Low patient activation levels in frail older adults: a cross-sectional study

Does patient activation matter? An examination of the relationships between patient activation and healthcare use in older adults with mild frailty after discharge from an emergency department

Objective Patient engagement, as measured by the Patient Activation Measure (PAM® ), has been used to assess patients' ability to manage their own care. This study aimed to determine whether the PAM® could predict healthcare use in older adults aged >70years, living independently in the community with mild frailty, within 30days after emergency department (ED) discharge. Methods A prospective single-centre observational cohort study was completed including older adults who presented to an ED. The 13-item PAM® and selected International Consortium for Health Outcomes Measures were completed prior to ED discharge. Results Two hundred patients were recruited with a mean age of 84.8years (s.d. 6.9). The mean PAM® score was 58.6 (s.d. 13.3), with 12.5% at Level 1 (n =25), 40% at Level 2 (n =80), 34.5% at Level 3 (n =69) and 13.0% at Level 4 (n =26). The PAM® level was significantly associated with ED presentations in the past 6months (P =0.030). The PAM® level did not predict healthcare use within 30days of discharge consisting of time until ED representation (P =0.557), number of ED representations (P =0.560), number of hospital admissions (P =0.499), length of stay in hospital (P =0.254) and number of post-discharge contacts (P =0.667). Conclusions Overall, the PAM® did not predict prospective short-term healthcare use. However, the PAM® was significantly associated with 6-month previous ED use. With more than 50% of patients at Level 1 or 2, indicating lower capacity for self-management, tailored interventions are required to assist mildly frail patients to manage discharge care plans and engage in preventative strategies.

Effect of medication adherence on quality of life, activation measures, and health imagine in the elderly people: a cross-sectional study

BACKGROUND

Usually, old age brings a poor quality of life due to illness and frailty. To prolong their lives and ensure their survival, all elderly patients with chronic diseases must adhere to their medications. In our study, we investigate medication adherence for elderly patients and its impact on the general health of the patient.

METHODS

We implemented a cross-sectional survey-based study with four sections in April 2022 in Saudi Arabia. Data about the participants' demographic characteristics, the Morisky Medication Adherence Scale, Patient Activation Measure (PAM) 13, and EQ-5D-5 L.

RESULTS

A total of 421 patients participated in this study, their mean age was 60.4 years, and most of them were males. Most of our population is living independently 87.9%. The vast majority of people have a low adherence record in the Morisky Medication Adherence Scale (8-MMAS) classes (score = < 6). Moreover, the average PAM13 score is 51.93 (Level2) indicating a low level of confidence and sufficient knowledge to take action. Our analysis showed a significant correlation between socioeconomic status and medication adherence. Also, there was an association between housing status and medication adherence. On the other hand, we found no correlation between medication adherence and quality of life (QOL) by EQ-5D-5 L.

CONCLUSION

Medication adherence is directly affected by living arrangements, as patients who live with a caretaker who can remind them to take their medications at the appropriate times have better medication adherence than those who live alone. Medication adherence was also significantly influenced by socioeconomic status, perhaps as a result of psychological effects and the belief of the lower-salaried population that they would be unable to afford the additional money required to cure any comorbidities that arose as a result of the disease. On the other hand, we did not find any correlation between medication adherence and quality of life. Finally, awareness of the necessity of adherence to medication for the elderly is essential.

The impact of patient activation on the effectiveness of digital health remote post-discharge follow-up and same-day-discharge after elective colorectal surgery

BACKGROUND

Low patient activation (PA) is associated with worse postoperative outcomes, however, its impact on the effectiveness of digital health interventions is unknown. We sought to determine the impact of PA on the effectiveness of digital health application for remote post-discharge follow-up for patients undergoing elective colectomy.

METHODS

Data analysis included a control cohort (CC) of patients undergoing elective colorectal surgery from 10/2017 to 04/2018 without the digital health intervention and a digital application cohort (DAC) that received a smart phone application for remote post-discharge follow-up from 03/2021 to 08/2022, including a subset of same-day discharge (SDD) patients. PA was measured using the Patient Activation Measure (PAM; score 0-100) and categorized into low (< 55.1) and high (≥ 55.1). The PAM was administered 4-6 weeks before surgery in the DAC group and on postoperative day (POD) 1 in the CC group. The main outcome measure was 30-day emergency department (ED) visits.

RESULTS

A total of 164 patients were included (89DAC with 50 SDD, 75CC), with no differences in patient characteristics other than more stoma closures in the DAC group. Overall, 77% of patients had high PA level, with no difference between CC and DAC (77% vs. 81%, p = 0.25). There was no difference in ED visits between CC and DAC (19% vs. 18%, p = 0.90). Overall, low PA was associated more ED visits (29% vs 14%, p = 0.04). In the SDD subgroup, low PA patients had more ED visits (38% vs. 7%, p = 0.015). PA level did not affect app usage metrics. On multiple regression, only low PA remained independently associated with ED visits (OR 3.42, 95%CI 1.27, 9.24).

CONCLUSION

Low PA remains an important predictor of surgical outcomes after elective colorectal surgery regardless of the use of a digital health application for remote post-discharge follow-up. This suggests that improving PA levels may improve postoperative outcomes.

A codesigned integrated kidney and diabetes model of care improves patient activation among patients from culturally and linguistically diverse backgrounds

BACKGROUND

Little is known about the relationship between patients' cultural and linguistic backgrounds and patient activation, especially in people with diabetes and chronic kidney disease (CKD). We examined the association between culturally and linguistically diverse (CALD) background and patient activation and evaluated the impact of a codesigned integrated kidney and diabetes model of care on patient activation by CALD status in people with diabetes and CKD.

METHODS

This longitudinal study recruited adults with diabetes and CKD (Stage 3a or worse) who attended a new diabetes and kidney disease service at a tertiary hospital. All completed the patient activation measure at baseline and after 12 months and had demographic and clinical data collected. Patients from CALD backgrounds included individuals who spoke a language other than English at home, while those from non-CALD backgrounds spoke English only as their primary language. Paired t-tests compared baseline and 12-month patient activation scores by CALD status.

RESULTS

Patients from CALD backgrounds had lower activation scores (52.1 ± 17.6) compared to those from non-CALD backgrounds (58.5 ± 14.6) at baseline. Within-group comparisons showed that patient activation scores for patients from CALD backgrounds significantly improved by 7 points from baseline to 12 months follow-up (52.1 ± 17.6-59.4 ± 14.7), and no significant change was observed for those from non-CALD backgrounds (58.5 ± 14.6-58.8 ± 13.6).

CONCLUSIONS

Among patients with diabetes and CKD, those from CALD backgrounds report worse activation scores. Interventions that support people from CALD backgrounds with comorbid diabetes and CKD, such as the integrated kidney and diabetes model of care, may address racial and ethnic disparities that exist in patient activation and thus improve clinical outcomes.

PATIENT OR PUBLIC CONTRIBUTION

Patients, caregivers and national consumer advocacy organisations (Diabetes Australia and Kidney Health Australia) codesigned a new model of care in partnership with healthcare professionals and researchers. The development of the model of care was informed by focus groups of patients and healthcare professionals and semi-structured interviews of caregivers and healthcare professionals. Patients and caregivers also provided a rigorous evaluation of the new model of care, highlighting its strengths and weaknesses.

Status and factors associated with patient activation and its relationship with HIV clinic outcomes among Yi minority people living with HIV in Liangshan, China: a cross-sectional study

INTRODUCTION

Patient activation is determined by an individual's knowledge, skills and confidence in managing his/her health. It is vital for people living with HIV (PLWH) to enhance their self-management skills and health outcomes, especially those from low- and middle-income regions, since they are at higher risk of worse health outcomes. However, literature from those regions is limited, especially in China.

OBJECTIVES

This study aimed to explore the status and factors associated with patient activation among Yi minority PLWH in Liangshan, China and to determine whether patient activation is associated with HIV clinic outcomes.

METHODS

This cross-sectional study included 403 Yi minority people living with HIV in Liangshan between September and October 2021. All participants completed an anonymous survey measuring sociodemographic characteristics, HIV-related information, patient activation and illness perception. Multivariate linear regression and multivariate binary logistic regression were used to explore factors associated with patient activation and the association between patient activation and HIV outcomes, respectively.

RESULTS

The Patient Activation Measure (PAM) score was low (mean = 29.8, standard deviation = 4.1). Participants with negative illness perception, low income, and self-rated antiretroviral therapy (ART) effect based on self-perception were most likely to have a lower PAM score (β = -0.3, -0.2, -0.1, respectively; all p < 0.05); those with having disease knowledge learning experiences and an HIV-positive spouse were more likely to have a higher PAM score (β = 0.2, 0.2, respectively; both p < 0.001). A higher PAM score (AOR=1.08, 95% CI: 1.02, 1.14) was associated with viral suppression, mediated by gender (AOR=2.25, 95% CI: 1.38, 3.69).

CONCLUSION

Low patient activation level among Yi minority PLWH impacts HIV care. Our findings indicate patient activation is associated with viral suppression for minority PLWH in low- and middle-income settings, suggesting that tailored interventions enhancing patient activation may improve viral suppression.

Engagement in Primary Prevention Program among Rural Veterans With Osteoporosis Risk

A primary osteoporosis prevention program using a virtual bone health team (BHT) was implemented to comanage the care of rural veterans in the Mountain West region of the United States. The BHT identified, screened, and treated rural veterans at risk for osteoporosis using telephone and United States Postal Service communications. Eligibility was determined by regular use of Veterans Health Administration primary care, age 50 or older, and evidence of fracture risk. This study was conducted to identify demographic and clinical factors associated with the acceptance of osteoporosis screening and the initiation of medication where indicated. A cross-sectional cohort design (N = 6985) was utilized with a generalized estimating equation and logit link function to account for facility-level clustering. Fully saturated and reduced models were fitted using backward selection. Less than a quarter of eligible veterans enrolled in BHT's program and completed screening. Factors associated with a lower likelihood of clinic enrollment included being of older age, unmarried, greater distance from VHA services, having a copayment, prior fracture, or history of rheumatoid arthritis. A majority of veterans with treatment indication started medication therapy (N = 453). In this subpopulation, Fisher's exact test showed a significant association between osteoporosis treatment uptake and a history of two or more falls in the prior year, self-reported parental history of fracture, current smoking, and weight-bearing exercise. The BHT was designed to reduce barriers to screening; however, for this population cost and travel continue to limit engagement. The remarkable rate of medication initiation notwithstanding, low enrollment reduces the impact of this primary prevention program, and findings pertaining to fracture, smoking, and exercise imply that health beliefs are an important contributing factor. Efforts to identify and address barriers to osteoporosis screening and treatment, such as clinical factors, social determinants of health, and health beliefs, may pave the way for effective implementation of population bone health care delivery systems. Published 2022. This article is a U.S. Government work and is in the public domain in the USA. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Experiences of patients with multimorbidity with primary care and the association with patient activation: a cross-sectional study in Germany

OBJECTIVES

This study aimed to explore the association between patient activation and patients' experience of care among an elderly multimorbid population in Germany.

DESIGN

Cross-sectional study.

SETTING

Primary care practices in two German settings.

PARTICIPANTS

346 patients with 3 or more chronic conditions aged 65 years and over from 36 primary care practices.

OUTCOME MEASURES

Patient activation was measured with the patient activation measure (PAM). To assess patient experiences with primary care, a set of questions concerning domains of primary care were included. Multilevel regression analyses were performed to examine which domains of care were associated with patient activation.

RESULTS

Out of 1243 invited patients, a total of 346 took part in the study (participation rate 27.8 %). Mean PAM score was 76.1. Across all patients, 3.8% achieved PAM level 1, 7.5% level 2, 27.2% level 3% and 60.7% level 4. PAM scores suggest a highly activated patient group. In the regression analysis, three out ten domains of patients' experiences showed an association with patient activation. The domains 'being involved in decision as much as desired' (B=-8.56, p=0.012) and 'receiving a self-management plan' (B=6.51, p=0.051) were associated with higher patient activation scores. Patients with an up-to-date medication plan had lower patient activation scores (B=-12.01, p=0.041).

CONCLUSION

Specific domains of primary care were found to be associated with patient activation. To enhance patient activation, primary care physicians may increase involvement of patients in decisions. Future research should examine the causality of these associations.

TRIAL REGISTRATION NUMBER

DRKS00015718.

Patient activation for self-management among adult patients with multimorbidity in primary healthcare settings

Background and Aims

Multimorbidity is a major public health and healthcare challenge around the world, including in Finland. As multimorbidity necessitates self-management in everyday life, the effects of patient activation - a patient's knowledge, skills, and confidence in managing own health - on the capacity for self-management warrant study, especially in primary healthcare settings. This study aimed to assess patient activation among multimorbid primary healthcare patients, identify factors associated with patient activation, and determine whether patients with low and high activation differ in terms of health and self-management behavior, related perceptions, and health-related quality of life (HRQoL).

Methods

A cross-sectional survey was conducted among multimorbid patients who attended Finnish primary healthcare consultations (November 2019 to May 2020). The main outcome, patient activation, was assessed using the patient activation measure, PAM-13®. Responses from 122 patients were analyzed using descriptive statistics, t-tests, analysis of variance, linear modeling, the χ 2 test, and binary regression analysis.

Results

The mean score of patient activation was 56.12 (SD 12.82) on a scale 0-100 where ≤55.1 indicate low activation. The lower activation scores were significantly associated with old age, obesity, loneliness, and lower perceived health, functional ability, and vitality. Patients with low activation (47%) had significantly poorer physical activity, diets, adherence to care, and HRQoL, and significantly worse perceptions related to self-management including motivation and energy, sense of normality, and support from physicians, nurses, and close people.

Conclusion

Patient activation among multimorbid outpatients was rather low. Findings indicate that patients' perceptions of their health and psychosocial factors may be important for activation and that patients with low and high activation differ with respect to several health variables. Determining patient activation in multimorbid patients may facilitate adaptation of care to better meet patient capabilities and needs in clinical settings. Knowledge of a patient's activation level may also be useful when developing interventions and care strategies for this patient group.

A cross-sectional study of factors associated with regular dog walking and intention to walk the dog

BACKGROUND

Dog walking is important for public health and dog welfare, yet some owners do not walk with their dogs regularly. This study examined factors associated with participation in regular dog walking and intention to dog walk, in order to inform physical activity interventions.

METHODS

191 dog-owning adults from a UK community were surveyed about their participation in dog walking, intention to dog walk, attitudes and behavioural beliefs regarding dog walking, and dog and owner demographics. Principal components analysis identified owner profiles regarding attitudes and behavioural beliefs about dog walking. Univariable and multivariable logistic regression were used to identify factors associated with being a regular dog walker (achieving 150mins per week of dog walking) and having a high intention to dog walk (at least 30 mins per day for at least 5 days per week over the next month).

RESULTS

Participants walked with their dogs for a median 7 times/week and 230 total minutes/week; regular dog walkers 9 times/week (400 minutes/week), compared to twice/week for irregular dog walkers (45 minutes/week). Being a regular dog walker was positively associated with having a high level of intention to walk the dog in the next month (OR=12.1 95%CI=3.5-42.4, P<0.001), being married or living with a partner (OR=33.5, 95%CI=2.5-458.8, P=0.01), and higher scores on a dog walking habit index (OR=2.1, 95%CI=1.3-3.5, P<0.01). However, higher support from friends for walking was negatively associated with being a regular dog walker (OR=0.3, 95%CI=0.1-0.7, P<0.01). High intention to dog walk was associated with female owners (OR=4.7, 95%CI=1.2-18.5, P=0.03), dogs that lay on the sofa (OR=6.9, 95%CI=1.5-31.8, P=0.01), high levels of self-efficacy to walk the dog over the next month (OR=5.8, 95%CI=1.5-21.9, P=0.01), owner type with an attitude of high responsibility and enjoyment from walking (OR=2.1, 95%CI=1.2-3.8, P=0.02), and higher scores on a dog walking habit index (OR=1.9, 95%CI=1.0-3.7, P=0.05). Reporting someone else walks the dog was negatively associated with high intention (OR=0.1, 95%CI=0.0-0.7, P=0.02).

CONCLUSIONS

Interventions to promote dog walking may benefit from increasing intention to dog walk in male owners, forming schedules and routines that involve multiple household members in dog walking, and establishing habits around dog walking. Interventions may also need to address how to overcome barriers and perceived challenges in regards to self-efficacy of dog walking, that may prevent intention from being translated into action.

Improving Patient Activation among Older Veterans: Results from a Social Worker-Led Care Transitions Intervention

Older veterans enrolled in the Veterans Health Administration (VHA) often use both VHA and non-VHA providers for their care. This dual use, especially around an inpatient visit, can lead to fragmented care during the time of transition post-discharge. Interventions that target patient activation may be valuable ways to help veterans manage complex medication regimens and care plans from multiple providers. The Care Transitions Intervention (CTI) is an evidence-based model that helps older adults gain confidence and skills to achieve their health goals post-discharge. Our study examined the impact of CTI upon patient activation for veterans discharged from non-VHA hospitals. In total, 158 interventions were conducted for 87 veterans. From baseline to follow-up there was a significant 1.7-point increase in patient activation scores, from 5.4 to 7.1. This association was only found among those who completed the intervention. The most common barriers to completion were difficulty reaching the veteran by phone, patient declining the intervention, and rehospitalization during the 30 days post-discharge. Care transitions guided by social workers may be a promising way to improve patient activation. However, future research and practice should address barriers to completion and examine the impact of increased patient activation on health outcomes.

Nursing staff's experiences of how weighted blankets influence resident's in nursing homes expressions of health

Purpose

The most common treatment for resident’s health problems is pharmacological. Little research has been done on how an intervention with a non-pharmacological method, such as a weighted blanket, Through the nursing staff view, we can learn how weighted blankets influence resident’s health in nursing homes. The aim of this study was to explore nursing staff’s experiences of how an intervention with weighted blankets influenced resident’s expressions of health.

Methods

The study had a descriptive qualitative design with semi-structured interviews with 20 nursing staff working in nursing homes, and an inductive content analysis was applied.

Results

The nursing staff expressed that the weighted blanket positively influenced resident’s health in the areas of sleep, physical activity, and psychological behaviour. The weighted blanket made them fall asleep faster, sleep was uninterrupted andthey felt more rested in the morning. The nursing staff observed an increased level of activity as the resident became more energetic . The nursing staff also experienced reduced negative psychological behaviours like anxiety and worrying.

Conclusion

This study indicated that the weighted blanket changed the health expression of resident in several crucial areas. Deep pressure treatment indicates an alternative health-improved treatment for resident in nursing homes.

Self-management perspectives of elderly patients with multimorbidity and practitioners - status, challenges and further support needed?

Background

Patients with multimorbidity (here defined as three or more chronic conditions) require constant treatment and care. Furthermore, they have to manage their health and diseases in daily life. Offering support to patients’ medical self-management is an important task of primary care. The aim of this study was to explore, what further support is needed from the perspective of patients’ and primary care practitioners.

Methods

A qualitative study using individual semi-structed interviews with 17 patients with multimorbidity and 7 practitioners (4 primary care physicians and 3 practice assistants) was conducted in Germany. Data were audio-recorded, pseudonymised and transcribed verbatim. Data analysis was performed using qualitative content analysis to structure data into themes and subthemes. All data were managed and organised in MAXQDA.

Results

The three broad themes: current status, challenges and further support emerged. Patients reported on unfulfilled needs regarding role or emotional management, like coping with loneliness, loss of independence and, changing habits. The importance of social contact was highlighted by patients and practitioners. Patients articulated further support from their primary care practitioners on coping with the disease. Practitioners’ wished for further support in aspects of social participation, public transport, and community resources.

Conclusion

Challenges regarding self-management of elderly patients with multimorbidity may be addressed by harnessing social support and community initiatives.

Patient Activation for Self-Management in Patients with Idiopathic Pulmonary Fibrosis or Sarcoidosis

BACKGROUND

Self-management is considered important in the management of patients with idiopathic pulmonary fibrosis (IPF) or sarcoidosis. However, data about the degree of activation for self-management is lacking.

OBJECTIVES

The aim of the study was to determine the degree of activation for self-management in patients with IPF or sarcoidosis using the Patient Activation Measure (PAM) and to evaluate the association between PAM scores, clinical characteristics, and health-related outcomes.

STUDY DESIGN AND METHODS

This cross-sectional prospective study assessed besides the PAM also demographics, lung function, dyspnea (modified Medical Research Council [mMRC]), fatigue (Checklist Individual Strength-Fatigue [CIS-Fatigue]), anxiety/depression (Hospital Anxiety and Depression Scale [HADS-A/HADS-D]), and generic health status (EuroQol five-dimensional-five-level [EQ-5D-5L]).

RESULTS

Mean PAM was 55.0 (9.1) points in patients with IPF (n = 59) and low levels of patient activation for self-management (PAM ≤55.1 points) were present in 56% of the patients. PAM Scores correlated significantly (p < 0.05) with mMRC (ρ = -0.476), HADS-A (ρ = -0.326), HADS-D (ρ = -0.459), and EQ-5D-5L (ρ = 0.393). In patients with sarcoidosis (n = 59), the mean PAM score was 55.7 (11.0) points, and 46% of the patients reported low PAM levels. Significant correlations were found with mMRC (ρ = -0.356), HADS-A (ρ = -0.394), HADS-D (ρ = -0.478), and EQ-5D-5L (ρ = 0.313).

CONCLUSION

About half of the outpatients with IPF or sarcoidosis have a low degree of activation for self-management, and these patients generally report more dyspnea, anxiety, depression, and a lower health status. Whether patients with a low degree of activation can be successful in self-managing their disease remains to be determined.

Factors of Anti-Vascular Endothelial Growth Factor Therapy Withdrawal in Patients with Neovascular Age-Related Macular Degeneration: Implications for Improving Patient Adherence

We investigated the factors associated with the discontinuation of anti-vascular endothelial growth factor (VEGF) therapies in patients with neovascular age-related macular degeneration (AMD). Japanese patients with AMD aged ≥50 years, reporting at least one prior injection of an anti-VEGF drug, completed an online survey covering reasons for discontinuation or dissatisfaction with therapy, quality of life (EQ-5D-5L) and patient activation (PAM-13). The respondents were divided into two cohorts: Cohort 1-patients who discontinued anti-VEGF therapy (n = 207); Cohort 2-patients continuing anti-VEGF therapy (n = 65). The most common reason for discontinuing therapy was the "doctor's decision" in 89.4% (Cohort 1-1). In the other 22 (10.6%) patients in Cohort 1 (Cohort 1-2), reasons included "no deterioration in vision", "financial burden" and "ineffective treatment". Patients in Cohort 2 were dissatisfied with "long waiting times" (77%), "financial burden" and "ineffective treatment". Pain/discomfort posed the greatest impact on quality of life. Only 5% of patients in Cohorts 1-1 and 2 and none in Cohort 1-2 were considered advocates for their own health. In conclusion, most patients who discontinued anti-VEGF therapy did so at their doctor's decision. Addressing the reasons associated with discontinuation or dissatisfaction with anti-VEGF therapies might help improve their continuation.

Home-based exercise for people living with frailty and chronic kidney disease: A mixed-methods pilot randomised controlled trial

Background

Frailty is associated with adverse health outcomes in people with chronic kidney disease (CKD). Evidence supporting targeted interventions is needed. This pilot randomised controlled trial (RCT) aimed to inform the design of a definitive RCT evaluating the effectiveness of a home-based exercise intervention for pre-frail and frail older adults with CKD.

Methods

Participants were recruited from nephrology outpatient clinics to this two-arm parallel group mixed-methods pilot RCT. Inclusion criteria were: ≥65 years old; CKD G3b-5; and Clinical Frailty Scale score ≥4. Participants categorised as pre-frail or frail using the Frailty Phenotype were randomised to a 12-week progressive multi-component home-based exercise programme or usual care. Primary outcome measures included eligibility, recruitment, adherence, outcome measure completion and participant attrition rate. Semi-structured interviews were conducted with participants to explore trial and intervention acceptability.

Results

Six hundred and sixty-five patients had an eligibility assessment with 217 (33%; 95% CI 29, 36) eligible. Thirty-five (16%; 95% CI 12, 22) participants were recruited. Six were categorised as robust and withdrawn prior to randomisation. Fifteen participants were randomised to exercise and 14 to usual care. Eleven (73%; 95% CI 45, 91) participants completed ≥2 exercise sessions/week. Retained participants completed all outcome measures (n = 21; 100%; 95% CI 81, 100). Eight (28%; 95% CI 13, 47) participants were withdrawn. Fifteen participated in interviews. Decision to participate/withdraw was influenced by perceived risk of exercise worsening symptoms. Participant perceived benefits included improved fitness, balance, strength, well-being, energy levels and confidence.

Conclusions

This pilot RCT demonstrates that progression to definitive RCT is possible provided recruitment and retention challenges are addressed. It has also provided preliminary evidence that home-based exercise may be beneficial for people living with frailty and CKD.

Trial registration

ISRCTN87708989; https://clinicaltrials.gov/.

Value-based chronic care model approach for vulnerable older patients with multiple chronic conditions

"Old age, itself, is not a disease" (Suborne 2007). The rising rate of the global aging population is predicted to create a health care crisis within the next three decades. Vulnerable older adults suffer from multiple chronic conditions (MCCs) in addition to cognitive and physical decline during the process of aging resulting in an inability to optimally achieve self-management. In terms of resource utilization, complex inpatient, and outpatient care results in higher physician visits, polypharmacy, and higher prescription costs. Health literacy has become known as an important social determinant of health affecting the older population. Both reductions in health literacy and self-management are associated with poorer health outcomes. The patient activation measure (PAM) has been coined "a vital sign" to ascertain a patient activation level throughout the continuum of care with the introduction of an intervention's progress. In this review, we conceptualize a systematic approach of the development of a "tailored" integrated community and care team to develop a partnership in assisting senior adults with MCCs. Through this intervention the value-based chronic care model (CCM) and PAM allows for an adaptable integration between the activated patient, their caregivers, and the community. The Model for Improvement (MFI) serves as a well-recognized technique for developing and executing quality improvement strategies in this "tailored" engaged and activated individual and community care team approach in achieving health outcomes and quality of life among the vulnerable older adult population worldwide.

Effectiveness of a nurse-led, face-to-face health coaching intervention in enhancing activation and secondary outcomes of primary care users with chronic conditions

Prevalence of chronic diseases and multimorbidity is rising, and it remains unclear what the best strategy is for activating people with chronic conditions in their self-care. We designed a two-group quasi-experimental time series trial to examine the effectiveness of a nurse-led, face-to-face, individually-tailored health coaching (HC) intervention in improving patient activation and secondary outcomes (self-efficacy, quality of life, anxiety and depression symptoms, medication adherence, hospitalization and emergency visits) among primary care users with chronic conditions. A total of 118 people with chronic conditions were recruited through a primary care center and allocated to either the intervention group (IG) (n = 58) or control group (CG) (n = 60). The IG received a nurse-led individually-tailored HC intervention involving 4-6 face-to-face multicomponent sessions covering six core activation topics. The CG received usual primary care. Data were collected at baseline, after the intervention (6 weeks after baseline for controls) and at 6 and 12 months from baseline. Compared with controls, the IG had significantly higher patient activation scores after the intervention (73.29 vs. 66.51, p = .006). However, this improvement was not maintained at follow-up and there were no significant differences in secondary outcomes across the study period. HC may be an effective strategy for achieving short-term improvements in the activation of primary care users with chronic conditions. Further studies with different methodological approaches are needed to elucidate how HC may improve and sustain changes in patient activation.

Patient Activation and its Predictors in Hospitalized Older Adults in Singapore

BACKGROUND

Patient activation is critical in hospitalized older adults preparing for discharge as it enhances their ability to self-care at home. Little is known about how person-centred care and demographic predictors could influence activation in Asian patients.

AIMS

To explore patient activation and its predictors in hospitalized older adults in Singapore.

METHODS

Multi-centre cross-sectional survey of hospitalized older adults. Multivariable analysis conducted with age, gender, education, socioeconomic status, functional dependency and perception of person-centred care as potential predictors to patient activation.

RESULTS

300 older adults were surveyed, 65% were at the top two levels of activation. Perception of person-centred nursing care was the strongest predictor with the largest effect on patient activation, (β=0.22, b=3.48, 95% CI:1.70-5.26, p<0.001). Other predictors were age, education, income and independence in care.

CONCLUSION

Our study highlights the importance of person-centred nursing care in raising patient activation in hospitalized older adults, enhancing their capacity to self-care.

Functional Independence in the Community Dwelling Older People: a Scoping Review

Ageing potentially poses a threat to independent functioning of older adults. Although clinicians commonly focus on physical factors limiting Functional Independence (FI), it is likely that personal and environmental interactions also seem important to maintain FI. Herewith, FI exceeds several professional borders and calls for a uniform, multidisciplinary interdisciplinary supported definition of FI. This study aims to provide such a definition of FI in community dwelling older people. A scoping review was performed. Pubmed/Medline, Psychinfo and CINAHL were searched for studies describing aspects of FI. A literature-based definition of FI was discussed by experts (n = 7), resulting in a formulated final definition of FI and insight into contributing factors to FI. A multidisciplinairy focusgroup a stakeholder consultation (n = 15) ensured clinical relevance for daily practice. Data from the focusgroup stakeholder consultation were analyzed by using Atlas.ti (version 8). Based on the literature search, 25 studies were included. FI was finally defined as “Functioning physically safely and independent from another person, within one’s own context”. The contributing factors of FI comprised physical capacity combined with coping, empowerment and health literacy. Moreover, the level of FI is influenced by someone’s own context. This study confirms the relevance of the physical aspect of FI, but additionally stresses the importance of psychological factors. In addition, this study shows that one’s context may affect the level of FI as well. This underlines the importance of a holistic view and calls for multidisciplinary interdisciplinary collaboration in community-dwelling older people.

Outcomes of a 12-month patient-centred medical home model in improving patient activation and self-management behaviours among primary care patients presenting with chronic diseases in Sydney, Australia: a before-and-after study

BACKGROUND

Studies report that increased levels of patient activation is associated with increased engagement with the health care system, better adherence to treatment protocols, and improved health outcomes. This study aims to evaluate the outcomes of a 12-month Patient-Centred Medical Home (PCMH) model called 'WellNet' on the activation levels of patients with one or more chronic diseases in general practices across Northern Sydney, Australia.

METHODS

A total of 636 patients aged 40 years and above with one or more chronic conditions consented to participate in the WellNet program which was delivered across six general practices in Northern Sydney, Australia. The WellNet intervention includes team-based care with general physicians and trained chronic disease management care coordinators collaborating with patients in designing a patient-tailored care plan with improved self-management support and care navigation according to the level of risk and health care needs. The level of patient activation was measured using the validated PAM 13-item scale at baseline and follow-up. A before and after case-series design was employed to determine the adjusted mean differences between baseline and 12-months using repeated measures analysis of covariance (ANCOVA). Additionally, the backward stepwise multivariable regression models were employed to identify significant predictors of activation at follow-up.

RESULTS

Of the 626 patients, 420 reported their PAM scores at follow-up. The mean (SD) baseline PAM score was 57.9 (13.0). The adjusted model showed significant mean difference in PAM scores by increase of 6.5 (95% CI 5.0-8.1; p-value< 0.001) after controlling for baseline covariates. The multivariable regression models showed that older age (B = - 0.14; 95% CI -0.28, - 0.01) and private insurance (uninsured patients) (B = - 3.41; 95% CI -6.50, - 0.32) were significantly associated with lower PAM scores at 12 months whereas higher baseline PAM score (B = 0.48; 95% CI 0.37, 0.59) was significantly associated with higher follow-up PAM score.

CONCLUSION

The WellNet study is the first of its kind in Australia to report on changes in the patient activation levels among patients with one or more chronic diseases. PCMH has the potential to improve patient activation and engagement which can lead to long-term health benefits and sustained self-management behaviours.

Meta-analysis and GRADE profiles of exercise interventions for falls prevention in long-term care facilities

AIMS

To provide a comprehensive collection of evidence on the effectiveness of exercise interventions to prevent falls and support clinical decision-making.

DESIGN

A systematic literature review and meta-analysis of randomized controlled trails were performed by combining trials from published systematic reviews and more recent ones from a separate literature search.

DATA SOURCES

The literature search was performed using PubMed, CINAHL, Cochrane Databases, and Google Scholar dating January 2007 - March 2018.

REVIEW METHODS

Comparable studies were pooled using the random-effects model. The GRADE approach was used to judge the evidence.

RESULTS

Exercises with a balance component or with technical devices reduced falls significantly, however, with low confidence in the evidence. The evidence indicated that exercises conducted longer than 6 months were beneficial. In frail residents, exercise interventions seemed to have substantially negative effects on falls.

CONCLUSIONS

Exercise interventions with technical devices, those with a balance component, and those performed longer than 6 months are recommended in long-term care settings. Frail residents need special attention when performing exercises due to their increased risk of falling.

IMPACT

Exercises with a balance component and exercises carried out with technical devices have beneficial effects, whereas exercises performed longer than 6 months are more effective than short-term performances. No significant reduction or decrease in the number of falls was found for exercise in cognitively impaired residents. In frail residents, however, the number of fall events increased substantially as a result of exercise interventions. The results of this review are useful for clinical decision-makers in long-term care facilities with regard to the planning and performance of exercise interventions for residents.

High Patient Activation Is Associated With Remission in Patients With Inflammatory Bowel Disease

BACKGROUND

High levels of patient activation (having the knowledge, skills, and confidence to effectively manage one's care), have been associated with improved outcomes in many chronic conditions. There have been few studies of the effects of activation in patients with inflammatory bowel disease (IBD). We performed a large, prospective Internet-based study to assess the relationship between patient activation level and clinical remission in patients with Crohn's disease or ulcerative colitis.

METHODS

We administered the Patient Activation Measure (Insignia Health) to 1486 cohort participants. Patients completed a follow-up survey within 13 months (median, 189 days). We collected demographic and clinical data; anxiety and depression were assessed using Patient-Reported Outcomes Measurement Information System instruments. We used bivariate analyses and multivariable logistic regression to identify characteristics associated with low or high patient activation and to evaluate the association between levels of patient activation and subsequent disease activity.

RESULTS

Higher anxiety (adjusted odds ratio [aOR], 0.32; 95% confidence interval [CI], 0.29-0.36) and depression (aOR, 0.33; 95% CI, 0.29-0.37) scores were associated with a decreased odds of high patient activation. After we adjusted for education status, smoking, medication use, and other confounders, we found that patients with high activation at baseline were more likely to be in clinical remission during the follow-up period (aOR, 1.71; 95% CI, 1.20-2.45).

CONCLUSIONS

In a large, prospective Internet-based cohort of patients with IBD, we found a strong association between patient activation and clinical remission. These findings suggest that patient activation affects disease outcomes.

Patient "Activation" of Patients Referred for Advanced Heart Failure Therapy

Advanced heart failure (HF) is a devastating chronic illness requiring complex treatment regimens and patient engagement. Having the information, motivation, and skills to live with a medical condition are conceptualized by the term, "activation." Patients referred for advanced HF therapy and their unpaid family caregiver were invited to participate in this study by completing the 10-item patient activation measure (PAM) questionnaire. Anxiety and depression were assessed via the hospital anxiety and depression scale. We compared activation, anxiety, and depression between those selected versus not selected for advanced HF therapy (left ventricular assist device or heart transplantation). We analyzed those who subsequently underwent advanced HF therapy in regards to activation and 1-year survival. There were 133 (68%) patients selected for therapy. Neither depression nor anxiety differed by selection status, but PAM levels did (p = 0.02). Those not selected for therapy were approximately 4 times more likely to have lower activation than those who were selected (8% vs 2%). Of the 133 selected patients, 110 (84%) subsequently underwent advanced HF therapy and 15 (14%) of those died within 1 year. Survival was independent of baseline anxiety (p = 0.92) and depression (p = 0.70), as well as patient and caregiver PAM (p = 0.50 and 0.77, respectively). In conclusion, patients with higher activation were more likely to be selected for advanced HF therapy.