1
|
Brown RT, Zamora K, Rizzo A, Spar MJ, Fung KZ, Santiago L, Campbell A, Nicosia FM. Improving measurement of functional status among older adults in primary care: A pilot study. PLoS One 2024; 19:e0303402. [PMID: 38739582 PMCID: PMC11090365 DOI: 10.1371/journal.pone.0303402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 04/23/2024] [Indexed: 05/16/2024] Open
Abstract
Despite its importance for clinical care and outcomes among older adults, functional status-the ability to perform basic activities of daily living (ADLs) and instrumental ADLs (IADLs)-is seldom routinely measured in primary care settings. The objective of this study was to pilot test a person-centered, interprofessional intervention to improve identification and management of functional impairment among older adults in Veterans Affairs (VA) primary care practices. The four-component intervention included (1) an interprofessional educational session; (2) routine, standardized functional status measurement among patients aged ≥75; (3) annual screening by nurses using a standardized instrument and follow-up assessment by primary care providers; and (4) electronic tools and templates to facilitate increased identification and improved management of functional impairment. Surveys, semi-structured interviews, and electronic health record data were used to measure implementation outcomes (appropriateness, acceptability and satisfaction, feasibility, fidelity, adoption/reach, sustainability). We analyzed qualitative interviews using rapid qualitative analysis. During the study period, all 959 eligible patients were screened (100% reach), of whom 7.3% (n = 58) reported difficulty or needing help with ≥1 ADL and 11.8% (n = 113) reported difficulty or needing help with ≥1 IADL. In a chart review among a subset of 50 patients with functional impairment, 78% percent of clinician notes for the visit when screening was completed had content related to function, and 48% of patients had referrals ordered to address impairments (e.g., physical therapy) within 1 week. Clinicians highly rated the quality of the educational session and reported increased ability to measure and communicate about function. Clinicians and patients reported that the intervention was appropriate, acceptable, and feasible to complete, even during the COVID pandemic. These findings suggest that this intervention is a promising approach to improve identification and management of functional impairment for older patients in primary care. Broader implementation and evaluation of this intervention is currently underway.
Collapse
Affiliation(s)
- Rebecca T. Brown
- Geriatrics and Extended Care Program, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, United States of America
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, United States of America
- Division of Geriatric Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Kara Zamora
- San Francisco VA Health Care System, San Francisco, California, United States of America
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, United States of America
| | - Anael Rizzo
- San Francisco VA Health Care System, San Francisco, California, United States of America
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, United States of America
| | - Malena J. Spar
- San Francisco VA Health Care System, San Francisco, California, United States of America
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, United States of America
| | - Kathy Z. Fung
- San Francisco VA Health Care System, San Francisco, California, United States of America
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, United States of America
| | - Lea Santiago
- San Francisco VA Health Care System, San Francisco, California, United States of America
| | - Annie Campbell
- Martinez VA Medical Center, Martinez, California, United States of America
| | - Francesca M. Nicosia
- San Francisco VA Health Care System, San Francisco, California, United States of America
- Institute for Health & Aging, School of Nursing, University of California, San Francisco, California, United States of America
| |
Collapse
|
2
|
Nicosia FM, Zamora K, Rizzo A, Spar MJ, Silvestrini M, Brown RT. Using multiple qualitative methods to inform intervention development: Improving functional status measurement for older veterans in primary care settings. PLoS One 2023; 18:e0290741. [PMID: 37616266 PMCID: PMC10449158 DOI: 10.1371/journal.pone.0290741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023] Open
Abstract
Functional status, or the ability to perform activities of daily living, is central to older adults' health and quality of life. However, health systems have been slow to incorporate routine measurement of function into patient care. We used multiple qualitative methods to develop a patient-centered, interprofessional intervention to improve measurement of functional status for older veterans in primary care settings. We conducted semi-structured interviews with patients, clinicians, and operations staff (n = 123) from 7 Veterans Health Administration (VHA) Medical Centers. Interviews focused on barriers and facilitators to measuring function. We used concepts from the Consolidated Framework for Implementation Science and sociotechnical analysis to inform rapid qualitative analyses and a hybrid deductive/inductive approach to thematic analysis. We mapped qualitative findings to intervention components. Barriers to measurement included time pressures, cumbersome electronic tools, and the perception that measurement would not be used to improve patient care. Facilitators included a strong interprofessional environment and flexible workflows. Findings informed the development of five intervention components, including (1) an interprofessional educational session; (2) routine, standardized functional status measurement among older patients; (3) annual screening by nurses using a standardized instrument and follow-up assessment by primary care providers; (4) electronic tools and templates to facilitate increased identification and improved management of functional impairment; and (5) tailored reports on functional status for clinicians and operations leaders. These findings show how qualitative methods can be used to develop interventions that are more responsive to real-world contexts, increasing the chances of successful implementation. Using a conceptually-grounded approach to intervention development has the potential to improve patient and clinician experience with measuring function in primary care.
Collapse
Affiliation(s)
- Francesca M. Nicosia
- San Francisco VA Health Care System, San Francisco, California, United States of America
- Division of Geriatrics, Department of Medicine of the University of California, San Francisco, San Francisco, California, United States of America
| | - Kara Zamora
- San Francisco VA Health Care System, San Francisco, California, United States of America
- Division of Geriatrics, Department of Medicine of the University of California, San Francisco, San Francisco, California, United States of America
| | - Anael Rizzo
- San Francisco VA Health Care System, San Francisco, California, United States of America
- Division of Geriatrics, Department of Medicine of the University of California, San Francisco, San Francisco, California, United States of America
| | - Malena J. Spar
- San Francisco VA Health Care System, San Francisco, California, United States of America
- Division of Geriatrics, Department of Medicine of the University of California, San Francisco, San Francisco, California, United States of America
| | - Molly Silvestrini
- San Francisco VA Health Care System, San Francisco, California, United States of America
- Division of Geriatrics, Department of Medicine of the University of California, San Francisco, San Francisco, California, United States of America
| | - Rebecca T. Brown
- Geriatrics and Extended Care Program, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, United States of America
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, United States of America
- Division of Geriatric Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| |
Collapse
|
3
|
Davenport TE, Chu L, Stevens SR, Stevens J, Snell CR, Van Ness JM. Two symptoms can accurately identify post-exertional malaise in myalgic encephalomyelitis/chronic fatigue syndrome. Work 2023; 74:1199-1213. [PMID: 36938769 DOI: 10.3233/wor-220554] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND Post-exertional malaise (PEM) is the hallmark symptom of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) yet its diverse manifestations make it difficult to recognize. Brief instruments for detecting PEM are critical for clinical and scientific progress. OBJECTIVE To develop a clinical prediction rule for PEM. METHOD 49 ME/CFS and 10 healthy, sedentary subjects recruited from the community completed two maximal cardiopulmonary exercise tests (CPETs) separated by 24 hours. At five different times, subjects reported symptoms which were then classified into 19 categories. The frequency of symptom reports between groups at each time point was compared using Fisher's exact test. Receiver operating characteristics (ROC) analysis with area under the curve calculation was used to determine the number of different types of symptom reports that were sufficient to differentiate between ME/CFS and sedentary groups. The optimal number of symptoms was determined where sensitivity and specificity of the types of symptom reports were balanced. RESULTS At all timepoints, a maximum of two symptoms was optimal to determine differences between groups. Only one symptom was necessary to optimally differentiate between groups at one week following the second CPET. Fatigue, cognitive dysfunction, lack of positive feelings/mood and decrease in function were consistent predictors of ME/CFS group membership across timepoints. CONCLUSION Inquiring about post-exertional cognitive dysfunction, decline in function, and lack of positive feelings/mood may help identify PEM quickly and accurately. These findings should be validated with a larger sample of patients.
Collapse
Affiliation(s)
- Todd E Davenport
- University of the Pacific, Stockton, CA, USA.,Workwell Foundation, Ripon, CA, USA
| | - Lily Chu
- Independent Consultant, Burlingame, CA, USA
| | | | | | | | - J Mark Van Ness
- University of the Pacific, Stockton, CA, USA.,Workwell Foundation, Ripon, CA, USA
| |
Collapse
|
4
|
Xu E, Nicosia FM, Zamora K, Barrientos M, Spar MJ, Reyes-Farias D, Karliner LS, Potter MB, Brown RT. When Functional Impairment Develops Early: Perspectives from Middle-Aged Adults. J Gen Intern Med 2023; 38:90-97. [PMID: 35391621 PMCID: PMC9849615 DOI: 10.1007/s11606-022-07541-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/29/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Difficulty performing basic daily activities such as bathing and dressing ("functional impairment") affects more than 15% of middle-aged people, and this proportion is increasing. Little is known about the experiences and needs of individuals who develop functional impairment in middle age. OBJECTIVE To examine the experiences and needs of adults who developed functional impairment in middle age. DESIGN Qualitative study using semi-structured interviews. PARTICIPANTS Forty patients aged 50-64 years who developed functional impairment in middle age, recruited from four primary care clinics in San Francisco. APPROACH Interviews included open-ended questions about participants' daily life, ability to perform activities of daily living (ADLs), and needs related to functional impairment. We analyzed interviews using qualitative thematic analysis. KEY RESULTS Interviews revealed several themes related to the psychosocial and physical impacts of developing functional impairment in middle age. Participants noted that losses associated with functional impairment, such as loss of independence, control, and social roles, caused conflict in their sense of identity. To cope with these losses, participants used strategies including acceptance, social comparison, adjusting standards, and engaging in valued life activities. Participants reflected on the intersection of their functional impairment with the aging process, noting that their impairments seemed premature compared to the more "natural" aging process in older adults. In terms of physical impacts, participants described how a lack of accommodations in the built environment exacerbated their impairments. While participants used behavioral strategies to overcome these challenges, unmet needs remained, resulting in downstream physical and psychological impacts including safety risks, falls, frustration, and fear. CONCLUSIONS Unmet psychosocial and physical needs were common among middle-aged adults with functional impairment and led to negative downstream effects. Eliciting and addressing unmet needs may help mitigate downstream health consequences for this growing population, optimizing function and quality of life.
Collapse
Affiliation(s)
- Edison Xu
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
- Geriatrics, Palliative, and Extended Care, San Francisco VA Health Care System, San Francisco, CA, USA.
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA.
| | - Francesca M Nicosia
- Geriatrics, Palliative, and Extended Care, San Francisco VA Health Care System, San Francisco, CA, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Kara Zamora
- Geriatrics, Palliative, and Extended Care, San Francisco VA Health Care System, San Francisco, CA, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Maureen Barrientos
- Geriatrics, Palliative, and Extended Care, San Francisco VA Health Care System, San Francisco, CA, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Malena J Spar
- Geriatrics, Palliative, and Extended Care, San Francisco VA Health Care System, San Francisco, CA, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA
| | - David Reyes-Farias
- Division of Geriatric Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Leah S Karliner
- Division of General Internal Medicine, Multiethnic Health Equity Research Center, University of California, San Francisco, San Francisco, CA, USA
| | - Michael B Potter
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Rebecca T Brown
- Division of Geriatric Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
- Geriatrics and Extended Care Program, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|