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Chronic Care Clinics: A Randomized Controlled Trial of a New Model of Primary Care for Frail Older Adults
Abstract
To determine whether a new model of primary care, Chronic Care Clinics, can improve outcomes of common geriatric syndromes (urinary incontinence, falls, depressive symptoms, high risk medications, functional impairment) in frail older adults.
Randomized controlled trial with 24 months of follow-up. Physician practices were randomized either to the Chronic Care Clinics intervention or to usual care.
Nine primary care physician practices that comprise an ambulatory clinic in a large staff-model HMO in western Washington State.
Those patients aged 65 and older in each practice with the highest risk for being hospitalized or experiencing functional decline.
Intervention practices (5 physicians, 96 patients) held half-day Chronic Care Clinics every 3 to 4 months. These clinics included an extended visit with the physician and nurse dedicated to planning chronic disease management; a pharmacist visit that emphasized reduction of polypharmacy and high-risk medications; and a patient self-management/support group. Control practices (4 physicians, 73 patients) received usual care.
Changes in self-reported urinary incontinence, frequency of falls, depressive symptoms, physical function, and satisfaction were analyzed using an intention-to-treat analysis adjusted for baseline differences, covariates, and practice-level variation. Prescriptions for high-risk medications and cost/utilization data obtained from administrative data were similarly analyzed.
After 24 months, no significant improvements in frequency of incontinence, proportion with falls, depression scores, physical function scores, or prescriptions for high risk medications were demonstrated. Costs of medical care including frequency of hospitalization, hospital days, emergency and ambulatory visits, and total costs of care were not significantly different between intervention and control groups. A higher proportion of intervention patients rated the overall quality of their medical care as excellent compared with control patients (40.0% vs 25.3%, P = .10).
Although intervention patients expressed high levels of satisfaction with Chronic Care Clinics, improved outcomes for selected geriatric syndromes were not demonstrated. These findings suggest the need for developing greater system-wide support for managing geriatric syndromes in primary care and illustrate the challenges of conducting practice improvement research in a rapidly changing delivery system.
... We screened a total of 5215 articles after removing duplicates (Figure 1), resulting in the inclusion of 11 systematic reviews, [6][7][8][9][12][13][14][15][16][17][18] all of which were MAs of RCTs that investigated outcomes associated with CGA delivered in the community to older adults. Results for 12 outcomes were reported, in some cases stratified for general and frail older adults. ...
... AMSTAR scores for included reviews are reported in Table 2, with 7 MAs meeting at least 50% of the AMSTAR criteria. 9,[12][13][14][16][17][18] Definition of CGA ...
... Only 1 very recent review by Chen and colleagues 18 met all 3 CGA criteria. Otherwise, there were a variety of CGA definitions used by each MA with the following elements described: multidimensional or complex assessment (8 studies 6,7,9,12,13,[16][17][18], active management and regular follow-up (5 studies 6,7,12,16,17 ), preventive focus (4 studies 7,9,12,14 ), referral to or delivery of health and social care or information (3 studies 6,7,17 ), personalized/individually tailored response (4 studies 6,7,17,18 ), care plan development (3 studies [16][17][18], integrated with primary care (1 study 14 ), and proactive/provider initiated (1 study 14 ). Multidisciplinary involvement was used within CGA definition for 1 review, 18 and was included in sub-analysis for several reviews. ...
Objectives:
To perform an umbrella review of systematic reviews with meta-analyses (MAs) examining the effectiveness of comprehensive geriatric assessment (CGA) delivered within community settings to general populations of community-dwelling older people against various health outcomes.
Design:
Umbrella review of MAs of randomized controlled trials (RCTs).
Setting and participants:
Systematic reviews with MAs examining associations between CGA conducted within the community and any health outcome, where participants were community-dwelling older people with a minimum mean age of 60 years or where at least 50% of study participants were aged ≥60 years. Studies focusing on residential care, hospitals, post-hospital care, outpatient clinics, emergency department, or patients with specific conditions were excluded.
Methods:
We examined CGA effectiveness against 12 outcomes: not living at home, nursing home admission, activities of daily living (ADLs) and instrumental ADLs (IADLs), physical function, falls, self-reported health status, quality of life, frailty, mental health, hospital admission, and mortality, searching the MEDLINE/PubMed, Cochrane Library, CINAHL, Embase databases from January 1, 1999, to August 10, 2022. AMSTAR-2 was used to assess the quality of included systematic reviews, including risk of bias.
Results:
We identified 10 MAs. Only not living at home (combined mortality and nursing home admission) demonstrated concordance between effect direction, significance, and magnitude. Significant effects were more typically observed in earlier rather than later studies.
Conclusion and implications:
Given the widespread adoption of CGA as a component of usual care within geriatric medicine, the lack of strong evidence demonstrating the protective effects of CGA may be indicative of a cohort effect. If so, future RCTs examining CGA effectiveness are unlikely to demonstrate significant findings. Future studies of CGA in the community should focus on implementation and adherence to key components.
Trial registration:
Study protocol registered in PROSPERO 2020 CRD42020169680.
... We identified 12 trials 18,[21][22][23][24]30,40,46,47,[50][51][52][53]55,57 that evaluated the effect of various educational interventions: provider education with feedback (k = 5); provider education without feedback (k = 2); patient education (k = 3); patient and provider education (k = 1); or patient and provider education with provider feedback (k = 1). The control groups were assigned I 2 = 0% * These participants who died were reported in the study flow chart but were not included in the analyses. ...
... All-cause mortality was reported in 6 trials (n = 121,314). 18,[21][22][23][24]30,40,53 None of the trials reported a difference between the intervention and control groups, and the data were not suitable for pooling due to heterogeneity of study interventions. Overall, educational interventions probably had no effect on all-cause mortality (moderate certainty). ...
... Four of the 5 trials that reported hospitalizations found no difference between the intervention and control groups. [21][22][23][24]40,53,57 Overall, education interventions probably do not reduce hospitalizations (moderate certainty). ...
Background
Polypharmacy and use of inappropriate medications have been linked to increased risk of falls, hospitalizations, cognitive impairment, and death. The primary objective of this review was to evaluate the effectiveness, comparative effectiveness, and harms of deprescribing interventions among community-dwelling older adults.Methods
We searched OVID MEDLINE Embase, CINAHL, and the Cochrane Library from 1990 through February 2019 for controlled clinical trials comparing any deprescribing intervention to usual care or another intervention. Primary outcomes were all-cause mortality, hospitalizations, health-related quality of life, and falls. The secondary outcome was use of potentially inappropriate medications (PIMs). Interventions were categorized as comprehensive medication review, educational initiatives, and computerized decision support. Data abstracted by one investigator were verified by another. We used the Cochrane criteria to rate risk of bias for each study and the GRADE system to determine certainty of evidence (COE) for primary outcomes.ResultsThirty-eight low and medium risk of bias clinical trials were included. Comprehensive medication review may have reduced all-cause mortality (OR 0.74, 95% CI: 0.58 to 0.95, I2 = 0, k = 12, low COE) but probably had little to no effect on falls, health-related quality of life, or hospitalizations (low to moderate COE). Nine of thirteen trials reported fewer PIMs in the intervention group. Educational interventions probably had little to no effect on all-cause mortality, hospitalizations, or health-related quality of life (low to moderate COE). The effect on falls was uncertain (very low COE). All 11 education trials that included PIMs reported fewer in the intervention than in the control groups. Two of 4 computerized decision support trials reported fewer PIMs in the intervention arms; none included any primary outcomes.DiscussionIn community-dwelling people aged 65 years and older, medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications.Registry InformationPROSPERO - CRD42019132420.
... Very few (six of 34) papers specifically note the training of nurses in new skills or roles: rather, the included trials are evaluations of care approaches, with the study reports focused on the relations between service delivery and outcome rather than the training that may have been used to enhance staff behaviour. Three of the studies evaluating nurse education as a component of the overall strategy were US-based (Coleman et al., 1999;Hunkeler et al., 2000;Rost et al., 2001), whilst two were conducted in the UK ( Mann et al., 1998;Peveler et al., 1999) and one in Finland ( Kiuttu et al., 1999). These individual studies are considered in the following section. ...
... Nine studies involved a change in the structure of service delivery which accompanied the training or staff development, that is predisposing together with enabling factors (Coleman et al., 1999;Hunkeler et al., 2000;Katon et al., 2004;Llewellyn-Jones et al., 1999;Mann et al., 1998;Nutting et al., 2005;Peveler et al., 1999;Rost et al., 2001;Wells et al., 2000). These works variously established new protocols for areas of care, or developed additional or extended staff roles. ...
... 12 randomised trials were judged to meet the highest standards: of these, three were UK studies of primary care-based interventions (Kendrick et al., 2005;Mynors- Wallis et al., 1997;Peveler et al., 1999). The remainder were US studies, four of which evaluated interventions for older people in community (Coleman et al., 1999) or residential and assisted living settings ( Meador et al., 1997;Ray et al., 1993;Teri et al., 2005a); and five concerned various collaborative, stepped care strategies to improve depression management in primary care (Hunkeler et al., 2000;Katon et al., 2004;Nutting et al., 2005;Rost et al., 2001;Wells et al., 2000). ...
Background: Common mental disorders are a most important cause of
suffering, disability, and mortality in the community, and there is strong evidence
of under-detection and suboptimal management.
Most published study of interventions to change clinicians’ behaviour relates solely
to medical professionals, relies upon short-term and uncontrolled measures of
learning, and often lacks clinical outcomes.
Aims: To investigate the effects of a training programme for district nursing staff
on attitudes, knowledge, and detection of psychiatric morbidity in their patients.
To determine the effect of staff training on mental health outcomes in their
patients.
Design: A series of seven once-weekly 2-hour sessions, based on clinical
guidelines and systematic needs assessment and concerning the understanding,
recognition and management of common mental disorders, was delivered to the
staff of the district nursing service of Jersey. The effects were evaluated by a
cluster randomised controlled trial design.
Measures: Patients were screened for common mental disorders using the
Geriatric Depression Scale and Hospital Anxiety and Depression Scale. Patient
functional disability was assessed using the Barthel Index.
Staff detection of probable caseness was ascertained by comparing patient selfreport
measures with a staff-completed 4-point global rating scale.
The attitudes and knowledge of staff were measured by the Depression Attitude
Questionnaire and a 33-item knowledge measure adapted from WHO primary care
mental health materials. Outcomes were measured at 3-months and 12-months after
baseline.
Findings: 45 staff were randomly allocated to receive either the training
programme or to continue care as usual. 272 of 462 eligible patients on their
caseloads were screened and monitored for probable depression and anxiety.
Significant improvements were found in the knowledge and attitudes of staff in the
intervention group, and in the psychological outcome of their patients. A nonsignificant
trend to better accuracy of disorder detection was associated with
training.
... 240 In 4 studies the intervention involved age-related medical assessments; 238-241 1 study was conducted in Australia. 238 Studies either focussed on people 65 years and older 239,241 or 75 years and older. 238,240 The 2 studies that focussed on people aged 65 years and older involved a medical assessment by a multidisciplinary team. ...
... 238,240 The 2 studies that focussed on people aged 65 years and older involved a medical assessment by a multidisciplinary team. 239,241 Teams included a medical practitioner, nurse, pharmacist and social worker. Assessments were conducted in either a general practice or an outpatient clinic with each member of the multidisciplinary team involved. ...
... No significant reduction in mortality, hospital admissions, ED attendances or quality of life were reported in the 3 studies that reviewed these outcomes. [238][239][240] Although a reduction in hospital admissions was not seen in the study of patients 75 years and older by Stuck et al., a significant reduction in the number of permanent aged-care facility admissions was observed (9 vs 20, p = 0.02). 240 This, along with a reduction in the need for assistance in performing the activities of daily living, led the authors to conclude that such an intervention can delay the development of disability and reduce permanent nursing home stays among elderly people living at home. ...
... There were six multi-interventional trials [25,31,34,41,43,44] with aspects of frailty as an endpoint; except for [31], they used medication review/optimization as one part of the intervention. Only three of them (including ref. 28) showed a positive impact on some aspects of frailty [25,34]. ...
... Only three of them (including ref. 28) showed a positive impact on some aspects of frailty [25,34]. However, the Jadad score was below 3 in three of these studies [31, 43,44]. ...
Background
Frailty and adverse drug effects are linked in the fact that polypharmacy is correlated with the severity of frailty; however, a causal relation has not been proven in older people with clinically manifest frailty.MethodsA literature search was performed in Medline to detect prospective randomized controlled trials (RCTs) testing the effects of pharmacological interventions or medication optimization in older frail adults on comprehensive frailty scores or partial aspects of frailty that were published from January 1998 to October 2019.ResultsTwenty-five studies were identified, 4 on comprehensive frailty scores and 21 on aspects of frailty. Two trials on comprehensive frailty scores showed positive results on frailty although the contribution of medication review in a multidimensional approach was unclear. In the studies on aspects related to frailty, ten individual drug interventions showed improvement in physical performance, muscle strength or body composition utilizing alfacalcidol, teriparatide, piroxicam, testosterone, recombinant human chorionic gonadotropin, or capromorelin. There were no studies examining negative effects of drugs on frailty.Conclusion
So far, data on a causal relationship between drugs and frailty are inconclusive or related to single-drug interventions on partial aspects of frailty. There is a clear need for RCTs on this topic that should be based on a comprehensive, internationally consistent and thus reproducible concept of frailty assessment.
... Randomised controlled studies have been conducted investigating the effectiveness of GP interventions in falls prevention. These have been Australian studies (Newbury, Marley, & Beilby, 2001;Pit et al., 2007;Whitehead, Wundke, R., Crotty, M., & Finucane, 2003), European studies (Barr, Stewart, Torgerson, Seymour, & Reid, 2005;Dapp et al., 2011;De Vries et al., 2010, Hendriks et al., 2008Lightbody, Watkins, Leathley, Sharma, & Lye, 2002;Palvanen et al., 2014;Siegrist et al., 2016;Spice et al., 2009;Van Haastreght, Diederiks, Van Rossum, de Witte, & Crebolder, 2000), North American (Coleman, Grodhaus, Sandhu, & Wagner, 1999;Tamblyn et al., 2012;Weber, White, & McIivried, 2008) and from New Zealand (Elley et al., 2008;Kerse, Elley, Robinson, & Arroll, 2005;Kolt et al., 2012). The types of GP activity varied but included GPs following up on recommendations provided by a screening intervention such as vitamin D and calcium prescription (Barr et al., 2005), GP initiation of falls prevention interventions such as exercise (Dapp et al.,2011), electronic or other alert systems informing GPs of patient falls risk/psychotropic medication risks (Pit et al., 2007;Tamblyn et al., 2012;Weber et al., 2008), screening and home visits by trained fall and fracture nurses (Elley et al., 2008), specific falls clinics (Coleman et al., 1999;De Vries et al., 2010;Palvanen et al., 2014), green prescriptions such as self-initiated exercise (Kerse et al., 2005;Kolt et al., 2012) and assessment in secondary level health care after attending emergency departments due to falls (Lightbody et al., 2002;Whitehead et al., 2003). ...
... These have been Australian studies (Newbury, Marley, & Beilby, 2001;Pit et al., 2007;Whitehead, Wundke, R., Crotty, M., & Finucane, 2003), European studies (Barr, Stewart, Torgerson, Seymour, & Reid, 2005;Dapp et al., 2011;De Vries et al., 2010, Hendriks et al., 2008Lightbody, Watkins, Leathley, Sharma, & Lye, 2002;Palvanen et al., 2014;Siegrist et al., 2016;Spice et al., 2009;Van Haastreght, Diederiks, Van Rossum, de Witte, & Crebolder, 2000), North American (Coleman, Grodhaus, Sandhu, & Wagner, 1999;Tamblyn et al., 2012;Weber, White, & McIivried, 2008) and from New Zealand (Elley et al., 2008;Kerse, Elley, Robinson, & Arroll, 2005;Kolt et al., 2012). The types of GP activity varied but included GPs following up on recommendations provided by a screening intervention such as vitamin D and calcium prescription (Barr et al., 2005), GP initiation of falls prevention interventions such as exercise (Dapp et al.,2011), electronic or other alert systems informing GPs of patient falls risk/psychotropic medication risks (Pit et al., 2007;Tamblyn et al., 2012;Weber et al., 2008), screening and home visits by trained fall and fracture nurses (Elley et al., 2008), specific falls clinics (Coleman et al., 1999;De Vries et al., 2010;Palvanen et al., 2014), green prescriptions such as self-initiated exercise (Kerse et al., 2005;Kolt et al., 2012) and assessment in secondary level health care after attending emergency departments due to falls (Lightbody et al., 2002;Whitehead et al., 2003). ...
Introduction:
Falls are an important issue in primary care. General practitioners (GPs) are in a key position to identify older people at risk of falls on their caseload and put preventative plans into action. Chronic Disease Management (CDM) plans allow GPs to refer to allied health practitioners (AHPs) for evidence-based falls interventions. A previous pilot study reduced falls risk factors using CDM pans with older people at risk of falls. This study aimed to conduct a process evaluation of how the intervention worked in the pilot study for providers and consumers.
Methods:
This process evaluation used qualitative descriptive methods by interviewing the GPs, AHPs and older people involved in the intervention study. An independent researcher conducted interviews. These were audiotaped, transcribed and analysed using thematic analysis. Data were also collected about the implementation of the programme.
Results:
Two GPs, three occupational therapists, three physiotherapists and eight older people were interviewed. Key themes emerged from the perspectives of providers and consumers. The programme was implemented as intended, adherence to the exercise diaries was variable and the falls calendars were fully completed for three months of follow-up. The programme was implemented as intended.
Conclusion:
The pilot CDM falls prevention programme did not identify common barriers attributed to GPs. Older people were amenable to the programme and participated freely. Private AHPs needed to make the CDM items work for their business model. This approach can be rolled out in a larger study and integrated pathways are needed to identify and intervene with older people at risk of falls in primary care.
... Elements of the interventions were grouped into eight sub-categories. Of these sub-categories, three were more common: 1) Performing regular face-to face clinical evaluations and follow-up [31, 34-39, 42-48, 50-62, 64, 67]; 2) Creating individualized and adapted interventions [31,36,38,41,44,47,48,51,55,57,58,62,64,65,67]; and 3) Consid- ering family or relatives needs [34, 37-39, 42-46, 49, 50, 52, 55, 56, 60, 62, 66]. Performing regular face-to-face clinical evaluations and follow-up was undoubtedly the element most frequently found in the literature. ...
... This scoping review found 34 studies reporting this intervention as an effective ap- proach for people with multimorbidity [31-33, 36, 40, 41, 43, 46, 48, 52-55, 57, 58, 60, 62-69, 73-75, 77-83]. Adapting training to patient and program needs was the most frequent element found in 10 studies [32,33,36,40,41,43,58,62,64,65,77,82]. For example, many studies in this category included comprehensive training for the healthcare professional to act as care manager [41,58,68]. ...
Background:
Interventions to improve patient-centered care for persons with multimorbidity are in constant growth. To date, the emphasis has been on two separate kinds of interventions, those based on a patient-centered care approach with persons with chronic disease and the other ones created specifically for persons with multimorbidity. Their effectiveness in primary healthcare is well documented. Currently, none of these interventions have synthesized a patient-centered care approach for care for multimorbidity. The objective of this project is to determine the particular elements of patient-centered interventions and interventions for persons with multimorbidity that are associated with positive health-related outcomes for patients.
Method:
A scoping review was conducted as the method supports the rapid mapping of the key concepts underpinning a research area and the main sources and types of evidence available. A five-stage approach was adopted: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; and (5) collating, summarizing and reporting results. We searched for interventions for persons with multimorbidity or patient-centered care in primary care. Relevant studies were identified in four systematic reviews (Smith et al. (2012;2016), De Bruin et al. (2012), and Dwamena et al. (2012)). Inductive analysis was performed.
Results:
Four systematic reviews and 98 original studies were reviewed and analysed. Elements of interventions can be grouped into three main types and clustered into seven categories of interventions: 1) Supporting decision process and evidence-based practice; 2) Providing patient-centered approaches; 3) Supporting patient self-management; 4) Providing case/care management; 5) Enhancing interdisciplinary team approach; 6) Developing training for healthcare providers; and 7) Integrating information technology. Providing patient-oriented approaches, self-management support interventions and developing training for healthcare providers were the most frequent categories of interventions with the potential to result in positive impact for patients with chronic diseases.
Conclusion:
This scoping review provides evidence for the adaption of patient-centered interventions for patients with multimorbidity. Findings from this scoping review will inform the development of a toolkit to assist chronic disease prevention and management programs in reorienting patient care.
... Searches resulted in 4151 potentially relevant articles. Of these, we included 11 randomized controlled trials [31][32][33][34][35][36][37][38][39][40][41] and seven observational studies. [42][43][44][45][46][47][48] Tables 2 and 3 summarize the study and intervention characteristics. ...
... Some programs used risk prediction algorithms that included prior diagnoses, laboratory values, and utilization. 33,40 Others focused on specific subpopulations and selected patients based on older age, an inability to perform activities of daily living, or homelessness. One chose patients based purely on prior health care utilization. ...
Background:
Multicomponent, interdisciplinary intensive primary care programs target complex patients with the goal of preventing hospitalizations, but programs vary, and their effectiveness is not clear. In this study, we systematically reviewed the impact of intensive primary care programs on all-cause mortality, hospitalization, and emergency department use.
Methods:
We searched PubMed, CINAHL, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Reviews of Effects from inception to March 2017. Additional studies were identified from reference lists, hand searching, and consultation with content experts. We included systematic reviews, randomized controlled trials (RCTs), and observational studies of multicomponent, interdisciplinary intensive primary care programs targeting complex patients at high risk of hospitalization or death, with a comparison to usual primary care. Two investigators identified studies and abstracted data using a predefined protocol. Study quality was assessed using the Cochrane risk of bias tool.
Results:
A total of 18 studies (379,745 participants) were included. Three major intensive primary care program types were identified: primary care replacement (home-based; three RCTs, one observational study, N = 367,681), primary care replacement (clinic-based; three RCTs, two observational studies, N = 9561), and primary care augmentation, in which an interdisciplinary team was added to existing primary care (five RCTs, three observational studies, N = 2503). Most studies showed no impact of intensive primary care on mortality or emergency department use, and the effectiveness in reducing hospitalizations varied. There were no adverse effects reported.
Discussion:
Intensive primary care interventions demonstrated varying effectiveness in reducing hospitalizations, and there was limited evidence that these interventions were associated with changes in mortality. While interventions could be grouped into categories, there was still substantial overlap between intervention approaches. Further work is needed to identify program features that may be associated with improved outcomes.
... The Patient Centered Medical Home is care in which the patient has an ongoing relationship with a personal physician who leads the medical team. [15][16][17][18][19][20][21][22] The model framework we use is the Chronic Care Model (CCM) [23][24][25][26][27][28][29][30][31][32][33][34] which includes pharmacists to manage complex conditions. 23,24,28,30 Over 100 studies have demonstrated improved outcomes for risk factors for CVD following physician/pharmacist collaboration. ...
... [15][16][17][18][19][20][21][22] The model framework we use is the Chronic Care Model (CCM) [23][24][25][26][27][28][29][30][31][32][33][34] which includes pharmacists to manage complex conditions. 23,24,28,30 Over 100 studies have demonstrated improved outcomes for risk factors for CVD following physician/pharmacist collaboration. A systematic review of 30 trials found significant improvements in risk factor control with pharmacist management (Santschi et al 2011). ...
... To do this, the intervention subcategories used comprised of 'care pathways' (defined as the link between evidence and daily practice in specific conditions), 'case management' (defined as the introduction, modification or elimination of strategies to improve the management of patients), 'teams' (defined as the delivery of care through a multidisciplinary team of healthcare workers), 'audit and feedback' (defined as a summary of the performance of health workers over a specified period of time). 17 In a study by Coleman et al, 31 the objective was to try to reorganise the provision of primary care services to better meet the needs of older people with chronic diseases, and the following subcategories were used: 'interprofessional education', 'educational outreach visits' (defined as personal visits by a trained person to health workers in their own working settings to provide information aimed at changing practice), 'tailored interventions' (defined as interventions intended to change the selected practice based on an assessment of the obstacles that need Table 2 Continued change), and 'shared care' (continuous collaborative clinical care provided by primary care physicians and specialists). ...
Introduction
Ageing entails a variety of physiological changes that increase the risk of chronic non-communicable diseases. The prevalence of these diseases leads to an increase in the use of health services. The care models implemented by health systems should provide comprehensive long-term healthcare. We conducted this systematic review to determine whether any model of care for older persons have proven to be effective.
Methods
A systematic review of literature was carried out to identify randomised clinical trials that have assessed how effective a care model for older patients with chronic diseases. A searches electronic databases such as MEDLINE, Turning Research Into Practice Database, Cochrane Library and Cochrane Central Register of controlled Trials was conducted from January 1966 to January 2021. Two independent reviewers assessed the eligibility of the studies. Interventions were identified and classified according to the taxonomies developed by the Cochrane Effective Practice and Organisation of Care and Cochrane Consumers and Communication groups.
Results
Of the 4952 bibliographic references that were screened, 577 were potentially eligible and the final sample included 25 studies that evaluated healthcare models in older people with chronic diseases. In the 25 care models, the most frequently implemented interventions were educational, and those based on the provision of healthcare. Only 22% of the outcomes of interventions were identified as being effective, whereas 21% were identified as being partially effective; thus, more than 50% of the outcomes were identified as being ineffective.
Conclusions
It was not possible to determine a care model as effective. The interventions implemented in the models are variable. The most effective outcomes were focused on improving the patient–healthcare professional relationship in the early stages of the intervention. The interventions addressed in the studies were similar to public health interventions as their main objectives focused on promoting health. Most studies were of low methodological quality.
... Comparative analysis of the ICMO configurations identified three key related factors underpinning the implementation Interventions were mostly carried out in the Netherlands (n=17), [28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44] with the others conducted (n=1) in France, 45 Switzerland, 46 Spain, 47 Canada, 48 Mexico 49 and the USA. 50 Common design features across these interventions included a focus on developing a care plan and consideration of patients' preferences, with some aiming to improve collaboration between primary and secondary care organisations. Participants in the intervention groups tended to receive an in-home multidimensional geriatric assessment by a nurse. ...
Objective
Identifying and managing the needs of frail people in the community is an increasing priority for policy makers. We sought to identify factors that enable or constrain the implementation of interventions for frail older persons in primary care.
Design
A rapid realist review.
Data sources
Cochrane Library, SCOPUS and EMBASE, and grey literature. The search was conducted in September 2019 and rerun on 8 January 2022.
Eligibility criteria for selecting studies
We considered all types of empirical studies describing interventions targeting frailty in primary care.
Analysis
We followed the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and publication criteria for our synthesis to systematically analyse and synthesise the existing literature and to identify (intervention-context-mechanism-outcome) configurations. We used normalisation processes theory to illuminate mechanisms surrounding implementation.
Results
Our primary research returned 1755 articles, narrowed down to 29 relevant frailty intervention studies conducted in primary care. Our review identified two families of interventions. They comprised: (1) interventions aimed at the comprehensive assessment and management of frailty needs; and (2) interventions targeting specific frailty needs. Key factors that facilitate or inhibit the translation of frailty interventions into practice related to the distribution of resources; patient engagement and professional skill sets to address identified need.
Conclusion
There remain challenges to achieving successful implementation of frailty interventions in primary care. There were a key learning points under each family. First, targeted allocation of resources to address specific needs allows a greater alignment of skill sets and reduces overassessment of frail individuals. Second, earlier patient involvement may also improve intervention implementation and adherence.
PROSPERO registration number
The published protocol for the review is registered with PROSPERO (CRD42019161193).
... Case management, care coordination, and other similar initiatives that ostensibly focused on patients with multiple chronic conditions including Chronic Care Clinics, the Chronic Care Model, Medicare Coordinated Care, the Guided Care Model, and GRACE used a variety of eligibility criteria but rarely explicitly focused on patients with multiple chronic diseases. (72)(73)(74)(75)(76)(77)(78)(79)(80)(81)(82)(83)(84)(85) Most would agree that these initiatives have elements that are important to address the needs of patients with multiple chronic conditions. Yet, for the most part, they did not improve outcomes or reduce utilization because they did not target the right patients. ...
... Twenty years ago, Glasgow raised the question, "Does the Chronic Care Model serve also as a template for improving prevention?," [75] which is a question we are still wrestling with today. Although self-management is only one component of the Chronic Care Model [76], it is the component that is most applicable to a variety of health behaviors. Although self-management is very discipline specific, many selfmanagement programs address the implications of general health-promoting behaviors including physical activity, healthy eating, smoking, and alcohol use on the specific condition [33,77]. ...
Chronic diseases are multi-dimensional and affect numerous aspects of people’s lives, including work. Depending on the chronic condition(s) involved, between 22% and 49% of employees experience difficulties meeting physical work demands, and between 27% and 58% report that they have problems meeting psychosocial work requirements. Work organizations are acutely aware of this issue and the impact of unmanaged chronic conditions on productivity and costs. For employees of 18–64 years old with fewer than four conditions, the average annual health care claims have increased from $1700 to $2000 per person for each additional chronic condition. Given chronic disease management efforts may have the largest impact on employers’ health care costs, and in light of the aging workforce, it is clear why organizations are making self-management programs an important part of their workplace health promotion efforts. This chapter reviews the extent of and the rationale for self-management in the workplace. It describes the workplace context, how it differs from other settings, and how self-management fits into workplace programs. This chapter highlights legal and ethical issues and presents case descriptions of self-management programs conducted in workplaces. This chapter concludes by offering future directions for self-management programs in the workplace.
... A review of 21 non-Korean studies on community-level multifactorial interventions in frail and high-risk seniors revealed that these interventions help reduce risk of declining physical function, depression, falls, and nutritional deficiencies (Lightbody, 2002). However, some studies have reported no beneficial effects as regards incontinence, fall risk, depression, physical function, medication costs, hospitalization rate, average length of hospital stay, and number of emergency room visits (Coleman et al., 1999). ...
This study identified changes in blood pressure, blood glucose, and cholesterol levels in frail elderly adults who received home health care nursing over 8 years in Korea. Secondary data extracted from nursing records (2010–2018) of a public health center were analyzed using a mixed model of repeated measure. Study participants were elderly people (n = 499) with a mean age of 81.9 ± 5.56 years. Systolic and diastolic blood pressure decreased by 8.97 and 15.78 mmHg, and by 2.92 and 5.01 mmHg, respectively, at 4-year and 8-year monitoring. This demonstrates that home health care nursing is effective and has both short- and long-term benefits.
... 10-21 The CVRS design was informed by the Chronic Care Model, 22-32 which includes pharmacists as care managers to reduce medication risks. 22,23,27,28 The Chronic Care Model uses scientific evidence with an emphasis on: self-management support, information systems, delivery system redesign, decision support, health care organization, and community resources. 23,25,26,33,34 Since most studies involved single Kennelty et al. ...
Background
Medical offices are increasingly hiring clinical pharmacists to improve management of cardiovascular disease (CVD). Most offices employ only one pharmacist, while the volume of patients with complex medical and social issues creates a struggle for providers to meet demand. We have developed a remote telehealth service provided by clinical pharmacists to complement CVD services provided by on-site clinical pharmacists and aid sites without a clinical pharmacist. This cardiovascular risk service (CVRS) has been studied in two NIH-funded trials, however, we identified barriers to optimal intervention implementation. The purpose of this study is to examine how to implement the CVRS into medical offices and see if the intervention will be sustained.
Methods
This is a 5-year, pragmatic, cluster-randomized clinical trial in 13 primary care clinics across the US. We randomized clinics to receive CVRS or usual care and will enroll 300 patient subjects and 288 key stakeholder subjects. We have obtained access to the electronic medical records (EMRs) of all study clinics to recruit subjects and provide the pharmacist intervention. The intervention is staggered so that after 12 months, the usual care sites will receive the intervention for 12 months. Follow-up will be accomplished though medical record abstraction at baseline, 12 months, 24 months, and 36 months.
Conclusions
This study will enroll subjects through 2021 and results available in 2024. This study will provide unique information on how the CVRS provided by remote clinical pharmacists can be effectively implemented in medical offices, many of which already employ on-site clinical pharmacists.
Clinical Trial Registration Information: NCT03660631: http://clinicaltrials.gov/ct2/show/NCT03660631
... 38 Self-management programs were not beneficial in the five studies in which they were reported (Class I). [38][39][40][41]45 Advice alone about fall risk factor modification (without measures to implement recommended changes) was of equivocal benefit in three 37 , 41 , 46 and of no benefit in two 39 , 40 studies (Class I). ...
BACKGROUND AND SIGNIFICANCE Falls are among the most common and serious problems facing elderly persons. Falling is associated with considerable mortality, morbidity, reduced functioning, and premature nursing home admissions. Falls generally result from an interaction of multiple and diverse risk factors and situations, many of which can be corrected. This interaction is modified by age, disease, and the presence of hazards in the environment. Frequently, older people are not aware of their risks of falling, and neither recognize risk factors nor report these issues to their physicians. Consequently opportunities for prevention of falling are often overlooked with risks becoming evident only after injury and disability have already occurred. Both the incidence of falls and the severity of fall-related complications rise steadily after age 60. In the age 65-and-over population as a whole, approximately 35% to 40% of community-dwelling, generally healthy older persons fall annually. After age 75, the rates are higher. Incidence rates of falls in nursing homes and hospitals are almost three times the rates for community-dwelling persons age 2:65 (1.5 falls per bed annually). Injury rates are also considerably higher with 10% to 25% of institutional falls resulting in fracture, laceration, or the need for hospital care. Fall-related injuries recently accounted for 6% of all medical expenditures for persons age 65 and older in the United States. A key concern is the combination of the high incidence of falls and a high susceptibility to injury. This paper provides a Guideline for future falls prevention.
... Publication years ranged from 1999 to 2017. Data reported on international studies undertaken in the USA [44,[54][55][56][57][58][59][60][61][62][63][64][65][66][67][68][69][70], Canada [71][72][73][74], Northern Ireland [75], Australia [76][77][78][79], Germany [80], Finland [81], the UK [82,83], Scotland [84,85] and Spain [86]. In two papers, no country was mentioned [26,87]. ...
Purpose
To review the international literature related to high-risk medication (HRM) in community care, in order to (1) define a definition of HRM and (2) list the medication that is considered HRM in community care.
Methods
Scoping review: Five databases were systematically searched (MEDLINE, Scopus, CINAHL, Web Of Science, and Cochrane) and extended with a hand search of cited references. Two researchers reviewed the papers independently. All extracted definitions and lists of HRM were subjected to a self-developed quality appraisal. Data were extracted, analysed and summarised in tables. Critical attributes were extracted in order to analyse the definitions.
Results
Of the 109 papers retrieved, 36 met the inclusion criteria and were included in this review. Definitions for HRM in community care were used inconsistently among the papers, and various recurrent attributes of the concept HRM were used. Taking the recurrent attributes and the quality score of the definitions into account, the following definition could be derived: “High-risk medication are medications with an increased risk of significant harm to the patient. The consequences of this harm can be more serious than those with other medications”. A total of 66 specific medications or categories were extracted from the papers. Opioids, insulin, warfarin, heparin, hypnotics and sedatives, chemotherapeutic agents (excluding hormonal agents), methotrexate and hypoglycaemic agents were the most common reported HRM in community care.
Conclusion
The existing literature pertaining to HRM in community care was examined. The definitions and medicines reported as HRM in the literature are used inconsistently. We suggested a definition for more consistent use in future research and policy. Future research is needed to determine more precisely which definitions should be considered for HRM in community care.
... First, power for the trial was calculated assuming 22% of usual care patients would experience a rehospitalization within 30 days post-discharge, a rate consistent with prior studies and our hospital tracking systems. 7,41,42 We calculated that 760 patients would be needed to provide 80% power to detect a 35% reduction in this rate, assuming a two-tailed alpha of 0.05. For administrative reasons, an enrollment site that was expected to provide more than half of the study sample never was able to enroll patients, and we did not reach this target sample. ...
Introduction:
Patients with chronic illness often require ongoing support postdischarge. This study evaluated a simple-to-use, mobile health-based program designed to improve postdischarge follow-up via (1) tailored communication to patients using automated calls, (2) structured feedback to informal caregivers, and (3) automated alerts to clinicians about urgent problems.
Methods:
A total of 283 patients with common medical diagnoses, including chronic obstructive pulmonary disease, coronary artery disease, pneumonia, and diabetes, were recruited from a university hospital, a community hospital, and a US Department of Veterans Affairs hospital. All patients identified an informal caregiver or "care partner" (CP) to participate in their postdischarge support. Patient-CP dyads were randomized to the intervention or usual care. Intervention patients received weekly automated assessment and behavior change calls. CPs received structured e-mail feedback. Outpatient clinicians received fax alerts about serious problems. Primary outcomes were 30-day readmission rate and the combined outcome of readmission/emergency department (ED) use. Information about postdischarge outpatient visits, rehospitalizations, and ED encounters was obtained from medical records.
Results:
Overall, 11.4% of intervention patients and 17.9% of controls were rehospitalized within 30 days postdischarge (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.31-1.11; p = 0.102). Compared to intervention patients with other illnesses, those with pulmonary diagnoses generated the most clinical alerts (p = 0.004). Pulmonary patients in the intervention group showed significantly reduced 30-day risk of rehospitalization relative to controls (HR: 0.31; 95% CI: 0.11-0.87; p = 0.026).
Conclusion:
The CP intervention did not improve 30-day readmission rates overall, although post hoc analyses suggested that it may be promising among patients with pulmonary diagnoses.
... The neurologists spent less time per patient during the SMAs, which lasted a mean of 16 minutes (range [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30], compared with the individual appointments, which averaged 25 minutes (range 20-30). In less than 8% of the patients, individual attention was needed after the SMA. ...
... Supporting evidence includes improved outcomes and fewer emergency admissions 54 and a lower incidence of urinary incontinence and medication. 61 Introducing group consultations widely offers patients more choice; this is why patients are often very strong advocates, once they have experience. 62 ...
Group consultations are an important care option that is -starting to gain traction in the USA and Australia. This review summarises the likely benefits accruing from a systems -approach to implementing group consultations widely in the NHS and other socialised healthcare systems. Existing evidence is mapped to five distinct systems approaches: (1) development; (2) different age groups; (3) patient-centred pathway of care; (4) NHS system changes; and (5) education. Implications are discussed for patients and staff, who both benefit from group consultations once embedded; ranging from improved access and efficiency to more enjoyable multidisciplinary team working, improved resource management, and maintained/better outcomes. Moreover, even patients who don't attend group consultations can benefit from system effects of long-term implementation. Changing behaviour and health systems is challenging, but change requires systematic experimentation and documentation of evidence. We conclude that group consultations have unique potential for delivering system-wide benefits across the NHS.
... To date, despite elaborate study designs, primary care interventions for elderly persons with multiple chronic conditions have demonstrated limited success [87][88][89]. Potential reasons may include targeting of complex interventions at patients too healthy to benefit, insufficient redesign of primary care processes, under-utilization of interprofessional resources, and, in some cases, limited integration of specialist resources with the patient's existing primary healthcare system [88][89][90][91][92]. A review of ideal chronic disease management in primary care suggests that patients with chronic conditions should be stratified according to risk of poor outcomes and that the intensity of management be tailored according to patient needs [47]. ...
With the aging population, escalating demand for seniors' care and limited specialist resources, new care delivery models are needed to improve capacity for primary health care for older adults. This paper describes the "C5-75" (Case-finding for Complex Chronic Conditions in Seniors 75+) program, an innovative care model aimed at identifying frailty and commonly associated geriatric conditions among older adults within a Canadian family practice setting and targeting interventions for identified conditions using a feasible, systematic, evidence-informed multi-disciplinary approach. We screen annually for frailty using gait speed and handgrip strength, screen for previously undiagnosed comorbid conditions, and offer frail older adults multi-faceted interventions that identify and address unrecognized medical and psychosocial needs. To date, we have assessed 965 older adults through this program; 14% were identified as frail based on gait speed alone, and 5% identified as frail based on gait speed with grip strength. The C5-75 program aims to re-conceptualize care from reactive interventions post-diagnosis for single disease states to a more proactive approach aimed at identifying older adults who are at highest risk of poor health outcomes, case-finding for unrecognized co-existing conditions, and targeting interventions to maintain health and well-being and potentially reduce vulnerability and health destabilization.
... This work describes a community-engaged process that will aid in the adaptation of provider-centered guidelines for individuals and caregivers of a hematologic disease to become informed and activated. This patient-driven approach resulted in a guideline booklet that the SCD community found useful and would want to use for productive discussions with a prepared, proactive practice team [74]. As guidelines continue to evolve, this patient-driven process will be useful for adapting future evidence-based care recommendations to be patient-centered, comprehensible, and accessible. ...
Background
Evidence-based guidelines for sickle cell disease (SCD) health maintenance and management have been developed for primary health care providers, but not for individuals with SCD. To improve the quality of care delivered to individuals with SCD and their caregivers, the main purposes of this study were to: (1) understand the desire for patient-centered guidelines among the SCD community; and (2) adapt guideline material to be patient-centered using community-engagement strategies involving health care providers, community -based organizations, and individuals with the disease.
Methods
From May–December 2016, a volunteer sample of 107 individuals with SCD and their caregivers gave feedback at community forums (n = 64) and community listening sessions (n = 43) about technology use for health information and desire for SCD-related guidelines. A team of community research partners consisting of community stakeholders, individuals living with SCD, and providers and researchers (experts) in SCD at nine institutions adapted guidelines to be patient-centered based on the following criteria: (1) understandable, (2) actionable, and (3) useful.
Results
In community forums (n = 64), almost all participants (91%) wanted direct access to the content of the guidelines. Participants wanted guidelines in more than one format including paper (73%) and mobile devices (79%). Guidelines were adapted to be patient-centered. After multiple iterations of feedback, 100% of participants said the guidelines were understandable, most (88%) said they were actionable, and everyone (100%) would use these adapted guidelines to discuss their medical care with their health care providers.
Conclusions
Individuals with SCD and their caregivers want access to guidelines through multiple channels, including technology. Guidelines written for health care providers can be adapted to be patient-centered using Community-engaged research involving providers and patients. These patient-centered guidelines provide a framework for patients to discuss their medical care with their health care providers.
Electronic supplementary material
The online version of this article (10.1186/s12878-018-0106-3) contains supplementary material, which is available to authorized users.
... Moreover, the great majority of these studies have analyzed the impact of CCMs in selected cohorts of patients, investigating outcomes relevant to specific chronic diseases (monitoring of diabetes, cardio-vascular risks, blood pressure, BMI,..) [34,35]. Few randomized controlled trials have enrolled a nonspecific chronic disease cohort with multi-morbidity, and none have investigated the impact of CCM on modality of recourse to the health care system [36][37][38]. The results of retrospective cohort studies, as well as case studies and case series, offer a greater numerical sample and an analysis of impact on healthcare practice. ...
Abstract Background Ageing is continuously increasing the prevalence of patients with chronic conditions, putting pressure on the sustainability of Healthcare Systems. Chronic Care Models (CCM) have been used to address the needs of frail people in the continuum of care, testifying to an improvement in health outcomes and more efficient access to healthcare services. The impact of CCM deployment has already been experienced in a selected cohort of patients affected by specific chronic illnesses. We have investigated its effects in a heterogeneous frail cohort included in a regional CCM-based program. Methods a retrospective population-based cohort study was carried out involving a non-oncological cohort of adult subjects with chronic diseases included in the CCM-oriented program (Puglia Care). Individuals in usual care with comparable demographic and clinical characteristics were selected for matched pair analysis. Study cohorts were defined by using a record linkage analysis of administrative databases and electronic medical records, including data on the adult population in the 6 local area health authorities of Puglia in Italy (approximately 2 million people). The effects of Puglia Care on the utilizations of healthcare resources were evaluated both in a before-after and in a case-control analysis. Results There were 1074 subjects included in Puglia Care and 2126 matched controls. In before-after analysis of the Puglia Care cohort, 240 unplanned hospitalizations occurred in the pre-inclusion period, while 239 were registered during follow-up. The incidence of unplanned hospitalization was 10.3 per 100 person/year (95% CI, 9.1–11.7) during follow-up and 12.1 per 100 person/year (95% CI, 10.7–13.8) in the pre-inclusion period (IRR, 0.84; 95% CI, 0.80–0.99). During follow-up a significant reduction in costs related to unplanned hospitalizations (IRR, 0.92; 95% CI, 0.91–0.92) was registered, while costs related to drugs (IRR, 1.14; p
... The neurologists spent less time per patient during the SMAs, which lasted a mean of 16 minutes (range [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30], compared with the individual appointments, which averaged 25 minutes (range 20-30). In less than 8% of the patients, individual attention was needed after the SMA. ...
This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of group medical appointments (GMAs) on the health status and well-being of patients with a primary physical illness as compared to one-to-one patient-clinician appointments. © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
... The CCM implementation is effective in many chronic care program settings. Some programs experienced mixed and ineffective results (Coleman et al. 1999;Solberg et al. 2000;Olivarius et al. 2001;Bodenheimer et al. 2002b;Schonlau et al. 2005). ...
The mounting burden of chronic disease associated with population ageing creates a challenge for health systems. Healthcare organisations are addressing this challenge by exploring new ways to improve patient health outcomes, including through the use of information technologies.
Aim. This research aimed to identify key design features of a chronic disease management (CDM) register for the public sector health services provided in the Australian Capital Territory.
Methods and setting. ACT Health, a government agency, is the largest health service provider in the ACT. An organisational analysis of ACT Health was conducted using qualitative, quantitative, and participant observation methods. Three index conditions- Chronic Heart Failure, Chronic Obstructive Pulmonary Disease, and Diabetes Mellitus Type 2 defined information according to the 'International Statistical Classification of Diseases and Health Related Problems: lOth Revision, Australian Modification' (ICD-10-AM) were chosen for data collection and analysis.
Results. ACT Health policies support evidence-based CDM interventions, but their implementation has been slow and disjointed. This research found that support for CDM in ACT Health is within the 'basic support' range as measured by the MacColl Institute's Assessment of Chronic Illness Care (ACIC) survey. The survey revealed continuity of care as a concern. On the positive side, factor analysis of the survey results identified a novel 'patient empowerment' factor that was strength within ACT Health. This patient empowerment factor is somewhat more than a concept; it is one of the powerful predictors of positive outcomes for CDM interventions, and has policy importance in this particular regional health system for working toward CDM goals.
In the participant observation aspect of this research, these findings were taken up to enrich the design features for an effective CDM register by incorporating the views of health professionals, patients and their carers. This research identified five data categories and associated variables required to support a CDM register. These five data categories are patient details, medical details, provider details, prevention details, and case coordination details. The prevention detail category is the centre of a CDM register intervention and consists of diagnostic, therapeutic and behavioural sub-categories. However, the research identified challenges regarding availability and completeness of these data in all five categories. Combining the survey and participant observation suggests that electronically incorporating standardised clinical information into a CDM register should enhance multidisciplinary communication, care planning and coordinated service delivery. A clinical data repository with data extraction and filtration systems compliant with the Health Level Seven International (HL7) metadata standard would enable the organisation to populate a CDM register's data fields from multiple sources.
Conclusion. A health service specific CDM register based on established data standards can actively support effective CDM interventions within the service. Further expansion toward a population-based CDM register would depend on implementation of local and national e-Health initiatives to standardise clinical information for automatic extraction into CDM registers. The research provides policy and design recommendations to further strengthen chronic care processes to benefit patients with chronic diseases, their carers and health service providers.
... Previous studies on the effect of pharmacotherapy reviews or pharmaceutical care have also shown little or no benefit to patients regarding the number of adverse drug events, the quality of life or survival. 8,9,[13][14][15][16][17][18][19]30 The HOMER study showed an increase in the number of hospital admissions. 14 A potential explanation for these contradictory findings may lie in the type of intervention. ...
... Our primary outcome is 30-day rehospitalization [86,87]. Power for the trial was calculated assuming 22% of usual care patients will experience a rehospitalization within 30 days post-discharge, a rate consistent with prior studies and our own hospital tracking systems [17,88,89]. We calculated the sample size of 760 subjects to provide 80% power to detect a 35% reduction in this rate, assuming a two-tailed alpha of 0.05. ...
Objective:
The goal of this trial is to evaluate a novel intervention designed to improve post-hospitalization support for older adults with chronic conditions via: (a) direct tailored communication to patients using regular automated calls post discharge, (b) support for informal caregivers outside of the patient's household via structured automated feedback about the patient's status plus advice about how caregivers can help, and (c) support for care management including a web-based disease management tool and alerts about potential problems.
Methods:
846 older adults with common chronic conditions are being identified upon hospital admission. Patients are asked to identify a "CarePartner" (CP) living outside their household, i.e., an adult child or other social network member willing to play an active role in their post-discharge transition support. Patient-CP pairs are randomized to the intervention or usual care. Intervention patients receive automated assessment and behavior change calls, and their CPs receives structured feedback and advice via email and automated calls following each assessment. Clinical teams have access to assessment results via the web and receive automated reports about urgent health problems. Patients complete surveys at baseline, 30 days, and 90 days post discharge; utilization data is obtained from hospital records. CPs, other caregivers, and clinicians are interviewed to evaluate intervention effects on processes of self-care support, caregiver stress and communication, and the intervention's potential for broader implementation. The primary outcome is 30-day readmission rates; other outcomes measured at 30 days and 90 days include functional status, self-care behaviors, and mortality risk.
Conclusion:
This trial uses accessible health technologies and coordinated communication among informal caregivers and clinicians to fill the growing gap between what discharged patients need and available resources. A unique feature of the intervention is the provision of transition support not only for patients but also for their informal caregivers.
Objective To synthesise evidence of the effectiveness of community based complex interventions, grouped according to their intervention components, to sustain independence for older people.
Design Systematic review and network meta-analysis.
Data sources Medline, Embase, CINAHL, PsycINFO, CENTRAL, clinicaltrials.gov, and International Clinical Trials Registry Platform from inception to 9 August 2021 and reference lists of included studies.
Eligibility criteria Randomised controlled trials or cluster randomised controlled trials with ≥24 weeks’ follow-up studying community based complex interventions for sustaining independence in older people (mean age ≥65 years) living at home, with usual care, placebo, or another complex intervention as comparators.
Main outcomes Living at home, activities of daily living (personal/instrumental), care home placement, and service/economic outcomes at 12 months.
Data synthesis Interventions were grouped according to a specifically developed typology. Random effects network meta-analysis estimated comparative effects; Cochrane’s revised tool (RoB 2) structured risk of bias assessment. Grading of recommendations assessment, development and evaluation (GRADE) network meta-analysis structured certainty assessment.
Results The review included 129 studies (74 946 participants). Nineteen intervention components, including “multifactorial action from individualised care planning” (a process of multidomain assessment and management leading to tailored actions), were identified in 63 combinations. For living at home, compared with no intervention/placebo, evidence favoured multifactorial action from individualised care planning including medication review and regular follow-ups (routine review) (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty); multifactorial action from individualised care planning including medication review without regular follow-ups (2.55, 0.61 to 10.60; low certainty); combined cognitive training, medication review, nutritional support, and exercise (1.93, 0.79 to 4.77; low certainty); and combined activities of daily living training, nutritional support, and exercise (1.79, 0.67 to 4.76; low certainty). Risk screening or the addition of education and self-management strategies to multifactorial action from individualised care planning and routine review with medication review may reduce odds of living at home. For instrumental activities of daily living, evidence favoured multifactorial action from individualised care planning and routine review with medication review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living: combined activities of daily living training, aids, and exercise; and combined activities of daily living training, aids, education, exercise, and multifactorial action from individualised care planning and routine review with medication review and self-management strategies. For personal activities of daily living, evidence favoured combined exercise, multifactorial action from individualised care planning, and routine review with medication review and self-management strategies (0.16, −0.51 to 0.82; low certainty). For homecare recipients, evidence favoured addition of multifactorial action from individualised care planning and routine review with medication review (0.60, 0.32 to 0.88; low certainty). High risk of bias and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty.
Conclusions The intervention most likely to sustain independence is individualised care planning including medicines optimisation and regular follow-up reviews resulting in multifactorial action. Homecare recipients may particularly benefit from this intervention. Unexpectedly, some combinations may reduce independence. Further research is needed to investigate which combinations of interventions work best for different participants and contexts.
Registration PROSPERO CRD42019162195.
Background
Chronic disease management (CDM) through sustained knowledge translation (KT) interventions ensures long-term, high-quality care. We assessed implementation of KT interventions for supporting CDM and their efficacy when sustained in older adults.
Methods
Design: Systematic review with meta-analysis engaging 17 knowledge users using integrated KT.
Eligibility criteria: Randomized controlled trials (RCTs) including adults (> 65 years old) with chronic disease(s), their caregivers, health and/or policy-decision makers receiving a KT intervention to carry out a CDM intervention for at least 12 months (versus other KT interventions or usual care).
Information sources: We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from each database’s inception to March 2020.
Outcome measures: Sustainability, fidelity, adherence of KT interventions for CDM practice, quality of life (QOL) and quality of care (QOC).
Data extraction, risk of bias (ROB) assessment: We screened, abstracted and appraised articles (Effective Practice and Organisation of Care ROB tool) independently and in duplicate. Data synthesis: We performed both random-effects and fixed-effect meta-analyses and estimated mean differences (MDs) for continuous and odds ratios (ORs) for dichotomous data.
Results
We included 158 RCTs (973,074 participants [961,745 patients, 5540 caregivers, 5789 providers]) and 39 companion reports comprising 329 KT interventions, involving patients (43.2%), healthcare providers (20.7%) or both (10.9%). We identified 16 studies described as assessing sustainability in 8.1% interventions, 67 studies as assessing adherence in 35.6% interventions and 20 studies as assessing fidelity in 8.7% of the interventions. Most meta-analyses suggested that KT interventions improved QOL, but imprecisely (36 item Short-Form mental [SF-36 mental]: MD 1.11, 95% confidence interval [CI] [− 1.25, 3.47], 14 RCTs, 5876 participants, I² = 96%; European QOL-5 dimensions: MD 0.01, 95% CI [− 0.01, 0.02], 15 RCTs, 6628 participants, I² = 25%; St George’s Respiratory Questionnaire: MD − 2.12, 95% CI [− 3.72, − 0.51] 44 12 RCTs, 2893 participants, I² = 44%). KT interventions improved QOC (OR 1.55, 95% CI [1.29, 1.85], 12 RCTS, 5271 participants, I² = 21%).
Conclusions
KT intervention sustainability was infrequently defined and assessed. Sustained KT interventions have the potential to improve QOL and QOC in older adults with CDM. However, their overall efficacy remains uncertain and it varies by effect modifiers, including intervention type, chronic disease number, comorbidities, and participant age.
Systematic review registration
PROSPERO CRD42018084810.
Background
Functional independence limitations restrict older adult self-sufficiency and can reduce quality of life. This systematic review and cost of impairment study examined the costs of functional independence limitations among community dwelling older adults to society, the health care system, and the person.
Methods
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines this systematic review included community dwelling older adults aged 60 years and older with functional independence limitations. Databases (Cochrane Database of Systematic Reviews, EconLit, NHS EED, Embase, CINAHL, AgeLine, and MEDLINE) were searched between 1990 and June 2020. Two reviewers extracted information on study characteristics and cost outcomes including mean annual costs of functional independence limitations per person for each cost perspective (2020 US prices). Quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.
Results
85 studies were included. The mean annual total costs per person (2020 US prices) were: $27,380.74 (95% CI: [$4075.53, $50,685.96]) for societal, $24,195.52 (95% CI: [$9679.77, $38,711.27]) for health care system, and $7455.49 (95% CI: [$2271.45, $12,639.53]) for personal. Individuals with cognitive markers of functional independence limitations accounts for the largest mean costs per person across all perspectives. Variations across studies included: cost perspective, measures quantifying functional independence limitations, cost items reported, and time horizon.
Conclusions
This study sheds light on the importance of targeting cognitive markers of functional independence limitations as they accounted for the greatest costs across all economic perspectives.
Background
The use of potentially inappropriate medications for older people (PIM) is associated with worse health outcomes due to the occurrence of adverse drug events (ADE) and drug interactions, leading to increased healthcare costs.
Objectives
Identify the costs of ADE related to PIM use, in addition to the costs predictors.
Methods
A systematic review was conducted in the PubMed and Scopus databases (until February, 2022), and the report of this study was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Interventional and observational studies that reported costs of ADE regardless of perspective (i.e., payer) were considered. Reporting and methodological quality were assessed using the tool proposed by Larg and Moss for evaluating cost-of-illness studies.
Results
Twenty studies (21 publications), published between 2001 and 2020, were included (236,888,744 older people). The ADE costs related to PIM use were mostly related to the use of health services [hospitalization (n=7), healthcare expenses (n=7), and emergency department visits (n=3)]. Among the eight studies that reported p-value, seven identified higher costs for PIM-users when compared to non-PIM users. Three studies reported cost predictors, being: highest number of PIM in use; age over 75 years; male gender; general health status in older people in use of benzodiazepines; and drug interactions in older people diagnosed with dementia. Regarding to assessment of reporting and methodological quality, all studies had at least one limitation (answer ‘no’).
Conclusions
Our findings suggest that PIMs use is associated with higher costs of hospitalization, healthcare expenses, and visits to emergency department due to ADE, regardless of PIM in use, health service, perspective, and screening tools used for PIMs identification. However, these findings should be interpreted with caution as all studies had at least one methodological limitation.
Background
Care coordination (CC) interventions involve systematic strategies to address fragmentation and enhance continuity of care. However, it remains unclear whether CC can sufficiently address patient needs and improve outcomes.Methods
We searched MEDLINE, CINAHL, Embase, Cochrane Database of Systematic Reviews, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program, from inception to September 2019. Two individuals reviewed eligibility and rated quality using modified AMSTAR 2. Eligible systematic reviews (SR) examined diverse CC interventions for community-dwelling adults with ambulatory care sensitive conditions and/or at higher risk for acute care. From eligible SR and relevant included primary studies, we abstracted the following: study and intervention characteristics; target population(s); effects on hospitalizations, emergency department (ED) visits, and/or patient experience; setting characteristics; and tools and approaches used. We also conducted semi-structured interviews with individuals who implemented CC interventions.ResultsOf 2324 unique citations, 16 SR were eligible; 14 examined case management or transitional care interventions; and 2 evaluated intensive primary care models. Two SR highlighted selection for specific risk factors as important for effectiveness; one of these also indicated high intensity (e.g., more patient contacts) and/or multidisciplinary plans were key. Most SR found inconsistent effects on reducing hospitalizations or ED visits; few reported on patient experience. Effective interventions were implemented in multiple settings, including rural community hospitals, academic medical centers (in urban settings), and public hospitals serving largely poor, uninsured populations. Primary studies reported variable approaches to improve patient-provider communication, including health coaching and role-playing. SR, primary studies, and key informant interviews did not identify tools for measuring patient trust or care team integration. Sustainability of CC interventions varied and some were adapted over time.DiscussionCC interventions have inconsistent effects on reducing hospitalizations and ED visits. Future work should address how they should be adapted to different healthcare settings and which tools or approaches are most helpful for implementation.Trial RegistrationPROSPERO #CRD42020156359
Current models of the deprescribing process are largely clinician driven and limited to a single point in time. Our objective with this work was to investigate the effects of these existing models on interventions targeting older adults. Studies identified in an existing systematic literature review were examined and classified in terms of who within the deprescribing process the intervention targeted (target classification) and when in the process they were targeted (temporal classification). It was found that the vast majority of interventions targeted clinicians and focused on actions taken before or during the deprescribing touchpoint. Additionally, older adults with dementia and their caregivers were often excluded from these studies. We argue that the deprescribing process needs to be reframed as a patient journey that unfolds over time in order to address these gaps.
Objectives: Falls are a significant health problem for the ageing population. This review aimed to identify effective falls prevention interventions with involvement of general practitioners (GPs). Methods: Systematic review of randomised controlled trials conducted from 1999-2019, with meta-analysis. Searches located 2736 articles. A quality assessment was conducted of all included studies. Results: 21 randomised controlled trials met the inclusion criteria and 19 studies could be included in a meta-analysis. Overall, studies were not effective for reducing multiple falls (Relative Risk (RR) 1.16, 95% CI .97-1.39 and p = .10) or reducing one or more falls (RR .91, 95% CI: .82-1.01 and p = .08), but were effective for reducing injurious falls (RR .76, 95% CI: .66-.87 and p = .001). Discussion: Studies involving the GP in an active role and aligned with the primary care context were effective. The fidelity of interventions was limited by independent GP decisions and older participants being required to initiate the intervention.
Background and objectives:
Families of children with medical complexity are experts on their child's baseline behavior and temperament and may recognize changes in their hospitalized child's health before clinicians. Our objective was to develop a comprehensive understanding of how families identify and communicate their child's deteriorating health with the hospital-based health care team.
Methods:
In this qualitative study, our multidisciplinary team recruited family members of hospitalized children with neurologic impairment. Interviews, conducted in the hospital, were audio recorded, deidentified, and transcribed. By using inductive thematic analysis, each transcript was independently coded by 3 or 4 team members. Members met regularly to reach consensus on coding decisions. Patterns observed were organized into themes and subthemes.
Results:
Participants included 28 family members of 26 hospitalized children 9 months to 17 years of age. Children had a mean of 9 hospitalizations in the previous 3 years. Analysis resulted in 6 themes. First, families often reported their child "writes his own book," meaning the child's illness narrative rarely conformed to textbooks. Second, families developed informal, learned pathways to navigate the inpatient system. Third, families stressed the importance of advocacy. Fourth, families self-identified as "not your typical parents" and discussed how they learned their roles as part of the care team. Fifth, medical culture often did not support partnership. Finally, families noted they are often "running on empty" from stress, fear, and lack of sleep.
Conclusions:
Families of children with medical complexity employ mature, experience-based pathways to identify deteriorating health. Existing communication structures in the hospital are poorly equipped to incorporate families' expertise.
Hospitalized patients often are readmitted soon after discharge, with many hospitalizations being potentially preventable. The authors evaluated a mobile health intervention designed to improve post-hospitalization support for older adults with common chronic conditions. All participants enrolled with an informal caregiver or “CarePartner” (CP). Intervention patients received automated assessment and behavior change calls. CPs received automated, structured feedback following each assessment. Clinicians received alerts about serious problems identified during patient calls. Controls had a 65% greater risk of hospitalization within 90 days post discharge than intervention patients ( P = .041). For every 6.8 enrollees, the intervention prevented 1 rehospitalization or emergency department encounter. The intervention improved physical functioning at 90 days ( P = .012). The intervention also improved medication adherence and indicators of the quality of communication with CPs (all P < .01). Automated telephone patient monitoring and self-care advice with feedback to primary care teams and CPs reduces readmission rates over 90 days.
Background:
Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.
Objectives:
To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.
Search methods:
We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.
Selection criteria:
We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.
Data collection and analysis:
Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.
Main results:
We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.
Authors' conclusions:
Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.
Background
Falls often cause unexpected injuries that older adults find difficult to recover from (e.g., hip and other major fractures, intracranial bleeding); therefore, fall prevention and interventions are of particular significance.
Objectives
This study aimed to examine the effectiveness of multifactorial fall prevention interventions among community-dwelling older adults and compare subgroups that differed in terms of their degree of fall risk and the intensity and components of interventions.
Methods
An exhaustive systematic literature search was undertaken using the following databases: Ovid-Medline, Ovid-Embase, and the Cochrane Central Register of Controlled Trials (Central). Two investigators independently extracted data and assessed the quality of the studies by examining the risk of bias. We conducted a meta-analysis of randomized controlled trials that had been published up to March 31st, 2019, using Review Manager.
Results
Of 1,328 studies, 45 articles were relevant to this study. In total, 29 studies included participants in the high-risk group, 3 in the frail group, and 13 in the healthy older adult group. Additionally, 28 and 17 studies used active and referral multifactorial interventions, respectively. Multifactorial interventions included the following components: exercise, education, environmental modification, medication, mobility aids, and vision and psychological management. Multifactorial interventions significantly reduced fall rates in the high-risk (risk ratio 0.66; 95% confidence interval 0.52–0.84) and healthy groups (risk ratio 0.72; 95% confidence interval 0.58–0.89), when compared to the control group. Active multifactorial interventions (risk ratio 0.64; 95% confidence interval 0.51–0.80) and those featuring exercise (risk ratio 0.66; 95% confidence interval 0.54–0.80) and environmental modification also showed significantly reduced fall rates (risk ratio 0.65; 95% confidence interval 0.54–0.79) compared to usual care. Multifactorial interventions had a significantly lower number of people who experienced falls during the study period compared to usual care in the healthy group (risk ratio 0.77; 95% confidence interval 0.62–0.95). Active multifactorial interventions (risk ratio 0.73; 95% confidence interval 0.60–0.89) and those featuring exercise (risk ratio 0.79; 95% confidence interval 0.66–0.95) and environmental modification (risk ratio 0.80; 95% confidence interval 0.68–0.95) had a significantly lower number of people who experienced falls compared to those receiving usual care.
Conclusions
Active multifactorial interventions had positive effects on fall rates and the number of people experiencing falls. Thus, healthcare workers, including nurses, should be involved in planning fall prevention programs so that older adults can be provided with optimal care; multifactorial interventions that include exercise and environmental modification are particularly effective in reducing falls.
Objective
To assess the longer term effects of multifactorial interventions for preventing falls in older people living in the community, and to explore whether prespecific trial-level characteristics are associated with greater fall prevention effects.
Design
Systematic review with meta-analysis and meta-regression.
Data sources
MEDLINE, EMBASE, CINHAL, CENTRAL and trial registries were searched up to 25 July 2018.
Study selection
We included randomised controlled trials (≥12 months’ follow-up) evaluating the effects of multifactorial interventions on falls in older people aged 65 years and over, living in the community, compared with either usual care or usual care plus advice.
Review methods
Two authors independently verified studies for inclusion, assessed risk of bias and extracted data. Rate ratios (RaR) with 95% CIs were calculated for rate of falls, risk ratios (RR) for dichotomous outcomes and standardised mean difference for continuous outcomes. Data were pooled using a random effects model. The Grading of Recommendations, Assessment, Development and Evaluation was used to assess the quality of the evidence.
Results
We included 41 trials totalling 19 369 participants; mean age 72–85 years. Exercise was the most common prespecified component of the multifactorial interventions (85%; n=35/41). Most trials were judged at unclear or high risk of bias in ≥1 domain. Twenty trials provided data on rate of falls and showed multifactorial interventions may reduce the rate at which people fall compared with the comparator (RaR 0.79, 95% CI 0.70 to 0.88; 20 trials; 10 116 participants; I ² =90%; low-quality evidence). Multifactorial interventions may also slightly lower the risk of people sustaining one or more falls (RR 0.95, 95% CI 0.90 to 1.00; 30 trials; 13 817 participants; I ² =56%; moderate-quality evidence) and recurrent falls (RR 0.88, 95% CI 0.78 to 1.00; 15 trials; 7277 participants; I ² =46%; moderate-quality evidence). However, there may be little or no difference in other fall-related outcomes, such as fall-related fractures, falls requiring hospital admission or medical attention and health-related quality of life. Very few trials (n=3) reported on adverse events related to the intervention. Prespecified subgroup analyses showed that the effect on rate of falls may be smaller when compared with usual care plus advice as opposed to usual care only. Overall, heterogeneity remained high and was not explained by the prespecified characteristics included in the meta-regression.
Conclusion
Multifactorial interventions (most of which include exercise prescription) may reduce the rate of falls and slightly reduce risk of older people sustaining one or more falls and recurrent falls (defined as two or more falls within a specified time period).
Trial registration number
CRD42018102549.
Hypertension, the leading risk factor for cardiovascular disease, originates from combined genetic, environmental, and social determinants. Environmental factors include overweight/obesity, unhealthy diet, excessive dietary sodium, inadequate dietary potassium, insufficient physical activity, and consumption of alcohol. Prevention and control of hypertension can be achieved through targeted and/or population-based strategies. For control of hypertension, the targeted strategy involves interventions to increase awareness, treatment, and control in individuals. Corresponding population-based strategies involve interventions designed to achieve a small reduction in blood pressure (BP) in the entire population. Having a usual source of care, optimizing adherence, and minimizing therapeutic inertia are associated with higher rates of BP control. The Chronic Care Model, a collaborative partnership among the patient, provider, and health system, incorporates a multilevel approach for control of hypertension. Optimizing the prevention, recognition, and care of hypertension requires a paradigm shift to team-based care and the use of strategies known to control BP.
Background:
Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing. This is the second update of this Cochrane Review.
Objectives:
To determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.
Search methods:
We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 7 February 2018, together with handsearching of reference lists to identify additional studies.
Selection criteria:
We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older, prescribed polypharmacy (four or more medicines), which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people).
Data collection and analysis:
Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach.
Main results:
We identified 32 studies, 20 from this update. Included studies consisted of 18 randomised trials, 10 cluster randomised trials (one of which was a stepped-wedge design), two non-randomised trials and two controlled before-after studies. One intervention consisted of computerised decision support (CDS); and 31 were complex, multi-faceted pharmaceutical-care based approaches (i.e. the responsible provision of medicines to improve patient's outcomes), one of which incorporated a CDS component as part of their multi-faceted intervention. Interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists and geriatricians, and all were conducted in high-income countries. Assessments using the Cochrane 'Risk of bias' tool, found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low.It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool), mean difference (MD) -4.76, 95% CI -9.20 to -0.33; 5 studies, N = 517; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs), (standardised mean difference (SMD) -0.22, 95% CI -0.38 to -0.05; 7 studies; N = 1832; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIMs, (risk ratio (RR) 0.79, 95% CI 0.61 to 1.02; 11 studies; N = 3079; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.81, 95% CI -0.98 to -0.64; 2 studies; N = 569; low-certainty evidence), however it must be noted that this effect estimate is based on only two studies, which had serious limitations in terms of risk bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPOs (RR 0.40, 95% CI 0.18 to 0.85; 5 studies; N = 1310; very low-certainty evidence). Pharmaceutical care may make little or no difference in hospital admissions (data not pooled; 12 studies; N = 4052; low-certainty evidence). Pharmaceutical care may make little or no difference in quality of life (data not pooled; 12 studies; N = 3211; low-certainty evidence). Medication-related problems were reported in eight studies (N = 10,087) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies.
Authors' conclusions:
It is unclear whether interventions to improve appropriate polypharmacy, such as reviews of patients' prescriptions, resulted in clinically significant improvement; however, they may be slightly beneficial in terms of reducing potential prescribing omissions (PPOs); but this effect estimate is based on only two studies, which had serious limitations in terms of risk bias.
Hypertension, the leading risk factor for cardiovascular disease, originates from combined genetic, environmental, and social determinants. Environmental factors include overweight/obesity, unhealthy diet, excessive dietary sodium, inadequate dietary potassium, insufficient physical activity, and consumption of alcohol. Prevention and control of hypertension can be achieved through targeted and/or population-based strategies. For control of hypertension, the targeted strategy involves interventions to increase awareness, treatment, and control in individuals. Corresponding population-based strategies involve interventions designed to achieve a small reduction in blood pressure (BP) in the entire population. Having a usual source of care, optimizing adherence, and minimizing therapeutic inertia are associated with higher rates of BP control. The Chronic Care Model, a collaborative partnership among the patient, provider, and health system, incorporates a multilevel approach for control of hypertension. Optimizing the prevention, recognition, and care of hypertension requires a paradigm shift to team-based care and the use of strategies known to control BP.
Background:
Falls and fall-related injuries are common, particularly in those aged over 65, with around one-third of older people living in the community falling at least once a year. Falls prevention interventions may comprise single component interventions (e.g. exercise), or involve combinations of two or more different types of intervention (e.g. exercise and medication review). Their delivery can broadly be divided into two main groups: 1) multifactorial interventions where component interventions differ based on individual assessment of risk; or 2) multiple component interventions where the same component interventions are provided to all people.
Objectives:
To assess the effects (benefits and harms) of multifactorial interventions and multiple component interventions for preventing falls in older people living in the community.
Search methods:
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature, trial registers and reference lists. Date of search: 12 June 2017.
Selection criteria:
Randomised controlled trials, individual or cluster, that evaluated the effects of multifactorial and multiple component interventions on falls in older people living in the community, compared with control (i.e. usual care (no change in usual activities) or attention control (social visits)) or exercise as a single intervention.
Data collection and analysis:
Two review authors independently selected studies, assessed risks of bias and extracted data. We calculated the rate ratio (RaR) with 95% confidence intervals (CIs) for rate of falls. For dichotomous outcomes we used risk ratios (RRs) and 95% CIs. For continuous outcomes, we used the standardised mean difference (SMD) with 95% CIs. We pooled data using the random-effects model. We used the GRADE approach to assess the quality of the evidence.
Main results:
We included 62 trials involving 19,935 older people living in the community. The median trial size was 248 participants. Most trials included more women than men. The mean ages in trials ranged from 62 to 85 years (median 77 years). Most trials (43 trials) reported follow-up of 12 months or over. We assessed most trials at unclear or high risk of bias in one or more domains.Forty-four trials assessed multifactorial interventions and 18 assessed multiple component interventions. (I2 not reported if = 0%).Multifactorial interventions versus usual care or attention controlThis comparison was made in 43 trials. Commonly-applied or recommended interventions after assessment of each participant's risk profile were exercise, environment or assistive technologies, medication review and psychological interventions. Multifactorial interventions may reduce the rate of falls compared with control: rate ratio (RaR) 0.77, 95% CI 0.67 to 0.87; 19 trials; 5853 participants; I2 = 88%; low-quality evidence. Thus if 1000 people were followed over one year, the number of falls may be 1784 (95% CI 1553 to 2016) after multifactorial intervention versus 2317 after usual care or attention control. There was low-quality evidence of little or no difference in the risks of: falling (i.e. people sustaining one or more fall) (RR 0.96, 95% CI 0.90 to 1.03; 29 trials; 9637 participants; I2 = 60%); recurrent falls (RR 0.87, 95% CI 0.74 to 1.03; 12 trials; 3368 participants; I2 = 53%); fall-related hospital admission (RR 1.00, 95% CI 0.92 to 1.07; 15 trials; 5227 participants); requiring medical attention (RR 0.91, 95% CI 0.75 to 1.10; 8 trials; 3078 participants). There is low-quality evidence that multifactorial interventions may reduce the risk of fall-related fractures (RR 0.73, 95% CI 0.53 to 1.01; 9 trials; 2850 participants) and may slightly improve health-related quality of life but not noticeably (SMD 0.19, 95% CI 0.03 to 0.35; 9 trials; 2373 participants; I2 = 70%). Of three trials reporting on adverse events, one found none, and two reported 12 participants with self-limiting musculoskeletal symptoms in total.Multifactorial interventions versus exerciseVery low-quality evidence from one small trial of 51 recently-discharged orthopaedic patients means that we are uncertain of the effects on rate of falls or risk of falling of multifactorial interventions versus exercise alone. Other fall-related outcomes were not assessed.Multiple component interventions versus usual care or attention controlThe 17 trials that make this comparison usually included exercise and another component, commonly education or home-hazard assessment. There is moderate-quality evidence that multiple interventions probably reduce the rate of falls (RaR 0.74, 95% CI 0.60 to 0.91; 6 trials; 1085 participants; I2 = 45%) and risk of falls (RR 0.82, 95% CI 0.74 to 0.90; 11 trials; 1980 participants). There is low-quality evidence that multiple interventions may reduce the risk of recurrent falls, although a small increase cannot be ruled out (RR 0.81, 95% CI 0.63 to 1.05; 4 trials; 662 participants). Very low-quality evidence means that we are uncertain of the effects of multiple component interventions on the risk of fall-related fractures (2 trials) or fall-related hospital admission (1 trial). There is low-quality evidence that multiple interventions may have little or no effect on the risk of requiring medical attention (RR 0.95, 95% CI 0.67 to 1.35; 1 trial; 291 participants); conversely they may slightly improve health-related quality of life (SMD 0.77, 95% CI 0.16 to 1.39; 4 trials; 391 participants; I2 = 88%). Of seven trials reporting on adverse events, five found none, and six minor adverse events were reported in two.Multiple component interventions versus exerciseThis comparison was tested in five trials. There is low-quality evidence of little or no difference between the two interventions in rate of falls (1 trial) and risk of falling (RR 0.93, 95% CI 0.78 to 1.10; 3 trials; 863 participants) and very low-quality evidence, meaning we are uncertain of the effects on hospital admission (1 trial). One trial reported two cases of minor joint pain. Other falls outcomes were not reported.
Authors' conclusions:
Multifactorial interventions may reduce the rate of falls compared with usual care or attention control. However, there may be little or no effect on other fall-related outcomes. Multiple component interventions, usually including exercise, may reduce the rate of falls and risk of falling compared with usual care or attention control.
Communication between providers and patients serves as a fundamental building block upon which all elements of successful chronic care are built. Effective patient-provider communication is linked with improved health outcomes, better rapport in patient interactions, decreased utilization, and overall patient and provider satisfaction. Traditional models of patient-provider communication focus on the interactions that occur during face-to-face office visits, and mastering communication in these encounters remains crucial to the successful provision of chronic care. The evolving healthcare landscape requires that providers are proficient in communication within new models of care, such as group visits, team-based care, interactions via new technological channels, and shared decision-making. Providers must be prepared to communicate effectively when presented with challenging situations that can arise during the course of chronic care relationships, such as the need to deliver bad news, conflict management, cultural differences between patients and providers, and interaction with patient companions and advocates.
Background:
Medication-related adverse events in primary care represent an important cause of hospital admissions and mortality. Adverse events could result from people experiencing adverse drug reactions (not usually preventable) or could be due to medication errors (usually preventable).
Objectives:
To determine the effectiveness of professional, organisational and structural interventions compared to standard care to reduce preventable medication errors by primary healthcare professionals that lead to hospital admissions, emergency department visits, and mortality in adults.
Search methods:
We searched CENTRAL, MEDLINE, Embase, three other databases, and two trial registries on 4 October 2016, together with reference checking, citation searching and contact with study authors to identify additional studies. We also searched several sources of grey literature.
Selection criteria:
We included randomised trials in which healthcare professionals provided community-based medical services. We also included interventions in outpatient clinics attached to a hospital where people are seen by healthcare professionals but are not admitted to hospital. We only included interventions that aimed to reduce medication errors leading to hospital admissions, emergency department visits, or mortality. We included all participants, irrespective of age, who were prescribed medication by a primary healthcare professional.
Data collection and analysis:
Three review authors independently extracted data. Each of the outcomes (hospital admissions, emergency department visits, and mortality), are reported in natural units (i.e. number of participants with an event per total number of participants at follow-up). We presented all outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We used the GRADE tool to assess the certainty of evidence.
Main results:
We included 30 studies (169,969 participants) in the review addressing various interventions to prevent medication errors; four studies addressed professional interventions (8266 participants) and 26 studies described organisational interventions (161,703 participants). We did not find any studies addressing structural interventions. Professional interventions included the use of health information technology to identify people at risk of medication problems, computer-generated care suggested and actioned by a physician, electronic notification systems about dose changes, drug interventions and follow-up, and educational interventions on drug use aimed at physicians to improve drug prescriptions. Organisational interventions included medication reviews by pharmacists, nurses or physicians, clinician-led clinics, and home visits by clinicians.There is a great deal of diversity in types of professionals involved and where the studies occurred. However, most (61%) of the interventions were conducted by pharmacists or a combination of pharmacists and medical doctors. The studies took place in many different countries; 65% took place in either the USA or the UK. They all ranged from three months to 4.7 years of follow-up, they all took place in primary care settings such as general practice, outpatients' clinics, patients' homes and aged-care facilities. The participants in the studies were adults taking medications and the interventions were undertaken by healthcare professionals including pharmacists, nurses or physicians. There was also evidence of potential bias in some studies, with only 18 studies reporting adequate concealment of allocation and only 12 studies reporting appropriate protection from contamination, both of which may have influenced the overall effect estimate and the overall pooled estimate. Professional interventionsProfessional interventions probably make little or no difference to the number of hospital admissions (risk ratio (RR) 1.24, 95% confidence interval (CI) 0.79 to 1.96; 2 studies, 3889 participants; moderate-certainty evidence). Professional interventions make little or no difference to the number of participants admitted to hospital (adjusted RR 0.99, 95% CI 0.92 to 1.06; 1 study, 3661 participants; high-certainty evidence). Professional interventions may make little or no difference to the number of emergency department visits (adjusted RR 0.71, 95% CI 0.50 to 1.02; 2 studies, 1067 participants; low-certainty evidence). Professional interventions probably make little or no difference to mortality in the study population (adjusted RR 0.98, 95% CI 0.82 to 1.17; 1 study, 3538 participants; moderate-certainty evidence). Organisational interventionsOverall, it is uncertain whether organisational interventions reduce the number of hospital admissions (adjusted RR 0.85, 95% CI 0.71 to 1.03; 11 studies, 6203 participants; very low-certainty evidence). Overall, organisational interventions may make little difference to the total number of people admitted to hospital in favour of the intervention group compared with the control group (adjusted RR 0.92, 95% CI 0.86 to 0.99; 13 studies, 152,237 participants; low-certainty evidence. Overall, it is uncertain whether organisational interventions reduce the number of emergency department visits in favour of the intervention group compared with the control group (adjusted RR 0.75, 95% CI 0.49 to 1.15; 5 studies, 1819 participants; very low-certainty evidence. Overall, it is uncertain whether organisational interventions reduce mortality in favour of the intervention group (adjusted RR 0.94, 95% CI 0.85 to 1.03; 12 studies, 154,962 participants; very low-certainty evidence.
Authors' conclusions:
Based on moderate- and low-certainty evidence, interventions in primary care for reducing preventable medication errors probably make little or no difference to the number of people admitted to hospital or the number of hospitalisations, emergency department visits, or mortality. The variation in heterogeneity in the pooled estimates means that our results should be treated cautiously as the interventions may not have worked consistently across all studies due to differences in how the interventions were provided, background practice, and culture or delivery of the interventions. Larger studies addressing both professional and organisational interventions are needed before evidence-based recommendations can be made. We did not identify any structural interventions and only four studies used professional interventions, and so more work needs to be done with these types of interventions. There is a need for high-quality studies describing the interventions in more detail and testing patient-related outcomes.
Background
Shared medical appointments (SMAs) are doctor-patient visits in which groups of patients are seen by one or more health care providers in a concurrent session. There is a growing interest in understanding the potential benefits of SMAs in various contexts to improve clinical outcomes and reduce healthcare costs. This study builds upon the existing evidence base that suggests SMAs are indeed effective. In this study, we explored how they are effective in terms of the underlying mechanisms of action and under what circumstances. Methods
Realist review methodology was used to synthesize the literature on SMAs, which included a broad search of 800+ published articles. 71 high quality primary research articles were retained to build a conceptual model of SMAs and 20 of those were selected for an in depth analysis using realist methodology (i.e.,middle-range theories and and context-mechanism-outcome configurations). ResultsNine main mechanisms that serve to explain how SMAs work were theorized from the data immersion process and configured in a series of context-mechanism-outcome configurations (CMOs). These are: (1) Group exposure in SMAs combats isolation, which in turn helps to remove doubts about one’s ability to manage illness; (2) Patients learn about disease self-management vicariously by witnessing others’ illness experiences; (3) Patients feel inspired by seeing others who are coping well; (4) Group dynamics lead patients and providers to developing more equitable relationships; (5) Providers feel increased appreciation and rapport toward colleagues leading to increased efficiency; (6) Providers learn from the patients how better to meet their patients’ needs; (7) Adequate time allotment of the SMA leads patients to feel supported; (8) Patients receive professional expertise from the provider in combination with first-hand information from peers, resulting in more robust health knowledge; and (9) Patients have the opportunity to see how the physicians interact with fellow patients, which allows them to get to know the physician and better determine their level of trust. Conclusions
Nine overarching mechanisms were configured in CMO configurations and discussed as a set of complementary middle-range programme theories to explain how SMAs work. It is anticipated that this innovative work in theorizing SMAs using realist review methodology will provide policy makers and SMA program planners adequate conceptual grounding to design contextually sensitive SMA programs in a wide variety of settings and advance an SMA research agenda for varied contexts.
In the past two decades, relationships among health plans, medical groups, and providers have grown more complex and the number of clinical management strategies has increased. In this context, determining the independent effect of a particular organizational strategy on quality of care has become more difficult. The authors review some of the issues a researcher must address when studying the relationship between organizational characteristics and quality of care. They offer criteria for selecting a research question, list organizational characteristics that may influence quality, and suggest sampling and study design techniques to reduce confounding. Since this type of research often requires a health care organization as collaborator, the authors discuss strategies for developing research partnerships and collecting data from the partner organization. Finally, they offer suggestions for translating research into policy.
This two-group, repeated-measures experimental study assessed the efficacy of a nurse practitioner-facilitated chronic kidney disease (CKD) group visit (GO model versus usual nephrology care for patients with Stage 4 CKD. The study enrolled patients from two sites of an outpatient nephrology practice (n = 30) and randomized subjects to usual care (n = 14) or to the GV model (n = 16). Data regarding CKD knowledge, self-efficacy/disease self management, and physiologic measures were collected at baseline, 6 months, and 9 months. Satisfaction was obtained at 6 months and 9 months. Usual nephrology office visit components were maintained during six monthly GVs, with group discussions of CKD-related topics. Results indicated a statistical improvement in CKD knowledge for both groups (F[1.498, 34.446] = 6.363, p = 0.008). An upward trend in mean scores for self management subscales and self-efficacy scores was demonstrated in the GV patients, with no improvement found in the usual care group. Twenty-six of 30 patients completed the study, with 92% attendance in the GV group. GV satisfaction was high.
The Cooperative Health Care Clinic (CHCC) model was originated by Dr. John C. Scott at Kaiser Permanente in Colorado in 1991 and was the first of today's three major group visit models to be developed. The CHCC model instills deep social bonds as it offers exceptional continuity of care for the 15–20 patients fortunate enough to receive it, because, in the CHCC, the same group of patients (typically high-utilizing patients as that is where maximum cost offset occurs) sees the same doctor and nurse at regular intervals. The CHCC was developed with the desire to improve the quality of care provided to high-utilizing, non-frail older patients. Although establishing homogeneous patient groupings by disease was considered initially, this plan was quickly abandoned as impractical due to the multiple chronic conditions that older patients so often experience.
Group clinics are a form of delivering specialist-led care in groups rather than in individual consultations.
Objective
To examine the evidence for the use of group clinics for patients with chronic health conditions.
Design
A systematic review of evidence from randomised controlled trials (RCTs) supplemented by qualitative studies, cost studies and UK initiatives.
Data sources
We searched MEDLINE, EMBASE, The Cochrane Library, Web of Science and Cumulative Index to Nursing and Allied Health Literature from 1999 to 2014. Systematic reviews and RCTs were eligible for inclusion. Additional searches were performed to identify qualitative studies, studies reporting costs and evidence specific to UK settings.
Review methods
Data were extracted for all included systematic reviews, RCTs and qualitative studies using a standardised form. Quality assessment was performed for systematic reviews, RCTs and qualitative studies. UK studies were included regardless of the quality or level of reporting. Tabulation of the extracted data informed a narrative synthesis. We did not attempt to synthesise quantitative data through formal meta-analysis. However, given the predominance of studies of group clinics for diabetes, using common biomedical outcomes, this subset was subject to quantitative analysis.
Results
Thirteen systematic reviews and 22 RCT studies met the inclusion criteria. These were supplemented by 12 qualitative papers (10 studies), four surveys and eight papers examining costs. Thirteen papers reported on 12 UK initiatives. With 82 papers covering 69 different studies, this constituted the most comprehensive coverage of the evidence base to date. Disease-specific outcomes – the large majority of RCTs examined group clinic approaches to diabetes. Other conditions included hypertension/heart failure and neuromuscular conditions. The most commonly measured outcomes for diabetes were glycated haemoglobin A
1c
(HbA
1c
), blood pressure and cholesterol. Group clinic approaches improved HbA
1c
and improved systolic blood pressure but did not improve low-density lipoprotein cholesterol. A significant effect was found for disease-specific quality of life in a few studies. No other outcome measure showed a consistent effect in favour of group clinics. Recent RCTs largely confirm previous findings. Health services outcomes – the evidence on costs and feasibility was equivocal. No rigorous evaluation of group clinics has been conducted in a UK setting. A good-quality qualitative study from the UK highlighted factors such as the physical space and a flexible appointment system as being important to patients. The views and attitudes of those who dislike group clinic provision are poorly represented. Little attention has been directed at the needs of people from ethnic minorities. The review team identified significant weaknesses in the included research. Potential selection bias limits the generalisability of the results. Many patients who could potentially be included do not consent to the group approach. Attendance is often interpreted liberally.
Limitations
This telescoped review, conducted within half the time period of a conventional systematic review, sought breadth in covering feasibility, appropriateness and meaningfulness in addition to effectiveness and cost-effectiveness and utilised several rapid-review methods. It focused on the contribution of recently published evidence from RCTs to the existing evidence base. It did not reanalyse trials covered in previous reviews. Following rapid review methods, we did not perform independent double data extraction and quality assessment.
Conclusions
Although there is consistent and promising evidence for an effect of group clinics for some biomedical measures, this effect does not extend across all outcomes. Much of the evidence was derived from the USA. It is important to engage with UK stakeholders to identify NHS considerations relating to the implementation of group clinic approaches.
Future work
The review team identified three research priorities: (1) more UK-centred evaluations using rigorous research designs and economic models with robust components; (2) clearer delineation of individual components within different models of group clinic delivery; and (3) clarification of the circumstances under which group clinics present an appropriate alternative to an individual consultation.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
We reviewed rigorous evaluations of programs to enhance the quality and economy of primary care. We identified 36 evaluations published from 1980 through 1992. We abstracted data on objectives, setting(s), patients and processes, outcomes, and costs of care. We identified successful programs, as well as significant gaps in our knowledge of how to improve aspects of care. In specific, computer reminders and social influence—based methods fostered preventive and economic care. Nurse implementation of prevention protocols increased their performance. Multidisciplinary teams improved access and economy. Regional organization of practices or telephone management improved access; regionalization also reduced emergency care. Improvements were not found in continuity, comprehensiveness, humanistic process, physical environment, or health outcomes. Primary care practices can implement several programs to continuously improve prevention and access, and to reduce costs and use of unnecessary services. Research documenting how to accomplish other major goals, including health outcome changes, in different practice types is needed.
(Arch Intern Med. 1995;155:1146-1156)
We surveyed medical directors of primary care clinics in California to learn how those clinics cared for their frail older patients. Of 143 questionnaires sent, 127 (89%) were returned. A median of 30% of all patient encounters were with persons aged 65 or older, and a median of 20% of older patients were considered frail. A total of 20% of the clinics routinely provided house calls to homebound elderly patients. Of clinics involved in training medical students of physicians (teaching clinics), 70% had at least one physician with an interest in geriatrics, compared with 42% of nonteaching clinics (P less than .005). For frail patients, 40% of the clinics routinely performed functional assessment, while 20% routinely did an interdisciplinary evaluation. Continuing education in geriatrics emerged as a significant independent correlate of both functional assessment and interdisciplinary evaluation. Among the 94 clinics with a standard appointment length for the history and physical examination, only 11 (12%) allotted more than 60 minutes for frail patients. The data suggest that certain geriatric approaches are being incorporated into clinic-based primary care in California but do not provide insight into their content or clinical effects.
To review the literature relating to the effectiveness of education strategies designed to change physician performance and health care outcomes.
We searched MEDLINE, ERIC, NTIS, the Research and Development Resource Base in Continuing Medical Education, and other relevant data sources from 1975 to 1994, using continuing medical education (CME) and related terms as keywords. We manually searched journals and the bibliographies of other review articles and called on the opinions of recognized experts.
We reviewed studies that met the following criteria: randomized controlled trials of education strategies or interventions that objectively assessed physician performance and/or health care outcomes. These intervention strategies included (alone and in combination) educational materials, formal CME activities, outreach visits such as academic detailing, opinion leaders, patient-mediated strategies, audit with feedback, and reminders. Studies were selected only if more than 50% of the subjects were either practicing physicians or medical residents.
We extracted the specialty of the physicians targeted by the interventions and the clinical domain and setting of the trial. We also determined the details of the educational intervention, the extent to which needs or barriers to change had been ascertained prior to the intervention, and the main outcome measure(s).
We found 99 trials, containing 160 interventions, that met our criteria. Almost two thirds of the interventions (101 of 160) displayed an improvement in at least one major outcome measure: 70% demonstrated a change in physician performance, and 48% of interventions aimed at health care outcomes produced a positive change. Effective change strategies included reminders, patient-mediated interventions, outreach visits, opinion leaders, and multifaceted activities. Audit with feedback and educational materials were less effective, and formal CME conferences or activities, without enabling or practice-reinforcing strategies, had relatively little impact.
Widely used CME delivery methods such as conferences have little direct impact on improving professional practice. More effective methods such as systematic practice-based interventions and outreach visits are seldom used by CME providers.
To determine whether a set of factors representing impairments in multiple areas could be identified that predisposes to falling, incontinence, and functional dependence.
Population-based cohort with a 1-year follow-up.
General community.
A total of 927 New Haven, Conn, residents, aged 72 years and older who completed the baseline and 1-year interviews.
At least one episode of urinary incontinence per week, at least two falls during the follow-up year, and dependence on human help for one or more basic activities of daily living.
At 1 year, urinary incontinence was reported by 16%, at least two falls by 10%, and functional dependence by 20% of participants. The four independent predisposing factors for the outcomes of incontinence, falling, and functional dependence included slow timed chair stands (lower extremity impairment), decreased arm strength (upper extremity impairment), decreased vision and hearing (sensory impairment), and either a high anxiety or depression score (affective impairment). There was a significant increase in each of incontinence, falling, and functional dependence as the number of these predisposing factors increased. For example, the proportion of participants experiencing functional dependence doubled (7% to 14% to 28% to 60%) (chi 2 = 119.8; P < .001) as the number of predisposing factors increased from zero to one to two at least three.
Our findings suggest that predisposition to geriatric syndromes and functional dependence may result when impairments in multiple domains compromise compensatory ability. It may be possible to restore compensatory ability and prevent or delay the onset of several geriatric syndromes and, perhaps, functional dependence by modifying a shared set of predisposing factors. Perhaps it is time to take a more unified approach to the geriatric syndromes and functional dependence.
Elderly patients taking inappropriate drugs are at increased risk for adverse outcomes. We investigated the prevalence of inappropriate drug use and its predisposing factors in community-residing older persons.
We conducted in-home interviews with 414 subjects aged 75 years and older living in the community of Santa Monica, Calif. Inappropriate medication use was evaluated using explicit criteria developed through a modified Delphi consensus process. These criteria identified drugs that should generally be avoided in elderly community-residing subjects regardless of dosage, duration of therapy, or clinical circumstances.
Based on these conservative criteria, 14.0% of the subjects were using at least one inappropriate drug. The most common examples were long-acting benzodiazepines, persantine, amitriptyline, and chlorpropamide. Subjects using three or more prescription drugs, compared with one or two, were more likely to be taking an inappropriate medication (odds ratio, 3.9; 95% confidence interval, 1.9 to 7.9). Furthermore, subjects with depressive symptoms had a higher risk of receiving inappropriate medications than nondepressive subjects (odds ratio, 2.2; 95% confidence interval, 1.1 to 4.1).
Inappropriate drug use is a common problem in community-residing older persons. The risk of inappropriate drug use is increased in patients taking multiple medications and in patients with depressive symptoms.
Because preventing disability and falls in older adults is a national priority, a randomized controlled trial was conducted to test a multicomponent intervention program.
From a random sample of health maintenance organization (HMO) enrollees 65 years and older, 1559 ambulatory seniors were randomized to one of three groups: a nurse assessment visit and follow-up interventions targeting risk factors for disability and falls (group 1, n = 635); a general health promotion nurse visit (group 2, n = 317); and usual care (group 3, n = 607). Data collection consisted of a baseline and two annual follow-up surveys.
After 1 year, group 1 subjects reported a significantly lower incidence of declining functional status and a significantly lower incidence of falls than group 3 subjects. Group 2 subjects had intermediate levels of most outcomes. After 2 years of follow-up, the differences narrowed.
The results suggest that a modest, one-time prevention program appeared to confer short-term health benefits on ambulatory HMO enrollees, although benefits diminished by the second year of follow-up. The mechanisms by which the intervention may have improved outcomes require further investigation.
Comprehensive geriatric assessment (CGA) in outpatient settings has not been shown to be as effective in reducing mortality and improving health as in hospital settings; this difference has been attributed in part to a lack of direct control over recommendation implementation.
To identify inhibiting and facilitating factors in physicians' compliance with consultative CGA recommendations, so that the effectiveness of outpatient CGA might be improved.
A 49-item questionnaire was administered via the telephone to 87 eligible community primary care physicians in Los Angeles, Calif, whose patients had received consultative outpatient CGAs as part of a study of CGA (response rate, 96%). The questionnaire assessed physician compliance with CGA recommendations, reasons for implementing or not implementing the recommendations, and specific physician attitudes, perceptions, and characteristics. The focus of the interview was the CGA recommendation that was determined to be the "most important" by the evaluating geriatrician. Recommendations addressed geriatric syndromes, general medical problems, or psychiatric conditions.
Of the 87 physician respondents, 62 (71%) implemented the most important recommendation. In multivariate analysis, 4 variables were predictive of physician compliance: (1) a patient's request that the recommendation be implemented (odds ratio [OR], 10.8; 95% confidence interval [CI], 1.9-61.3; P = .007); (2) perceived legal liability resulting from nonimplementation of the recommendation (OR, 10.8; 95% CI, 1.1-108.2; P = .04); (3) female physician gender (OR, 9.6; 95% CI, 1.4-67.9; P = .04); and (4) perceived cost-effectiveness of the recommendation (OR, 7.0; 95% CI, 1.6-30.5; P = .01).
Patient behavior, which may be modifiable, was among the strongest determinants of physician compliance with recommended care. Specifically, when patients requested that a recommendation be implemented, physicians were highly likely to comply. Changing patient behavior within the physician-patient relationship as a way of effecting desired changes in physician health care practices merits further attention.
In consultative models of Comprehensive Geriatric Assessment (CGA), lack of implementation of CGA recommendations is well documented and appears to be a potential explanation for negative findings. The purpose of this study is to identify patient determinants of adherence to recommendations received from a community-based CGA consultative model program.
Subjects (N = 139) received self-care and/or physician-initiated CGA recommendations and were interviewed three months later to determine adherence with the most important recommendation, and health belief, communication, and social support factors associated with adherence. Independent variables were organized into the Andersen Behavioral Model for analysis.
At the bivariate level, one predisposing factor (intention) and six enabling factors (low difficulty level, high support, high utility, high self-efficacy, agreement on the importance of the recommendation and good specific communication about the recommendation) were significant determinants of adherence. Two functional health measures and seriousness of the target condition of the recommendation were significant need factors. In the final logistic regression model, one predisposing variable (intention), one enabling variable (utility), and one need factor (high functional status), and two interaction terms significantly predicted adherence.
CGA recommendations that are seen as worthwhile, not too much trouble, and able to be accomplished are the most likely to be initiated. Older adults with relatively higher functional levels are also more likely to follow through with CGA recommendations even though their needs may be lower. We found the Andersen Behavioral Model useful in the analysis of factors associated with adherence behavior to consultative CGA recommendations.
Significant symptoms of depression are common in the older community-dwelling population. Although depressive symptoms and disability may commonly occur in the same person, whether depressive symptoms contribute to subsequent functional decline has not been elucidated.
To determine whether depressive symptoms in older persons increase the risk of subsequent decline in physical function as measured by objective performance-based tests.
A 4-year prospective cohort study.
The communities of Iowa and Washington counties, Iowa.
A total of 1286 persons aged 71 years and older who completed a short battery of physical performance tests in 1988 and again 4 years later.
Baseline depressive symptoms were assessed by the Center for Epidemiological Studies Depression Scale. Physical performance tests included an assessment of standing balance, a timed 2.4-m (8-ft) walk, and a timed test of 5 repetitions of rising from a chair and sitting down.
After adjustment for baseline performance score, health status, and sociodemographic factors, increasing levels of depressive symptoms were predictive of greater decline in physical performance over 4 years (odds ratio for decline in those with depressed mood vs those without, 1.55; 95% confidence interval [CI], 1.02-2.34). Even among those at the high end of the functional spectrum, who reported no disability, the severity of depressive symptoms predicted subsequent decline in physical performance (odds ratio for decline, 1.03; 95% CI, 1.00-1.08).
This study provides evidence that older persons who report depressive symptoms are at higher risk of subsequent physical decline. These results suggest that prevention or reduction of depressed mood could play a role in reducing functional decline in older persons.
Although the implementation of clinical preventive services is a high priority on the national agenda and physicians acknowledge the importance of these services, implementation rates remain far below the target years after the recommendations have been released. Physicians repeatedly report that the reason for not providing preventive services is that they do not have "time." In this article, we identify attributes of the health-services system that create this phenomenon. We present evidence that formal delivery systems for preventive services must be developed if the "time" problem is to be solved, and we review why preventive-services systems need to be integrated into the current health-services system. Finally, we list the attributes that we believe a preventive-services system must have if it is to be successful. The success of clinical trials of such systems indicates that our goals of preventive services can be achieved if all persons who have an investment in clinical preventive services commit themselves to developing and supporting these systems.
Objective.
—To examine the amount of inappropriate drug prescribing for Americans aged 65 years or older living in the community.Design.
—Cross-sectional survey of a national probability sample of older adults.Setting.
—The 1987 National Medical Expenditure Survey, a national probability sample of the US civilian noninstitutionalized population, with oversampling of some population groups, including the elderly.Subjects.
—The 6171 people aged 65 years or older in the National Medical Expenditure Survey sample, using appropriate weighting procedures to produce national estimates.Main Outcome Measures.
—Incidence of prescribing 20 potentially inappropriate drugs, using explicit criteria previously developed by 13 United States and Canadian geriatrics experts through a modified Delphi consensus technique. Three cardiovascular drugs identified as potentially inappropriate were analyzed separately since they may be considered appropriate for some noninstitutionalized elderly patients.Results.
—A total of 23.5% (95% confidence interval [CI], 22.4% to 24.6%) of people aged 65 years or older living in the community, or 6.64 million Americans (95% CI, 6.28 million to 7.00 million), received at least one of the 20 contraindicated drugs. While 79.6% (95% CI, 77.2% to 82.0%) of people receiving potentially inappropriate medications received only one such drug, 20.4% received two or more. The most commonly prescribed of these drugs were dipyridamole, propoxyphene, amitriptyline, chlorpropamide, diazepam, indomethacin, and chlordiazepoxide, each used by at least half a million people aged 65 years or older. Including the three controversial cardiovascular agents (propranolol, methyldopa, and reserpine) in the list of contraindicated drugs increased the incidence of probably inappropriate medication use to 32% (95% CI, 30.7% to 33.3%), or 9.04 million people (95% CI, 8.64 million to 9.44 million).Conclusion.
—Physicians prescribe potentially inappropriate medications for nearly a quarter of all older people living in the community, placing them at risk of drug adverse effects such as cognitive impairment and sedation. Although most previous strategies for improving drug prescribing for the elderly have focused on nursing homes, broader educational and regulatory initiatives are needed.(JAMA. 1994;272:292-296)
Objective.
—To review the literature relating to the effectiveness of education strategies designed to change physician performance and health care outcomes.Data Sources.
—We searched MEDLINE, ERIC, NTIS, the Research and Development Resource Base in Continuing Medical Education, and other relevant data sources from 1975 to 1994, using continuing medical education (CME) and related terms as keywords. We manually searched journals and the bibliographies of other review articles and called on the opinions of recognized experts.Study Selection.
—We reviewed studies that met the following criteria: randomized controlled trials of education strategies or interventions that objectively assessed physician performance and/or health care outcomes. These intervention strategies included (alone and in combination) educational materials, formal CME activities, outreach visits such as academic detailing, opinion leaders, patient-mediated strategies, audit with feedback, and reminders. Studies were selected only if more than 50% of the subjects were either practicing physicians or medical residents.Data Extraction.
—We extracted the specialty of the physicians targeted by the interventions and the clinical domain and setting of the trial. We also determined the details of the educational intervention, the extent to which needs or barriers to change had been ascertained prior to the intervention, and the main outcome measure(s).Data Synthesis.
—We found 99 trials, containing 160 interventions, that met our criteria. Almost two thirds of the interventions (101 of 160) displayed an improvement in at least one major outcome measure: 70% demonstrated a change in physician performance, and 48% of interventions aimed at health care outcomes produced a positive change. Effective change strategies included reminders, patient-mediated interventions, outreach visits, opinion leaders, and multifaceted activities. Audit with feedback and educational materials were less effective, and formal CME conferences or activities, without enabling or practice-reinforcing strategies, had relatively little impact.Conclusion.
—Widely used CME delivery methods such as conferences have little direct impact on improving professional practice. More effective methods such as systematic practice-based interventions and outreach visits are seldom used by CME providers.(JAMA. 1995;274:700-705)
Abstract Objective: To review the literature,relating,to the
This paper proposes an extension of generalized linear models to the analysis of longitudinal data. We introduce a class of
estimating equations that give consistent estimates of the regression parameters and of their variance under mild assumptions
about the time dependence. The estimating equations are derived without specifying the joint distribution of a subject's observations
yet they reduce to the score equations for niultivariate Gaussian outcomes. Asymptotic theory is presented for the general
class of estimators. Specific cases in which we assume independence, m-dependence and exchangeable correlation structures from each subject are discussed. Efficiency of the pioposecl estimators
in two simple situations is considered. The approach is closely related to quasi-likelihood.
The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The new scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of de pression.
Objective.
—To examine whether depressive symptoms in older adults contribute to increased cost of general medical services.Design.
—A 4-year prospective cohort study.Setting.
—Four primary care clinics of a large staff-model health maintenance organization (HMO) in Seattle, Wash.Patients.
—A total of 5012 Medicare enrollees older than 65 years were invited to participate in the study; 2558 subjects (51%) were successfully enrolled. Nonparticipants were somewhat older and had a higher level of chronic medical illness.Main Outcome Measures.
—Depressive symptoms as measured by the Center for Epidemiological Studies Depression scale, which was administered as part of a mail survey at baseline, at 2 years, and at 4 years; and total cost of medical services from the perspective of the HMO. Data were obtained from the cost accounting system of the HMO.Results.
—In this cohort of older adults, depressive symptoms were common, persistent, and associated with a significant increase in the cost of general medical services. This increase was seen for every component of health care costs and was not accounted for by an increase in specialty mental health care. The increase in health care costs remained significant after adjusting for differences in age, sex, and chronic medical illness.Conclusions.
—Depressive symptoms in older adults are associated with a significant increase in the cost of medical services, even after adjusting for the severity of chronic medical illness.
Presents important issues surrounding minor depression in late life. Minor depression is a type of depressive disorder that does not fulfill the duration criteria or show the number of symptoms necessary to make the diagnosis of major depression. Defining minor depression, therefore, is difficult because of the many different syndromes and constructs it subsumes. Minor depression is more prevalent than major depression. It has a significant impact on functioning, quality of life, and social support of patients, and is associated with greater use of health services. Minor depression is potentially reversible with drug treatment and psychotherapy. This important depressive disorder requires further study. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Objective.
—To determine whether a set of factors representing impairments in multiple areas could be identified that predisposes to falling, incontinence, and functional dependence.Design.
—Population-based cohort with a 1-year follow-up.Setting.
—General community.Participants.
—A total of 927 New Haven, Conn, residents, aged 72 years and older who completed the baseline and 1-year interviews.Main Outcome Measures.
—At least one episode of urinary incontinence per week, at least two falls during the follow-up year, and dependence on human help for one or more basic activities of daily living.Results.
—At 1 year, urinary incontinence was reported by 16%, at least two falls by 10%, and functional dependence by 20% of participants. The four independent predisposing factors for the outcomes of incontinence, falling, and functional dependence included slow timed chair stands (lower extremity impairment), decreased arm strength (upper extremity impairment), decreased vision and hearing (sensory impairment), and either a high anxiety or depression score (affective impairment). There was a significant increase in each of incontinence, falling, and functional dependence as the number of these predisposing factors increased. For example, the proportion of participants experiencing functional dependence doubled (7% to 14% to 28% to 60%) (X2=119.8; P<.001) as the number of predisposing factors increased from zero to one to two to at least three.Conclusions.
—Our findings suggest that predisposition to geriatric syndromes and functional dependence may result when impairments in multiple domains compromise compensatory ability. It may be possible to restore compensatory ability and prevent or delay the onset of several geriatric syndromes and, perhaps, functional dependence by modifying a shared set of predisposing factors. Perhaps it is time to take a more unified approach to the geriatric syndromes and functional dependence.(JAMA. 1995;273:1348-1353)
The current health care environment in the United States is in turmoil, especially in regions that are further ahead in the transition from fee-for-service to managed care. This article examines turmoil within primary care during a health-maintenance-organization-sponsored and federally funded randomized trial of using continuous quality improvement for adult clinical preventive services. The external and internal changes in structure and leadership occurring in primary care clinics are profound and prevalent. The sponsors of the project have responded to the turmoil by encouraging greater leadership involvement within the clinic and by supporting more skill building for change management.
(C) Williams & Wilkins 1997. All Rights Reserved.
In the belief that there was need for diabetic clinics in general practice, 14 of them have been started in the Wolverhampton area. Provided that patients with diabetes that is difficult to control, or who need extra care, remain the responsibility of the hospital diabetic department, this system is an advantage for the hospital department, general practice, and the patient. We believe that many patients are now getting better care in general-practice clinics than they were in the hospital department.
This paper presents a general statistical methodology for the analysis of multivariate categorical data arising from observer reliability studies. The procedure essentially involves the construction of functions of the observed proportions which are directed at the extent to which the observers agree among themselves and the construction of test statistics for hypotheses involving these functions. Tests for interobserver bias are presented in terms of first-order marginal homogeneity and measures of interobserver agreement are developed as generalized kappa-type statistics. These procedures are illustrated with a clinical diagnosis example from the epidemiological literature.
Using population-based automated pharmacy data, patterns of use of selected prescription medications during a 1 year time period identified by a consensus judgement process were used to construct a measure of chronic disease status (Chronic Disease Score). This score was evaluated in terms of its stability over time and its association with other health status measures. In a pilot test sample of high utilizers of ambulatory health care well known to their physicians (n = 219), Chronic Disease Score (CDS) was correlated with physician ratings of physical disease severity (r = 0.57). In a second random sample of patients (n = 722), its correlation with physician-rated disease severity was 0.46. In a total population analysis (n = 122,911), it was found to predict hospitalization and mortality in the following year after controlling for age, gender and health care visits. In a population sample (n = 790), CDS showed high year to year stability (r = 0.74). Based on health survey data, CDS showed a moderate association with self rated health status and self reported disability. Unlike self-rated health status and health care utilization, CDS was not associated with depression or anxiety. We conclude that scoring automated pharmacy data can provide a stable measure of chronic disease status that, after controlling for health care utilization, is associated with physician-rated disease severity, patient-rated health status, and predicts subsequent mortality and hospitalization rates. Specific methods of scoring automated pharmacy data to measure global chronic disease status may require adaptation to local prescribing practices. Scoring might be improved by empirical estimation of weighting factors to optimize prediction of mortality and other health status measures.
Using a population-based hospital discharge registry with E codes, we examine the 1989 hospitalizations of older adults in Washington State for fall-related injuries. Fall-related trauma accounted for 5.3% of all hospitalizations of older adults, with hospital charges totaling $53,346,191, and resulted in discharge to nursing care more often than other such hospitalizations. An annual hospitalization rate of 13.5 per 1000 persons and an annual cost of $92 per person is reported. The importance of preventing fall-related injuries in older adults is discussed.
The third of a series on the Institute of Medicine study on a quality review and assurance program for Medicare, this article describes findings on two separate series of focus groups held with Medicare beneficiaries and with physicians in private practice. The respondents' perceptions of quality of care, understanding of the Medicare program and QA activities, and recommendations for improvement are reported directly and examined for implications for designing a coherent QA strategy. A surprising finding is that both beneficiaries and physicians define quality of care in terms of the "art of care" as well as in technical and clinical terms.
To investigate variation in older adults' perceived health and functioning that is associated with self-reported sleep disturbance, falling, and urinary incontinence, controlling for self-reported depression, ambulation difficulty, number of chronic conditions, and subjects' sociodemographic characteristics.
Multicenter prospective study (FICSIT).
Persons age 70 and older living in the community evaluated at baseline.
239 women, 113 men; mean age = 77.
Sleep disturbance score based on EPESE questions, recent falls history (Y/N), incontinent episodes (Y/N), CES-D score, SIP Ambulation score, and 4 MOS SF-36 scale scores.
Women were significantly more likely than men to report multiple conditions (sleep disturbance, falling, incontinence) and to report lower levels of functioning as measured by 3 of 4 SF-36 scales. In regression analyses, sleep disturbance and urinary incontinence were significant predictors of perceived limitations in usual role activities because of physical health problems. Depression and ambulation measures significantly predicted scores on all 4 SF-36 scales.
Our analysis suggests that it is important to address depressive symptomatology and ambulation difficulty--which in turn are related to sleep disturbance, falling, and urinary incontinence--in efforts to enhance older adults' perceived health and functioning.
To examine the amount of inappropriate drug prescribing for Americans aged 65 years or older living in the community.
Cross-sectional survey of a national probability sample of older adults.
The 1987 National Medical Expenditure Survey, a national probability sample of the US civilian noninstitutionalized population, with oversampling of some population groups, including the elderly.
The 6171 people aged 65 years or older in the National Medical Expenditure Survey sample, using appropriate weighting procedures to produce national estimates.
Incidence of prescribing 20 potentially inappropriate drugs, using explicit criteria previously developed by 13 United States and Canadian geriatrics experts through a modified Delphi consensus technique. Three cardiovascular drugs identified as potentially inappropriate were analyzed separately since they may be considered appropriate for some noninstitutionalized elderly patients.
A total of 23.5% (95% confidence interval [CI], 22.4% to 24.6%) of people aged 65 years or older living in the community, or 6.64 million Americans (95% CI, 6.28 million to 7.00 million), received at least one of the 20 contraindicated drugs. While 79.6% (95% CI, 77.2% to 82.0%) of people receiving potentially inappropriate medications received only one such drug, 20.4% received two or more. The most commonly prescribed of these drugs were dipyridamole, propoxyphene, amitriptyline, chlorpropamide, diazepam, indomethacin, and chlordiazepoxide, each used by at least half a million people aged 65 years or older. Including the three controversial cardiovascular agents (propranolol, methyldopa, and reserpine) in the list of contraindicated drugs increased the incidence of probably inappropriate medication use to 32% (95% CI, 30.7% to 33.3%), or 9.04 million people (95% CI, 8.64 million to 9.44 million).
Physicians prescribe potentially inappropriate medications for nearly a quarter of all older people living in the community, placing them at risk of drug adverse effects such as cognitive impairment and sedation. Although most previous strategies for improving drug prescribing for the elderly have focused on nursing homes, broader educational and regulatory initiatives are needed.
The goals of this study were to develop and determine the feasibility of interventions designed to increase both primary care physician implementation of and patient adherence to recommendations from ambulatory-based consultative comprehensive geriatric assessment (CGA), and to identify sociodemographic and intervention-related predictors of physician and patient adherence.
One hundred thirty-nine community-dwelling older persons who failed a screen for functional impairment, depressive symptoms, falls, or urinary incontinence received outpatient CGA consultation. These patients and the 115 physicians who provided primary care for them received one of three adherence interventions, each of which had a physician education component and a patient education and empowerment component. Recommendations were classified as physician-initiated or self-care and as "major" or "minor"; one was deemed "most important". Adherence rates were determined on the basis of face-to-face interviews with patients.
Based on 528 recommendations for 139 subjects, physician implementation of "most important" recommendations was 83% and of major recommendations was 78.5%. Patient adherence with physician-initiated "most important" and "major" recommendations were 81.8% and 78.8% respectively. In multivariate models, only the status of the recommendation of "most important" (odds ratio 2.4, 95% CI [confidence interval] 1.3 to 4.5) and health maintenance organization (HMO) status of the patient (odds ratio 2.1, 95% CI 1.3 to 3.6) remained significant in predicting physician implementation. The logistic model predicting patient adherence to physician-initiated recommendations included male patient gender (odds ratio 3.1, 95% CI 1.3 to 7.0), the status of the recommendation of "most important" (odds ratio 1.9, 95% CI 1.0 to 3.8), total number of recommendations (odds ratio 0.7, 95% CI 0.5 to 0.9), and total number of problems identified by CGA (odds ratio 1.8, 95% CI 1.2 to 2.7).
These findings indicate that relatively modest interventions strategies are feasible and lead to high levels of physician implementation of and patient adherence to physician-initiated CGA recommendations. These interventions appear to be particularly effective in HMO patients and for recommendations that were deemed to be "most important".
To develop and test the inter-rater reliability of a coding system for geriatric problems identified through Comprehensive Geriatric Assessment (CGA) of hospitalized older persons, recommendations generated by the assessment, and implementation strategies for these recommendations.
Validation study.
A health maintenance organization and a geriatrics academic program.
A total of 49 hospitalized older persons, who met at least 1 of 13 inclusionary "targeting" criteria, two geriatricians, and one social worker who coded forms.
Standardized coding of CGA consultation sheets into (1) geriatric problems identified, (2) recommendations, and (3) implementation strategies; inter-rater reliability testing of coding system using two physicians and a social worker.
On average, each assessed patient had 4.8 recommendations. The largest percentages of recommendations were for non-physician referrals (18.2%), advance directives (13.4%), medication adjustments (11.5%), diagnostic evaluation/monitoring (11.5%), and community services (10.9%). The proportions of agreement between raters in coding problems ranged from 0.77 to 0.90, in coding recommendations from 0.69 to 0.86, and in coding implementation strategies from 0.68 to 0.83.
A classification system for measuring some components of the process of care of CGA has satisfactory inter-rater reliability, can be adapted for other settings, and may provide valuable insight into determining which components of CGA confer health benefits.
In summary, the promise of HMOs in caring for older adults far exceeds their performance to date. Until recently they had neither the motivation nor the knowledge to revamp their delivery systems to better needs of older, chronically ill patients. Market pressures and skyrocketing costs have provided the motivation. Physicians and researchers trained in epidemiology and health services research from programs such as that at UCLA are providing the knowledge. Based on the literature and experience described above, HMOs with the characteristics supportive of population-based care can put into place an approach to geriatric care likely to improve outcomes if they heed their patients and professionals rather than their accountants. These organizations will give highest priority to preserving function and will be guided by explicit clinical guidelines. Care will be rendered by organized primary care teams supported by systematic self-management approaches, standardized interventions for key risk factors, clinically useful computer systems, and available geriatric expertise. It will require a small revolution as old approaches, roles, and relationships will not go quietly. We are in the early phases of this revolution, and it's not too late to join us on the barricades.
Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.
To evaluate the responses of primary care physicians and patients to recommendations from a community-based comprehensive geriatric assessment (CGA) program for management of four target conditions: falls, depression, urinary incontinence, and functional impairment.
Case series.
Senior centers, meal sites, senior housing, and other community sites as screening locations; and a community-bases academic practice as the location for CGA.
A total of 150 older patients living in the community who have one or more of the four target conditions and who received CGA.
Physician implementation and patient adherence rates were ascertained during a face-to-face structured interview with the patient 3 months after CGA.
Two hundred twelve of 528 (40%) CGA recommendations were clearly or possible related to the target or target-related conditions. Of these 212 recommendations, 59% required a physician's order for implementation. The remaining 41% were patient self-care recommendations. Overall physician implementation across conditions was 70%; implementation rates were highest for falls and lowest for functional impairment. Overall patient adherence rate was 85% for physician-implemented recommendations and 46% for self-care recommendations. Patient adherence to recommendations for counseling or support groups and exercise programs was particularly low.
When examining the process of care of community-based CGA, patient as well as physician adherence must be considered. Although patient adherence to physician-initiated recommendations was high for all conditions, it varied substantially across target conditions and types of recommendations for self-care recommendations.
To compare the impact of group outpatient visits to traditional "physician-patient dyad" care among older chronically ill HMO members on health services utilization and cost, self-reported health status, and patient and physician satisfaction.
A 1-year randomized trial.
A group model HMO in the Denver Metropolitan area.
Three hundred twenty-one members aged 65 and older, randomized to a group visit intervention (n = 160) or to usual care (n = 161).
Patients with high health services utilization and one or more chronic conditions had monthly group visits with their primary care physician and nurse. Visits included health education, prevention measures, opportunities for socialization, mutual support, and for one-to-one consultations with their physician, where necessary.
Health services utilization and associated cost, health status, and patient and physician satisfaction.
Outcome measures obtained after a 1-year follow-up period showed that group participants had fewer emergency room visits (P = .009), visits to subspecialists (P = .028), and repeat hospital admissions per patient (P = .051). Group participants made more visits (P = .021) and calls (P = .038) to nurses than control group patients and fewer calls to physicians (P = .019). In addition, a greater percentage of group participants received influenza and pneumonia vaccinations (P < .001). Group participants had greater overall satisfaction with care (P = .019), and participating physicians reported higher levels of satisfaction with the groups than with individual care. No differences were observed between groups on self-reported health and functional status. Cost of care per member per month was $14.79 less for the group participants.
Group visits for chronically ill patients reduce repeat hospital admissions and emergency care use, reduce cost of care, deliver certain preventive services more effectively, and increase patient and physician satisfaction.
To examine whether depressive symptoms in older adults contribute to increased cost of general medical services.
A 4-year prospective cohort study.
Four primary care clinics of a large staff-model health maintenance organization (HMO) in Seattle, Wash.
A total of 5012 Medicare enrollees older than 65 years were invited to participate in the study; 2558 subjects (51%) were successfully enrolled. Non-participants were somewhat older and had a higher level of chronic medical illness.
Depressive symptoms as measured by the Center for Epidemiological Studies Depression scale, which was administered as part of a mail survey at baseline, at 2 years, and at 4 years; and total cost of medical services from the perspective of the HMO. Data were obtained from the cost accounting system of the HMO.
In this cohort of older adults, depressive symptoms were common, persistent, and associated with a significant increase in the cost of general medical services. This increase was seen for every component of health care costs and was not accounted for by an increase in specialty mental health care. The increase in health care costs remained significant after adjusting for differences in age, sex, and chronic medical illness.
Depressive symptoms in older adults are associated with a significant increase in the cost of medical services, even after adjusting for the severity of chronic medical illness.
To test the effectiveness of a 10-minute office-staff administered screen to evaluate malnutrition/weight loss, visual impairment, hearing loss, cognitive impairment, urinary incontinence, depression, physical limitations, and reduced leg mobility among older persons seen in office practice. This screen was coupled with clinical summaries to assist the physician in further evaluating and managing the screen-included problems.
Twenty-six community-based office practices of internists and family physicians in Los Angeles were randomized to intervention or control groups. Two hundred and sixty-one patients aged > or = 70 years and seeing these physicians for a new visit or a physical examination participated in the study. At the enrollment visit intervention group patients were administered the screening measure and their physicians were given the pertinent clinical summaries. Outcome measures were detection of, and intervention for conditions screened, and health status 6 months after the intervention.
Hearing loss was both more commonly detected (40% intervention versus 28% control) and further evaluated (29% versus 16%) by physicians in the intervention group (P < 0.05). No other differences in the frequency of problem detection or intervention were noted between groups. Six months after the intervention no differences were noted in health status between groups.
A brief measure to screen for common conditions in older persons was associated with more frequent detection and follow-up assessment of hearing loss. Although the measure was well accepted by physicians and their staffs, it did not appear to affect detection and intervention in regard to the other screen-included conditions, or health status at 6 months.
To examine decisions not to treat problems identified during outpatient geriatric assessment, particularly problems of cognitive impairment, depression, or urinary incontinence.
A descriptive study using patients' medical charts and survey data and interviews with clinical staff.
Four hospital-based, ambulatory, geriatric assessment clinics in Allegheny Country, PA.
The sample comprised 128 older adults, recruited to a randomized, controlled clinical trial, who had problems associated with cognitive impairment, depression, or urinary incontinence.
Although treatment was recommended for most of the problems relating to cognitive impairment, depression, and/or incontinence experienced by this group, slightly more than one-third of cognitive impairment and depression problems and nearly one-half of incontinence did not receive treatment recommendations. Treatment rates varied considerably by condition and combination of comorbidity. Decisions not to treat are classified into six categories: patient or family refused treatment, the assessment was not completed, an intervention was already in place, concurrent problems or comorbities might have interfered with treatment, there was no documented diagnosis or there was a documented consideration and rule out of the problem, or no documented reason.
Outpatient geriatric assessment units are designed to deal with the multiple problems experienced by their geriatric patients, and they identify successfully most problems presented by their frail constituents. However, identification of the patient's problems is only the first step in the assessment process and does not necessarily lead to either a documented diagnosis or to a treatment recommendation. Multiple social, cultural, environmental, and medical factors complicate the assessment process and, hence, the decision clinicians face when they decide whether to make recommendations to treat. These clinicians must weigh all medical and non-medical factors, including the patient's receptivity to treatment, when prioritizing the problems they deem to be treatable and making recommendations to treat.
To explore general practitioners' (GPs') beliefs about health promotion for older people and attitudes towards educational strategies likely to improve practice in this area.
Four discussion groups, each lasting one and a half hours, completed in Melbourne, Australia in August and September 1995. Interviews were transcribed verbatim and analysed for major themes.
A convenience sample of 20 GPs took part; 11 university affiliates, four participant contacts and five GPs from telephone book listings.
GPs' perceptions of their health promotion practice varied from "integrated into all medical care", to "something separate from usual practice". Positive views of older people contrasted with ageist views, with a few GPs expressing a nihilistic approach to medical care of older people. Regardless of the GPs' attitudes, lack of time and reimbursement disincentives were perceived to limit preventive practice and the potential impact of health promotion interventions. GPs felt overwhelmed with their workloads, and initial reactions to the idea of any "new" program were negative. Reactions to educational strategies varied, with choice and relevance to ease of practice being important for GP participation.
GPs differ in their views of health promotion and in their approaches to its delivery for older people. Educational programs are often viewed negatively, but if they offer the opportunity to save time, increased participation may be more likely.
To compare the predictive accuracy of two validated indices, one that uses self-reported variables and a second that uses variables derived from administrative data sources, to predict future hospitalization. To compare the predictive accuracy of these same two indices for predicting future functional decline.
A longitudinal cohort study with 4 years of follow-up.
A large staff model HMO in western Washington State.
HMO Enrollees 65 years and older (n = 2174) selected at random to participate in a health promotion trial and who completed a baseline questionnaire.
Predicted probabilities from the two indices were determined for study participants for each of two outcomes: hospitalization two or more times in 4 years and functional decline in 4 years, measured by Restricted Activity Days. The two indices included similar demographic characteristics, diagnoses, and utilization predictors. The probabilities from each index were entered into a Receiver Operating Characteristic (ROC) curve program to obtain the Area Under the Curve (AUC) for comparison of predictive accuracy.
For hospitalization, the AUC of the self-report and administrative indices were .696 and .694, respectively (difference between curves, P = .828). For functional decline, the AUC of the two indices were .714 and .691, respectively (difference between curves, P = .144).
Compared with a self-report index, the administrative index affords wider population coverage, freedom from nonresponse bias, lower cost, and similar predictive accuracy. A screening strategy utilizing administrative data sources may thus prove more valuable for identifying high risk older health plan enrollees for population-based interventions designed to improve their health status.
Patients can have several illnesses concurrently, yet some of these diseases may be neglected if one problem consumes attention. We conducted a population-based analysis in Ontario, Canada - where universal health insurance is provided - to determine whether unrelated disorders are less likely to be treated in patients with chronic diseases.
We studied the 1,344,145 residents of Ontario in 1995 who were 65 or older and eligible to receive prescription medications free of charge as part of the Ontario Drug Benefit program. Patients with diabetes mellitus were identified by prescriptions for insulin, pulmonary emphysema by prescriptions for ipratropium bromide, and psychotic syndromes by prescriptions for haloperidol. For each chronic disease, we selected an unrelated treatment: estrogen-replacement therapy for patients with diabetes mellitus, lipid-lowering medications for those with pulmonary emphysema, and medical treatment of arthritis for those with psychotic syndromes.
The 30,669 patients with diabetes mellitus were less likely to receive estrogen-replacement therapy than the other subjects in the study (2.4 percent vs. 5.9 percent, P<0.001). The disease was associated with a 60 percent reduction in the odds of estrogen treatment (odds ratio, 0.40; 95 percent confidence interval, 0.37 to 0.43). Findings were similar for the 56,779 patients with pulmonary emphysema, who were less likely to receive lipid-lowering medications (odds ratio, 0.69; 95 percent confidence interval, 0.67 to 0.72; P<0.001), and the 17,336 patients with psychotic syndromes, who were less likely to receive medical treatments for arthritis (odds ratio, 0.59; 95 percent confidence interval, 0.57 to 0.62; P<0.001).
In patients 65 or older who have chronic medical diseases and who receive prescription medications free of charge, unrelated disorders are undertreated. Clinicians caring for patients with chronic diseases should remain alert to other disorders and minimize the number of missed opportunities for treating them.
Risk Stratification System for Medicare Managed Care
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GHAA's Consumer Satisfaction Survey and User's Manual
- Davies Ar Ware
Helping practices reaching primary care goals: Lessons from the literature
- Yamo
GHAA's Consumer Satisfaction Survey and User's Manual 2nd Ed
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