IN-PEACE cut emergency visits, hospitalizations in half helping individuals remain at home
INDIANAPOLIS – IN-PEACE, which provides palliative care integrated with state-of-the-art dementia care to patients with dementia and their caregivers, cut in half the number of emergency department visits and hospitalizations of study participants. African American individuals and those with lower incomes benefited the most in reduction of use of these medical facilities.
A decrease of 50 percent in emergency department visits and hospitalizations has the potential to greatly benefit millions of patients and caregivers by keeping individuals with dementia at home and out of these settings where they often develop complications and decline in function. Reduction of use of these facilities also conveys cost savings to the healthcare system.
“Palliative Care Program for Community-Dwelling Individuals with Dementia and Caregivers: The IN-PEACE Randomized Clinical Trial” is published in the Journal of the American Medical Association (JAMA).
The IN-PEACE, an acronym for Indiana Palliative Excellence in Alzheimer Care Efforts, randomized clinical trial is believed to be the first study to explicitly combine palliative and dementia care for individuals living, typically with family caregivers, at home rather than in a nursing home. Participants in both arms of IN-PEACE were older, frailer and experienced more severe Alzheimer’s disease or other dementias than many individuals who have participated in previously developed dementia management programs.
Patient and family participants in the intervention arm of the IN-PEACE study received monthly check-ins via telephone for up to two years from an experienced, highly trained nurse or social worker to help caregivers manage a number of concerns including patients’ neuropsychiatric symptoms, caregiver distress and palliative care issues such as advance care planning and referral to hospice. Education and communication skills were emphasized in this innovative supportive care model.
Regular contact enabled problems to be tackled with advice and coaching to help prevent escalation to an emergency room visit or hospitalization. Those in the usual care arm of the study were given publicly available educational material from the Alzheimer’s Association and other sources but did not receive care manager support. Emergency department visits and hospitalizations did not decline in the usual care group.
“With IN-PEACE we built upon decades of design and implementation of seminal dementia care management programs by Regenstrief Institute and Indiana University brain care experts to novelly graft our expertise in palliative care to dementia care, combining formerly separate lines of work,” said Greg A. Sachs, M.D., of Regenstrief Institute and the Indiana University School of Medicine, who led the IN-PEACE study.
“Typically, if patients with dementia receive palliative care they receive it very late in the course of their illness, sometimes not until they enroll in hospice in the last weeks or months of life. We pushed palliative care further upstream so that people could be receiving it for months to years, providing robust support to both the patient and the family and enabling them to better manage without having to go to the emergency department or the hospital.
“While we were pleased with the dramatic cut in emergency department visits and hospitalizations, we did not see a decrease in neuropsychiatric symptoms such as depression or anxiety, which we had hoped to find in the patients in our study. This may be because the IN-PEACE care managers were available to promptly address patients’ changes in condition and suggest options other than going to an ED or a hospital, or because our patient population had a low burden of symptoms or both.”
“African American individuals are at higher risk of developing dementia than their White counterparts, yet tend to have a delay in diagnosis of dementia and to receive care for their dementia rather late in the disease,” noted Dr. Sachs. “More than 40 percent of patients and of caregivers in our study were African American, a significantly higher percentage than in many other dementia studies. “IN-PEACE provided access to resources to individuals who typically wouldn’t receive this kind of care and they benefited the most.
“Many studies describe health disparities; IN-PEACE actually made a difference!”
Additional information on IN-PEACE study participants:
- 201 patient-caregiver pairs were enrolled and randomized to the dementia palliative care group (99) or the usual care group (102).
- Average age of patients was 84 years.
- Average age of caregivers was 61 years.
- Approximately 90 percent of patients had moderately severe to severe dementia.
- Approximately 68 percent of patients were women. Female predominance is fairly typical for dementia studies.
- Approximately 40 percent of patients in each arm of the study died during the study. Study participants were frail and heavily impacted by COVID-19.
“Our findings indicate that for every 100 persons with advanced dementia being cared for at home, IN-PEACE could lead to 59 fewer hospitalizations and 72 fewer emergency department visits over a 2-year period,” said study senior author Kurt Kroenke, M.D., of Regenstrief Institute and IU School of Medicine. “This would not only decrease the burden of these events for patients and caregivers but also enough cost savings to more than pay for the program.”
The Centers for Medicare and Medicaid Services’ new Guiding an Improved Dementia Experience (GUIDE) payment model provides health systems and medical practices with financial resources to provide the kind of comprehensive management of patients and support for caregivers that the IN-PEACE model addresses.
The study was funded by the National Institutes of Health’s National Institute on Aging, grant RO1AG057733 (PI: Greg Sachs, M.D.).
Authors and affiliations as listed in the paper:
Greg A. Sachs, M.D.; Nina M. Johnson, M.A., CCRP; Sujuan Gao, PhD: Alexia M. Torke, M.D., M.S.; Susan E. Hickman, PhD; Amy Pemberton, MSN, R.N.; Andrea Vrobel, MSW, LCSW; Minmin Pan, M.S.; Jennifer West, PhD; Kurt Kroenke, M.D.
- Indiana University Center for Aging Research, Regenstrief Institute, (Sachs, Johnson, Torke, Hickman);
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis (Sachs, Torke, Kroenke);
- Eskenazi Health, Indianapolis (Sachs);
- Indiana University Health Physicians, Indianapolis (Sachs, Torke, Pemberton, Vrobel);
- Department of Biostatistics and Health Data Sciences, Indiana University School of Medicine, Indianapolis (Gao, Pan);
- Indiana University School of Nursing, Indianapolis (Hickman);
- Center for Health Services Research, Regenstrief Institute, Indianapolis, (West, Kroenke).
Greg A. Sachs, M.D.
In addition to his role as a research scientist with the Indiana University Center for Aging Research at Regenstrief Institute, Greg A. Sachs, M.D., is chief of the Division of General Internal Medicine and Geriatrics at the Indiana University School of Medicine. He is also the co-director of Research in Palliative and End-of-Life Communication and Training (RESPECT) Center, a professor of medicine and neurology, and holder of an endowed chair in health services research at the Indiana University School of Medicine.
Kurt Kroenke, M.D.
In addition to his role as a research scientist with the William M. Tierney Center for Health Services Research at Regenstrief Institute, Dr. Kroenke is also an Indiana University Indianapolis Chancellor’s Professor and a professor of medicine at the Indiana University School of Medicine.
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