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Putrik P, Grobler L, Lalor A, Ramsay H, Gorelik A, Karnon J, Parker D, Morgan M, Buchbinder R, O'Connor D. Models for delivery and co-ordination of primary or secondary health care (or both) to older adults living in aged care facilities. Cochrane Database Syst Rev 2024; 3:CD013880. [PMID: 38426600 PMCID: PMC10905654 DOI: 10.1002/14651858.cd013880.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co-ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost-effectiveness of alternative models of providing health care to ACF residents. OBJECTIVES Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost-effectiveness of the alternative models. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA We included individual and cluster-randomised trials, and cost/cost-effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co-ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co-ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline-recommended care, health-related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work-related satisfaction and work-related stress of ACF staff. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care. MAIN RESULTS We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co-ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low-certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I2 = 53%; 8 trials, 1263 participants; low-certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low-certainty evidence) and adherence to guideline-recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health-related quality of life of ACF residents (MD -0.016, 95% CI -0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low-certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate-certainty evidence). We did not pool the cost-effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co-ordination of care), we are uncertain of the cost-effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low. AUTHORS' CONCLUSIONS Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health-related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost-effectiveness of alternative models of care due to the limited, disparate data available.
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Affiliation(s)
- Polina Putrik
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Liesl Grobler
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Aislinn Lalor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Helen Ramsay
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alexandra Gorelik
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jonathan Karnon
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Deborah Parker
- Faculty of Health, The University of Technology Sydney, Sydney, NSW, Australia
| | - Mark Morgan
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Denise O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Hamel C, Garritty C, Hersi M, Butler C, Esmaeilisaraji L, Rice D, Straus S, Skidmore B, Hutton B. Models of provider care in long-term care: A rapid scoping review. PLoS One 2021; 16:e0254527. [PMID: 34270578 PMCID: PMC8284811 DOI: 10.1371/journal.pone.0254527] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/28/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION One of the current challenges in long-term care homes (LTCH) is to identify the optimal model of care, which may include specialty physicians, nursing staff, person support workers, among others. There is currently no consensus on the complement or scope of care delivered by these providers, nor is there a repository of studies that evaluate the various models of care. We conducted a rapid scoping review to identify and map what care provider models and interventions in LTCH have been evaluated to improve quality of life, quality of care, and health outcomes of residents. METHODS We conducted this review over 10-weeks of English language, peer-reviewed studies published from 2010 onward. Search strategies for databases (e.g., MEDLINE) were run on July 9, 2020. Studies that evaluated models of provider care (e.g., direct patient care), or interventions delivered to facility, staff, and residents of LTCH were included. Study selection was performed independently, in duplicate. Mapping was performed by two reviewers, and data were extracted by one reviewer, with partial verification by a second reviewer. RESULTS A total of 7,574 citations were screened based on the title/abstract, 836 were reviewed at full text, and 366 studies were included. Studies were classified according to two main categories: healthcare service delivery (n = 92) and implementation strategies (n = 274). The condition/ focus of the intervention was used to further classify the interventions into subcategories. The complex nature of the interventions may have led to a study being classified in more than one category/subcategory. CONCLUSION Many healthcare service interventions have been evaluated in the literature in the last decade. Well represented interventions (e.g., dementia care, exercise/mobility, optimal/appropriate medication) may present opportunities for future systematic reviews. Areas with less research (e.g., hearing care, vision care, foot care) have the potential to have an impact on balance, falls, subsequent acute care hospitalization.
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Affiliation(s)
- Candyce Hamel
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Chantelle Garritty
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mona Hersi
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Claire Butler
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Leila Esmaeilisaraji
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Danielle Rice
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sharon Straus
- Department of Medicine, University of Toronto and St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Becky Skidmore
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Brian Hutton
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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Childs A, Zullo AR, Joyce NR, McConeghy KW, van Aalst R, Moyo P, Bosco E, Mor V, Gravenstein S. The burden of respiratory infections among older adults in long-term care: a systematic review. BMC Geriatr 2019; 19:210. [PMID: 31382895 PMCID: PMC6683564 DOI: 10.1186/s12877-019-1236-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/30/2019] [Indexed: 11/22/2022] Open
Abstract
Background Respiratory infections among older adults in long-term care facilities (LTCFs) are a major global concern, yet a rigorous systematic synthesis of the literature on the burden of respiratory infections in the LTCF setting is lacking. To address the critical need for evidence regarding the global burden of respiratory infections in LTCFs, we assessed the burden of respiratory infections in LTCFs through a systematic review of the published literature. Methods We identified articles published between April 1964 and March 2019 through searches of PubMed (MEDLINE), EMBASE, and the Cochrane Library. Experimental and observational studies published in English that included adults aged ≥60 residing in LTCFs who were unvaccinated (to identify the natural infection burden), and that reported measures of occurrence for influenza, respiratory syncytial virus (RSV), or pneumonia were included. Disagreements about article inclusion were discussed and articles were included based on consensus. Data on study design, population, and findings were extracted from each article. Findings were synthesized qualitatively. Results A total of 1451 articles were screened for eligibility, 345 were selected for full-text review, and 26 were included. Study population mean ages ranged from 70.8 to 90.1 years. Three (12%) studies reported influenza estimates, 7 (27%) RSV, and 16 (62%) pneumonia. Eighteen (69%) studies reported incidence estimates, 7 (27%) prevalence estimates, and 1 (4%) both. Seven (27%) studies reported outbreaks. Respiratory infection incidence estimates ranged from 1.1 to 85.2% and prevalence estimates ranging from 1.4 to 55.8%. Influenza incidences ranged from 5.9 to 85.2%. RSV incidence proportions ranged from 1.1 to 13.5%. Pneumonia prevalence proportions ranged from 1.4 to 55.8% while incidence proportions ranged from 4.8 to 41.2%. Conclusions The reported incidence and prevalence estimates of respiratory infections among older LTCF residents varied widely between published studies. The wide range of estimates offers little useful guidance for decision-making to decrease respiratory infection burden. Large, well-designed epidemiologic studies are therefore still necessary to credibly quantify the burden of respiratory infections among older adults in LTCFs, which will ultimately help inform future surveillance and intervention efforts. Electronic supplementary material The online version of this article (10.1186/s12877-019-1236-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Arielle Childs
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA
| | - Andrew R Zullo
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA. .,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA. .,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA.
| | - Nina R Joyce
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.,Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA
| | - Kevin W McConeghy
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Robertus van Aalst
- Sanofi Pasteur, Swiftwater, PA, USA.,Faculty of Medical Sciences, University of Groningen, Groningen, NL, the Netherlands
| | - Patience Moyo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA
| | - Elliott Bosco
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Stefan Gravenstein
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
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Abstract
The importance of better care integration is emphasized in many national dementia plans. The inherent complexity of organizing care for people with dementia provides both the justification for improving care integration and the challenges to achieving it. The prevention, detection, and early diagnosis of cognitive disorders mainly resides in primary care, but how this is best integrated within the range of disorders that primary care clinicians are expected to screen is unclear. Models of integrated community dementia assessment and management have varying degrees of involvement of primary and specialist care, but share an emphasis on improving care coordination, interdisciplinary teamwork, and personalized care. Integrated care strategies in acute care are still in early development, but have been a focus of investigation in the past decade. Integrated care outreach strategies to reduce transfers from long-term residential care to acute care have been consistently effective. Integrated long-term residential care includes considerations of end-of-life care. Future directions should include strategies for training and education, early detection in anticipation of disease modifying treatments, integration of technological developments into dementia care, integration of dementia care into general health and social care, and the encouragement of a dementia-friendly society.
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Affiliation(s)
- Brian Draper
- a School of Psychiatry , University of NSW , Sydney , NSW , Australia
| | - Lee-Fay Low
- b Faculty of Health Sciences , University of Sydney , Sydney , NSW , Australia
| | - Henry Brodaty
- c Centre for Healthy Brain Ageing , University of NSW Sydney , Sydney , NSW , Australia
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Santosaputri E, Laver K, To T. Efficacy of interventions led by staff with geriatrics expertise in reducing hospitalisation in nursing home residents: A systematic review. Australas J Ageing 2018; 38:5-14. [DOI: 10.1111/ajag.12593] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Elita Santosaputri
- Department of Rehabilitation, Aged Care, and Palliative Care Flinders Medical Centre Adelaide South Australia Australia
| | - Kate Laver
- Department of Rehabilitation, Aged Care, and Palliative Care Flinders Medical Centre Adelaide South Australia Australia
- College of Medicine and Public Health Flinders University Adelaide South Australia Australia
| | - Timothy To
- Department of Rehabilitation, Aged Care, and Palliative Care Flinders Medical Centre Adelaide South Australia Australia
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Abstract
Background: Geriatric care increasingly needs more multidisciplinary
health care services to deliver the necessary complex and continuous care. The
aim of this study is to summarize indicators of effective interprofessional
outcomes for this population. Method: A systematic review is performed in the Cochrane Library,
Pubmed (Medline), Embase, Cinahl and Psychinfo with a search until June
2014. Results: Overall, 689 references were identified of which 29 studies
met the inclusion criteria. All outcome indicators were summarized in three
categories: collaboration, patient level outcome and costs. Seventeen out of 24
outcome indicators within the category of ‘collaboration’ reached
significant difference in advantage of the intervention group. On ‘patient
outcome level’ only 15 out of 32 outcome parameters met statistical
significance. In the category of ‘costs’ only one study reached
statistical significance. Discussion and conclusion: The overall effects of interprofessional
interventions for elderly are positive, but based on heterogeneous outcomes.
Outcome indicators of interprofessional collaboration for elderly with a
significant effect can be summarized in three main categories:
‘collaboration’, patient level’ and ‘costs’. For
‘collaboration’ the outcome indicators are key elements of
collaboration, involved disciplines, professional and patient satisfaction and
quality of care. On ‘patient level’ the outcome indicators are pain,
fall incidence, quality of life, independence for daily life activities,
depression and agitated behaviour, transitions, length of stay in hospital,
mortality and period of rehabilitation. ‘Costs’ of interprofessional
interventions on short- and long-term for elderly need further investigation.
When organizing interprofessional collaboration or interprofessional education
these outcome indicators can be considered as important topics to be addressed.
Overall more research is needed to gain insight in the process of
interprofessional collaboration and so to learn to work interprofessionally.
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Nazir A, Unroe K, Tegeler M, Khan B, Azar J, Boustani M. Systematic Review of Interdisciplinary Interventions in Nursing Homes. J Am Med Dir Assoc 2013; 14:471-8. [DOI: 10.1016/j.jamda.2013.02.005] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 02/10/2013] [Accepted: 02/11/2013] [Indexed: 10/27/2022]
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