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Caponnetto V, Dante A, El Aoufy K, Melis MR, Ottonello G, Napolitano F, Ferraiuolo F, Camero F, Cuoco A, Erba I, Rasero L, Sasso L, Bagnasco A, Alvaro R, Manara DF, Rocco G, Zega M, Cicolini G, Mazzoleni B, Lancia L. Community health services in European literature: A systematic review of their features, outcomes, and nursing contribution to care. Int Nurs Rev 2024. [PMID: 39073363 DOI: 10.1111/inr.13033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 07/12/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND To meet the population's needs, community care should be customized and continuous, adequately equipped, and monitored. INTRODUCTION Considering their fragmented and heterogeneous nature, a summary of community healthcare services described in European literature is needed. The aim of this study was to summarize their organizational models, outcomes, nursing contribution to care, and nursing-related determinants of outcomes. METHODS A systematic review was performed by searching PubMed, CINAHL, Scopus, and Embase in October 2022 and October 2023 (for updated results). Quantitative studies investigating the effects of community care, including nursing contribution, on patient outcomes were included and summarized. Reporting followed the PRISMA checklist. The review protocol was registered on PROSPERO (CRD42022383856). RESULTS Twenty-three studies describing six types of community care services were included, which are heterogeneous in terms of target population, country, interventions, organizational characteristics, and investigated outcomes. Heterogeneous services' effects were observed for access to emergency services, satisfaction, and compliance with treatment. Services revealed a potential to reduce rehospitalizations of people with long-term conditions, frail or older persons, children, and heart failure patients. Models are mainly multidisciplinary and, although staffing and workload may also have an impact on provided care, this was not enough investigated. DISCUSSION Community health services described in European literature in the last decade are in line with population needs and suggest different suitable models and settings according to different care needs. Community care should be strengthened in health systems, although the influence of staffing, workload, and work environment on nursing care should be investigated by developing new management models. CONCLUSIONS AND IMPLICATIONS FOR HEALTH POLICY Community care models are heterogeneous across Europe, and the optimum organizational structure is not clear yet. Future policies should consider the impact of community care on both health and economic outcomes and enhance nursing contributions to care.
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Affiliation(s)
- Valeria Caponnetto
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Angelo Dante
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Khadija El Aoufy
- Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Giulia Ottonello
- Department of Health Sciences, University of Genoa, Genova, Italy
- Ingram School of Nursing, McGill University, Montreal, Canada
- Direction of Health Professionals, "IRCCS Istituto Giannina Gaslini,", Genova, Italy
| | - Francesca Napolitano
- Department of Health Sciences, University of Genoa, Genova, Italy
- Department of Emergency and Admission, Policlinic Hospital "IRCSS San Martino,", Genova, Italy
| | - Fabio Ferraiuolo
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Francesco Camero
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Angela Cuoco
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
- Orthopedic and Traumatology Clinic, Orthopedic Institute "IRCSS Rizzoli,", Bologna, Italy
| | - Ilaria Erba
- Bachelor of Science in Nursing, Saint Camillus International University of Health and Medical Sciences, Rome, Italy
| | - Laura Rasero
- Department of Health Sciences, University of Florence, Florence, Italy
- Scientific Committee CERSI-FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
| | - Loredana Sasso
- Department of Health Sciences, University of Genoa, Genova, Italy
- Scientific Committee CERSI-FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
| | - Annamaria Bagnasco
- Department of Health Sciences, University of Genoa, Genova, Italy
- Scientific Committee CERSI-FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
| | - Rosaria Alvaro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
- Scientific Committee CERSI-FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
| | - Duilio Fiorenzo Manara
- Scientific Committee CERSI-FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
- Center for Nursing Research and Innovation, Vita-Salute San Raffaele University, Milan, Italy
| | - Gennaro Rocco
- Center of Excellence for Nursing Scholarship, Rome, Italy
- Faculty of Medicine, University "Our Lady of the Good Counsel", Tirana, Albania
| | - Maurizio Zega
- Center of Excellence for Nursing Scholarship, Rome, Italy
- FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
| | - Giancarlo Cicolini
- FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
- Section of Nursing and Midwifery, Department of Innovative Technologies in Medicine & Dentistry, University "G. d'Annunzio" Chieti - Pescara, Chieti, Italy
| | - Beatrice Mazzoleni
- FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Loreto Lancia
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
- Scientific Committee CERSI-FNOPI, Federazione Nazionale Ordini Professioni Infermieristiche, Rome, Italy
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Bang HJ, Yoo AJ, Lee HJ, Choi JW. Impact of a Pilot Project for Integrated Care on Hospitalization Rate among Older Adults in South Korea. Int J Integr Care 2024; 24:20. [PMID: 38828123 PMCID: PMC11141512 DOI: 10.5334/ijic.7665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 05/21/2024] [Indexed: 06/05/2024] Open
Abstract
Introduction Since 2019, the Korean government has implemented a pilot project for integrated care to encourage healthy aging of older adults. This study investigated the changes in hospitalization rates among older adults who participated in the integrated care pilot project. Methods Administrative survey data collected from 13 local governments and the National Health Insurance Database were used in present study. The participants comprised 17,801 older adults who participated in the pilot project between August 01, 2019 and April 30, 2022 and 68,145 matched controls. A propensity score matching method was employed to select the control group, and this study employed difference-in-differences (DID) approach to examine variations in the hospitalization rate. Results The DID analysis revealed that the odds ratio for rates of hospitalization among older adults who participated in the pilot project was 0.88 (95% confidence interval [CI] 0.84, 0.91) in comparison to control group. In specifically, as compared to the control group, the odds ratio for hospitalization rates among the pilot project's discharged patients was 0.17 (95% CI 0.15, 0.20). Although not statistically significant, the odds ratio of older adults who utilized LTCI services was 0.93 (95% CI 0.83, 1.05), and the odds ratio of older adults who applied for LTCI but were rejected or were intensive social care was 1.09 (95% CI 0.95, 1.26) compared to the comparison group. Discussion The findings imply that the discharged patient group had greater medical demands than the other types, and it can be claimed that this is the group that may anticipate greater efficacy while using health services. In addition, the integrated care services provided by the pilot project have the effect of reducing unnecessary hospitalization such as social hospitalization. Conclusion Participants in the integrated care pilot project showed a lower hospitalization rate than the older adults who did not participate in the project but had similar characteristics. In particular, the admission rate of discharged patients showed a sharp decline.
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Affiliation(s)
- Hyo Jung Bang
- Integrated Care Research Center, Health Insurance Research Institute, National Health Insurance Service, Gangwon, Korea
| | - Ae Jung Yoo
- Integrated Care Research Center, Health Insurance Research Institute, National Health Insurance Service, Gangwon, Korea
| | - Hyun Ji Lee
- Integrated Care Research Center, Health Insurance Research Institute, National Health Insurance Service, Gangwon, Korea
| | - Jae Woo Choi
- Integrated Care Research Center, Health Insurance Research Institute, National Health Insurance Service, Gangwon, Korea
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Hsiao ML, Su CY, Loh CH, Kao SL. Effects of integrated care with case management and nutritional counselling for frail older adults with nutritional risk in the primary care setting. Fam Pract 2024:cmae011. [PMID: 38423070 DOI: 10.1093/fampra/cmae011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND The effects of integrated care with case management and nutritional counselling for frail patients with nutritional risk are unclear. OBJECTIVES To assess the impact of the integrated care model for frail patients with nutritional risk in the primary care setting. METHODS This was a retrospective observational study. We enrolled 100 prefrail or frail patients according to Clinical Frailty Scale (CFS) aged ≥ 60 years with nutritional risk from the geriatric clinic. We implemented the frailty intervention model, including integrated care with comprehensive geriatric assessments (CGA), case management, and nutritional counselling by the dietitian. We obtained measures of CGA components, physical performance, body mass index (BMI), and daily caloric intake before and after the 2-month care program. We used the Wilcoxon signed-rank test to analyse differences after the care program and applied multiple linear regression to determine the predictive factors for CFS improvement. RESULTS Among the 100 patients (mean age, 75.0 ± 7.2 years; females, 71.0%; frail patients, 26%), 93% improved their CFS status, and 91% achieved > 80% of recommended daily caloric intake after the care program. The Mini Nutritional Assessment Short-Form significantly improved after the program. BMI and daily caloric intake increased significantly after nutritional counselling. The post-test short physical performance battery (SPPB) significantly increased with a faster 4 m gait speed. Baseline poor CFS was a significant predictor for CFS improvement. CONCLUSIONS Integrated care with case management and nutritional counselling for prefrail and frail patients with nutritional risk in the primary care setting may improve physical performance and nutritional status.
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Affiliation(s)
- Mei-Lan Hsiao
- Department of Nursing, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Sec. 3, Chung Yang Rd., Hualien 970, Taiwan
| | - Chen-Ying Su
- Department of Nutrition, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707, Sec. 3, Chung Yang Rd., Hualien 970, Taiwan
| | - Ching-Hui Loh
- Center for Aging and Health, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Department of Family Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707 Sec. 3, Chung Yang Rd., Hualien 970, Taiwan
- Department of Family Medicine, College of Medicine, Tzu Chi University, No. 701, Sec. 3, Chung Yang Rd., Hualien 970, Taiwan
| | - Sheng-Lun Kao
- Department of Family Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 707 Sec. 3, Chung Yang Rd., Hualien 970, Taiwan
- Department of Family Medicine, College of Medicine, Tzu Chi University, No. 701, Sec. 3, Chung Yang Rd., Hualien 970, Taiwan
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Duncan S, Bergler HU, Menclova A, Pickering JW, Nishtala PS, Ailabouni N, Hilmer SN, Mangin D, Jamieson H. The Drug Burden Index and Level of Frailty as Determinants of Healthcare Costs in a Cohort of Older Frail Adults in New Zealand. Value Health Reg Issues 2024; 41:72-79. [PMID: 38245933 DOI: 10.1016/j.vhri.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 11/02/2023] [Accepted: 11/15/2023] [Indexed: 01/23/2024]
Abstract
OBJECTIVES Frailty is common in older people and is associated with increased use of healthcare services and ongoing use of multiple medications. This study provides insights into the healthcare cost structure of a frail group of older adults in Aotearoa, New Zealand. Furthermore, we investigated the relationship between participants' anticholinergic and sedative medication burden and their total healthcare costs to explore the viability of deprescribing interventions within this cohort. METHODS Healthcare cost analysis was conducted using data collected during a randomized controlled trial within a frail, older cohort. The collected information included participant demographics, medications used, frailty, cost of service use of aged residential care and outpatient hospital services, hospital admissions, and dispensed medications. RESULTS Data from 338 study participants recruited between 25 September 2018 and 30 October 2020 with a mean age of 80 years were analyzed. The total cost of healthcare per participant ranged from New Zealand $15 (US dollar $10) to New Zealand $270 681 (US dollar $175 943) over 6 months postrecruitment into the study. Four individuals accounted for 26% of this cohort's total healthcare cost. We found frailty to be associated with increased healthcare costs, whereas the drug burden was only associated with increased pharmaceutical costs, not overall healthcare costs. CONCLUSIONS With no relationship found between a patient's anticholinergic and sedative medication burden and their total healthcare costs, more research is required to understand how and where to unlock healthcare cost savings within frail, older populations.
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Affiliation(s)
- Shnece Duncan
- Department of Economics and Finance, University of Canterbury, Christchurch, New Zealand.
| | - Hans Ulrich Bergler
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
| | - Andrea Menclova
- Department of Economics and Finance, University of Canterbury, Christchurch, New Zealand
| | - John W Pickering
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
| | - Prasad S Nishtala
- Department of Life Sciences, Centre for Therapeutic Innovation, University of Bath, Bath, England, UK
| | - Nagham Ailabouni
- The Pharmacy Australian Centre of Excellence (PACE), School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
| | - Sarah N Hilmer
- Geriatric Pharmacology, Faculty of Medicine and Health, Northern Clinical School, Kolling Institute, University of Sydney and Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Dee Mangin
- Primary Care Research Group, University of Otago, Christchurch, New Zealand; Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Hamish Jamieson
- Department of Medicine, Burwood Hospital, University of Otago, Christchurch, New Zealand
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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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Payen A, Godard-Sebillotte C, Sourial N, Soula J, Verloop D, Defebvre MM, Dupont C, Dambre D, Lamer A, Beuscart JB. The impact of including a medication review in an integrated care pathway: A pilot study. Br J Clin Pharmacol 2023; 89:1036-1045. [PMID: 36164674 DOI: 10.1111/bcp.15543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 08/09/2022] [Accepted: 08/31/2022] [Indexed: 12/01/2022] Open
Abstract
AIM The objective of the present study was to measure the impact of the intervention of combining a medication review with an integrated care approach on potentially inappropriate medications (PIMs) and hospital readmissions in frail older adults. METHODS A cohort of hospitalized older adults enrolled in the French PAERPA integrated care pathway (the exposed cohort) was matched retrospectively with hospitalized older adults not enrolled in the pathway (unexposed cohort) between January 1st, 2015, and December 31st, 2018. The study was an analysis of French health administrative database. The inclusion criteria for exposed patients were admission to an acute care department in a general hospital, age 75 years or over, at least three comorbidities or the prescription of diuretics or oral anticoagulants, discharge alive and performance of a medication review. RESULTS For the study population (n = 582), the mean ± standard deviation age was 82.9 ± 4.9 years, and 380 (65.3%) were women. Depending on the definition used, the overall median number of PIMs ranged from 2 [0;3] on admission to 3 [0;3] at discharge. The intervention was not associated with a significant difference in the mean number of PIMs. Patients in the exposed cohort were half as likely to be readmitted to hospital within 30 days of discharge relative to patients in the unexposed cohort. CONCLUSION Our results show that a medication review was not associated with a decrease in the mean number of PIMs. However, an integrated care intervention including the medication review was associated with a reduction in the number of hospital readmissions at 30 days.
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Affiliation(s)
- Anaïs Payen
- University of Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | | | - Nadia Sourial
- Department of Health Management, Evaluation and Policy, School of Public Health, University of Montreal, Montreal, Québec, Canada
| | - Julien Soula
- University of Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - David Verloop
- Agence Régionale de Santé Hauts-de-France, Lille, France
| | | | - Corinne Dupont
- Agence Régionale de Santé Hauts-de-France, Lille, France
| | - Delphine Dambre
- Service de Médecine Polyvalente, Centre Hospitalier de Saint-Amand-les-Eaux, Saint-Amand-les-Eaux, France
| | - Antoine Lamer
- University of Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Jean-Baptiste Beuscart
- University of Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
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Naouri D, Panjo H, Moïsi L, El Khoury C, Serre P, Schmidt J, Yordanov Y, Pelletier-Fleury N. The Association Between Age and Admission to an Inappropriate Ward: A Cross-Sectional Survey in France. Health Serv Insights 2023; 16:11786329231174340. [PMID: 37197083 PMCID: PMC10184193 DOI: 10.1177/11786329231174340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 04/15/2023] [Indexed: 05/19/2023] Open
Abstract
Half of elderly patient hospitalizations are preceded by an emergency department (ED) visit. Hospitalization in inappropriate wards (IWs), which is more frequent in case of ED overcrowding and high hospital occupancy, leads to increased morbidity. Elderly individuals are the most exposed to these negative health care outcomes. Based on a nationwide cross-sectional survey involving all EDs in France, the aim of this study was to explore whether age was associated with admission to an IW after visiting an ED. Among the 4384 patients admitted in a medical ward, 4065 were admitted in the same hospital where the ED was located, among which 17.7% were admitted to an IW. Older age was associated with an increased likelihood of being admitted to an IW (OR = 1.39; 95% CI = 1.02-1.90 for patients aged 85 years and older and OR = 1.40; 95% CI = 1.02-1.91 for patients aged 75-84 years, compared with those under 45 years). ED visits during peak periods and cardio-pulmonary presenting complaint were also associated with an increased likelihood of admission to an IW. Despite their higher vulnerability, elderly patients are more likely to be admitted to an IW than younger patients. This result reinforces the need for special attention to be given to the hospitalization of this fragile population.
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Affiliation(s)
- Diane Naouri
- Centre for Research in Epidemiology and Population Health, French National Institute of Health and Medical Research (INSERM U1018), Université Paris-Saclay, Université Paris-Sud, UVSQ, Villejuif, France
- D Naouri, Centre de recherche en épidémiologie et santé des populations (CESP), Hôpital Paul Brousse, 12 Avenue Paul Vaillant Couturier, Villejuif 94800, France.
| | - Henri Panjo
- Centre for Research in Epidemiology and Population Health, French National Institute of Health and Medical Research (INSERM U1018), Université Paris-Saclay, Université Paris-Sud, UVSQ, Villejuif, France
| | - Laura Moïsi
- Sorbonne Université, AP-HP, Hôpital Saint Antoine, Unité de Gériatrie Aigue, Paris, France
| | | | - Patrice Serre
- French Society of Emergency Medicine (SFMU), Paris, France
| | | | - Youri Yordanov
- French Society of Emergency Medicine (SFMU), Paris, France
| | - Nathalie Pelletier-Fleury
- Centre for Research in Epidemiology and Population Health, French National Institute of Health and Medical Research (INSERM U1018), Université Paris-Saclay, Université Paris-Sud, UVSQ, Villejuif, France
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Alharbi K, Blakeman T, van Marwijk H, Reeves D, Tsang JY. Understanding the implementation of interventions to improve the management of frailty in primary care: a rapid realist review. BMJ Open 2022; 12:e054780. [PMID: 35649605 PMCID: PMC9161080 DOI: 10.1136/bmjopen-2021-054780] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 01/24/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Identifying and managing the needs of frail people in the community is an increasing priority for policy makers. We sought to identify factors that enable or constrain the implementation of interventions for frail older persons in primary care. DESIGN A rapid realist review. DATA SOURCES Cochrane Library, SCOPUS and EMBASE, and grey literature. The search was conducted in September 2019 and rerun on 8 January 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We considered all types of empirical studies describing interventions targeting frailty in primary care. ANALYSIS We followed the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and publication criteria for our synthesis to systematically analyse and synthesise the existing literature and to identify (intervention-context-mechanism-outcome) configurations. We used normalisation processes theory to illuminate mechanisms surrounding implementation. RESULTS Our primary research returned 1755 articles, narrowed down to 29 relevant frailty intervention studies conducted in primary care. Our review identified two families of interventions. They comprised: (1) interventions aimed at the comprehensive assessment and management of frailty needs; and (2) interventions targeting specific frailty needs. Key factors that facilitate or inhibit the translation of frailty interventions into practice related to the distribution of resources; patient engagement and professional skill sets to address identified need. CONCLUSION There remain challenges to achieving successful implementation of frailty interventions in primary care. There were a key learning points under each family. First, targeted allocation of resources to address specific needs allows a greater alignment of skill sets and reduces overassessment of frail individuals. Second, earlier patient involvement may also improve intervention implementation and adherence. PROSPERO REGISTRATION NUMBER The published protocol for the review is registered with PROSPERO (CRD42019161193).
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Affiliation(s)
- Khulud Alharbi
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Thomas Blakeman
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Harm van Marwijk
- Division of Primary Care and Public Health, University of Brighton, Falmer, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - David Reeves
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Jung Yin Tsang
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
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9
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Briggs R, McDonough A, Ellis G, Bennett K, O'Neill D, Robinson D. Comprehensive Geriatric Assessment for community-dwelling, high-risk, frail, older people. Cochrane Database Syst Rev 2022; 5:CD012705. [PMID: 35521829 PMCID: PMC9074104 DOI: 10.1002/14651858.cd012705.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining an older person's medical, psychological and functional capability in order to develop a co-ordinated and integrated care plan. CGA is not limited simply to assessment, but also directs a holistic management plan for older people, which leads to tangible interventions. While there is established evidence that CGA reduces the likelihood of death and disability in acutely unwell older people, the effectiveness of CGA for community-dwelling, frail, older people at risk of poor health outcomes is less clear. OBJECTIVES To determine the effectiveness of CGA for community-dwelling, frail, older adults at risk of poor health outcomes in terms of mortality, nursing home admission, hospital admission, emergency department visits, serious adverse events, functional status, quality of life and resource use, when compared to usual care. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, three trials registers (WHO ICTRP, ClinicalTrials.gov and McMaster Aging Portal) and grey literature up to April 2020; we also checked reference lists and contacted study authors. SELECTION CRITERIA We included randomised trials that compared CGA for community-dwelling, frail, older people at risk of poor healthcare outcomes to usual care in the community. Older people were defined as 'at risk' either by being frail or having another risk factor associated with poor health outcomes. Frailty was defined as a vulnerability to sudden health state changes triggered by relatively minor stressor events, placing the individual at risk of poor health outcomes, and was measured using objective screening tools. Primary outcomes of interest were death, nursing home admission, unplanned hospital admission, emergency department visits and serious adverse events. CGA was delivered by a team with specific gerontological training/expertise in the participant's home (domiciliary Comprehensive Geriatric Assessment (dCGA)) or other sites such as a general practice or community clinic (community Comprehensive Geriatric Assessment (cCGA)). DATA COLLECTION AND ANALYSIS Two review authors independently extracted study characteristics (methods, participants, intervention, outcomes, notes) using standardised data collection forms adapted from the Cochrane Effective Practice and Organisation of Care (EPOC) data collection form. Two review authors independently assessed the risk of bias for each included study and used the GRADE approach to assess the certainty of evidence for outcomes of interest. MAIN RESULTS We included 21 studies involving 7893 participants across 10 countries and four continents. Regarding selection bias, 12/21 studies used random sequence generation, while 9/21 used allocation concealment. In terms of performance bias, none of the studies were able to blind participants and personnel due to the nature of the intervention, while 14/21 had a blinded outcome assessment. Eighteen studies were at low risk of attrition bias, and risk of reporting bias was low in 7/21 studies. Fourteen studies were at low risk of bias in terms of differences of baseline characteristics. Three studies were at low risk of bias across all domains (accepting that it was not possible to blind participants and personnel to the intervention). CGA probably leads to little or no difference in mortality during a median follow-up of 12 months (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.76 to 1.02; 18 studies, 7151 participants (adjusted for clustering); moderate-certainty evidence). CGA results in little or no difference in nursing home admissions during a median follow-up of 12 months (RR 0.93, 95% CI 0.76 to 1.14; 13 studies, 4206 participants (adjusted for clustering); high-certainty evidence). CGA may decrease the risk of unplanned hospital admissions during a median follow-up of 14 months (RR 0.83, 95% CI 0.70 to 0.99; 6 studies, 1716 participants (adjusted for clustering); low-certainty evidence). The effect of CGA on emergency department visits is uncertain and evidence was very low certainty (RR 0.65, 95% CI 0.26 to 1.59; 3 studies, 873 participants (adjusted for clustering)). Only two studies (1380 participants; adjusted for clustering) reported serious adverse events (falls) with no impact on the risk; however, evidence was very low certainty (RR 0.82, 95% CI 0.58 to 1.17). AUTHORS' CONCLUSIONS CGA had no impact on death or nursing home admission. There is low-certainty evidence that community-dwelling, frail, older people who undergo CGA may have a reduced risk of unplanned hospital admission. Further studies examining the effect of CGA on emergency department visits and change in function and quality of life using standardised assessments are required.
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Affiliation(s)
- Robert Briggs
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Anna McDonough
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Graham Ellis
- Medicine for the Elderly, Monklands Hospital, Airdrie, UK
| | - Kathleen Bennett
- Department of Pharmacology and Therapeutics, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Desmond O'Neill
- Centre for Ageing, Neuroscience and the Humanities, Trinity College, Dublin, Ireland
| | - David Robinson
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
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10
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Giguere A, Holroyd-Leduc JM, Straus SE, Urquhart R, Turcotte V, Durand PJ, Turgeon A. Prioritization of indicators of the quality of care provided to older adults with frailty by key stakeholders from five canadian provinces. BMC Geriatr 2022; 22:149. [PMID: 35197016 PMCID: PMC8864862 DOI: 10.1186/s12877-022-02843-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 02/15/2022] [Indexed: 11/10/2022] Open
Abstract
Background To meet the needs of older adults with frailty better, it is essential to understand which aspects of care are important from their perspective. We therefore sought to assess the importance of a set of quality indicators (QI) for monitoring outcomes in this population. Methods In this mixed-method study, key stakeholders completed a survey on the importance of 36 QIs, and then explained their ratings in a semi-structured interview. Stakeholders included older adults with frailty and their caregivers, healthcare providers (HCPs), and healthcare administrators or policy/decision makers (DMs). We conducted descriptive statistical analyses of quantitative variables, and deductive thematic qualitative analyses of interview transcripts. Results The 42 participants (8 older adults, 18 HCPs, and 16 DMs) rated six QIs as more important: increasing the patients’ quality of life; increasing healthcare staff skills; decreasing patients’ symptoms; decreasing family caregiver burden; increasing patients’ satisfaction with care; and increasing family doctor continuity of care. Conclusions Key stakeholders prioritized QIs that focus on outcomes targeted to patients and caregivers, whereas the current healthcare systems generally focus on processes of care. Quality improvement initiatives should therefore take better account of aspects of care that are important for older adults with frailty, such as having a chance to express their individual goals of care, receiving quality communications from HCPs, or monitoring symptoms that they might not spontaneously describe. Our results point to the need for patient-centred care that is oriented toward quality of life for older adults with frailty. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-02843-9.
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Affiliation(s)
- Anik Giguere
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, Canada. .,Quebec Excellence Centre on Aging, Quebec, Canada. .,VITAM - Research Centre on Sustainable Health (Centre de recherche en santé durable), 2480, chemin de la Canardière, QC, G1J 0A4, Québec, Canada.
| | | | - Sharon E Straus
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Robin Urquhart
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
| | | | - Pierre J Durand
- Department of Social and Preventive Medicine, Université Laval, Quebec, Canada
| | - Alexis Turgeon
- Population Health and Optimal Health Practices Research Unit, Division of Critical Care Medicine, CHU de Quebec - Université Laval Research Centre, Université Laval, Quebec, Canada
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11
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Klunder JH, Bordonis V, Heymans MW, van der Roest HG, Declercq A, Smit JH, Garms-Homolova V, Jónsson PV, Finne-Soveri H, Onder G, Joling KJ, Maarsingh OR, van Hout HPJ. Predicting unplanned hospital visits in older home care recipients: a cross-country external validation study. BMC Geriatr 2021; 21:551. [PMID: 34649526 PMCID: PMC8515741 DOI: 10.1186/s12877-021-02521-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background Accurate identification of older persons at risk of unplanned hospital visits can facilitate preventive interventions. Several risk scores have been developed to identify older adults at risk of unplanned hospital visits. It is unclear whether risk scores developed in one country, perform as well in another. This study validates seven risk scores to predict unplanned hospital admissions and emergency department (ED) visits in older home care recipients from six countries. Methods We used the IBenC sample (n = 2446), a cohort of older home care recipients from six countries (Belgium, Finland, Germany, Iceland, Italy and The Netherlands) to validate four specific risk scores (DIVERT, CARS, EARLI and previous acute admissions) and three frailty indicators (CHESS, Fried Frailty Criteria and Frailty Index). Outcome measures were unplanned hospital admissions, ED visits or any unplanned hospital visits after 6 months. Missing data were handled by multiple imputation. Performance was determined by assessing calibration and discrimination (area under receiver operating characteristic curve (AUC)). Results Risk score performance varied across countries. In Iceland, for any unplanned hospital visits DIVERT and CARS reached a fair predictive value (AUC 0.74 [0.68–0.80] and AUC 0.74 [0.67–0.80]), respectively). In Finland, DIVERT had fair performance predicting ED visits (AUC 0.72 [0.67–0.77]) and any unplanned hospital visits (AUC 0.73 [0.67–0.77]). In other countries, AUCs did not exceed 0.70. Conclusions Geographical validation of risk scores predicting unplanned hospital visits in home care recipients showed substantial variations of poor to fair performance across countries. Unplanned hospital visits seem considerably dependent on healthcare context. Therefore, risk scores should be validated regionally before applied to practice. Future studies should focus on identification of more discriminative predictors in order to develop more accurate risk scores. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02521-2.
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Affiliation(s)
- Jet H Klunder
- Department of General Practice, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Veronique Bordonis
- Department of General Practice, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Martijn W Heymans
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Henriëtte G van der Roest
- Department on Aging, Netherlands Institute of Mental Health and Addiction (Trimbos Institute), Utrecht, The Netherlands
| | - Anja Declercq
- Center for Care Research & Consultancy (LUCAS) & Center for Sociological Research (CESO), KU Leuven, Leuven, Belgium
| | - Jan H Smit
- Department of Psychiatry, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Vjenka Garms-Homolova
- Department of Economics and Law, HTW Berlin University of Applied Sciences, Berlin, Germany
| | - Pálmi V Jónsson
- Department of Geriatrics, Landspitali University Hospital and Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Harriet Finne-Soveri
- Department of Wellbeing, National Institute for Health and Wellbeing, Helsinki, Finland
| | - Graziano Onder
- Department of Cardiovascular, Endocrine-Metabolic Diseases and Aging, Istituto Superiore di Sanità, Rome, Italy
| | - Karlijn J Joling
- Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Otto R Maarsingh
- Department of General Practice, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Hein P J van Hout
- Department of General Practice, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Medicine for Older People, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
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12
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Neto JBF, de Moraes GLA, de Souza Aredes J, Giacomin KC, de Melo LP, Sempe L, Lloyd-Sherlock P. Building the capacity of community health workers to support health and social care for dependent older people in Latin America: a pilot study in Fortaleza, Brazil. BMC Geriatr 2021; 21:526. [PMID: 34600482 PMCID: PMC8487332 DOI: 10.1186/s12877-021-02477-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 09/17/2021] [Indexed: 11/29/2022] Open
Abstract
Background Brazil is seeing rapid population ageing, which is leading to new demands on primary health care services. There is a need to develop and assess the effectiveness of new interventions to build the capacity of staff, including community health workers, to meet the needs of groups such as care-dependent older people and their care-givers. This study examines the feasibility of a small training intervention piloted in the Brazilian city of Fortaleza. Methods The study evaluated participants’ own assessments of key knowledge and skills related to the needs of care-dependent older people, both before and after the training intervention. It also assessed their capacity to implement a simple screening tool of geriatric risk factors. Results The participant self-assessments indicate significant improvements in their perceived knowledge and capacity in responding to the health needs of care-dependent older people. Additionally, participants were able to successfully conduct the home visits and screening for risk factors. Conclusions The study demonstrates the feasibility of developing interventions to enhance the capacity of community health workers to meet the needs of dependent older people in countries like Brazil. The evidence of effectiveness, though limited and subjective, provides justification for a larger, formally evaluated intervention. The experience of Fortaleza provides valuable lessons for other cities and countries in the region which are facing similar challenges.
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Affiliation(s)
| | - Gerídice Lorna Andrade de Moraes
- Universidade Estadual do Ceará. Av. Dr. Silas Munguba, 1700 - Campus do Itaperi Fortaleza, CE (85) 31019800 / 3101-9795. CEP: 60.714.903, Fortaleza, Brazil
| | - Janaína de Souza Aredes
- Centre for Studies in Public Health and Aging, René Rachou Institute, Fiocruz, Minas Gerais, Brazil
| | | | | | - Lucas Sempe
- University of East Anglia, School of International Development, Norwich, UK
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13
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The Seniors' Community Hub: An Integrated Model of Care for the Identification and Management of Frailty in Primary Care. Geriatrics (Basel) 2021; 6:geriatrics6010018. [PMID: 33673051 PMCID: PMC8005937 DOI: 10.3390/geriatrics6010018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/04/2021] [Accepted: 02/10/2021] [Indexed: 12/11/2022] Open
Abstract
(1) Background: Integrated models of primary care deliver the comprehensive and preventative approach needed to identify and manage frailty in older people. Seniors' Community Hub (SCH) was developed to deliver person-centered, evidence-informed, coordinated, and integrated care services to older community dwelling adults living with frailty. This paper aims to describe the SCH model, and to present patient-oriented results of the pilot. (2) Methods: SCH was piloted in an academic clinic with six family physicians. Eligible patients were community dwelling, 65 years of age and older, and considered to be at risk of frailty (eFI > 0.12). Health professionals within the clinic received training in geriatrics and interprofessional teamwork to form the SCH team working with family physicians, patients and caregivers. The SCH intervention consisted of a team-based multi-domain assessment with person-centered care planning and follow-up. Patient-oriented outcomes (EQ-5D-5L and EQ-VAS) and 4-metre gait speed were measured at initial visit and 12 months later. (3) Results: 88 patients were enrolled in the pilot from April 2016-December 2018. No statistically significant differences in EQ-5D-5L/VAS or the 4-metre gait speed were detected in 38 patients completing the 12-month assessment. (4) Conclusions: Future larger scale studies of longer duration are needed to demonstrate impacts of integrated models of primary care on patient-oriented outcomes for older adults living with frailty.
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14
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Dunn T, Bliss J, Ryrie I. The impact of community nurse-led interventions on the need for hospital use among older adults: An integrative review. Int J Older People Nurs 2021; 16:e12361. [PMID: 33486899 DOI: 10.1111/opn.12361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/30/2020] [Accepted: 12/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hospital avoidance services are important for older people who risk deteriorating health and independence when in hospital. However, the evidence base for nurse-led community services is equivocal. OBJECTIVES To determine the impact of community nurse-led interventions on the need for hospital use among older adults. METHODS The integrative review method of Whittemore and Knafl was employed and reported in accordance with PRIMSA guidelines. Medline, EMBASE and CINAHL were searched from January 2011 to January 2019. Outcomes were coded and findings reported by outcome domain to provide an integrated, narrative synthesis. RESULTS Nine studies were included in the review. Whilst disparities in the evidence base persist, specialist high-intensity, team-based hospital-at-home services were significantly more likely to reduce hospital admissions than standard care. An individual case management services that incorporated self-help education for chronic disease management also reduced hospital admissions. Financial data suggest that whilst high-intensity services are costly, they can lead to significant efficiency savings in the longer-term. CONCLUSION This topic remains an important area for further investment, managerial support and research because of the risks faced by older people when admitted to hospital, for whom health, quality of life and independence are vital considerations. IMPLICATIONS FOR PRACTICE The provision of high-intensity team-based services and self-help education can optimise health outcomes and reduce the need for hospital use among older adults living in the community.
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Affiliation(s)
| | - Julie Bliss
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, London, UK
| | - Iain Ryrie
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, London, UK
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15
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Multicomponent interventions for enhancing primary care: a systematic review. Br J Gen Pract 2020; 71:e10-e21. [PMID: 33257458 PMCID: PMC7716873 DOI: 10.3399/bjgp20x714199] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/17/2020] [Indexed: 01/13/2023] Open
Abstract
Background Many countries have implemented interventions to enhance primary care to strengthen their health systems. These programmes vary widely in features included and their impact on outcomes. Aim To identify multiple-feature interventions aimed at enhancing primary care and their effects on measures of system success — that is, population health, healthcare costs and utilisation, patient satisfaction, and provider satisfaction (quadruple-aim outcomes). Design and setting Systematic review and narrative synthesis. Method Electronic, manual, and grey-literature searches were performed for articles describing multicomponent primary care interventions, providing details of their innovation features, relationship to the ‘4Cs’ (first contact, comprehensiveness, coordination, and continuity), and impact on quadruple-aim outcomes. After abstract and full-text screening, articles were selected and their quality appraised. Results were synthesised in a narrative form. Results From 37 included articles, most interventions aimed to improve access, enhance incentives for providers, provide team-based care, and introduce technologies. The most consistent improvements related to increased primary care visits and screening/preventive services, and improved patient and provider satisfaction; mixed results were found for hospital admissions, emergency department visits, and expenditures. The available data were not sufficient to link interventions, achievement of the 4Cs, and outcomes. Conclusion Most analysed interventions improved some aspects of primary care while, simultaneously, producing non-statistically significant impacts, depending on the features of the interventions, the measured outcome(s), and the populations being studied. A critical research gap was revealed, namely, in terms of which intervention features to enhance primary care (alone or in combination) produce the most consistent benefits.
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16
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Gentin M, Marquestaut O, de Stampa M. [Clinical characteristics, care professionals' intervention and care complexity for elderly patients in home hospitalization]. SANTE PUBLIQUE (VANDOEUVRE-LES-NANCY, FRANCE) 2020; 31:269-276. [PMID: 33263377 DOI: 10.3917/spub.192.0269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The number of elderly patients in home care in France is currently increasing. Our objective is to describe the clinical characteristics, the care professionals' intervention and the complexity of follow-up care for this elderly population. METHODS This is a cross-sectional study with a sample of 50 elderly patients aged 75 and over living at home and followed-up in home hospitalization in 2016 by the Assistance Publique Hôpitaux de Paris. The collection of data used the interRAI-CA tool (Resident Assessment Instrument - Contact Assessment). RESULTS The average age of the sample was 84 years with 48% women, 26% living alone and 96% having a caregiver who had difficulty in caring in 33.3% of cases. Patients had numerous diseases with 68% of the sample who had cognitive difficulties with functional disabilities; Most of them reported pain and 52% had unstable clinical situation. The main care interventions were complex wounds, supportive care and palliative care with technical care and 80% of the sample mobilized more than 3 professionals. Care was considered to be of a high level of complexity for 74% of the elderly patients. CONCLUSION Our study showed that elderly patients had care complexity with technical and multi-faceted care implying coordination of stakeholders and support for caregivers. Implementing at-home hospitalization allows to transfer some geriatric patients from hospitalization to the home care and helps the structuration of the geriatric expertise among the primary care services.
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17
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Davis AC, Osuji TA, Chen J, Lyons LJL, Gould MK. Identifying Populations with Complex Needs: Variation in Approaches Used to Select Complex Patient Populations. Popul Health Manag 2020; 24:393-402. [PMID: 32941105 DOI: 10.1089/pop.2020.0153] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Interventions to support patients with complex needs are proliferating. However, little attention has been paid to methods for identifying complex patients. This study aims to summarize approaches used to define populations with complex needs in practice, by cataloging specific population criteria and organizing them into a taxonomy. The authors conducted a pragmatic review of literature published January 2000-December 2018 using PubMed. Search results were limited to English-language studies of adults that specified a set of objective criteria to identify a population with complex needs. The authors abstracted data from each article on population parameters, and conducted thematic analysis guided by deductive coding. The review identified 70 studies reflecting 90 unique complex population definitions. Complex populations criteria reflected 3 approaches: stratification, segmentation, and targeting. Six domains of population criteria were found within, including age-based criteria (59 populations); income (12); health care costs (45); health care utilization (39); health conditions (35); and subjective criteria (15). Criteria from multiple domains were frequently used in combination, and exact specifications were highly variable within each domain. Overall, 83% of the 90 population definitions included at least 1 cost- or utilization-based criterion. Nearly every study in the review presented a unique approach to identifying patients with complex needs but a limited number of "schools of thought" were found. Variability in definitions and inconsistent terminology are potential sources of ambiguity between stakeholders. Greater specificity and transparency in complex population definition would be a substantial contribution to the emerging field of complex care.
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Affiliation(s)
- Anna C Davis
- Center for Effectiveness and Safety Research, Kaiser Permanente, Pasadena, California, USA.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Thearis A Osuji
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - John Chen
- Department of Internal Medicine, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Lindsay Joe L Lyons
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Michael K Gould
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA.,Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
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18
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Santaeugènia SJ, Mas MA, Tarazona-Santabalbina FJ, García-Lázaro M, Alventosa AM, Gutiérrez-Benito A, Monterde A, Cunill J. Clinical effectiveness of an intermediate care inpatient model based on integrated care pathways. Geriatr Gerontol Int 2020; 20:366-372. [PMID: 32072727 DOI: 10.1111/ggi.13877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 12/30/2019] [Accepted: 01/12/2020] [Indexed: 01/24/2023]
Abstract
AIM The aim of this study was to compare the clinical impact of two intermediate care pathways. METHODS A prospective, uncontrolled before-after study was carried out to compare two non-synchronic intermediate care frameworks in Spain. Participants in the control group were transferred to the intermediate care center by hospital request, whereas those in the intervention group (Badalona Integrated Care Model [BICM]) were transferred based on a territory approach considering the assessment of an intermediate care team. The clinical characteristics of study participants were assessed at admission and discharge. RESULTS Compared with participants in the control group, those in the BICM group were significantly older (mean age 81.6 years [SD 10.3] vs 78.3 years [10.1], P < 0.001) and had a lower Barthel score (mean score 32.8 [SD 25.9] vs 39.9 [28.4]; P < 0.001), and a higher proportion of participants with total dependence (38.4% vs 32.2%; P = 0.001). The length of stay in intermediate care was similar in both groups; however, stay in acute care was significantly shorter in the BICM group than in the control group (mean 21 days [SD 19.5] vs 25 days [SD 23]; P < 0.001). No significant differences were found regarding the Barthel Index at discharge, although participants in the BICM group had significantly higher functional gain. CONCLUSIONS The implementation of a territory-based integrated care pathway in an intermediate care center shifted the profile of admitted patients toward higher complexity. Despite this, patients managed under the integrated care model reduced their dependency and the referral rate to an acute unit during their stay in the intermediate care center. Geriatr Gerontol Int 2020; 20: 366-372.
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Affiliation(s)
- Sebastià J Santaeugènia
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain.,Chronic Care Program, Ministry of Health, Barcelona, Spain.,Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Universitat de Vic - University of Vic-Central University of Catalonia (UVIC-UCC), Vic, Spain
| | - Miquel A Mas
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain.,RE-FiT bcn Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain
| | - Francisco J Tarazona-Santabalbina
- Department of Geriatric Medicine, Hospital Universitario de la Ribera, Valencia, Spain.,Valencia Catholic University Saint Vincent Martyr, Valencia, Spain
| | - Manuela García-Lázaro
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain
| | - Ana Maria Alventosa
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain
| | - Alícia Gutiérrez-Benito
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain
| | - Albert Monterde
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain
| | - Joan Cunill
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain
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19
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Garrard JW, Cox NJ, Dodds RM, Roberts HC, Sayer AA. Comprehensive geriatric assessment in primary care: a systematic review. Aging Clin Exp Res 2020; 32:197-205. [PMID: 30968287 PMCID: PMC7033083 DOI: 10.1007/s40520-019-01183-w] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 03/23/2019] [Indexed: 11/29/2022]
Abstract
Background Comprehensive geriatric assessment (CGA) involves the multidimensional assessment and management of an older person. It is well described in hospital and home-based settings. A novel approach could be to perform CGA within primary healthcare, the initial community located healthcare setting for patients, improving accessibility to a co-located multidisciplinary team. Aim To appraise the evidence on CGA implemented within the primary care practice. Methods The review followed PRISMA recommendations. Eligible studies reported CGA on persons aged ≥ 65 in a primary care practice. Studies focusing on a single condition were excluded. Searches were run in five databases; reference lists and publications were screened. Two researchers independently screened for eligibility and assessed study quality. All study outcomes were reviewed. Results The authors screened 9003 titles, 145 abstracts and 97 full texts. Four studies were included. Limited study bias was observed. Studies were heterogeneous in design and reported outcomes. CGAs were led by a geriatrician (n = 3) or nurse practitioner (n = 1), with varied length and extent of follow-up (12–48 months). Post-intervention hospital admission rates showed mixed results, with improved adherence to medication modifications. No improvement in survival or functional outcomes was observed. Interventions were widely accepted and potentially cost-effective. Discussion The four studies demonstrated that CGA was acceptable and provided variable outcome benefit. Further research is needed to identify the most effective strategy for implementing CGA in primary care. Particular questions include identification of patients suitable for CGA within primary care CGA, a consensus list of outcome measures, and the role of different healthcare professionals in delivering CGA. Electronic supplementary material The online version of this article (10.1007/s40520-019-01183-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- James W Garrard
- Radcliffe Department of Medicine, University of Oxford, Oxford, OX1 2JD, UK.
| | - Natalie J Cox
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Richard M Dodds
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- AGE Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
| | - Helen C Roberts
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Wessex, University of Southampton, Southampton, UK
| | - Avan A Sayer
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- AGE Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
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Abstract
Older adults are rarely consulted on health care restructuring. To address this gap, our study explored older adults' views on "repositioning", a restructuring initiative to support independent living for older adults with complex chronic disease (CCD). We collected and analysed data from 83 older adults living in one small city and nine rural small towns where "repositioning" of primary and community care was occurring. Average participant age was 75 years; 56 (67%) were women, 44 (53%) had CCD, and 20 (24%) identified as Indigenous or South Asian. The four themes were: unfamiliarity with repositioning; optimism versus skepticism; improving primary and community care (through better home care, improved transportation, and more doctors); and, playing an active role to effect change. For repositioning to be successful, diverse service users must be fully included; rural-dwelling older adults' priorities for primary and community care need to be addressed, rather than using a "cookie-cutter" approach.
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21
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Sempé L, Billings J, Lloyd-Sherlock P. Multidisciplinary interventions for reducing the avoidable displacement from home of frail older people: a systematic review. BMJ Open 2019; 9:e030687. [PMID: 31678943 PMCID: PMC6830674 DOI: 10.1136/bmjopen-2019-030687] [Citation(s) in RCA: 8] [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: 03/27/2019] [Revised: 07/04/2019] [Accepted: 09/03/2019] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To synthesise existing literature on interventions addressing a new concept of avoidable displacement from home for older people with multimorbidity or frailty. The review focused on home-based interventions by any type of multidisciplinary team aimed at reducing avoidable displacement from home to hospital settings. A second objective was to characterise these interventions to inform policy. DESIGN A systematic search of the main bibliographic databases was conducted to identify studies relating to interventions addressing avoidable displacement from home for older people. Studies focusing on one specific condition or interventions without multidisciplinary teams were excluded. A narrative synthesis of data was conducted, and themes were identified by using an adapted thematic framework analysis approach. RESULTS The search strategy was performed using the following electronic databases: the American National Library of Medicine and the National Institutes of Health (PubMed), Scopus, Cochrane Library (Central and CDRS), CINAHL, Social Care Online, Web of Science as well as the database of the Latin American and Caribbean Health Sciences Literature. The database search was done in September 2018 and completed in October 2018. Overall 3927 articles were identified and 364 were retained for full text screening. Fifteen studies were included in the narrative review. Four themes were identified and discussed: (1) types of interventions, (2) composition of teams, (3) intervention effectiveness and (4) types of outcomes. Within intervention types, three categories of care types were identified; transitional care, case-management services and hospital at home. Each individual article was assessed in terms of risk of bias following Cochrane Collaboration guidelines. CONCLUSIONS The review identified some potential interventions and relevant topics to be addressed in order to develop effective and sustainable interventions to reduce the avoidable displacement from home of older people. However the review was not able to identify robust impact evidence, either in terms of quantity or quality from the studies presented. As such, the available evidence is not sufficiently robust to inform policy or interventions for reducing avoidable displacement from home. This finding reflects the complexity of these interventions and a lack of systematic data collection. PROSPERO REGISTRATION NUMBER CRD42018108116.
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Affiliation(s)
- Lucas Sempé
- School of International Development, University of East Anglia, Norwich, UK
| | - Jenny Billings
- Centre for Integrated Care Research, University of Kent, Canterbury, UK
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Naseer M, Agerholm J, Fastbom J, Schön P, Ehrenberg A, Dahlberg L. Factors associated with emergency department revisits among older adults in two Swedish regions: A prospective cohort study. Arch Gerontol Geriatr 2019; 86:103960. [PMID: 31704624 DOI: 10.1016/j.archger.2019.103960] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/09/2019] [Accepted: 10/01/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To assess the association between baseline characteristics at an index ED visit and ED revisit within 30 days among adults aged ≥ 65 years in two Swedish regions. METHODS This was a register-based prospective cohort study. The sample included (N=16 688; N=101 017) older adults who have had an index ED visit in 2014 at hospital based EDs in the regions of Dalarna and Stockholm, Sweden. Several registers were linked to obtain information on sociodemographic factors, living conditions, social care, polypharmacy and health care use. Multivariate logistic regression was used to analyse the data. RESULTS Seventeen percent of the study sample in Dalarna and 20.1% in Stockholm revisited ED within 30 days after an index ED visit. In both regions, male gender, being in the last year of life, excessive polypharmacy (≥ 10 drugs), ≥11 primary care visits and ED care utilization were positively associated with ED revisits. In Stockholm, but not in Dalarna, low level of education, polypharmacy, and institutional care was also associated with ED revisits. In contrast, home help was associated with ED revisits in Dalarna but not in Stockholm. CONCLUSION These findings call for further in-depth examinations of variations within single countries. ED revisits among older adults are driven by need of care but also by the social and care situation.
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Affiliation(s)
- Mahwish Naseer
- School of Education, Health and Social Studies, Dalarna University, SE-791 88 Falun, Sweden; Aging Research Center, Karolinska Institutet & Stockholm University, Tomtebodavägen18A, SE-171 65 Solna, Sweden.
| | - Janne Agerholm
- Aging Research Center, Karolinska Institutet & Stockholm University, Tomtebodavägen18A, SE-171 65 Solna, Sweden.
| | - Johan Fastbom
- Aging Research Center, Karolinska Institutet & Stockholm University, Tomtebodavägen18A, SE-171 65 Solna, Sweden.
| | - Pär Schön
- Aging Research Center, Karolinska Institutet & Stockholm University, Tomtebodavägen18A, SE-171 65 Solna, Sweden.
| | - Anna Ehrenberg
- School of Education, Health and Social Studies, Dalarna University, SE-791 88 Falun, Sweden.
| | - Lena Dahlberg
- School of Education, Health and Social Studies, Dalarna University, SE-791 88 Falun, Sweden; Aging Research Center, Karolinska Institutet & Stockholm University, Tomtebodavägen18A, SE-171 65 Solna, Sweden.
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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: 28] [Impact Index Per Article: 5.6] [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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Liljas AEM, Brattström F, Burström B, Schön P, Agerholm J. Impact of Integrated Care on Patient-Related Outcomes Among Older People - A Systematic Review. Int J Integr Care 2019; 19:6. [PMID: 31367205 PMCID: PMC6659761 DOI: 10.5334/ijic.4632] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 07/10/2019] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The growing number of older adults with multiple needs increases the pressure to reform existing healthcare systems. Integrated care may be part of such reforms. The aim of this systematic review was to identify important patient-related outcomes of integrated care provided to older adults. METHODS A systematic search of 5 databases to identify studies comprising older adults assessing hospital admission, length of hospital stay, hospital readmission, patient satisfaction and mortality in integrated care settings. Retrieved literature was analysed employing a narrative synthesis. RESULTS Twelve studies were included (2 randomised controlled trials, 7 quasi-experimental design, 2 comparison studies, 1 survey evaluation). Five studies investigated patient satisfaction, 9 hospital admission, 7 length of stay, 3 readmission and 5 mortality. Findings show that integrated care tends to have a positive impact on hospital admission rates, some positive impact on length of stay and possibly also on readmission and patient satisfaction but not on mortality. CONCLUSIONS Integrated care may reduce hospital admission rates and lengths of hospital stay. However due to lack of robust findings, the effectiveness of integrated care on patient-related outcomes in later life remain largely unknown. Further research is needed to establish the effect of integrated care on these patient-related outcomes. PROSPERO REGISTRATION NUMBER CRD42018110491.
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Affiliation(s)
- Ann E. M. Liljas
- Department of Public Health Sciences, Division of Social Medicine, Karolinska Institutet, Stockholm, SE
| | - Fanny Brattström
- Department of Public Health Sciences, Division of Social Medicine, Karolinska Institutet, Stockholm, SE
| | - Bo Burström
- Department of Public Health Sciences, Division of Social Medicine, Karolinska Institutet, Stockholm, SE
- Centre for Epidemiology and Community Medicine, Stockholm County Council Health Services, Stockholm, SE
| | - Pär Schön
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, SE
| | - Janne Agerholm
- Department of Public Health Sciences, Division of Social Medicine, Karolinska Institutet, Stockholm, SE
- Centre for Epidemiology and Community Medicine, Stockholm County Council Health Services, Stockholm, SE
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Gutman SA, Amarantos K, Berg J, Aponte M, Gordillo D, Rice C, Smith J, Perry A, Wills T, Chen E, Peters R, Schluger Z. Home Safety Fall and Accident Risk Among Prematurely Aging, Formerly Homeless Adults. Am J Occup Ther 2019; 72:7204195030p1-7204195030p9. [PMID: 29953833 DOI: 10.5014/ajot.2018.028050] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Homelessness prematurely ages people. A large subgroup of formerly homeless adults between ages 40 and 64 yr have health conditions similar to or worse than people categorized as elderly. Little is known about the impact of this group's chronic health conditions on their ability to safely function in supportive housing. METHOD Home safety visits were carried out with 25 formerly homeless adults, ages 40-64 yr, now residing in supportive housing. RESULTS Participants had physical, cognitive, and mental health problems that significantly interfered with their ability to perform daily life skills, safely function in an apartment, and manage chronic health conditions. Home safety hazards included cluttered walking paths, the presence of steps, and the lack of grab bars and nonskid flooring. CONCLUSION The homeless population would benefit from aging specialists, such as occupational therapists, who could help people to maintain and function more safely in their homes. Without such services, this population may be at risk for home safety events leading to hospitalization and mortality.
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Affiliation(s)
- Sharon A Gutman
- Sharon A. Gutman, PhD, OTR, FAOTA, is Professor of Rehabilitation and Regenerative Medicine, Programs in Occupational Therapy, Columbia University Medical Center, New York, NY;
| | - Kevin Amarantos
- Kevin Amarantos, MS, OTR, Jan Berg, MS, OTR, Melissa Aponte, MS, OTR, Daniela Gordillo, MS, OTR, Christopher Rice, MS, OTR, Jonathan Smith, MS, OTR, Anna Perry, MS, OTR, Tamara Wills, MS, OTR, Ethan Chen, MS, OTR, Richard Peters, MS, OTR, and Zachary Schluger, MS, OTR, are Occupational Therapists, Programs in Occupational Therapy, Columbia University Medical Center, New York, NY
| | - Jan Berg
- Kevin Amarantos, MS, OTR, Jan Berg, MS, OTR, Melissa Aponte, MS, OTR, Daniela Gordillo, MS, OTR, Christopher Rice, MS, OTR, Jonathan Smith, MS, OTR, Anna Perry, MS, OTR, Tamara Wills, MS, OTR, Ethan Chen, MS, OTR, Richard Peters, MS, OTR, and Zachary Schluger, MS, OTR, are Occupational Therapists, Programs in Occupational Therapy, Columbia University Medical Center, New York, NY
| | - Melissa Aponte
- Kevin Amarantos, MS, OTR, Jan Berg, MS, OTR, Melissa Aponte, MS, OTR, Daniela Gordillo, MS, OTR, Christopher Rice, MS, OTR, Jonathan Smith, MS, OTR, Anna Perry, MS, OTR, Tamara Wills, MS, OTR, Ethan Chen, MS, OTR, Richard Peters, MS, OTR, and Zachary Schluger, MS, OTR, are Occupational Therapists, Programs in Occupational Therapy, Columbia University Medical Center, New York, NY
| | - Daniela Gordillo
- Kevin Amarantos, MS, OTR, Jan Berg, MS, OTR, Melissa Aponte, MS, OTR, Daniela Gordillo, MS, OTR, Christopher Rice, MS, OTR, Jonathan Smith, MS, OTR, Anna Perry, MS, OTR, Tamara Wills, MS, OTR, Ethan Chen, MS, OTR, Richard Peters, MS, OTR, and Zachary Schluger, MS, OTR, are Occupational Therapists, Programs in Occupational Therapy, Columbia University Medical Center, New York, NY
| | - Christopher Rice
- Kevin Amarantos, MS, OTR, Jan Berg, MS, OTR, Melissa Aponte, MS, OTR, Daniela Gordillo, MS, OTR, Christopher Rice, MS, OTR, Jonathan Smith, MS, OTR, Anna Perry, MS, OTR, Tamara Wills, MS, OTR, Ethan Chen, MS, OTR, Richard Peters, MS, OTR, and Zachary Schluger, MS, OTR, are Occupational Therapists, Programs in Occupational Therapy, Columbia University Medical Center, New York, NY
| | - Jonathan Smith
- Kevin Amarantos, MS, OTR, Jan Berg, MS, OTR, Melissa Aponte, MS, OTR, Daniela Gordillo, MS, OTR, Christopher Rice, MS, OTR, Jonathan Smith, MS, OTR, Anna Perry, MS, OTR, Tamara Wills, MS, OTR, Ethan Chen, MS, OTR, Richard Peters, MS, OTR, and Zachary Schluger, MS, OTR, are Occupational Therapists, Programs in Occupational Therapy, Columbia University Medical Center, New York, NY
| | - Anna Perry
- Kevin Amarantos, MS, OTR, Jan Berg, MS, OTR, Melissa Aponte, MS, OTR, Daniela Gordillo, MS, OTR, Christopher Rice, MS, OTR, Jonathan Smith, MS, OTR, Anna Perry, MS, OTR, Tamara Wills, MS, OTR, Ethan Chen, MS, OTR, Richard Peters, MS, OTR, and Zachary Schluger, MS, OTR, are Occupational Therapists, Programs in Occupational Therapy, Columbia University Medical Center, New York, NY
| | - Tamara Wills
- Kevin Amarantos, MS, OTR, Jan Berg, MS, OTR, Melissa Aponte, MS, OTR, Daniela Gordillo, MS, OTR, Christopher Rice, MS, OTR, Jonathan Smith, MS, OTR, Anna Perry, MS, OTR, Tamara Wills, MS, OTR, Ethan Chen, MS, OTR, Richard Peters, MS, OTR, and Zachary Schluger, MS, OTR, are Occupational Therapists, Programs in Occupational Therapy, Columbia University Medical Center, New York, NY
| | - Ethan Chen
- Kevin Amarantos, MS, OTR, Jan Berg, MS, OTR, Melissa Aponte, MS, OTR, Daniela Gordillo, MS, OTR, Christopher Rice, MS, OTR, Jonathan Smith, MS, OTR, Anna Perry, MS, OTR, Tamara Wills, MS, OTR, Ethan Chen, MS, OTR, Richard Peters, MS, OTR, and Zachary Schluger, MS, OTR, are Occupational Therapists, Programs in Occupational Therapy, Columbia University Medical Center, New York, NY
| | - Richard Peters
- Kevin Amarantos, MS, OTR, Jan Berg, MS, OTR, Melissa Aponte, MS, OTR, Daniela Gordillo, MS, OTR, Christopher Rice, MS, OTR, Jonathan Smith, MS, OTR, Anna Perry, MS, OTR, Tamara Wills, MS, OTR, Ethan Chen, MS, OTR, Richard Peters, MS, OTR, and Zachary Schluger, MS, OTR, are Occupational Therapists, Programs in Occupational Therapy, Columbia University Medical Center, New York, NY
| | - Zachary Schluger
- Kevin Amarantos, MS, OTR, Jan Berg, MS, OTR, Melissa Aponte, MS, OTR, Daniela Gordillo, MS, OTR, Christopher Rice, MS, OTR, Jonathan Smith, MS, OTR, Anna Perry, MS, OTR, Tamara Wills, MS, OTR, Ethan Chen, MS, OTR, Richard Peters, MS, OTR, and Zachary Schluger, MS, OTR, are Occupational Therapists, Programs in Occupational Therapy, Columbia University Medical Center, New York, NY
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Looman WM, Huijsman R, Fabbricotti IN. The (cost-)effectiveness of preventive, integrated care for community-dwelling frail older people: A systematic review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2019; 27:1-30. [PMID: 29667259 PMCID: PMC7379491 DOI: 10.1111/hsc.12571] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/19/2018] [Indexed: 05/28/2023]
Abstract
Integrated care is increasingly promoted as an effective and cost-effective way to organise care for community-dwelling frail older people with complex problems but the question remains whether high expectations are justified. Our study aims to systematically review the empirical evidence for the effectiveness and cost-effectiveness of preventive, integrated care for community-dwelling frail older people and close attention is paid to the elements and levels of integration of the interventions. We searched nine databases for eligible studies until May 2016 with a comparison group and reporting at least one outcome regarding effectiveness or cost-effectiveness. We identified 2,998 unique records and, after exclusions, selected 46 studies on 29 interventions. We assessed the quality of the included studies with the Effective Practice and Organization of Care risk-of-bias tool. The interventions were described following Rainbow Model of Integrated Care framework by Valentijn. Our systematic review reveals that the majority of the reported outcomes in the studies on preventive, integrated care show no effects. In terms of health outcomes, effectiveness is demonstrated most often for seldom-reported outcomes such as well-being. Outcomes regarding informal caregivers and professionals are rarely considered and negligible. Most promising are the care process outcomes that did improve for preventive, integrated care interventions as compared to usual care. Healthcare utilisation was the most reported outcome but we found mixed results. Evidence for cost-effectiveness is limited. High expectations should be tempered given this limited and fragmented evidence for the effectiveness and cost-effectiveness of preventive, integrated care for frail older people. Future research should focus on unravelling the heterogeneity of frailty and on exploring what outcomes among frail older people may realistically be expected.
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Affiliation(s)
- Wilhelmina Mijntje Looman
- Department Health Services Management & OrganisationErasmus School of Health Policy & ManagementErasmus UniversityRotterdamThe Netherlands
| | - Robbert Huijsman
- Department Health Services Management & OrganisationErasmus School of Health Policy & ManagementErasmus UniversityRotterdamThe Netherlands
| | - Isabelle Natalina Fabbricotti
- Department Health Services Management & OrganisationErasmus School of Health Policy & ManagementErasmus UniversityRotterdamThe Netherlands
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Marino M, de Belvis AG, Tanzariello M, Dotti E, Bucci S, Colotto M, Ricciardi W, Boccia S. Effectiveness and cost-effectiveness of integrated care models for elderly, complex patients: A narrative review. Don’t we need a value-based approach? INTERNATIONAL JOURNAL OF CARE COORDINATION 2018. [DOI: 10.1177/2053434518817019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction The management of patients with complex health and social needs is one of the main challenges for healthcare systems. Integrated care seems to respond to this issue, with collaborative working and integration efforts of the care system components professionals and service providers aimed at improving efficiency, appropriateness and person centeredness of care. We conducted a narrative review to analyse the available evidences published on effectiveness and cost-effectiveness of integrated care models targeted on the management of such elderly patients. Methods MEDLINE, Scopus and EBSCO were searched. We reported this narrative review according to the PRISMA Checklist. For studies to be included, they had to: (i) refer to integrated care models through implemented experimental or demonstration projects; (ii) focus on frail elderly ≥65 years old, with complex health and social needs, not disease-specific; (iii) evaluate effectiveness and/or cost and/or cost-effectiveness; (iv) report quantitative data (e.g. health outcomes, utilization outcomes, cost and cost-effectiveness). Results Thirty articles were included, identifying 13 integrated care models. Common features were identified in case management, geriatric assessment and multidisciplinary team. Favourable impacts on healthcare facilities utilization rates, though with mixed results on costs, were found. The development of community-based and cost-effective integrated systems of care for the elderly is possible, thanks to the cooperation across care professionals and providers, to achieving a relevant impact on healthcare and efficient resource management. The elements of success or failure are not always unique and identifiable, but the potential clearly exists for these models to be successful and generalized on a large scale. Discussion We found out a favourable impact of integrated care models/methods on health outcomes, care utilization and costs. The selected interventions are likely to be implemented at community level, focused on the patient management in terms of continuity of care. Thus, we propose a value-based framework for the evaluation of these services.
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Baxter S, Johnson M, Chambers D, Sutton A, Goyder E, Booth A. Understanding new models of integrated care in developed countries: a systematic review. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06290] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BackgroundThe NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care.ObjectivesThe study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes.DesignThe study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings.SettingAny setting.ParticipantsPatients receiving a health-care service and/or staff delivering services.InterventionsChanges to service delivery that increase integration and co-ordination of health and health-related services.Main outcome measuresOutcomes related to the delivery of services, including the views and perceptions of patients/service users and staff.Study designEmpirical work of a quantitative or qualitative design.Data sourcesWe searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review.Review methodsThe identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence.ResultsWe included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs.LimitationsDefining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness.ConclusionsThere is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models.Future workLinks between elements of new models and outcomes require further study, together with research in a wider variety of populations.Study registrationThis study is registered as PROSPERO CRD37725.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Susan Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Maxine Johnson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anthea Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Baxter S, Johnson M, Chambers D, Sutton A, Goyder E, Booth A. The effects of integrated care: a systematic review of UK and international evidence. BMC Health Serv Res 2018; 18:350. [PMID: 29747651 PMCID: PMC5946491 DOI: 10.1186/s12913-018-3161-3] [Citation(s) in RCA: 310] [Impact Index Per Article: 51.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/29/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context. METHODS The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence. RESULTS One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users. CONCLUSIONS Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand. TRIAL REGISTRATION Prospero registration number: 42016037725 .
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Affiliation(s)
- Susan Baxter
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S14DA UK
| | - Maxine Johnson
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S14DA UK
| | - Duncan Chambers
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S14DA UK
| | - Anthea Sutton
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S14DA UK
| | - Elizabeth Goyder
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S14DA UK
| | - Andrew Booth
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S14DA UK
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Khatib AH, Hamdan-Mansour AM, Bani Hani MA. Theoretical Perspectives of Hospitalized Older Patients and Their Health-Related Problems and Quality of Care: Systematic Literature Review. ACTA ACUST UNITED AC 2017. [DOI: 10.2174/1874944501710010215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Introduction:The proportion of aged people is growing worldwide. Older persons are affected by a number of physical, psychological and social factors that influence their health and quality of life. These factors are usually multiple and are often masked by sensory and cognitive impairments.Purpose:The purpose of this study was to examine the available literature emphasizing older persons’ care, care-related problems, and older persons’ quality of healthcare. Also, the paper aimed at exploring the future direction of research needs.Results:Good quality older patients’ care involves safety, professional interventions, recognition and management of physical and emotional wellbeing. Care of older patients requires addressing the aging process itself, the expected decrease in functionality, and diminished cognitive ability. Little statistical data were found to address the quality of hospitalized elderly patients in particular as well as study on healthcare facilities and nursing homes. Literature does not provide much guidance to the effectiveness of care strategies.Conclusion:The results assert that elderly health care is a priority. However, health care systems are not specific about elderly patients’ needs, leading to low quality of elderly care. There is a need to use an integrated model of care to improve the quality of life and quality of care provided to hospitalized older patients.
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Kirst M, Im J, Burns T, Baker GR, Goldhar J, O'Campo P, Wojtak A, Wodchis WP. What works in implementation of integrated care programs for older adults with complex needs? A realist review. Int J Qual Health Care 2017; 29:612-624. [PMID: 28992156 PMCID: PMC5890872 DOI: 10.1093/intqhc/mzx095] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 06/08/2017] [Accepted: 07/04/2017] [Indexed: 12/29/2022] Open
Abstract
PURPOSE A realist review of the evaluative evidence was conducted on integrated care (IC) programs for older adults to identify key processes that lead to the success or failure of these programs in achieving outcomes such as reduced healthcare utilization, improved patient health, and improved patient and caregiver experience. DATA SOURCES International academic literature was searched in 12 indexed, electronic databases and gray literature through internet searches, to identify evaluative studies. STUDY SELECTION Inclusion criteria included evaluative literature on integrated, long-stay health and social care programs, published between January 1980 and July 2015, in English. DATA EXTRACTION Data were extracted on the study purpose, period, setting, design, population, sample size, outcomes, and study results, as well as explanations of mechanisms and contextual factors influencing outcomes. RESULTS OF DATA SYNTHESIS A total of 65 articles, representing 28 IC programs, were included in the review. Two context-mechanism-outcome configurations (CMOcs) were identified: (i) trusting multidisciplinary team relationships and (ii) provider commitment to and understanding of the model. Contextual factors such as strong leadership that sets clear goals and establishes an organizational culture in support of the program, along with joint governance structures, supported team collaboration and subsequent successful implementation. Furthermore, time to build an infrastructure to implement and flexibility in implementation, emerged as key processes instrumental to success of these programs. CONCLUSIONS This review included a wide range of international evidence, and identified key processes for successful implementation of IC programs that should be considered by program planners, leaders and evaluators.
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Affiliation(s)
- Maritt Kirst
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
- Department of Psychology, Wilfrid Laurier University, 75 University Ave. West, Waterloo, ON, Canada N2L 3C5
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
| | - Jennifer Im
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
| | - Tim Burns
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
| | - G. Ross Baker
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
| | - Jodeme Goldhar
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
- The Change Foundation, 200 Front Street West, Toronto, Canada M5V 3M1
| | - Patricia O'Campo
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St., Toronto, Canada M5B 1W8
| | - Anne Wojtak
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
- Toronto Central Local Health Integration Network, 250 Dundas St. West, Toronto, Canada M5T 2Z5
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, Canada M5T 3M6
- Toronto Rehabilitation Institute, 550 University Ave., Toronto, Canada M5G 2A2
- Institute for Clinical Evaluative Sciences, 2075 Bayview Ave., Toronto, Canada M4N 3M5
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Santaeugènia SJ, García-Lázaro M, Alventosa AM, Gutiérrez-Benito A, Monterde A, Cunill J. [New integrated care model for older people admitted to Intermediate Care Units in Catalonia: A quasi-experimental study protocol]. Rev Esp Geriatr Gerontol 2017; 52:201-208. [PMID: 27451388 DOI: 10.1016/j.regg.2016.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 05/27/2016] [Accepted: 06/01/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To evaluate the clinical effectiveness of an intermediate care model based on a system of care focused on integrated care pathways compared to the traditional model of geriatric care (usual care) in Catalonia. PATIENTS AND METHODS The design is a quasi-experimental pre-post non-randomised study with non-synchronous control group. The intervention consists of the development and implementation of integrated care pathways and the creation of specialised interdisciplinary teams in each of the processes. The two groups will be compared for demographic, clinical variables on admission and discharge, geriatric syndromes, and use of resources. DISCUSSION This quasi-experimental study, aims to assess the clinical impact of the transformation of a traditional model of geriatric care to an intermediate care model in an integrated healthcare organisation. It is believed that the results of this study may be useful for future randomised controlled studies.
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Affiliation(s)
| | - Manuela García-Lázaro
- Servicio Geriatría y Cuidados Paliativos, Badalona Serveis Assistencials, Badalona, España
| | - Ana María Alventosa
- Servicio Geriatría y Cuidados Paliativos, Badalona Serveis Assistencials, Badalona, España
| | | | - Albert Monterde
- Servicio Geriatría y Cuidados Paliativos, Badalona Serveis Assistencials, Badalona, España
| | - Joan Cunill
- Servicio Geriatría y Cuidados Paliativos, Badalona Serveis Assistencials, Badalona, España
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McKissick HD, Cady RG, Looman WS, Finkelstein SM. The Impact of Telehealth and Care Coordination on the Number and Type of Clinical Visits for Children With Medical Complexity. J Pediatr Health Care 2017; 31:452-458. [PMID: 28017489 PMCID: PMC5481493 DOI: 10.1016/j.pedhc.2016.11.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 11/14/2016] [Accepted: 11/27/2016] [Indexed: 01/22/2023]
Abstract
INTRODUCTION The purpose of this analysis was to evaluate the effects of an advanced practice nurse-delivered telehealth intervention on health care use by children with medical complexity (CMC). Because CMC account for a large share of health care use costs, finding effective ways to care for them is an important challenge requiring exploration. METHOD This was a secondary analysis of data from a randomized clinical trial with a control group and two intervention groups. The focus of the analysis was planned and unplanned clinical and therapy visits by CMC over a 30-month data collection period. Nonparametric tests were used to compare visit counts among and within the three groups. RESULTS The number of unplanned visits decreased over time across all groups, with the greatest decrease in the video telehealth intervention group. Planned visits were higher in the video telehealth group across all time periods. DISCUSSION Advanced practice registered nurse-delivered telehealth care coordination may support a shift from unplanned to planned health care service use among CMC.
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Di Pollina L, Guessous I, Petoud V, Combescure C, Buchs B, Schaller P, Kossovsky M, Gaspoz JM. Integrated care at home reduces unnecessary hospitalizations of community-dwelling frail older adults: a prospective controlled trial. BMC Geriatr 2017; 17:53. [PMID: 28196486 PMCID: PMC5310012 DOI: 10.1186/s12877-017-0449-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 02/11/2017] [Indexed: 11/27/2022] Open
Abstract
Background Care of frail and dependent older adults with multiple chronic conditions is a major challenge for health care systems. The study objective was to test the efficacy of providing integrated care at home to reduce unnecessary hospitalizations, emergency room visits, institutionalization, and mortality in community dwelling frail and dependent older adults. Methods A prospective controlled trial was conducted, in real-life clinical practice settings, in a suburban region in Geneva, Switzerland, served by two home visiting nursing service centers. Three hundred and one community-dwelling frail and dependent people over 60 years old were allocated to previously randomized nursing teams into Control (N = 179) and Intervention (N = 122) groups: Controls received usual care by their primary care physician and home visiting nursing services, the Intervention group received an additional home evaluation by a community geriatrics unit with access to a call service and coordinated follow-up. Recruitment began in July 2009, goals were obtained in July 2012, and outcomes assessed until December 2012. Length of follow-up ranged from 5 to 41 months (mean 16.3). Primary outcome measure was the number of hospitalizations. Secondary outcomes were reasons for hospitalizations, the number and reason of emergency room visits, institutionalization, death, and place of death. Results The number of hospitalizations did not differ between groups however, the intervention led to lower cumulative incidence for the first hospitalization after the first year of follow-up (69.8%, CI 59.9 to 79.6 versus 87 · 6%, CI 78 · 2 to 97 · 0; p = .01). Secondary outcomes showed that the intervention compared to the control group had less frequent unnecessary hospitalizations (4.1% versus 11.7%, p = .03), lower cumulative incidence for the first emergency room visit, 8.3%, CI 2.6 to 13.9 versus 23.2%, CI 13.1 to 33.3; p = .01), and death occurred more frequently at home (44.4 versus 14.7%; p = .04). No significant differences were found for institutionalization and mortality. Conclusions Integrated care that included a home visiting multidisciplinary geriatric team significantly reduced unnecessary hospitalizations, emergency room visits and allowed more patients to die at home. It is an effective tool to improve coordination and access to care for frail and dependent older adults. Trial registration Clinical Trials.gov Identifier: NCT02084108. Retrospectively registered on March 10th 2014.
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Affiliation(s)
- Laura Di Pollina
- Division of Primary Care Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, 1, avenue Calas, Geneva, 1206, Switzerland.
| | - Idris Guessous
- Division of Primary Care Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, 1, avenue Calas, Geneva, 1206, Switzerland. .,Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland.
| | - Véronique Petoud
- Institution genevoise de maintien à domicile (IMAD), Carouge, Switzerland
| | - Christophe Combescure
- Clinical Research Centre and Division of Clinical-Epidemiology, Department of Health and Community Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
| | - Bertrand Buchs
- Association des médecins genevois (AMG), Geneva, Switzerland
| | | | - Michel Kossovsky
- Division of Primary Care Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, 1, avenue Calas, Geneva, 1206, Switzerland
| | - Jean-Michel Gaspoz
- Division of Primary Care Medicine, Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, 1, avenue Calas, Geneva, 1206, Switzerland
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Legramante JM, Morciano L, Lucaroni F, Gilardi F, Caredda E, Pesaresi A, Coscia M, Orlando S, Brandi A, Giovagnoli G, Di Lecce VN, Visconti G, Palombi L. Frequent Use of Emergency Departments by the Elderly Population When Continuing Care Is Not Well Established. PLoS One 2016; 11:e0165939. [PMID: 27973563 PMCID: PMC5156362 DOI: 10.1371/journal.pone.0165939] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 10/20/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction The elderly, who suffer from multiple chronic diseases, represent a substantial proportion of Emergency Department (ED) frequent users, thus contributing to ED overcrowding, although they could benefit from other health care facilities, if those were available. The aim of this study was to evaluate and characterize hospital visits of older patients (age 65 or greater) to the ED of a university teaching hospital in Rome from the 1st of January to the 31st of December 2014, in order to identify clinical and social characteristics potentially associated with “elderly frequent users”. Material and Methods A retrospective study was performed during the calendar year 2014 (1st January 2014 – 31st December 2014) analyzing all ED admissions to the University Hospital of Rome Tor Vergata. Variables collected included age, triage code, arrival data, discharge diagnosis, and visit outcome. We performed a risk analysis using univariate binary logistic regression models. Results A total number of 38,016 patients accessed the ED, generating 46,820 accesses during the study period, with an average of 1.23 accesses for patient. The elderly population represented a quarter of the total ED population and had an increased risk of frequent use (OR 1.5: CI 1.4–1.7) and hospitalization (OR 3.8: CI 3.7–4). Moreover, they showed a greater diagnostic complexity, as demonstrated by the higher incidence of yellow and red priority codes compared to other ED populations (OR 3.1: CI 2.9–3.2). Discussion Older patients presented clinical and social characteristics related to the definition of “elderly frail frequent users”. The fact that a larger number of hospitalizations occurred in such patients is indirect evidence of frailty in this specific population, suggesting that hospital admissions may be an inappropriate response to frailty, especially when continued care is not established. Conclusion Enhancement of continuity of care, establishment of a tracking system for those who are at greater risk of visiting the ED and evaluating fragile individuals should be the highest priority in addressing ED frequent usage by the elderly.
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Affiliation(s)
- Jacopo M. Legramante
- Department of Medical Systems, University of Rome Tor Vergata, Foundation Policlinico Tor Vergata, Rome, Italy
- Emergengy Department, Foundation Policlinico Tor Vergata, Rome, Italy
| | - Laura Morciano
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Francesca Lucaroni
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Francesco Gilardi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Emanuele Caredda
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Alessia Pesaresi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Massimo Coscia
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Stefano Orlando
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Antonella Brandi
- Emergengy Department, Foundation Policlinico Tor Vergata, Rome, Italy
| | | | - Vito N. Di Lecce
- Emergengy Department, Foundation Policlinico Tor Vergata, Rome, Italy
| | | | - Leonardo Palombi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
- * E-mail:
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Engel PA, Spencer J, Paul T, Boardman JB. The Geriatrics in Primary Care Demonstration: Integrating Comprehensive Geriatric Care into the Medical Home: Preliminary Data. J Am Geriatr Soc 2016; 64:875-9. [PMID: 27100583 DOI: 10.1111/jgs.14026] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Three thousand nine hundred thirty-one veterans aged 75 and older receive primary care (PC) in two large practices of the Department of Veterans Affairs (VA) Boston Healthcare System. Cognitive and functional disabilities are endemic in this group, creating needs that predictably exceed available or appropriate resources. To address this problem, Geriatrics in Primary Care (GPC) embeds geriatric services directly into primary care. An on-site consulting geriatrician and geriatric nurse care manager work directly with PC colleagues in medicine, nursing, social work, pharmacy, and mental health within the VA medical home. This design delivers interdisciplinary geriatric care within PC that emphasizes comprehensive evaluations, care management, planned transitions, informed resource use, and a shift in care focus from multiple subspecialties to PC. Four hundred thirty-five veterans enrolled during the project's 4-year course. Complex, fragmented care was evident in a series of 50 individuals (aged 82 ± 7) enrolled during Months 1 to 6. The year before, these individuals made 372 medical or surgical subspecialty clinic visits (7.4 ± 9.8); 34% attended five or more subspecialty clinics, 48% had dementia, and 18% lacked family caregivers. During the first year after enrollment the mean number of subspecialty clinic visits declined significantly (4.7 ± 5.0, P = .01), whereas the number of PC-based visits remained stable (3.1 ± 1.5 and 3.3 ± 1.5, respectively, P = .50). Telephone contact by GPC (2.3 ± 2.0) and collaboration with PC clinicians replaced routine follow-up geriatric care. GPC facilitated planned transitions to rehabilitation centers (n = 5), home hospice (n = 2), dementia units (n = 3), and home care (n = 37). GPC provides efficient, comprehensive geriatric care and case management while preserving established relationships between patients and the PC team. Preliminary results suggest "care defragmentation," as reflected by a significant reduction in subspecialty clinic use. Model simplicity and flexibility facilitated ready implementation.
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Affiliation(s)
- Peter A Engel
- Geriatric Research, Education and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jacqueline Spencer
- Harvard Medical School, Boston, Massachusetts.,Primary and Ambulatory Care, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Todd Paul
- Department of Nursing, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Judith B Boardman
- Department of Nursing, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
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Lin KP, Chen PC, Huang LY, Mao HC, Chan DCD. Predicting Inpatient Readmission and Outpatient Admission in Elderly: A Population-Based Cohort Study. Medicine (Baltimore) 2016; 95:e3484. [PMID: 27100455 PMCID: PMC4845859 DOI: 10.1097/md.0000000000003484] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Recognizing potentially avoidable hospital readmission and admissions are important health care quality issues. We develop prediction models for inpatient readmission and outpatient admission to hospitals for older adults In the retrospective cohort study with 2 million sampling file of the National Health Insurance Research Database in Taiwan, older adults (aged ≥65 y/o) with a first admission in 2008 were enrolled in the inpatient cohort (N = 39,156). The outpatient cohort included subjects who had ≥1 outpatient visit in 2008 (N = 178,286). Each cohort was split into derivation (3/4) and validation (1/4) data set. Primary outcome of the inpatient cohort: 30-day readmission from the date of discharge. The outpatient cohort included hospital admissions within the 1-year follow-up period. Candidate risk factors include demographics, comorbidities, and previous health care utilizations. Series of logistic regression models were applied with area under the receiver operating curves (AUCs) to identify the best model. Roughly 1 of 7 (14.6%) of the inpatients was readmitted within 30 days, and 1 of 5 (19.1%) of the outpatient cohort was admitted within 1 year. Age, education, use of home health care, and selected comorbidities (e.g., cancer with metastasis) were included in the final model. The AUC of the inpatient readmission model was 0.655 (95% confidence interval [CI] 0.646-0.664) and outpatient admission model was 0.642 (95% CI 0.639-0.646). Predictive performance was maintained in both validation data sets. The goodness-to-fit model demonstrated good calibration in both groups. We developed and validated practical clinical prediction models for inpatient readmission and outpatient admissions for general older adults with indicators easily obtained from an administrative data set.
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Affiliation(s)
- Kun-Pei Lin
- From the Department of Geriatrics and Gerontology (K-PL, H-CM, D-CC); Department of Internal Medicine (K-PL, D-CC), National Taiwan University Hospital; Institute of Epidemiology and Preventive Medicine (P-CC), College of Public Health, National Taiwan University; Clinical Informatics and Medical Statistics Research Center (P-CC); Department of Neurology (P-CC), Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi, Taiwan; Chang-Gung University; National Taiwan University Health Data Research Center (L-YH); and National Taiwan University Hospital Chu-Tung Branch (D-CC), Chu-Tung, Taiwan
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Stokes J, Panagioti M, Alam R, Checkland K, Cheraghi-Sohi S, Bower P. Effectiveness of Case Management for 'At Risk' Patients in Primary Care: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0132340. [PMID: 26186598 PMCID: PMC4505905 DOI: 10.1371/journal.pone.0132340] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 06/14/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND An ageing population with multimorbidity is putting pressure on health systems. A popular method of managing this pressure is identification of patients in primary care 'at-risk' of hospitalisation, and delivering case management to improve outcomes and avoid admissions. However, the effectiveness of this model has not been subjected to rigorous quantitative synthesis. METHODS AND FINDINGS We carried out a systematic review and meta-analysis of the effectiveness of case management for 'at-risk' patients in primary care. Six bibliographic databases were searched using terms for 'case management', 'primary care', and a methodology filter (Cochrane EPOC group). Effectiveness compared to usual care was measured across a number of relevant outcomes: Health--self-assessed health status, mortality; Cost--total cost of care, healthcare utilisation (primary and non-specialist care and secondary care separately), and; Satisfaction--patient satisfaction. We conducted secondary subgroup analyses to assess whether effectiveness was moderated by the particular model of case management, context, and study design. A total of 15,327 titles and abstracts were screened, 36 unique studies were included. Meta-analyses showed no significant differences in total cost, mortality, utilisation of primary or secondary care. A very small significant effect favouring case management was found for self-reported health status in the short-term (0.07, 95% CI 0.00 to 0.14). A small significant effect favouring case management was found for patient satisfaction in the short- (0.26, 0.16 to 0.36) and long-term (0.35, 0.04 to 0.66). Secondary subgroup analyses suggested the effectiveness of case management may be increased when delivered by a multidisciplinary team, when a social worker was involved, and when delivered in a setting rated as low in initial 'strength' of primary care. CONCLUSIONS This was the first meta-analytic review which examined the effects of case management on a wide range of outcomes and considered also the effects of key moderators. Current results do not support case management as an effective model, especially concerning reduction of secondary care use or total costs. We consider reasons for lack of effect and highlight key research questions for the future. REVIEW PROTOCOL The review protocol is available as part of the PROSPERO database (registration number: CRD42014010824).
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Affiliation(s)
- Jonathan Stokes
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Maria Panagioti
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Rahul Alam
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Kath Checkland
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Sudeh Cheraghi-Sohi
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Peter Bower
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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Marazzi MC, Inzerilli MC, Madaro O, Palombi L, Scarcella P, Orlando S, Maurici M, Liotta G. Impact of the Community-Based Active Monitoring Program on the Long Term Care Services Use and In-Patient Admissions of the Over-74 Population. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/aar.2015.46020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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