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Unterkofler J, Hertwig M, Bollheimer LC, Brokmann JC. [Focusing on intersectorality-strategies and current research projects for the care of geriatric people]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2024; 67:595-604. [PMID: 38478025 PMCID: PMC11093782 DOI: 10.1007/s00103-024-03851-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 01/19/2024] [Indexed: 05/15/2024]
Abstract
In view of the demographic change, the need for intersectoral care of the aging population has already been identified. The strategies for implementation are diverse and address different approaches, each of which requires different sectors to overlap. This article provides an overview of already completed and ongoing projects for the care of geriatric patients. It becomes apparent that the development of networks as an indispensable basis for intersectoral care cannot be measured in terms of direct intervention effects and therefore makes it difficult to prove the cost-benefit. It is also evident that some research projects fail to be implemented into standard care due to financial and staff shortages.Do we need a rethinking in Germany or less innovation-related funding lines for better implementation and research of existing concepts? International role models such as Japan show that cost reduction for the care of the aging population should be considered in the long term, which requires increased financial volumes in the short term. For a sustainable implementation of cross-sectoral approaches into everyday life, research should therefore reorganize tight and/or entrenched structures, processes, and financing. By linking the countless existing projects and integrating ideas from different sectors, future demands of intersectoral geriatric care may be achieved.
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Affiliation(s)
- Jenny Unterkofler
- Klinik für Anästhesiologie, Uniklinik RWTH Aachen (NRW), Aachen, Deutschland
| | - Miriam Hertwig
- Zentrum für klinische Akut- und Notfallmedizin, Uniklinik RWTH Aachen (NRW), Aachen, Deutschland.
| | | | - Jörg Christian Brokmann
- Zentrum für klinische Akut- und Notfallmedizin, Uniklinik RWTH Aachen (NRW), Aachen, Deutschland
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Sadler E, Khadjesari Z, Ziemann A, Sheehan KJ, Whitney J, Wilson D, Bakolis I, Sevdalis N, Sandall J, Soukup T, Corbett T, Gonçalves-Bradley DC, Walker DM. Case management for integrated care of older people with frailty in community settings. Cochrane Database Syst Rev 2023; 5:CD013088. [PMID: 37218645 PMCID: PMC10204122 DOI: 10.1002/14651858.cd013088.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND Ageing populations globally have contributed to increasing numbers of people living with frailty, which has significant implications for use of health and care services and costs. The British Geriatrics Society defines frailty as "a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves". This leads to an increased susceptibility to adverse outcomes, such as reduced physical function, poorer quality of life, hospital admissions, and mortality. Case management interventions delivered in community settings are led by a health or social care professional, supported by a multidisciplinary team, and focus on the planning, provision, and co-ordination of care to meet the needs of the individual. Case management is one model of integrated care that has gained traction with policymakers to improve outcomes for populations at high risk of decline in health and well-being. These populations include older people living with frailty, who commonly have complex healthcare and social care needs but can experience poorly co-ordinated care due to fragmented care systems. OBJECTIVES To assess the effects of case management for integrated care of older people living with frailty compared with usual care. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Health Systems Evidence, and PDQ Evidence and databases from inception to 23 September 2022. We also searched clinical registries and relevant grey literature databases, checked references of included trials and relevant systematic reviews, conducted citation searching of included trials, and contacted topic experts. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared case management with standard care in community-dwelling people aged 65 years and older living with frailty. DATA COLLECTION AND ANALYSIS We followed standard methodological procedures recommended by Cochrane and the Effective Practice and Organisation of Care Group. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 20 trials (11,860 participants), all of which took place in high-income countries. Case management interventions in the included trials varied in terms of organisation, delivery, setting, and care providers involved. Most trials included a variety of healthcare and social care professionals, including nurse practitioners, allied healthcare professionals, social workers, geriatricians, physicians, psychologists, and clinical pharmacists. In nine trials, the case management intervention was delivered by nurses only. Follow-up ranged from three to 36 months. We judged most trials at unclear risk of selection and performance bias; this consideration, together with indirectness, justified downgrading the certainty of the evidence to low or moderate. Case management compared to standard care may result in little or no difference in the following outcomes. • Mortality at 12 months' follow-up (7.0% in the intervention group versus 7.5% in the control group; risk ratio (RR) 0.98, 95% confidence interval (CI) 0.84 to 1.15; I2 = 11%; 14 trials, 9924 participants; low-certainty evidence) • Change in place of residence to a nursing home at 12 months' follow-up (9.9% in the intervention group versus 13.4% in the control group; RR 0.73, 95% CI 0.53 to 1.01; I2 = 0%; 4 trials, 1108 participants; low-certainty evidence) • Quality of life at three to 24 months' follow-up (results not pooled; mean differences (MDs) ranged from -6.32 points (95% CI -11.04 to -1.59) to 6.1 points (95% CI -3.92 to 16.12) when reported; 11 trials, 9284 participants; low-certainty evidence) • Serious adverse effects at 12 to 24 months' follow-up (results not pooled; 2 trials, 592 participants; low-certainty evidence) • Change in physical function at three to 24 months' follow-up (results not pooled; MDs ranged from -0.12 points (95% CI -0.93 to 0.68) to 3.4 points (95% CI -2.35 to 9.15) when reported; 16 trials, 10,652 participants; low-certainty evidence) Case management compared to standard care probably results in little or no difference in the following outcomes. • Healthcare utilisation in terms of hospital admission at 12 months' follow-up (32.7% in the intervention group versus 36.0% in the control group; RR 0.91, 95% CI 0.79 to 1.05; I2 = 43%; 6 trials, 2424 participants; moderate-certainty evidence) • Change in costs at six to 36 months' follow-up (results not pooled; 14 trials, 8486 participants; moderate-certainty evidence), which usually included healthcare service costs, intervention costs, and other costs such as informal care. AUTHORS' CONCLUSIONS We found uncertain evidence regarding whether case management for integrated care of older people with frailty in community settings, compared to standard care, improved patient and service outcomes or reduced costs. There is a need for further research to develop a clear taxonomy of intervention components, to determine the active ingredients that work in case management interventions, and identify how such interventions benefit some people and not others.
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Affiliation(s)
- Euan Sadler
- School of Health Sciences, University of Southampton, Southampton, UK
- Southern Health NHS Foundation Trust, Southampton, UK
| | | | - Alexandra Ziemann
- Department of Social & Policy Sciences, University of Bath, Bath, UK
| | - Katie J Sheehan
- School of Life Course & Population Sciences, King's College London, London, UK
| | - Julie Whitney
- School of Life Course & Population Sciences, King's College London, London, UK
- Department of Clinical Gerontology, King's College Hospital NHS Foundation Trust, London, UK
| | - Dan Wilson
- Department of Clinical Gerontology, King's College Hospital NHS Foundation Trust, London, UK
| | - Ioannis Bakolis
- Health Service & Population Research Department, King's College London, London, UK
| | - Nick Sevdalis
- Centre for Behavioural & Implementation Science Interventions (BISI), National University of Singapore, Singapore, Singapore
| | - Jane Sandall
- Department of Women and Children's Health, King's College London, London, UK
| | - Tayana Soukup
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Teresa Corbett
- Faculty of Sport, Health and Social Sciences, Solent University, Southampton, UK
| | | | - Dawn-Marie Walker
- School of Health Sciences, University of Southampton, Southampton, UK
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Xie F, Wen S, Deng A, Chen J, Xiong R. Evaluation of a community-based integrated care model (CIE) for frail older people in rural Foshan, China: study protocol for a stepped-wedge cluster randomized controlled trial {1}. Trials 2023; 24:315. [PMID: 37158975 PMCID: PMC10165829 DOI: 10.1186/s13063-023-07328-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 04/25/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND While community-based eldercare has proven to be effective in qualitative studies, there is limited evidence on the effectiveness of this geriatric care model in rural communities where caring for older people is traditionally the responsibility of family members, but a formal long-term care was recently introduced in China. CIE is a rural community-embedded intervention using multidisciplinary team, to provide evidenced-based integrated care services for frail older people including social care services and allied primary healthcare and community-based rehabilitation services. METHODS CIE is a prospective stepped-wedge cluster randomized trial conducted at 5 community eldercare centers in rural China. The multifaceted CIE intervention, guided by chronic care model and integrated care model, consists of five components: comprehensive geriatric assessment, individualized care planning, community-based rehabilitation, interdisciplinary case management, and care coordination. The intervention is rolled out in a staggered manner in these clusters of centers at an interval of 1 month. The primary outcomes include functional status, quality of life, and social support. Process evaluation will also be conducted. Generalized linear mixed model is employed for binary outcomes. DISCUSSION This study is expected to provide important new evidence on clinical effectiveness and implementation process of an integrated care model for frail older people. The CIE model is also unique as the first registered trial implementing a community-based eldercare model using multidisciplinary team to promote individualized social care services integrated with primary healthcare and community-based rehabilitation services for frail older people in rural China, where formal long-term care was recently introduced. TRIAL REGISTRATION {2A}: China Clinical Trials Register ( http://www.chictr.org.cn/historyversionpub.aspx?regno=ChiCTR2200060326 ). May 28th, 2022.
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Affiliation(s)
- Fengjiao Xie
- Department of General Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Shuang Wen
- Department of Thoracic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Aiwen Deng
- Department of Rehabilitation, The Seventh Affiliated Hospital, Southern Medical University, Foshan, China
| | - Jianhao Chen
- Department of Rehabilitation, The Seventh Affiliated Hospital, Southern Medical University, Foshan, China
| | - Ribo Xiong
- Department of Rehabilitation, The Seventh Affiliated Hospital, Southern Medical University, Foshan, China.
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Herrler A, Kukla H, Vennedey V, Stock S. Which features of ambulatory healthcare are preferred by people aged 80 and over? Findings from a systematic review of qualitative studies and appraisal of confidence using GRADE-CERQual. BMC Geriatr 2022; 22:428. [PMID: 35578168 PMCID: PMC9109291 DOI: 10.1186/s12877-022-03006-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 03/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background Despite healthcare providers’ goal of patient-centeredness, current models for the ambulatory (i.e., outpatient) care of older people have not as yet systematically incorporated their views. Moreover, there is no systematic overview of the preferable features of ambulatory care from the perspective of people aged 80 and over. Therefore, the aim of this study was to summarize their specific wishes and preferences regarding ambulatory care from qualitative studies. Methods The study was based on qualitative studies identified in a prior systematic review. Firstly, the findings of the qualitative studies were meta-summarized, following Sandelowski and Barroso. Secondly, a list of preferred features of care from the perspective of older people was derived from the included studies’ findings through inductive coding. Thirdly, the review findings were appraised using the GRADE-CERQual tool to determine the level of confidence in the qualitative evidence. The appraisal comprised four domains: methodological limitations, coherence, data adequacy, and data relevance. Two reviewers independently evaluated every review finding in each domain. The final appraisals were discussed and ultimately summarized for the respective review finding (high, moderate, low, or very low confidence). Results The 22 qualitative studies included in the systematic review were mainly conducted in Northern and Western Europe (n = 15). In total, the studies comprised a sample of 330 participants (n = 5 to n = 42) with a mean or median age of 80 and over. From the studies’ findings, 23 preferred features of ambulatory care were identified. Eight features concerned care relationships (e.g., “Older people wish to receive personal attention”), and 15 features concerned healthcare structures (e.g., “Older want more time for their care”). The findings emphasized that older people wish to build strong relationships with their care providers. The majority of the review findings reached a moderate or high confidence appraisal. Conclusions While the listed features of healthcare structures are common elements of care models for older people (e.g., Geriatric Care Model), aspects of care relationships are somewhat underrepresented or are not addressed explicitly at all. Future research should further explore the identified preferred features and their impact on patient and care outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03006-6.
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Affiliation(s)
- Angélique Herrler
- Faculty of Human Sciences and Faculty of Medicine, Graduate School GROW - Gerontological Research on Well-being, University of Cologne, Albertus-Magnus-Platz, 50923, Cologne, Germany. .,Institute for Health Economics and Clinical Epidemiology, University Hospital Cologne, 50935, Cologne, Germany.
| | - Helena Kukla
- Faculty of Human Sciences and Faculty of Medicine, Graduate School GROW - Gerontological Research on Well-being, University of Cologne, Albertus-Magnus-Platz, 50923, Cologne, Germany
| | - Vera Vennedey
- Institute for Health Economics and Clinical Epidemiology, University Hospital Cologne, 50935, Cologne, Germany
| | - Stephanie Stock
- Institute for Health Economics and Clinical Epidemiology, University Hospital Cologne, 50935, Cologne, Germany
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Brettel JH, Manuwald U, Hornstein H, Kugler J, Rothe U. Chronic-Care-Management Programs for Multimorbid Patients with Diabetes in Europe: A Scoping Review with the Aim to Identify the Best Practice. J Diabetes Res 2021; 2021:6657718. [PMID: 34796236 PMCID: PMC8595013 DOI: 10.1155/2021/6657718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 10/20/2021] [Indexed: 11/29/2022] Open
Abstract
AIM This scoping review is aimed at providing a current descriptive overview of care programs based on the chronic care model (CCM) according to E. H. Wagner. The evaluation is carried out within Europe and assesses the methodology and comparability of the studies. METHODS A systematic search in the databases PubMed, Embase, and MEDLINE via OVID was conducted. In the beginning, 2309 articles were found and 48 full texts were examined, 19 of which were incorporated. Included were CCM-based programs from Belgium, Cyprus, Germany, Italy, Switzerland, and the Netherlands. All 19 articles were presented descriptively whereof 11 articles were finally evaluated in a checklist by Rothe et al. (2020). In this paper, the studies were tabulated and evaluated conforming to the same criteria. RESULTS Due to the complexity of the CCM and the heterogeneity of the studies in terms of setting and implementation, a direct comparison proved difficult. Nevertheless, the review shows that CCM was successfully implemented in various care situations and also can be useful in single practices, which often dominate the primary care sector in many European health systems. The present review was able to provide a comprehensive overview of the current care situation of chronically ill patients with multimorbidities. CONCLUSIONS A unified nomenclature concerning the distinction between disease management programs and CCM-based programs should be aimed for. Similarly, homogeneous quality standards and a Europe-wide evaluation strategy would be necessary to identify best practice models and to provide better care for the steadily growing number of chronically multimorbid patients.
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Affiliation(s)
- Julia Heike Brettel
- Technische Universität Dresden, Faculty of Medicine “Carl Gustav Carus”, IPAS/Health Sciences/Public Health, Fetscherstraße 74, 01307 Dresden, Germany
| | - Ulf Manuwald
- Technische Universität Dresden, Faculty of Medicine “Carl Gustav Carus”, IPAS/Health Sciences/Public Health, Fetscherstraße 74, 01307 Dresden, Germany
| | - Henriette Hornstein
- Technische Universität Dresden, Faculty of Medicine “Carl Gustav Carus”, IPAS/Health Sciences/Public Health, Fetscherstraße 74, 01307 Dresden, Germany
| | - Joachim Kugler
- Technische Universität Dresden, Faculty of Medicine “Carl Gustav Carus”, IPAS/Health Sciences/Public Health, Fetscherstraße 74, 01307 Dresden, Germany
| | - Ulrike Rothe
- Technische Universität Dresden, Faculty of Medicine “Carl Gustav Carus”, IPAS/Health Sciences/Public Health, Fetscherstraße 74, 01307 Dresden, Germany
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Herrler A, Kukla H, Vennedey V, Stock S. What matters to people aged 80 and over regarding ambulatory care? A systematic review and meta-synthesis of qualitative studies. Eur J Ageing 2021; 19:325-339. [PMID: 36052193 PMCID: PMC9424416 DOI: 10.1007/s10433-021-00633-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 04/23/2023] Open
Abstract
AbstractThe growing percentage of the population aged 80 and over is challenging for healthcare systems, as frailty and other complex health issues are common in this age group. In order to provide patient-centered ambulatory healthcare, their preferences and expectations need to be explored. Therefore, the aim of this study was to systematically search for and synthesize qualitative evidence on how people aged 80 and over believe ambulatory healthcare (medical and nursing care) should be delivered to them. Medline, PsycINFO, CINAHL, Web of Science Core Collection and Google Scholar were searched for full research reports of qualitative studies focusing on the preferences, wishes, needs, expectations and experiences of people aged 80 and over regarding ambulatory medical and nursing care. The results were screened by two independent reviewers using a two-step approach. The included studies were meta-synthesized using Thomas and Harden’s ‘thematic synthesis’ approach in order to gain a new, second-order interpretation of the findings of the primary studies. In the intermediate synthesis step, 14 aspects of healthcare structures and care relationships were identified as relevant. Based on these, three underlying wishes were found: feeling safe, feeling like a meaningful human being, and maintaining control and independence. The results of this review are in line with other research, such as reviews focusing on the preferences of the younger age group (65–80). However, the importance of aspects of care relationships as an integral part of favorable ambulatory healthcare and the wish to be strengthened as a meaningful human being are emphasized more strongly.
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Kim H, Jung YI, Kim GS, Choi H, Park YH. Effectiveness of a Technology-Enhanced Integrated Care Model for Frail Older People: A Stepped-Wedge Cluster Randomized Trial in Nursing Homes. THE GERONTOLOGIST 2021; 61:460-469. [PMID: 32668005 PMCID: PMC8355475 DOI: 10.1093/geront/gnaa090] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The objective of this study was to evaluate the impact of an information and communication technologies (ICT)-enhanced, multidisciplinary integrated care model, called Systems for Person-centered Elder Care (SPEC), on frail older adults at nursing homes. RESEARCH DESIGN AND METHODS SPEC was implemented at 10 nursing homes in South Korea in random order using a stepped-wedge design. Data were collected on all participating older residents in the homes before the first implementation and until 6 months after the last implementation. The 21-month SPEC intervention guided by the chronic care model (CCM) consists of 5 strategies: comprehensive geriatric assessment, care planning, optional interdisciplinary case conferences, care coordination, and a cloud-based ICT tool along with a free messaging app. The primary outcome was quality of care measured by a composite quality indicator (QI) from the interRAI assessment system. Usual care continued over the control periods. Nursing home staff were not blinded to the intervention. RESULTS There were a total of 482 older nursing home residents included in the analysis. Overall quality of care measured by the composite QI was significantly improved (adjusted mean difference: -0.025 [95% CI: -0.037 to -0.014, p < .0001]). The intervention effect was consistent in the subgroup analysis by cognition and activities of daily living. There were no important adverse events or side effects. DISCUSSION AND IMPLICATIONS The SPEC, a CCM-guided, ICT-supported, multidisciplinary integrated care management intervention, can improve the quality of care measured by health and functional outcomes for frail older persons residing in nursing homes with limited health care provision. CLINICAL TRIALS REGISTRATION NUMBER ISRCTN11972147.
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Affiliation(s)
- Hongsoo Kim
- Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, South Korea.,Institute of Aging, Seoul National University, South Korea
| | - Young-Il Jung
- Department of Environmental Health, Korea National Open University, Seoul, South Korea
| | - Gi-Soo Kim
- Department of Statistics, Seoul National University, South Korea
| | | | - Yeon-Hwan Park
- College of Nursing, Research Institute of Nursing Science, Seoul National University, South Korea
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Lung T, Si L, Hooper R, Di Tanna GL. Health Economic Evaluation Alongside Stepped Wedge Trials: A Methodological Systematic Review. PHARMACOECONOMICS 2021; 39:63-80. [PMID: 33015754 DOI: 10.1007/s40273-020-00963-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/16/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Recently, there has been an increase in use of the stepped wedge trial (SWT) design in the context of health services research, due to its pragmatic and methodological advantages over the parallel group design. OBJECTIVE Our objective was to summarise the statistical methods used when conducting economic evaluations alongside SWTs. METHODS A systematic literature search extending to February 2020 was conducted in the PubMed, Scopus, Cochrane and National Health Service Economic Evaluation Database (NHS-EED) databases to find and evaluate studies where there was an intention to conduct an economic evaluation alongside an SWT. Studies were assessed for their eligibility, findings, reporting of statistical methods and quality of reporting. RESULTS Of the 586 studies retrieved from the literature search, 69 studies were identified and included in this systematic review. A total of 54 studies were published protocols, with eight economic evaluations and seven studies reporting full trial results. Included studies varied in terms of their reporting of statistical methods, in both detail and methodology. There were 34 studies that did not report any statistical methods for the economic evaluation, and only 16 studies reported appropriate methods, mainly using some form of mixed/multilevel model, and two used seemingly unrelated regression. Twelve studies reported the use of generic bootstrap methods and other modelling techniques, whilst the remaining studies failed to appropriately account for clustering, correlation or adjustment for time. CONCLUSIONS The use of appropriate statistical methods that account for time, clustering and correlation between costs and outcomes is an important part of SWT health economics analysis, one that will benefit from an effort to communicate the methods available and their performance.
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Affiliation(s)
- Thomas Lung
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, 2042, Australia
- Faculty of Medicine and Health, School of Public Health, Edward Ford Building A27, University of Sydney, Sydney, NSW, 2006, Australia
| | - Lei Si
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, 2042, Australia
- School of Health Policy & Management, Nanjing Medical University, Nanjing, China
| | - Richard Hooper
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Gian Luca Di Tanna
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, 2042, Australia.
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Lette M, Boorsma M, Lemmens L, Stoop A, Nijpels G, Baan C, de Bruin S. Unknown makes unloved-A case study on improving integrated health and social care in the Netherlands using a participatory approach. HEALTH & SOCIAL CARE IN THE COMMUNITY 2020; 28:670-680. [PMID: 31773803 PMCID: PMC7028071 DOI: 10.1111/hsc.12901] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 10/04/2019] [Accepted: 11/11/2019] [Indexed: 06/10/2023]
Abstract
Many initiatives integrating health and social care have been implemented in order to provide adequate care and support to older people living at home. Further development of existing initiatives requires iterative processes of developing, implementing and evaluating improvements to current practice. This case study provides insight into the process of improving an existing integrated care initiative in the Netherlands. Using a participatory approach, researchers and local stakeholders collaborated to develop and implement activities to further improve collaboration between health and social care professionals. Improvement activities included interprofessional meetings focussing on reflection and mutual learning and workplace visits. Researchers evaluated the improvement process, using data triangulation of multiple qualitative and quantitative data sources. According to participating professionals, the improvement activities improved their communication and collaboration by establishing mutual understanding and trust. Enabling factors included the safe and informal setting in which the meetings took place and the personal relationships they developed during the project. Different organisational cultures and interests and a lack of ownership and accountability among managers hindered the improvement process, whereas issues such as staff shortages, time constraints and privacy regulations made it difficult to implement improvements on a larger scale. Still, the participatory approach encouraged the development of partnerships and shared goals on the level of both managers and professionals. This case study highlights that improving communication between professionals is an important first step in improving integrated care. In addition, it shows that a participatory approach, in which improvements are co-created and tailored to local priorities and needs, can help in the development of shared goals and trust between stakeholders with different perspectives. However, stakeholders' willingness and ability to participate in such an improvement process is challenged by many factors.
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Affiliation(s)
- Manon Lette
- Department of General Practice and Elderly Care MedicineAmsterdam Public Health Research InstituteAmsterdam UMC – VU University AmsterdamAmsterdamThe Netherlands
- Centre for Nutrition, Prevention and Health Services ResearchNational Institute for Public Health and the EnvironmentBilthovenThe Netherlands
| | - Marijke Boorsma
- Department of General Practice and Elderly Care MedicineAmsterdam Public Health Research InstituteAmsterdam UMC – VU University AmsterdamAmsterdamThe Netherlands
| | - Lidwien Lemmens
- Centre for Nutrition, Prevention and Health Services ResearchNational Institute for Public Health and the EnvironmentBilthovenThe Netherlands
| | - Annerieke Stoop
- Department of General Practice and Elderly Care MedicineAmsterdam Public Health Research InstituteAmsterdam UMC – VU University AmsterdamAmsterdamThe Netherlands
- Centre for Nutrition, Prevention and Health Services ResearchNational Institute for Public Health and the EnvironmentBilthovenThe Netherlands
- Scientific Centre for Transformation in Care and Welfare (Tranzo)University of TilburgTilburgThe Netherlands
| | - Giel Nijpels
- Department of General Practice and Elderly Care MedicineAmsterdam Public Health Research InstituteAmsterdam UMC – VU University AmsterdamAmsterdamThe Netherlands
| | - Caroline Baan
- Centre for Nutrition, Prevention and Health Services ResearchNational Institute for Public Health and the EnvironmentBilthovenThe Netherlands
- Scientific Centre for Transformation in Care and Welfare (Tranzo)University of TilburgTilburgThe Netherlands
| | - Simone de Bruin
- Centre for Nutrition, Prevention and Health Services ResearchNational Institute for Public Health and the EnvironmentBilthovenThe Netherlands
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The Shared Subjective Frames of Interdisciplinary Practitioners Involved in Function-Focused Care in a Nursing Home: Q-Methodology. J Nurs Res 2019; 28:e69. [PMID: 31644506 DOI: 10.1097/jnr.0000000000000347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND An interdisciplinary team-based approach in nursing homes has been suggested in the literature as a strategy for delaying functional decline in residents. Function-focused care is a philosophy-based approach in which interdisciplinary practitioners assess functional capacity and help older adults to optimize and maintain their remaining abilities. PURPOSE This study explored and described the shared subjective frames of interdisciplinary practitioners as regards function-focused care for nursing home residents. METHODS Q-methodology was used to analyze the subjectivity of each factor of function-focused care for nursing home residents. Data were collected from August to September 2016. Thirty-four Q-statements were selected and scored by the 30 interdisciplinary practitioners on a 9-point scale with a normal distribution. Data were analyzed using the PQ Method 2.33 program. RESULTS The results revealed four factors of function-focused care, including (a) using a wait-and-see approach to encourage self-care, (b) maintaining interactive communications to identify and respond to changes, (c) reinforcing residents' inner and outer strengths for homeostasis, and (d) using a tailored approach based on comparisons between the past and the present. Shared subjectivity may provide an important collaborative framework to identify and solve complex problems related to the functional needs of nursing home residents. CONCLUSIONS The results of this study elucidate the subjectivities of interdisciplinary practitioners and better enable their provision of effective care in support of the remaining functional abilities of older adults living in nursing homes. The findings may be used as a reference to establish communication methods and shared documentation for interdisciplinary practitioners in nursing homes and construct interdisciplinary function-focused care practice guidelines.
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Stoop A, Lette M, van Gils PF, Nijpels G, Baan CA, de Bruin SR. Comprehensive geriatric assessments in integrated care programs for older people living at home: A scoping review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2019; 27:e549-e566. [PMID: 31225946 PMCID: PMC6852049 DOI: 10.1111/hsc.12793] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 05/10/2019] [Accepted: 05/16/2019] [Indexed: 06/09/2023]
Abstract
In many integrated care programs, a comprehensive geriatric assessment (CGA) is conducted to identify older people's problems and care needs. Different ways for conducting a CGA are in place. However, it is still unclear which CGA instruments and procedures for conducting them are used in integrated care programs, and what distinguishes them from each other. Furthermore, it is yet unknown how and to what extent CGAs, as a component of integrated care programs, actually reflect the main principles of integrated care, being comprehensiveness, multidisciplinarity and person-centredness. Therefore, the objectives of this study were to: (a) describe and compare different CGA instruments and procedures conducted within integrated care programs for older people living at home, and (b) describe how the principles of integrated care were applied in these CGAs. A scoping review of the scientific literature on CGAs in the context of integrated care was conducted for the period 2006-2018. Data were extracted on main characteristics of the identified CGA instruments and procedures, and on how principles of integrated care were applied in these CGAs. Twenty-seven integrated care programs were included in this study, of which most were implemented in the Netherlands and the United States. Twenty-one different CGAs were identified, of which the EASYcare instrument, RAI-HC/RAI-CHA and GRACE tool were used in multiple programs. The majority of CGAs seemed to reflect comprehensiveness, multidisciplinarity and person-centredness, although the way and extent to which principles of integrated care were incorporated differed between the CGAs. This study highlights the high variability of CGA instruments and procedures used in integrated care programs. This overview of available CGAs and their characteristics may promote (inter-)national exchange of CGAs, which could enable researchers and professionals in choosing from the wide range of existing CGAs, thereby preventing them from unnecessarily reinventing the wheel.
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Affiliation(s)
- Annerieke Stoop
- Centre for NutritionPrevention and
Health ServicesNational Institute for Public Health and the EnvironmentBilthoventhe Netherlands
- Amsterdam Public Health Research Institute, Department of General Practice and Elderly Care MedicineAmsterdam UMC ‐ VU University AmsterdamAmsterdamthe Netherlands
- Scientific Center for Transformation in Care and Welfare (Tranzo)University of TilburgTilburgthe Netherlands
| | - Manon Lette
- Amsterdam Public Health Research Institute, Department of General Practice and Elderly Care MedicineAmsterdam UMC ‐ VU University AmsterdamAmsterdamthe Netherlands
| | - Paul F. van Gils
- Centre for NutritionPrevention and
Health ServicesNational Institute for Public Health and the EnvironmentBilthoventhe Netherlands
| | - Giel Nijpels
- Amsterdam Public Health Research Institute, Department of General Practice and Elderly Care MedicineAmsterdam UMC ‐ VU University AmsterdamAmsterdamthe Netherlands
| | - Caroline A. Baan
- Centre for NutritionPrevention and
Health ServicesNational Institute for Public Health and the EnvironmentBilthoventhe Netherlands
- Scientific Center for Transformation in Care and Welfare (Tranzo)University of TilburgTilburgthe Netherlands
| | - Simone R. de Bruin
- Centre for NutritionPrevention and
Health ServicesNational Institute for Public Health and the EnvironmentBilthoventhe Netherlands
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12
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Dent E, Morley JE, Cruz-Jentoft AJ, Woodhouse L, Rodríguez-Mañas L, Fried LP, Woo J, Aprahamian I, Sanford A, Lundy J, Landi F, Beilby J, Martin FC, Bauer JM, Ferrucci L, Merchant RA, Dong B, Arai H, Hoogendijk EO, Won CW, Abbatecola A, Cederholm T, Strandberg T, Gutiérrez Robledo LM, Flicker L, Bhasin S, Aubertin-Leheudre M, Bischoff-Ferrari HA, Guralnik JM, Muscedere J, Pahor M, Ruiz J, Negm AM, Reginster JY, Waters DL, Vellas B. Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management. J Nutr Health Aging 2019; 23:771-787. [PMID: 31641726 PMCID: PMC6800406 DOI: 10.1007/s12603-019-1273-z] [Citation(s) in RCA: 425] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/02/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The task force of the International Conference of Frailty and Sarcopenia Research (ICFSR) developed these clinical practice guidelines to overview the current evidence-base and to provide recommendations for the identification and management of frailty in older adults. METHODS These recommendations were formed using the GRADE approach, which ranked the strength and certainty (quality) of the supporting evidence behind each recommendation. Where the evidence-base was limited or of low quality, Consensus Based Recommendations (CBRs) were formulated. The recommendations focus on the clinical and practical aspects of care for older people with frailty, and promote person-centred care. Recommendations for Screening and Assessment: The task force recommends that health practitioners case identify/screen all older adults for frailty using a validated instrument suitable for the specific setting or context (strong recommendation). Ideally, the screening instrument should exclude disability as part of the screening process. For individuals screened as positive for frailty, a more comprehensive clinical assessment should be performed to identify signs and underlying mechanisms of frailty (strong recommendation). Recommendations for Management: A comprehensive care plan for frailty should address polypharmacy (whether rational or nonrational), the management of sarcopenia, the treatable causes of weight loss, and the causes of exhaustion (depression, anaemia, hypotension, hypothyroidism, and B12 deficiency) (strong recommendation). All persons with frailty should receive social support as needed to address unmet needs and encourage adherence to a comprehensive care plan (strong recommendation). First-line therapy for the management of frailty should include a multi-component physical activity programme with a resistance-based training component (strong recommendation). Protein/caloric supplementation is recommended when weight loss or undernutrition are present (conditional recommendation). No recommendation was given for systematic additional therapies such as cognitive therapy, problem-solving therapy, vitamin D supplementation, and hormone-based treatment. Pharmacological treatment as presently available is not recommended therapy for the treatment of frailty.
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Affiliation(s)
- E Dent
- E. Dent, Torrens University Australia, Adelaide, Australia,
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13
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Rankin A, Cadogan CA, Patterson SM, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2018; 9:CD008165. [PMID: 30175841 PMCID: PMC6513645 DOI: 10.1002/14651858.cd008165.pub4] [Citation(s) in RCA: 192] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Audrey Rankin
- Queen's University BelfastSchool of Pharmacy97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
| | - Cathal A Cadogan
- Royal College of Surgeons in IrelandSchool of PharmacyDublinIreland
| | - Susan M Patterson
- No affiliationIntegrated Care40 Dunmore RoadBallynahinchNorthern IrelandUKBT24 8PR
| | - Ngaire Kerse
- University of AucklandDepartment of General Practice and Primary Health CarePrivate Bag 92019AucklandNew Zealand
| | - Chris R Cardwell
- Queen's University BelfastCentre for Public HealthSchool of MedicineDentistry and Biomedical SciencesBelfastNorthern IrelandUKBT12 6BJ
| | - Marie C Bradley
- National Cancer Institute9609 Medical Center DriveRockvilleMDUSA20850
| | - Cristin Ryan
- Trinity College DublinSchool of Pharmacy and Pharmaceutical Sciences111 St Stephen’s GreenDublin 2Ireland
| | - Carmel Hughes
- Queen's University BelfastSchool of Pharmacy97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
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14
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Dent E, Lien C, Lim WS, Wong WC, Wong CH, Ng TP, Woo J, Dong B, de la Vega S, Hua Poi PJ, Kamaruzzaman SBB, Won C, Chen LK, Rockwood K, Arai H, Rodriguez-Mañas L, Cao L, Cesari M, Chan P, Leung E, Landi F, Fried LP, Morley JE, Vellas B, Flicker L. The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. J Am Med Dir Assoc 2018. [PMID: 28648901 DOI: 10.1016/j.jamda.2017.04.018] [Citation(s) in RCA: 352] [Impact Index Per Article: 58.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To develop Clinical Practice Guidelines for the screening, assessment and management of the geriatric condition of frailty. METHODS An adapted Grading of Recommendations, Assessment, Development, and Evaluation approach was used to develop the guidelines. This process involved detailed evaluation of the current scientific evidence paired with expert panel interpretation. Three categories of Clinical Practice Guidelines recommendations were developed: strong, conditional, and no recommendation. RECOMMENDATIONS Strong recommendations were (1) use a validated measurement tool to identify frailty; (2) prescribe physical activity with a resistance training component; and (3) address polypharmacy by reducing or deprescribing any inappropriate/superfluous medications. Conditional recommendations were (1) screen for, and address modifiable causes of fatigue; (2) for persons exhibiting unintentional weight loss, screen for reversible causes and consider food fortification and protein/caloric supplementation; and (3) prescribe vitamin D for individuals deficient in vitamin D. No recommendation was given regarding the provision of a patient support and education plan. CONCLUSIONS The recommendations provided herein are intended for use by healthcare providers in their management of older adults with frailty in the Asia Pacific region. It is proposed that regional guideline support committees be formed to help provide regular updates to these evidence-based guidelines.
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Affiliation(s)
- Elsa Dent
- Center for Research in Geriatric Medicine, School of Medicine, The University of Queensland, Brisbane, Australia.
| | - Christopher Lien
- Department of Geriatric Medicine, Changi General Hospital, Singapore, Singapore
| | - Wee Shiong Lim
- Department of Geriatric Medicine, Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital, Singapore, Singapore
| | - Wei Chin Wong
- Department of Geriatric Medicine, Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital, Singapore, Singapore
| | - Chek Hooi Wong
- Geriatric Education and Research Institute, Singapore, Singapore
| | - Tze Pin Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jean Woo
- The S H Ho Center for Gerontology and Geriatrics, The Chinese University of Hong Kong, Hong Kong, China
| | - Birong Dong
- Geriatrics Center Huaxi Hospital, Sichuan University, Chengdu, China
| | - Shelley de la Vega
- University of the Philippines College of Medicine, Manila, Philippines; Institute on Aging, National Institutes of Health, University of the Philippines, Manila, Philippines
| | - Philip Jun Hua Poi
- Division of Geriatrics, University of Malaya Medical Center, Kuala Lumpur, Malaysia
| | | | - Chang Won
- Department of Family Medicine, Kyung Hee University School of Medicine, Seoul, South Korea
| | - Liang-Kung Chen
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital; Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
| | | | - Hidenori Arai
- National Center for Geriatrics and Gerontology, Obu, Japan
| | | | - Li Cao
- Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | | | - Piu Chan
- Department of Geriatrics, Neurology, and Neurobiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Edward Leung
- Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong
| | | | - Linda P Fried
- Mailman School of Public Health, Columbia University Medical Center, New York, NY
| | - John E Morley
- Divisions of Geriatric Medicine and Endocrinology, Saint Louis University, St. Louis, MO
| | | | - Leon Flicker
- Western Australia Center for Health and Aging, University of Western Australia, Perth, Australia
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15
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Leijten FR, Struckmann V, van Ginneken E, Czypionka T, Kraus M, Reiss M, Tsiachristas A, Boland M, de Bont A, Bal R, Busse R, Rutten-van Mölken M. The SELFIE framework for integrated care for multi-morbidity: Development and description. Health Policy 2018; 122:12-22. [DOI: 10.1016/j.healthpol.2017.06.002] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 05/31/2017] [Accepted: 06/12/2017] [Indexed: 12/17/2022]
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16
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Bujold M, Pluye P, Légaré F, Haggerty J, Gore GC, Sherif RE, Poitras MÈ, Beaulieu MC, Beaulieu MD, Bush PL, Couturier Y, Débarges B, Gagnon J, Giguère A, Grad R, Granikov V, Goulet S, Hudon C, Kremer B, Kröger E, Kudrina I, Lebouché B, Loignon C, Lussier MT, Martello C, Nguyen Q, Pratt R, Rihoux B, Rosenberg E, Samson I, Senn N, Li Tang D, Tsujimoto M, Vedel I, Ventelou B, Wensing M. Decisional needs assessment of patients with complex care needs in primary care: a participatory systematic mixed studies review protocol. BMJ Open 2017; 7:e016400. [PMID: 29133314 PMCID: PMC5695438 DOI: 10.1136/bmjopen-2017-016400] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 07/28/2017] [Accepted: 08/23/2017] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Patients with complex care needs (PCCNs) often suffer from combinations of multiple chronic conditions, mental health problems, drug interactions and social vulnerability, which can lead to healthcare services overuse, underuse or misuse. Typically, PCCNs face interactional issues and unmet decisional needs regarding possible options in a cascade of interrelated decisions involving different stakeholders (themselves, their families, their caregivers, their healthcare practitioners). Gaps in knowledge, values clarification and social support in situations where options need to be deliberated hamper effective decision support interventions. This review aims to (1) assess decisional needs of PCCNs from the perspective of stakeholders, (2) build a taxonomy of these decisional needs and (3) prioritise decisional needs with knowledge users (clinicians, patients and managers). METHODS AND ANALYSIS This review will be based on the interprofessional shared decision making (IP-SDM) model and the Ottawa Decision Support Framework. Applying a participatory research approach, we will identify potentially relevant studies through a comprehensive literature search; select relevant ones using eligibility criteria inspired from our previous scoping review on PCCNs; appraise quality using the Mixed Methods Appraisal Tool; conduct a three-step synthesis (sequential exploratory mixed methods design) to build taxonomy of key decisional needs; and integrate these results with those of a parallel PCCNs' qualitative decisional need assessment (semistructured interviews and focus group with stakeholders). ETHICS AND DISSEMINATION This systematic review, together with the qualitative study (approved by the Centre Intégré Universitaire de Santé et Service Sociaux du Saguenay-Lac-Saint-Jean ethical committee), will produce a working taxonomy of key decisional needs (ontological contribution), to inform the subsequent user-centred design of a support tool for addressing PCCNs' decisional needs (practical contribution). We will adapt the IP-SDM model, normally dealing with a single decision, for PCCNs who experience cascade of decisions involving different stakeholders (theoretical contribution). Knowledge users will facilitate dissemination of the results in the Canadian primary care network. PROSPERO REGISTRATION NUMBER CRD42015020558.
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Affiliation(s)
- Mathieu Bujold
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Pierre Pluye
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Université Laval, Montréal, Québec, Canada
| | - Jeannie Haggerty
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | | | - Reem El Sherif
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Marie-Ève Poitras
- Department of Family Medicine and Emergency Medicine, Université Laval, Montréal, Québec, Canada
| | | | | | - Paula L Bush
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Yves Couturier
- École de travail social, Université de Sherbrooke, Canada
| | | | - Justin Gagnon
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Anik Giguère
- Department of Family Medicine and Emergency Medicine, Université Laval, Montréal, Québec, Canada
| | - Roland Grad
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Vera Granikov
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Serge Goulet
- Department of Family Medicine, Université de Sherbrooke, Canada
| | - Catherine Hudon
- Department of Family Medicine, Université de Sherbrooke, Canada
| | | | | | - Irina Kudrina
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Bertrand Lebouché
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | | | | | - Cristiano Martello
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Quynh Nguyen
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Rebekah Pratt
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, United States
| | - Benoit Rihoux
- Centre de Science Politique et de Politique Comparée, Université catholique de Louvain, Belgium
| | - Ellen Rosenberg
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | - Isabelle Samson
- Department of Family Medicine and Emergency Medicine, Université Laval, Montréal, Québec, Canada
| | | | - David Li Tang
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
| | | | - Isabelle Vedel
- Department of Family Medicine, McGill University, Montréal, Québec, Canada
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Struckmann V, Leijten FRM, van Ginneken E, Kraus M, Reiss M, Spranger A, Boland MRS, Czypionka T, Busse R, Rutten-van Mölken M. Relevant models and elements of integrated care for multi-morbidity: Results of a scoping review. Health Policy 2017; 122:23-35. [PMID: 29031933 DOI: 10.1016/j.healthpol.2017.08.008] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 08/19/2017] [Accepted: 08/21/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND In order to provide adequate care for the growing group of persons with multi-morbidity, innovative integrated care programmes are appearing. The aims of the current scoping review were to i) identify relevant models and elements of integrated care for multi-morbidity and ii) to subsequently identify which of these models and elements are applied in integrated care programmes for multi-morbidity. METHODS A scoping review was conducted in the following scientific databases: Cochrane, Embase, PubMed, PsycInfo, Scopus, Sociological Abstracts, Social Services Abstracts, and Web of Science. A search strategy encompassing a) models, elements and programmes, b) integrated care, and c) multi-morbidity was used to identify both models and elements (aim 1) and implemented programmes of integrated care for multi-morbidity (aim 2). Data extraction was done by two independent reviewers. Besides general information on publications (e.g. publication year, geographical region, study design, and target group), data was extracted on models and elements that publications refer to, as well as which models and elements are applied in recently implemented programmes in the EU and US. RESULTS In the review 11,641 articles were identified. After title and abstract screening, 272 articles remained. Full text screening resulted in the inclusion of 92 articles on models and elements, and 50 articles on programmes, of which 16 were unique programmes in the EU (n=11) and US (n=5). Wagner's Chronic Care Model (CCM) and the Guided Care Model (GCM) were most often referred to (CCM n=31; GCM n=6); the majority of the other models found were only referred to once (aim 1). Both the CCM and GCM focus on integrated care in general and do not explicitly focus on multi-morbidity. Identified elements of integrated care were clustered according to the WHO health system building blocks. Most elements pertained to 'service delivery'. Across all components, the five elements referred to most often are person-centred care, holistic or needs assessment, integration and coordination of care services and/or professionals, collaboration, and self-management (aim 1). Most (n=10) of the 16 identified implemented programmes for multi-morbidity referred to the CCM (aim 2). Of all identified programmes, the elements most often included were self-management, comprehensive assessment, interdisciplinary care or collaboration, person-centred care and electronic information system (aim 2). CONCLUSION Most models and elements found in the literature focus on integrated care in general and do not explicitly focus on multi-morbidity. In line with this, most programmes identified in the literature build on the CCM. A comprehensive framework that better accounts for the complexities resulting from multi-morbidity is needed.
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Affiliation(s)
- Verena Struckmann
- Berlin University of Technology, Department of Health Care Management, Germany.
| | - Fenna R M Leijten
- Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands
| | - Ewout van Ginneken
- WHO Observatory on Health Systems and Policies, Berlin University of Technology, Department of Health Care Management, Germany
| | | | | | - Anne Spranger
- Berlin University of Technology, Department of Health Care Management, Germany
| | - Melinde R S Boland
- Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands
| | | | - Reinhard Busse
- Berlin University of Technology, Department of Health Care Management, Germany
| | - Maureen Rutten-van Mölken
- Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands; Institute for Medical Technology Assessment, Erasmus University Rotterdam, The Netherlands
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18
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Muntinga ME, van Leeuwen KM, Jansen APD, Nijpels G, Schellevis FG, Abma TA. The Importance of Trust in Successful Home Visit Programs for Older People. Glob Qual Nurs Res 2017; 3:2333393616681935. [PMID: 28462353 PMCID: PMC5342295 DOI: 10.1177/2333393616681935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 10/06/2016] [Accepted: 10/20/2016] [Indexed: 11/16/2022] Open
Abstract
Outcomes of proactive home visit programs for frail, older people might be influenced by aspects of the caregiver-receiver interaction. We conducted a naturalistic case study to explore the interactional process between a nurse and an older woman during two home visits. Using an ethics of care, we posit that a trusting relationship is pivotal for older people to accept care that is proactively offered to them. Trust can be build when nurses meet the relational needs of older people. Nurses can achieve insight in these needs by exploring older people's value systems and life stories. We argue that a strong focus on older people's relational needs might contribute to success of proactive home visits for frail, older people.
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Kim H, Park YH, Jung YI, Choi H, Lee S, Kim GS, Yang DW, Paik MC, Lee TJ. Evaluation of a technology-enhanced integrated care model for frail older persons: protocol of the SPEC study, a stepped-wedge cluster randomized trial in nursing homes. BMC Geriatr 2017; 17:88. [PMID: 28420324 PMCID: PMC5395967 DOI: 10.1186/s12877-017-0459-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 03/07/2017] [Indexed: 01/18/2023] Open
Abstract
Background Limited evidence exists on the effectiveness of the chronic care model for people with multimorbidity. This study aims to evaluate the effectiveness of an information and communication technology- (ICT-)enhanced integrated care model, called Systems for Person-centered Elder Care (SPEC), for frail older adults at nursing homes. Methods/Design SPEC is a prospective stepped-wedge cluster randomized trial conducted at 10 nursing homes in South Korea. Residents aged 65 or older meeting the inclusion/exclusion criteria in all the homes are eligible to participate. The multifaceted SPEC intervention, a geriatric care model guided by the chronic care model, consists of five components: comprehensive geriatric assessment for need/risk profiling, individual need-based care planning, interdisciplinary case conferences, person-centered care coordination, and a cloud-based information and communications technology (ICT) tool supporting the intervention process. The primary outcome is quality of care for older residents using a composite measure of quality indicators from the interRAI LTCF assessment system. Outcome assessors and data analysts will be blinded to group assignment. Secondary outcomes include quality of life, healthcare utilization, and cost. Process evaluation will be also conducted. Discussion This study is expected to provide important new evidence on the effectiveness, cost-effectiveness, and implementation process of an ICT-supported chronic care model for older persons with multiple chronic illnesses. The SPEC intervention is also unique as the first registered trial implementing an integrated care model using technology to promote person-centered care for frail older nursing home residents in South Korea, where formal LTC was recently introduced. Trial registration
10.1186/ISRCTN11972147
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Affiliation(s)
- Hongsoo Kim
- Department of Public Health Science at Graduate School of Public Health, Institute of Aging, Institute of Health and Environment, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, South Korea.
| | - Yeon-Hwan Park
- College of Nursing, the Research Institute of Nursing Science, Seoul National University, Daehakro 103, Jongno-Gu, Seoul, South Korea
| | - Young-Il Jung
- Institute of Health and Environment, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, South Korea
| | - Hyoungshim Choi
- Youngsan University, College of Nursing, Yangsan Campus, 288 Junam-ro, 50510, Yangsan, Gyeongnam, South Korea
| | - Seyune Lee
- Department of Public Health Science at Graduate School of Public Health, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, South Korea
| | - Gi-Soo Kim
- College of Natural Sciences, Department of Statistics, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, South Korea
| | - Dong-Wook Yang
- Department of Public Health Science at Graduate School of Public Health, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, South Korea
| | - Myunghee Cho Paik
- College of Natural Sciences, Department of Statistics, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, South Korea
| | - Tae-Jin Lee
- Department of Public Health Science at Graduate School of Public Health, Institute of Health and Environment, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, South Korea
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Hoogendijk EO. How effective is integrated care for community-dwelling frail older people? The case of the Netherlands. Age Ageing 2016; 45:585-8. [PMID: 27146300 DOI: 10.1093/ageing/afw081] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 04/05/2016] [Indexed: 11/14/2022] Open
Abstract
Integrated care programs have been developed to enhance the quality care for older adults in primary care. These programs usually consist of a multidisciplinary approach, with personalised care based on comprehensive geriatric assessments. However, there is limited evidence for the effectiveness of these programs in frail older people. In this article, we review the results of three recent intervention studies carried out as part of the Dutch National Care for the Elderly Programme. The results illustrate how difficult it is to improve outcomes in community-dwelling frail older adults by means of integrated care. Furthermore, we discuss the implications of these studies for future research into frailty interventions.
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Affiliation(s)
- Emiel O Hoogendijk
- Department of Epidemiology and Biostatistics, VU University Medical Center, EMGO+ Institute for Health and Care Research, Amsterdam, The Netherlands Department of General Practice and Elderly Care Medicine, VU University Medical Center, EMGO+ Institute for Health and Care Research, Amsterdam, The Netherlands
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21
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van der Borg WE, Schipper K, Abma TA. Protocol of a mixed method, randomized controlled study to assess the efficacy of a psychosocial intervention to reduce fatigue in patients with End-Stage Renal Disease (ESRD). BMC Nephrol 2016; 17:73. [PMID: 27391406 PMCID: PMC4939050 DOI: 10.1186/s12882-016-0277-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 06/14/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Patients with end-stage renal disease (ESRD) commonly suffer from severe fatigue, which strongly impacts their quality of life (QoL). Although fatigue is often attributed to disease- and treatment characteristics, research also shows that behavioural, psychological and social factors affect perceived fatigue in dialysis patients. Whereas studies on fatigue in other chronic patient groups suggest that psychological or psychosocial interventions are effective in reducing fatigue, such interventions are not yet available for ESRD patients on dialysis treatment. The objective of this study is to examine the efficacy of a psychosocial intervention for dialysis patients aimed at reducing fatigue (primary outcome) and improving QoL (secondary outcome). The intervention consists of counselling sessions led by a social worker. The implementation process and patients' and social workers' expectations and experiences with the intervention will also be evaluated. METHODS/DESIGN This study follows a mixed-methods design in which both quantitative and qualitative data will be collected. A multi-centre, randomised controlled trial (RCT) with repeated measures will be conducted to quantitatively assess the efficacy of the psychosocial intervention in reducing fatigue and improving QoL in ESRD patients. Additional secondary outcomes and medical parameters will be assessed. Outcomes will be compared to patients receiving usual care. A sample of 74 severely fatigued dialysis patients will be recruited from 10 dialysis centres. Patients will be randomly assigned to the intervention or control group. Outcomes will be assessed at baseline, post intervention/16 weeks, and at three and six-month follow-ups. A qualitative process evaluation will be conducted parallel to/following the effectiveness RCT. Interviews and focus groups will be conducted to gain insight into patients' and social workers' perspectives on outcomes and implementation procedures. Implementation fidelity will be assessed by audio-taped and written registrations. Participatory methods ensure the continuous input of experiential knowledge, improving the quality of study procedures and the applicability of outcomes. DISCUSSION This is the first mixed method study (including an RCT and qualitative process evaluation) to examine the effect and implementation process of a psychosocial intervention on reducing fatigue and improving QoL in ESRD patients on dialysis treatment. TRIAL REGISTRATION NTR5366 , The Netherlands National Trial Register (NTR), registered August 26, 2015.
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Affiliation(s)
- Wieke E van der Borg
- Department of Medical Humanities, VU University Medical Center/EMGO+, De Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands.
| | - Karen Schipper
- Department of Medical Humanities, VU University Medical Center/EMGO+, De Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands
| | - Tineke A Abma
- Department of Medical Humanities, VU University Medical Center/EMGO+, De Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands
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Girling AJ, Hemming K. Statistical efficiency and optimal design for stepped cluster studies under linear mixed effects models. Stat Med 2016; 35:2149-66. [PMID: 26748662 PMCID: PMC4949721 DOI: 10.1002/sim.6850] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 10/01/2015] [Accepted: 11/27/2015] [Indexed: 12/03/2022]
Abstract
In stepped cluster designs the intervention is introduced into some (or all) clusters at different times and persists until the end of the study. Instances include traditional parallel cluster designs and the more recent stepped-wedge designs. We consider the precision offered by such designs under mixed-effects models with fixed time and random subject and cluster effects (including interactions with time), and explore the optimal choice of uptake times. The results apply both to cross-sectional studies where new subjects are observed at each time-point, and longitudinal studies with repeat observations on the same subjects. The efficiency of the design is expressed in terms of a 'cluster-mean correlation' which carries information about the dependency-structure of the data, and two design coefficients which reflect the pattern of uptake-times. In cross-sectional studies the cluster-mean correlation combines information about the cluster-size and the intra-cluster correlation coefficient. A formula is given for the 'design effect' in both cross-sectional and longitudinal studies. An algorithm for optimising the choice of uptake times is described and specific results obtained for the best balanced stepped designs. In large studies we show that the best design is a hybrid mixture of parallel and stepped-wedge components, with the proportion of stepped wedge clusters equal to the cluster-mean correlation. The impact of prior uncertainty in the cluster-mean correlation is considered by simulation. Some specific hybrid designs are proposed for consideration when the cluster-mean correlation cannot be reliably estimated, using a minimax principle to ensure acceptable performance across the whole range of unknown values. © 2016 The Authors. Statistics in Medicine published by John Wiley & Sons Ltd.
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Affiliation(s)
- Alan J. Girling
- Institute of Applied Health ResearchUniversity of BirminghamB15 2TTU.K.
| | - Karla Hemming
- Institute of Applied Health ResearchUniversity of BirminghamB15 2TTU.K.
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Barker D, McElduff P, D'Este C, Campbell MJ. Stepped wedge cluster randomised trials: a review of the statistical methodology used and available. BMC Med Res Methodol 2016; 16:69. [PMID: 27267471 PMCID: PMC4895892 DOI: 10.1186/s12874-016-0176-5] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 05/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous reviews have focussed on the rationale for employing the stepped wedge design (SWD), the areas of research to which the design has been applied and the general characteristics of the design. However these did not focus on the statistical methods nor addressed the appropriateness of sample size methods used.This was a review of the literature of the statistical methodology used in stepped wedge cluster randomised trials. METHODS Literature Review. The Medline, Embase, PsycINFO, CINAHL and Cochrane databases were searched for methodological guides and RCTs which employed the stepped wedge design. RESULTS This review identified 102 trials which employed the stepped wedge design compared to 37 from the most recent review by Beard et al. 2015. Forty six trials were cohort designs and 45 % (n = 46) had fewer than 10 clusters. Of the 42 articles discussing the design methodology 10 covered analysis and seven covered sample size. For cohort stepped wedge designs there was only one paper considering analysis and one considering sample size methods. Most trials employed either a GEE or mixed model approach to analysis (n = 77) but only 22 trials (22 %) estimated sample size in a way which accounted for the stepped wedge design that was subsequently used. CONCLUSIONS Many studies which employ the stepped wedge design have few clusters but use methods of analysis which may require more clusters for unbiased and efficient intervention effect estimates. There is the need for research on the minimum number of clusters required for both types of stepped wedge design. Researchers should distinguish in the sample size calculation between cohort and cross sectional stepped wedge designs. Further research is needed on the effect of adjusting for the potential confounding of time on the study power.
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Affiliation(s)
- D Barker
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - P McElduff
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - C D'Este
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT, 0200, Australia
| | - M J Campbell
- Medical Statistics Group, ScHARR, University of Sheffield, Sheffield, UK
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Muntinga ME, Jansen APD, Schellevis FG, Nijpels G. Expanding access to pain care for frail, older people in primary care: a cross-sectional study. BMC Nurs 2016; 15:26. [PMID: 27110220 PMCID: PMC4842300 DOI: 10.1186/s12912-016-0147-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 04/16/2016] [Indexed: 12/15/2022] Open
Abstract
Background Although untreated pain has a negative impact on quality of life and health outcomes, research has shown that older people do not always have access to adequate pain care. Practice nurse-led, comprehensive geriatric assessments (CGAs) may increase access to tailored pain care for frail, older people who live at home. To explore this, we investigated whether new pain cases were identified by practice nurses during CGAs administered as part of an intervention with the Geriatric Care Model, a comprehensive care model based on the Chronic Care Model, and whether the intervention led to tailored pain action plans in care plans of frail, older people. Methods We used cross-sectional data from the older Adults: Care in Transition (ACT) study, a 2-year clinical trial carried out in two regions of the Netherlands. Practice nurses proactively visited older people at home and administered an in-home CGA that included an assessment of pain. Pain care-related agreements and actions (pain action plans) based on CGA results were described in a tailored care plan. We analyzed care plans of 781 older people who received a first-time CGA by a practice nurse for the presence of pain, pain location and cause, new pain cases, and pain action plans. We used descriptive statistics to analyze our data. Results We found that 315 (40.3 %) older people experienced any type of pain. Practice nurses identified 20 (10.6 %) new pain cases, and 188 (59.7 %) older people with pain formulated at least one therapeutic or non-therapeutic pain action plan together with a practice nurse. More than half of the older people whose pain had already been identified by a primary care physician wanted a pain action plan. Most pain action plans consisted of actions or agreements related to continuity of care. Discussion and conclusion Practice nurses in primary care can contribute to expanding older people's access to tailored pain care. Future researchers should continue to direct their focus at ways to overcome the barriers that restrict older people’s access to pain care.
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Affiliation(s)
- M E Muntinga
- Department of General Practice and Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - A P D Jansen
- Department of General Practice and Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - F G Schellevis
- Department of General Practice and Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands ; NIVEL (Netherlands Institute for Health Services Research), Utrecht, The Netherlands
| | - G Nijpels
- Department of General Practice and Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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25
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Different methods to analyze stepped wedge trial designs revealed different aspects of intervention effects. J Clin Epidemiol 2016; 72:75-83. [DOI: 10.1016/j.jclinepi.2015.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 10/15/2015] [Accepted: 11/03/2015] [Indexed: 11/21/2022]
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Hoogendijk EO, van der Horst HE, van de Ven PM, Twisk JWR, Deeg DJH, Frijters DHM, van Leeuwen KM, van Campen JPCM, Nijpels G, Jansen APD, van Hout HPJ. Effectiveness of a Geriatric Care Model for frail older adults in primary care: Results from a stepped wedge cluster randomized trial. Eur J Intern Med 2016; 28:43-51. [PMID: 26597341 DOI: 10.1016/j.ejim.2015.10.023] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 10/27/2015] [Accepted: 10/30/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Primary care-based comprehensive care programs have the potential to improve outcomes in frail older adults. We evaluated the impact of the Geriatric Care Model (GCM) on the quality of life of community-dwelling frail older adults. METHODS A 24-month stepped wedge cluster randomized controlled trial was conducted between May 2010 and March 2013 in 35 primary care practices in the Netherlands, and included 1147 frail older adults. The intervention consisted of a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Reassessment occurred every six months. Nurses worked together with primary care physicians and were supervised and trained by geriatric expert teams. Complex patients were reviewed in multidisciplinary consultations. The primary outcome was quality of life (SF-12). Secondary outcomes were health-related quality of life, functional limitations, self-rated health, psychological wellbeing, social functioning and hospitalizations. RESULTS Intention-to-treat analyses based on multilevel modeling showed no significant differences between the intervention group and usual care regarding SF-12 and most secondary outcomes. Only for IADL limitations we found a small intervention effect in patients who received the intervention for 18months (B=-0.25, 95%CI=-0.43 to -0.06, p=0.007), but this effect was not statistically significant after correction for multiple comparisons. CONCLUSION The GCM did not show beneficial effects on quality of life in frail older adults in primary care, compared to usual care. This study strengthens the idea that comprehensive care programs add very little to usual primary care for this population. TRIAL REGISTRATION The Netherlands National Trial Register NTR2160.
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Affiliation(s)
- Emiel O Hoogendijk
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Gérontopôle, Department of Internal Medicine and Geriatrics, Toulouse University Hospital, Toulouse, France; Department of Epidemiology & Biostatistics, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Henriëtte E van der Horst
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Peter M van de Ven
- Department of Epidemiology & Biostatistics, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Jos W R Twisk
- Department of Epidemiology & Biostatistics, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Dorly J H Deeg
- Department of Epidemiology & Biostatistics, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Dinnus H M Frijters
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Karen M van Leeuwen
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands; Department of Health Sciences, EMGO+ Institute for Health and Care Research, Faculty of Earth & Life Sciences, VU University, Amsterdam, The Netherlands.
| | - Jos P C M van Campen
- Department of Geriatric Medicine, Slotervaart Hospital, Amsterdam, The Netherlands.
| | - Giel Nijpels
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Aaltje P D Jansen
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Hein P J van Hout
- Department of General Practice & Elderly Care Medicine, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
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van Leeuwen KM, Bosmans JE, Jansen APD, Hoogendijk EO, Muntinga ME, van Hout HPJ, Nijpels G, van der Horst HE, van Tulder MW. Cost-Effectiveness of a Chronic Care Model for Frail Older Adults in Primary Care: Economic Evaluation Alongside a Stepped-Wedge Cluster-Randomized Trial. J Am Geriatr Soc 2015; 63:2494-2504. [PMID: 26663424 DOI: 10.1111/jgs.13834] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the cost-effectiveness of the Geriatric Care Model (GCM), an integrated care model for frail older adults based on the Chronic Care Model, with that of usual care. DESIGN Economic evaluation alongside a 24-month stepped-wedge cluster-randomized controlled trial. SETTING Primary care (35 practices) in two regions in the Netherlands. PARTICIPANTS Community-dwelling older adults who were frail according to their primary care physicians and the Program on Research for Integrating Services for the Maintenance of Autonomy case-finding tool questionnaire (N = 1,147). INTERVENTION The GCM consisted of the following components: a regularly scheduled in-home comprehensive geriatric assessment by a practice nurse followed by a customized care plan, management and training of practice nurses by a geriatric expert team, and coordination of care through community network meetings and multidisciplinary team consultations of individuals with complex care needs. MEASUREMENTS Outcomes were measured every 6 months and included costs from a societal perspective, health-related quality of life (Medical Outcomes Study 12-item Short-Form Survey (SF-12) physical (PCS) and mental component summary (MCS) scales), functional limitations (Katz activities of daily living and instrumental activities of daily living), and quality-adjusted life years based on the EQ-5D. RESULTS Multilevel regression models adjusted for time and baseline confounders showed no significant differences in costs ($356, 95% confidence interval = -$488-1,134) and outcomes between intervention and usual care phases. Cost-effectiveness acceptability curves showed that, for the SF-12 PCS and MCS, the probability of the intervention being cost-effective was 0.76 if decision-makers are willing to pay $30,000 per point improvement on the SF-12 scales (range 0-100). For all other outcomes the probability of the intervention being cost-effective was low. CONCLUSION Because the GCM was not cost-effective compared to usual care after 24 months of follow-up, widespread implementation in its current form is not recommended.
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Affiliation(s)
- Karen M van Leeuwen
- Department of General Practice and Elderly Care Medicine, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,Department of Health Sciences, Faculty of Earth & Life Sciences, Emgo+ Institute for Health and Care Research, VU University, Amsterdam, the Netherlands
| | - Judith E Bosmans
- Department of Health Sciences, Faculty of Earth & Life Sciences, Emgo+ Institute for Health and Care Research, VU University, Amsterdam, the Netherlands
| | - Aaltje P D Jansen
- Department of General Practice and Elderly Care Medicine, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Emiel O Hoogendijk
- Department of General Practice and Elderly Care Medicine, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,Gérôntopole, Toulouse University Hospital, Toulouse, France
| | - Maaike E Muntinga
- Department of General Practice and Elderly Care Medicine, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,Department of Medical Humanities, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Hein P J van Hout
- Department of General Practice and Elderly Care Medicine, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Giel Nijpels
- Department of General Practice and Elderly Care Medicine, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Henriette E van der Horst
- Department of General Practice and Elderly Care Medicine, Emgo+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Earth & Life Sciences, Emgo+ Institute for Health and Care Research, VU University, Amsterdam, the Netherlands
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Lette M, Baan CA, van den Berg M, de Bruin SR. Initiatives on early detection and intervention to proactively identify health and social problems in older people: experiences from the Netherlands. BMC Geriatr 2015; 15:143. [PMID: 26518369 PMCID: PMC4628317 DOI: 10.1186/s12877-015-0131-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 10/14/2015] [Indexed: 12/18/2022] Open
Abstract
Background Over the last years, several initiatives on early detection and intervention have been put in place to proactively identify health and social problems in (frail) older people. An overview of the initiatives currently available in the Netherlands is lacking, and it is unknown whether they meet the preferences and needs of older people. Therefore, the objectives of this study were threefold: 1. To identify initiatives on early detection and intervention for older people in the Netherlands and compare their characteristics; 2. To explore the experiences of professionals with these initiatives; and 3. To explore to what extent existing initiatives meet the preferences and needs of older people. Methods We performed a qualitative descriptive study in which we conducted semi-structured interviews with seventeen experts in preventive elderly care and three group interviews with volunteer elderly advisors. Data were analysed using the framework analysis method. Results We identified eight categories of initiatives based on the setting (e.g. general practitioner practice, hospital, municipality) in which they were offered. Initiatives differed in their aims and target groups. The utilization of peers to identify problems and risks, as was done by some initiatives, was seen as a strength. Difficulties were experienced with identifying the target group that would benefit from proactive delivery of care and support most, and with addressing prevalent issues among older people (e.g. psychosocial issues, self-reliance issues). Conclusion Although there is a broad array of initiatives available, there is a discrepancy between supply and demand. Current initiatives insufficiently address needs of (frail) older people. More insight is needed in “what should be done by whom, for which target group and at what moment”, in order to improve current practice in preventive elderly care.
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Affiliation(s)
- Manon Lette
- Centre for Nutrition, Prevention and Health Services, National Institute of Public Health and the Environment, Bilthoven, The Netherlands.
| | - Caroline A Baan
- Centre for Nutrition, Prevention and Health Services, National Institute of Public Health and the Environment, Bilthoven, The Netherlands. .,Scientific Centre for Transformation in Care and Welfare (Tranzo), University of Tilburg, Tilburg, The Netherlands.
| | - Matthijs van den Berg
- Centre for Nutrition, Prevention and Health Services, National Institute of Public Health and the Environment, Bilthoven, The Netherlands.
| | - Simone R de Bruin
- Centre for Nutrition, Prevention and Health Services, National Institute of Public Health and the Environment, Bilthoven, The Netherlands.
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Lette M, Baan CA, van den Berg M, de Bruin SR. Initiatives on early detection and intervention to proactively identify health and social problems in older people: experiences from the Netherlands. BMC Geriatr 2015. [PMID: 26518369 DOI: 10.1186/s12877-12015-10131-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2023] Open
Abstract
BACKGROUND Over the last years, several initiatives on early detection and intervention have been put in place to proactively identify health and social problems in (frail) older people. An overview of the initiatives currently available in the Netherlands is lacking, and it is unknown whether they meet the preferences and needs of older people. Therefore, the objectives of this study were threefold: 1. To identify initiatives on early detection and intervention for older people in the Netherlands and compare their characteristics; 2. To explore the experiences of professionals with these initiatives; and 3. To explore to what extent existing initiatives meet the preferences and needs of older people. METHODS We performed a qualitative descriptive study in which we conducted semi-structured interviews with seventeen experts in preventive elderly care and three group interviews with volunteer elderly advisors. Data were analysed using the framework analysis method. RESULTS We identified eight categories of initiatives based on the setting (e.g. general practitioner practice, hospital, municipality) in which they were offered. Initiatives differed in their aims and target groups. The utilization of peers to identify problems and risks, as was done by some initiatives, was seen as a strength. Difficulties were experienced with identifying the target group that would benefit from proactive delivery of care and support most, and with addressing prevalent issues among older people (e.g. psychosocial issues, self-reliance issues). CONCLUSION Although there is a broad array of initiatives available, there is a discrepancy between supply and demand. Current initiatives insufficiently address needs of (frail) older people. More insight is needed in "what should be done by whom, for which target group and at what moment", in order to improve current practice in preventive elderly care.
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Affiliation(s)
- Manon Lette
- Centre for Nutrition, Prevention and Health Services, National Institute of Public Health and the Environment, Bilthoven, The Netherlands.
| | - Caroline A Baan
- Centre for Nutrition, Prevention and Health Services, National Institute of Public Health and the Environment, Bilthoven, The Netherlands.
- Scientific Centre for Transformation in Care and Welfare (Tranzo), University of Tilburg, Tilburg, The Netherlands.
| | - Matthijs van den Berg
- Centre for Nutrition, Prevention and Health Services, National Institute of Public Health and the Environment, Bilthoven, The Netherlands.
| | - Simone R de Bruin
- Centre for Nutrition, Prevention and Health Services, National Institute of Public Health and the Environment, Bilthoven, The Netherlands.
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Measured outcomes of chronic care programs for older adults: a systematic review. BMC Geriatr 2015; 15:139. [PMID: 26503159 PMCID: PMC4621859 DOI: 10.1186/s12877-015-0136-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 10/19/2015] [Indexed: 11/10/2022] Open
Abstract
Background Wagner’s Chronic Care Model (CCM), as well as the expanded version (ECCM) developed by Barr and colleagues, have been widely adopted as frameworks for prevention and management of chronic disease. Given the high prevalence of chronic illness in older persons, these frameworks can play a valuable role in reorienting the health care system to better serve the needs of seniors. We aimed to identify and assess the measured goals of E/CCM interventions in older populations. In particular, our objective was to determine the extent to which published E/CCM initiatives were evaluated based on population, community, system and individual-level outcomes (including clinical, functional and quality of life measures). Methods We conducted a systematic search of the Science Citation Index Web of Knowledge search tool to gather articles published between January 2003 and July 2014. We included published CCM interventions that cited at least one of the fundamental papers that introduced and described the CCM and ECCM. Studies retained for review reported evaluations of senior-focused E/CCM initiatives in community-based settings, with the topic of “older adults” OR senior* OR elder* OR geriatric OR aged. The resulting 619 published articles were independently reviewed for inclusion by two researchers. We excluded the following: systematic reviews, meta-analyses, descriptions of proposed programs, and studies whose populations did not focus on seniors. Results We identified 14 articles that met inclusion criteria. Studies used a wide range of measures, with little consensus between studies. All of the included studies used the original CCM. While a range of system-level and individual patient outcomes have been used to evaluate CCM interventions, no studies employed measures of population or community health outcomes. Conclusions Future efforts to test E/CCM interventions with seniors would be aided by more consistent outcome measures, greater attention to outcomes for the caregivers of older persons with chronic illness, and a greater focus on population and community impacts.
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Tranmer JE, Colley L, Edge DS, Sears K, VanDenKerkhof E, Levesque L. Trends in nurse practitioners' prescribing to older adults in Ontario, 2000-2010: a retrospective cohort study. CMAJ Open 2015; 3:E299-304. [PMID: 26457291 PMCID: PMC4596118 DOI: 10.9778/cmajo.20150029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Nurse prescribing is a practice that has evolved and will continue to evolve in response to emerging trends, particularly in primary care. The goal of this study was to describe the trends and patterns in medication prescription to adults 65 years of age or older in Ontario by nurse practitioners over a 10-year period. METHODS We conducted a population-based descriptive retrospective cohort study. All nurse practitioners registered in the Corporate Provider Database between Jan. 1, 2000, and Dec. 31, 2010, were identified. We identified actively prescribing nurse practitioners through linkage of dispensed medications to people aged 65 years or older from the Ontario Drug Benefit database. For comparison, all prescription medications dispensed by family physicians to a similar group were identified. Geographic location was determined based on site of nurse practitioner practice. RESULTS The number and proportion of actively prescribing nurse practitioners prescribing to older adults increased during the study period, from 44/340 (12.9%) to 888/1423 (62.4%). The number and proportion of medications dispensed for chronic conditions by nurse practitioners increased: in 2010, 9 of the 10 top medications dispensed were for chronic conditions. There was substantial variation in the proportion of nurse practitioners dispensing medication to older adults across provincial Local Health Integration Networks. INTERPRETATION Prescribing by nurse practitioners to older adults, particularly of medications related to chronic conditions, increased between 2000 and 2010. The integration of nurse practitioners into primary care has not been consistent across the province and has not occurred in relation to population changes and perhaps population needs.
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Affiliation(s)
- Joan E Tranmer
- School of Nursing (Tranmer, Edge, Sears, VanDenKerkhof); Department of Public Health Sciences (Tranmer, Colley, Levesque); Department of Anaesthesiology and Perioperative Medicine (VanDenKerkhof), Queen's University, Kingston, Ont
| | - Lindsey Colley
- School of Nursing (Tranmer, Edge, Sears, VanDenKerkhof); Department of Public Health Sciences (Tranmer, Colley, Levesque); Department of Anaesthesiology and Perioperative Medicine (VanDenKerkhof), Queen's University, Kingston, Ont
| | - Dana S Edge
- School of Nursing (Tranmer, Edge, Sears, VanDenKerkhof); Department of Public Health Sciences (Tranmer, Colley, Levesque); Department of Anaesthesiology and Perioperative Medicine (VanDenKerkhof), Queen's University, Kingston, Ont
| | - Kim Sears
- School of Nursing (Tranmer, Edge, Sears, VanDenKerkhof); Department of Public Health Sciences (Tranmer, Colley, Levesque); Department of Anaesthesiology and Perioperative Medicine (VanDenKerkhof), Queen's University, Kingston, Ont
| | - Elizabeth VanDenKerkhof
- School of Nursing (Tranmer, Edge, Sears, VanDenKerkhof); Department of Public Health Sciences (Tranmer, Colley, Levesque); Department of Anaesthesiology and Perioperative Medicine (VanDenKerkhof), Queen's University, Kingston, Ont
| | - Linda Levesque
- School of Nursing (Tranmer, Edge, Sears, VanDenKerkhof); Department of Public Health Sciences (Tranmer, Colley, Levesque); Department of Anaesthesiology and Perioperative Medicine (VanDenKerkhof), Queen's University, Kingston, Ont
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van Leeuwen KM, Jansen APD, Muntinga ME, Bosmans JE, Westerman MJ, van Tulder MW, van der Horst HE. Exploration of the content validity and feasibility of the EQ-5D-3L, ICECAP-O and ASCOT in older adults. BMC Health Serv Res 2015; 15:201. [PMID: 25976227 PMCID: PMC4435604 DOI: 10.1186/s12913-015-0862-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 05/05/2015] [Indexed: 11/30/2022] Open
Abstract
Background In economic evaluations of care services for older adults health-related quality of life (QoL) measures such as the EQ-5D are increasingly replaced by the ICECAP-O and ASCOT, which cover a broader scope of QoL than health alone. Little is known about the content validity and feasibility of these measures. The purpose of this study was to explore the content validity and feasibility of the EQ-5D-3L, ICECAP-O and ASCOT in older adults. Methods Ten older adults were purposively sampled using a maximum variation principle. Think-aloud and verbal probing techniques were used to identify response issues encountered during the interpretation of items and the selection of response options. We used constant comparative methods to analyse the data. Results Two types of response issues were identified for various items in all three measures: interpretation issues and positive responses. Issues with the mapping of a response on one of the response options were least often encountered for the EQ-5D-3L items. Older adults considered the items of the ICECAP-O and ASCOT valuable though more abstract than the EQ-5D-3L. Conclusions Researchers who intend to use the EQ-5D, ICECAP-O or ASCOT in economic evaluations of care services for older adults, should be aware of the response issues that occur during the administration of these measures. Older adults perceived none of the measures as providing a comprehensive picture of their QoL. A preference from older adults for one of the measures depends on the extent to which the items reflect current personal concerns in life.
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Affiliation(s)
- Karen M van Leeuwen
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands. .,Department of Health Sciences and EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
| | - Aaltje P D Jansen
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
| | - Maaike E Muntinga
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands. .,Department of Medical Humanities and EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
| | - Judith E Bosmans
- Department of Health Sciences and EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
| | - Marjan J Westerman
- Department of Health Sciences and EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
| | - Maurits W van Tulder
- Department of Health Sciences and EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
| | - Henriette E van der Horst
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
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van Leeuwen KM, Bosmans JE, Jansen AP, Rand SE, Towers AM, Smith N, Razik K, Trukeschitz B, van Tulder MW, van der Horst HE, Ostelo RW. Dutch translation and cross-cultural validation of the Adult Social Care Outcomes Toolkit (ASCOT). Health Qual Life Outcomes 2015; 13:56. [PMID: 25963944 PMCID: PMC4427948 DOI: 10.1186/s12955-015-0249-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 03/17/2015] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The Adult Social Care Outcomes Toolkit was developed to measure outcomes of social care in England. In this study, we translated the four level self-completion version (SCT-4) of the ASCOT for use in the Netherlands and performed a cross-cultural validation. METHODS The ASCOT SCT-4 was translated into Dutch following international guidelines, including two forward and back translations. The resulting version was pilot tested among frail older adults using think-aloud interviews. Furthermore, using a subsample of the Dutch ACT-study, we investigated test-retest reliability and construct validity and compared response distributions with data from a comparable English study. RESULTS The pilot tests showed that translated items were in general understood as intended, that most items were reliable, and that the response distributions of the Dutch translation and associations with other measures were comparable to the original English version. Based on the results of the pilot tests, some small modifications and a revision of the Dignity items were proposed for the final translation, which were approved by the ASCOT development team. The complete original English version and the final Dutch translation can be obtained after registration on the ASCOT website ( http://www.pssru.ac.uk/ascot ). CONCLUSIONS This study provides preliminary evidence that the Dutch translation of the ASCOT is valid, reliable and comparable to the original English version. We recommend further research to confirm the validity of the modified Dutch ASCOT translation.
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Affiliation(s)
- Karen M van Leeuwen
- Department of General Practice & Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
- Department of Health Sciences and EMGO Institute for Health and Care Research, Faculty of Earth & Life Sciences, VU University, Amsterdam, The Netherlands.
| | - Judith E Bosmans
- Department of Health Sciences and EMGO Institute for Health and Care Research, Faculty of Earth & Life Sciences, VU University, Amsterdam, The Netherlands.
| | - Aaltje Pd Jansen
- Department of General Practice & Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Stacey E Rand
- Personal Social Services Research Unit and Quality and Outcomes of Person-Centred Care Research Unit, University of Kent, Canterbury, Kent, UK.
| | - Ann-Marie Towers
- Personal Social Services Research Unit and Quality and Outcomes of Person-Centred Care Research Unit, University of Kent, Canterbury, Kent, UK.
| | - Nick Smith
- Personal Social Services Research Unit and Quality and Outcomes of Person-Centred Care Research Unit, University of Kent, Canterbury, Kent, UK.
| | - Kamilla Razik
- Personal Social Services Research Unit and Quality and Outcomes of Person-Centred Care Research Unit, University of Kent, Canterbury, Kent, UK.
| | - Birgit Trukeschitz
- Research Institute for Economics of Aging, WU Vienna University of Economics and Business, Vienna, Austria.
| | - Maurits W van Tulder
- Department of Health Sciences and EMGO Institute for Health and Care Research, Faculty of Earth & Life Sciences, VU University, Amsterdam, The Netherlands.
| | - Henriette E van der Horst
- Department of General Practice & Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Raymond W Ostelo
- Department of Health Sciences and EMGO Institute for Health and Care Research, Faculty of Earth & Life Sciences, VU University, Amsterdam, The Netherlands.
- Department of Epidemiology & Biostatistics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
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Herr M, Robine JM, Pinot J, Arvieu JJ, Ankri J. Polypharmacy and frailty: prevalence, relationship, and impact on mortality in a French sample of 2350 old people. Pharmacoepidemiol Drug Saf 2015; 24:637-46. [PMID: 25858336 DOI: 10.1002/pds.3772] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 02/09/2015] [Accepted: 02/24/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE To assess the prevalence of polypharmacy and frailty, to examine their association, and to establish their independent and combined effects on mortality in a sample of French old people. METHODS This is a cross-sectional population study of people aged 70 years and over. A total of 2350 respondents were interviewed at home in 2008-2010. Frailty was defined as impairment in three domains or more among nutrition, energy, physical activity, strength, and mobility, in the absence of difficulties in basic activities of daily living. Mortality data were documented after a mean follow-up period of 2.6 years. RESULTS Mean age of the population was 83.3 +/- 7.5 years, with 59.4% of women. Prevalence of frailty was 17.0%. Polypharmacy (5-9 drugs) was reported in 53.6% of the population, and excessive polypharmacy (10 drugs or more) in 13.8%. After adjustment for socio-demographic and health variables, polypharmacy and excessive polypharmacy were associated with frailty with odds ratio 1.77 [1.20-2.61] and 4.47 [2.37-8.42], respectively. Frailty (hazard ratio [HR] 2.56 [1.63-4.04]) and excessive polypharmacy (HR 1.83 [1.28-2.62]) were independent predictors of mortality. Compared with non-frail people without polypharmacy, frail people with excessive polypharmacy were six times more likely to die during the follow-up period (HR 6.30 [3.09-12.84]). CONCLUSION By showing the independent and combined effects of polypharmacy and frailty on mortality risk, this study should reinforce the awareness of clinicians with regard to these factors, rather prevalent in old people.
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Affiliation(s)
- Marie Herr
- INSERM, VIMA: Aging and Chronic Diseases. Epidemiological and Public Health Approaches, U1168, Villejuif, France.,UVSQ, UMR-S 1168, Université Versailles St-Quentin-en-Yvelines, France
| | | | - Juliette Pinot
- INSERM, VIMA: Aging and Chronic Diseases. Epidemiological and Public Health Approaches, U1168, Villejuif, France.,UVSQ, UMR-S 1168, Université Versailles St-Quentin-en-Yvelines, France
| | - Jean-Jacques Arvieu
- AG2R La Mondiale, Direction des Etudes, Prévoyance Individuelle et IARD, Paris, France
| | - Joël Ankri
- INSERM, VIMA: Aging and Chronic Diseases. Epidemiological and Public Health Approaches, U1168, Villejuif, France.,UVSQ, UMR-S 1168, Université Versailles St-Quentin-en-Yvelines, France
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Fatemi Y, Jacobson RM. The stepped wedge cluster randomized trial and its potential for child health services research: a narrative review. Acad Pediatr 2015; 15:128-33. [PMID: 25613913 DOI: 10.1016/j.acap.2014.10.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 10/13/2014] [Accepted: 10/26/2014] [Indexed: 11/25/2022]
Affiliation(s)
| | - Robert M Jacobson
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn.
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From concept to content: assessing the implementation fidelity of a chronic care model for frail, older people who live at home. BMC Health Serv Res 2015; 15:18. [PMID: 25608876 PMCID: PMC4312437 DOI: 10.1186/s12913-014-0662-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 12/15/2014] [Indexed: 11/25/2022] Open
Abstract
Background Implementation fidelity, the degree to which a care program is implemented as intended, can influence program impact. Since results of trials that aim to implement comprehensive care programs for frail, older people have been conflicting, assessing implementation fidelity alongside these trials is essential to differentiate between flaws inherent to the program and implementation issues. This study demonstrates how a theory-based assessment of fidelity can increase insight in the implementation process of a complex intervention in primary elderly care. Methods The Geriatric Care Model was implemented among 35 primary care practices in the Netherlands. During home visits, practice nurses conducted a comprehensive geriatric assessment and wrote a tailored care plan. Multidisciplinary team consultations were organized with the aim to enhance the coordination between professionals caring for a single patient with complex needs. To assess fidelity, we identified 5 key intervention components and formulated corresponding research questions using Carroll’s framework for fidelity. Adherence (coverage, frequency, duration, content) was assessed per intervention component during and at the end of the intervention period. Two moderating factors (participant responsiveness and facilitation strategies) were assessed at the end of the intervention. Results Adherence to the geriatric assessments and care plans was high, but decreased over time. Adherence to multidisciplinary consultations was initially poor, but increased over time. We found that individual differences in adherence between practice nurses and primary care physicians were moderate, while differences in participant responsiveness (satisfaction, involvement) were more distinct. Nurses deviated from protocol due to contextual factors and personal work routines. Conclusions Adherence to the Geriatric Care Model was high for most of the essential intervention components. Study limitations include the limited number of assessed moderating factors. We argue that a longitudinal investigation of adherence per intervention component is essential for a complete understanding of the implementation process, but that such investigations may be complicated by practical and methodological challenges. Trial registration The Netherlands National Trial Register (NTR). Trial number: 2160.
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37
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van Leeuwen KM, Bosmans JE, Jansen APD, Hoogendijk EO, van Tulder MW, van der Horst HE, Ostelo RW. Comparing measurement properties of the EQ-5D-3L, ICECAP-O, and ASCOT in frail older adults. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:35-43. [PMID: 25595232 DOI: 10.1016/j.jval.2014.09.006] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 07/22/2014] [Accepted: 09/30/2014] [Indexed: 05/14/2023]
Abstract
BACKGROUND The ICEpop CAPability measure for Older people (ICECAP-O) and the Adult Social Care Outcomes Toolkit (ASCOT) are preference-based measures for assessing quality of life (QOL) from a broader perspective than do traditional health-related QOL measures such as the EuroQol five-dimensional questionnaire (EQ-5D). Measurement properties of these instruments have not yet been directly compared. OBJECTIVE The purpose of this study was to compare the test-retest reliability, construct validity, and responsiveness of the three-level EQ-5D (EQ-5D-3L), ICECAP-O, and ASCOT in frail older adults living at home. METHODS Cross-sectional data and longitudinal data were used. Parameters for reliability (the intraclass correlation coefficient) and agreement (standard error of measurement) were used to assess test-retest reliability after 1 week. We formulated hypotheses about correlations with other measures and tested these to assess construct validity and responsiveness (longitudinal validity). RESULTS The reliability parameters for all three scales were considered good (intraclass correlation coefficient values above 0.70). Standard error of measurement values were less than 10% of the scale. Hypotheses regarding construct validity were in general accepted; the EQ-5D-3L was more strongly associated with physical limitations than were ICECAP-O and ASCOT and less strongly with instruments measuring aspects beyond health. Longitudinally, as hypothesized, mental health was most strongly associated with ICECAP-O, and self-perceived QOL, mastery, and client-centeredness of home care most strongly with ASCOT. CONCLUSIONS Our findings support the adoption of ICECAP-O and ASCOT as outcome measures in economic evaluations of care interventions for older adults that have a broader aim than health-related QOL because they are at least as reliable as the EQ-5D-3L and are associated with aspects of QOL broader than health.
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Affiliation(s)
- Karen M van Leeuwen
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
| | - Judith E Bosmans
- Department of Health Sciences and EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University, Amsterdam, The Netherlands
| | - Aaltje P D Jansen
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Emiel O Hoogendijk
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences and EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University, Amsterdam, The Netherlands
| | - Henriette E van der Horst
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Raymond W Ostelo
- Department of Health Sciences and EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2014:CD008165. [PMID: 25288041 DOI: 10.1002/14651858.cd008165.pub3] [Citation(s) in RCA: 187] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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. OBJECTIVES This review sought 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 In November 2013, for this first update, a range of literature databases including MEDLINE and EMBASE were searched, and handsearching of reference lists was performed. Search terms included 'polypharmacy', 'medication appropriateness' and 'inappropriate prescribing'. SELECTION CRITERIA A range of study designs were eligible. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people 65 years of age and older in which a validated measure of appropriateness was used (e.g. Beers criteria, Medication Appropriateness Index (MAI)). DATA COLLECTION AND ANALYSIS Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. Study-specific estimates were pooled, and a random-effects model was used to yield summary estimates of effect and 95% confidence intervals (CIs). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall quality of evidence for each pooled outcome. MAIN RESULTS Two studies were added to this review to bring the total number of included studies to 12. One intervention consisted of computerised decision support; 11 complex, multi-faceted pharmaceutical approaches to interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals, such as prescribers and pharmacists. Appropriateness of prescribing was measured using validated tools, including the MAI score post intervention (eight studies), Beers criteria (four studies), STOPP criteria (two studies) and START criteria (one study). Interventions included in this review resulted in a reduction in inappropriate medication usage. Based on the GRADE approach, the overall quality of evidence for all pooled outcomes ranged from very low to low. A greater reduction in MAI scores between baseline and follow-up was seen in the intervention group when compared with the control group (four studies; mean difference -6.78, 95% CI -12.34 to -1.22). Postintervention pooled data showed a lower summated MAI score (five studies; mean difference -3.88, 95% CI -5.40 to -2.35) and fewer Beers drugs per participant (two studies; mean difference -0.1, 95% CI -0.28 to 0.09) in the intervention group compared with the control group. Evidence of the effects of interventions on hospital admissions (five studies) and of medication-related problems (six studies) was conflicting. AUTHORS' CONCLUSIONS It is unclear whether interventions to improve appropriate polypharmacy, such as pharmaceutical care, resulted in clinically significant improvement; however, they appear beneficial in terms of reducing inappropriate prescribing.
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Affiliation(s)
- Susan M Patterson
- No affiliation, 12-22 Linenhall Street, Belfast, Northern Ireland, UK, BT2 8BS
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Measurement properties of the Client-centered Care Questionnaire (CCCQ): factor structure, reliability and validity of a questionnaire to assess self-reported client-centeredness of home care services in a population of frail, older people. Qual Life Res 2014; 23:2063-72. [DOI: 10.1007/s11136-014-0650-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
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40
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Hoogendijk EO, Muntinga ME, van Leeuwen KM, van der Horst HE, Deeg DJ, Frijters DH, Hermsen LA, Jansen AP, Nijpels G, van Hout HP. Self-perceived met and unmet care needs of frail older adults in primary care. Arch Gerontol Geriatr 2014; 58:37-42. [DOI: 10.1016/j.archger.2013.09.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 09/03/2013] [Accepted: 09/05/2013] [Indexed: 01/21/2023]
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Ness KK, Krull KR, Jones KE, Mulrooney DA, Armstrong GT, Green DM, Chemaitilly W, Smith WA, Wilson CL, Sklar CA, Shelton K, Srivastava DK, Ali S, Robison LL, Hudson MM. Physiologic frailty as a sign of accelerated aging among adult survivors of childhood cancer: a report from the St Jude Lifetime cohort study. J Clin Oncol 2013; 31:4496-503. [PMID: 24248696 PMCID: PMC3871511 DOI: 10.1200/jco.2013.52.2268] [Citation(s) in RCA: 213] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Frailty, a phenotype reported among 9.9% of individuals 65 years old and older (9.6% of women; 5.2% of men), has not been assessed among adult childhood cancer survivors (CCS). We estimated the prevalence of frailty and examined associations with morbidity and mortality. METHODS Participants included 1,922 CCS at least 10 years from original cancer diagnosis (men, 50.3%; mean age, 33.6 ± 8.1 years) and a comparison population of 341 participants without cancer histories. Prefrailty and frailty were defined as two and ≥ three of the following conditions: low muscle mass, self-reported exhaustion, low energy expenditure, slow walking speed, and weakness. Morbidity was defined as grade 3 to 4 chronic conditions (Common Terminology Criteria for Adverse Events version 4.0). Fisher's exact tests were used to compare, by frailty status, percentages of those with morbidity. In a subset of 162 CCS who returned for a second visit, Poisson regression was used to evaluate associations between frailty and new onset morbidity. Cox proportional hazards regression was used to evaluate associations between frailty and death. RESULTS The prevalence of prefrailty and frailty were 31.5% and 13.1% among women and 12.9% and 2.7% among men, respectively, with prevalence increasing with age. Frail CCS were more likely than nonfrail survivors to have a chronic condition (82.1% v 73.8%). In models adjusted for existing chronic conditions, baseline frailty was associated with risk of death (hazard ratio, 2.6; 95% CI, 1.2 to 6.2) and chronic condition onset (relative risk, 2.2; 95% CI, 1.2 to 4.2). CONCLUSION The prevalence of frailty among young adult CCS is similar to that among adults 65 years old and older, suggesting accelerated aging.
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Affiliation(s)
- Kirsten K. Ness
- Kirsten K. Ness, Kevin R. Krull, Kendra E. Jones, Daniel A. Mulrooney, Gregory T. Armstrong, Daniel M. Green, Wassim Chemaitilly, Webb A. Smith, Carmen L. Wilson, Kyla Shelton, Deo Kumar Srivastava, Sabeen Ali, Leslie L. Robison, Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Kevin R. Krull
- Kirsten K. Ness, Kevin R. Krull, Kendra E. Jones, Daniel A. Mulrooney, Gregory T. Armstrong, Daniel M. Green, Wassim Chemaitilly, Webb A. Smith, Carmen L. Wilson, Kyla Shelton, Deo Kumar Srivastava, Sabeen Ali, Leslie L. Robison, Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Kendra E. Jones
- Kirsten K. Ness, Kevin R. Krull, Kendra E. Jones, Daniel A. Mulrooney, Gregory T. Armstrong, Daniel M. Green, Wassim Chemaitilly, Webb A. Smith, Carmen L. Wilson, Kyla Shelton, Deo Kumar Srivastava, Sabeen Ali, Leslie L. Robison, Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Daniel A. Mulrooney
- Kirsten K. Ness, Kevin R. Krull, Kendra E. Jones, Daniel A. Mulrooney, Gregory T. Armstrong, Daniel M. Green, Wassim Chemaitilly, Webb A. Smith, Carmen L. Wilson, Kyla Shelton, Deo Kumar Srivastava, Sabeen Ali, Leslie L. Robison, Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Gregory T. Armstrong
- Kirsten K. Ness, Kevin R. Krull, Kendra E. Jones, Daniel A. Mulrooney, Gregory T. Armstrong, Daniel M. Green, Wassim Chemaitilly, Webb A. Smith, Carmen L. Wilson, Kyla Shelton, Deo Kumar Srivastava, Sabeen Ali, Leslie L. Robison, Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Daniel M. Green
- Kirsten K. Ness, Kevin R. Krull, Kendra E. Jones, Daniel A. Mulrooney, Gregory T. Armstrong, Daniel M. Green, Wassim Chemaitilly, Webb A. Smith, Carmen L. Wilson, Kyla Shelton, Deo Kumar Srivastava, Sabeen Ali, Leslie L. Robison, Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Wassim Chemaitilly
- Kirsten K. Ness, Kevin R. Krull, Kendra E. Jones, Daniel A. Mulrooney, Gregory T. Armstrong, Daniel M. Green, Wassim Chemaitilly, Webb A. Smith, Carmen L. Wilson, Kyla Shelton, Deo Kumar Srivastava, Sabeen Ali, Leslie L. Robison, Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Webb A. Smith
- Kirsten K. Ness, Kevin R. Krull, Kendra E. Jones, Daniel A. Mulrooney, Gregory T. Armstrong, Daniel M. Green, Wassim Chemaitilly, Webb A. Smith, Carmen L. Wilson, Kyla Shelton, Deo Kumar Srivastava, Sabeen Ali, Leslie L. Robison, Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Carmen L. Wilson
- Kirsten K. Ness, Kevin R. Krull, Kendra E. Jones, Daniel A. Mulrooney, Gregory T. Armstrong, Daniel M. Green, Wassim Chemaitilly, Webb A. Smith, Carmen L. Wilson, Kyla Shelton, Deo Kumar Srivastava, Sabeen Ali, Leslie L. Robison, Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Charles A. Sklar
- Kirsten K. Ness, Kevin R. Krull, Kendra E. Jones, Daniel A. Mulrooney, Gregory T. Armstrong, Daniel M. Green, Wassim Chemaitilly, Webb A. Smith, Carmen L. Wilson, Kyla Shelton, Deo Kumar Srivastava, Sabeen Ali, Leslie L. Robison, Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Kyla Shelton
- Kirsten K. Ness, Kevin R. Krull, Kendra E. Jones, Daniel A. Mulrooney, Gregory T. Armstrong, Daniel M. Green, Wassim Chemaitilly, Webb A. Smith, Carmen L. Wilson, Kyla Shelton, Deo Kumar Srivastava, Sabeen Ali, Leslie L. Robison, Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Deo Kumar Srivastava
- Kirsten K. Ness, Kevin R. Krull, Kendra E. Jones, Daniel A. Mulrooney, Gregory T. Armstrong, Daniel M. Green, Wassim Chemaitilly, Webb A. Smith, Carmen L. Wilson, Kyla Shelton, Deo Kumar Srivastava, Sabeen Ali, Leslie L. Robison, Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Sabeen Ali
- Kirsten K. Ness, Kevin R. Krull, Kendra E. Jones, Daniel A. Mulrooney, Gregory T. Armstrong, Daniel M. Green, Wassim Chemaitilly, Webb A. Smith, Carmen L. Wilson, Kyla Shelton, Deo Kumar Srivastava, Sabeen Ali, Leslie L. Robison, Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Leslie L. Robison
- Kirsten K. Ness, Kevin R. Krull, Kendra E. Jones, Daniel A. Mulrooney, Gregory T. Armstrong, Daniel M. Green, Wassim Chemaitilly, Webb A. Smith, Carmen L. Wilson, Kyla Shelton, Deo Kumar Srivastava, Sabeen Ali, Leslie L. Robison, Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Melissa M. Hudson
- Kirsten K. Ness, Kevin R. Krull, Kendra E. Jones, Daniel A. Mulrooney, Gregory T. Armstrong, Daniel M. Green, Wassim Chemaitilly, Webb A. Smith, Carmen L. Wilson, Kyla Shelton, Deo Kumar Srivastava, Sabeen Ali, Leslie L. Robison, Melissa M. Hudson, St Jude Children's Research Hospital, Memphis, TN; Charles A. Sklar, Memorial Sloan-Kettering Cancer Center, New York, NY
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