This is a revised continuation application. It proposes a longitudinal study among persons with Senile Dementia of an Alzheimer's type (SDAT), comparing day-care users to non-users. The primary outcome is time to entry into institutional long-term care; secondary outcomes include patterns of use of hospital and other health-care services, change in client behaviors, especially aggression and other negative behaviors, change in client physical disability and cognitive function and change in caregiver health and function. The hypotheses are: 1) among persons with SDAT, use of day care, on average, delays placement in institutional long-term care and is mediated by positive effects on client and caregiver health, especially lower rates of negative client behaviors. The study will use a dynamic expansion of the Andersen-- Newman model, by explicitly including short-term services in the model. The study will enroll a cohort of 450 participants, including 225 non-users of day care and 225 day-care users, with the user group equally divided between users of dementia-specific day care and users of day-care programs serving clients with many different conditions. Participants will be followed for 3 years, with assessment every 6 months. Each evaluation will be structured and will include behavioral assessment and direct performance testing of physical disability and cognitive function. Responses to the prior critique are summarized on pages 38-40. They are as follows: 1) Design problems: a) design concerns are addressed by presenting data that demonstrate the comparability between the control and intervention groups, on pages 52-54, and plans to address cross-over on page 54; b) sample size concerns are addressed on pg. 64-65; c) expansion of the Andersen-Newman model is discussed on pages 49-50 and 61 & 64. 2) Presentation of prior work: a) more data from the first 4 years of the grant are presented on pages 46-47; b) the justification for the non-daycare-user comparison group is presented on pages 44-45; 3) Data collection: a) data collection burden has been evaluated, and the interval between data collection points increased from 4 to 6 months (pg. 56-57; b) proposed data collection measures are discussed on pages 57-62 and examples are provided in the appendices; c) important variables noted to be missing in the prior application are now addressed on pages 55-6O; d) Dr. Frederic Wolinsky was added to the investigative team due to his expertise in health-care utilization; e) the ability to enroll the required number of participants is noted on pages 54-55; f) a detailed time line is provided on pg. 65; 4) Budget: a) reducing the length of time for the project and Dr. McCann's effort were considered, but found to be detrimental to the conduct of the study, as justified on pages 64-65 and pg. 8; b) funds for obtaining HCFA data and increased programmer time have now been requested on pages 12 and 10 respectively.
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