iracema Leroi, Stanton Newman, John O'Brien, Fiona Poland, John Woolham, Richard Gray, Robert Howard

Original languageEnglish
Pages (from-to)1-156
Number of pages156
JournalHealth technology assessment (Winchester, England)
Volume25
Issue number19
DOIs
Published1 Mar 2021

Bibliographical note

Funding Information: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 19. See the NIHR Journals Library website for further project information. Funding Information: The research reported in this issue of the journal was funded by the HTA programme as project number 10/50/02. The contractual start date was in January 2013. The draft report began editorial review in September 2019 and was accepted for publication in December 2019. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report. Funding Information: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 19. See the NIHR Journals Library website for further project information. The ATTILA trial triallists group Writing Committee Rebecca Gathercole, Catherine Henderson, Rosie Bradley, Anna Davies, Shashivadan Hirani, Stefano Brini, Stanton Newman, Kirsty Forsyth, Matthew Lariviere, Chris Fox, Fiona Poland, Martin Knapp, Iracema Leroi, John Woolham, Richard Gray and Robert Howard. Data Monitoring Committee Professor Ian McKeith, Institute for Ageing and Health, Newcastle University (chairperson); Professor James Lindesay, Department of Health Sciences, Leicester University Hospitals NHS Trust; and Dr Tracey Young, School of Health and Related Research, University of Sheffield. Trial Steering Committee Dr Peter Bentham, The Barberry Centre, Birmingham and Solihull Mental Health NHS Foundation Trust (chairperson); Dr Louise Brown, Medical Research Council Clinical Trials Unit at University College London; and Mrs Gillian Harrison and Mrs Sue Tucker, Service User Representatives, Alzheimer?s Society. Trial Management Group Rebecca Gathercole, Emma Harper, Linda Kelly, Natalie Lam, Lynn Pank, Rosie Bradley and Richard Gray and Robert Howard. Health Economics Catherine Henderson and Martin Knapp (London School of Economics and Political Science). Participating centres South London and Maudsley NHS Foundation Trust: Robert Howard (principal investigator), Rebecca Gathercole, Heather Westwood, Bethany Scutt and Grace Lavelle. Cambridge Community Services NHS Trust, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust: John O?Brien (principal investigator), Andrew Bateman (principal investigator), Rachel Winson, Samantha Nunn and Victoria Ordonez Montano. Oxford and Buckinghamshire Mental Health NHS Foundation Trust: Rupert McShane (principal investigator), Sarah-Jane Cellan-Jones, Marni Moran and Rowena Johns. Norfolk and Suffolk NHS Foundation Trust: Chris Fox (principal investigator) and Emma Talbot. Lancashire Care NHS Foundation Trust: Iracema Leroi (principal investigator) and Emma Hooper. Nottinghamshire Healthcare NHS Foundation Trust: Dr Anand Ramakrishnan (principal investigator) and David Trevor. South West Yorkshire Partnership NHS Foundation Trust: Seelam Kalyan (principal investigator), Lubena Mirza and Amber Hemmingway. Funding Information: Declared competing interests of authors: Samantha Nunn reports that a National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme grant was awarded to King’s College London, and that study activity at Cambridgeshire Community Services NHS Trust was funded by this grant. Peter Bentham reports personal fees from TauRx Therapeutics Ltd (Aberdeen, UK) outside the submitted work. Catherine Henderson reports grants from the NIHR HTA programme during the conduct of the study. John O’Brien reports personal fees from TauRx Therapeutics Ltd, AXON Neuroscience SE (Larnaca, Cyprus), GE Healthcare (Chicago, IL, USA) and Eisai Co., Ltd (Tokyo, Japan), grants and personal fees from Avid Radiopharmaceuticals (Eli Lilly and Company, Indianapolis, IN, USA) and grants from Alliance Medical (Warwick, UK) outside the submitted work. Richard Gray reports grants from the NIHR HTA programme during the conduct of the study. Robert Howard reports grants from the NIHR HTA programme during the conduct of the study. He also reports that he was a member of the HTA programme Commissioning Sub-board (Expressions of Interest) (2009–11) and of the HTA Programme Commissioning Committee (2013–18). Funding Information: The trial was sponsored by South London and Maudsley NHS Foundation Trust. Publisher Copyright: © 2021 Gathercole et al. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.

King's Authors

Abstract

Background: Assistive technology and telecare have been promoted to manage the risks associated with independent living for people with dementia, but there is limited evidence of their effectiveness. Objectives: This trial aimed to establish whether or not assistive technology and telecare assessments and interventions extend the time that people with dementia can continue to live independently at home and whether or not they are cost-effective. Caregiver burden, the quality of life of caregivers and of people with dementia and whether or not assistive technology and telecare reduce safety risks were also investigated. Design: This was a pragmatic, randomised controlled trial. Blinding was not undertaken as it was not feasible to do so. All consenting participants were included in an intention-to-treat analysis. Setting: This trial was set in 12 councils in England with adult social services responsibilities. Participants: Participants were people with dementia living in the community who had an identified need that might benefit from assistive technology and telecare. Interventions: Participants were randomly assigned to receive either assistive technology and telecare recommended by a health or social care professional to meet their assessed needs (a full assistive technology and telecare package) or a pendant alarm, non-Monitored smoke and carbon monoxide detectors and a key safe (a basic assistive technology and telecare package). Main outcome measures: The primary outcomes were time to admission to care and cost-effectiveness. Secondary outcomes assessed caregivers using the 10-item Center for Epidemiological Studies Depression Scale, the State-Trait Anxiety Inventory 6-item scale and the Zarit Burden Interview. Results: Of 495 participants, 248 were randomised to receive full assistive technology and telecare and 247 received the limited control. Comparing the assistive technology and telecare group with the control group, the hazard ratio for institutionalisation was 0.76 (95% confidence interval 0.58 to 1.01; p = 0.054). After adjusting for an imbalance in the baseline activities of daily living score between trial arms, the hazard ratio was 0.84 (95% confidence interval 0.63 to 1.12; p = 0.20). At 104 weeks, there were no significant differences between groups in health and social care resource use costs (intervention group - control group difference: mean -£909, 95% confidence interval -£5336 to £3345) or in societal costs (intervention group - control group difference: mean -£3545; 95% confidence interval -£13,914 to £6581). At 104 weeks, based on quality-adjusted life-years derived from the participant-rated EuroQol-5 Dimensions questionnaire, the intervention group had 0.105 (95% confidence interval -0.204 to -0.007) fewer quality-adjusted life-years than the control group. The number of quality-adjusted life-years derived from the proxy-rated EuroQol-5 Dimensions questionnaire did not differ between groups. Caregiver outcomes did not differ between groups over 24 weeks. Limitations: Compliance with the assigned trial arm was variable, as was the quality of assistive technology and telecare needs assessments. Attrition from assessments led to data loss additional to that attributable to care home admission and censoring events. Conclusions: A full package of assistive technology and telecare did not increase the length of time that participants with dementia remained in the community, and nor did it decrease caregiver burden, depression or anxiety, relative to a basic package of assistive technology and telecare. Use of the full assistive technology and telecare package did not increase participants’ health and social care or societal costs. Quality-adjusted life-years based on participants’ EuroQol-5 Dimensions questionnaire responses were reduced in the intervention group compared with the control group; groups did not differ in the number of quality-adjusted life-years based on the proxy-rated EuroQol-5 Dimensions questionnaire.

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