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Kamei T, Kawada A, Minami K, Takahashi Z, Ishigaki Y, Yamanaka T, Yamamoto N, Yamamoto Y, Suzuki Y, Watanabe T, Iijima K. Effectiveness of an interdisciplinary home care approach for older adults with chronic conditions: A systematic review and meta-analysis. Geriatr Gerontol Int 2024. [PMID: 39021240 DOI: 10.1111/ggi.14931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 06/15/2024] [Accepted: 06/18/2024] [Indexed: 07/20/2024]
Abstract
The effectiveness of interdisciplinary home healthcare service consisting of at least two or more healthcare providers, such as a nurse, physician and physiotherapist, for community-dwelling older adults remains unclear. This systematic review assesses the effects of interdisciplinary home care on quality of life (QOL) and health outcomes in older adults with chronic conditions using validated tools. Databases were searched using CINAHL Plus with Full Text, PubMed, EMBASE, CENTRAL, PsycINFO, and OpenGrey from inception to January 25, 2021. Eligibility criteria included (i) an interdisciplinary home care approach, (ii) participants aged 65 years and older with chronic conditions, (iii) randomized controlled trials (RCTs), and (iv) original literature in English. The study reviewer's dyad independently screened the literature and assessed the study quality using the Cochrane's Risk of Bias 2 tool. The analysis employed qualitative and quantitative integration and Grading of Recommendations Assessment, Development, and Evaluation. This study included 13 RCTs with 4709 participants. Four RCTs indicated that interdisciplinary home healthcare services reduced hospital admissions during the initial 6 months after the start of home care interventions (risk ratio [RR] = 0.73; 95% confidence interval [CI] = 0.61-0.88; p < 0.001; I2 = 0%). However, evidence certainty was moderate; QOL and mortality showed low certainty; and institutionalization and adherence showed moderate certainty of evidence. This study suggests that the interdisciplinary home care approach reduces hospital admissions but lacks effects on other outcomes. More robust studies are required to evaluate this evidence. Geriatr Gerontol Int 2024; ••: ••-••.
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Affiliation(s)
- Tomoko Kamei
- Graduate School of Nursing Science, St Luke's International University, Tokyo, Japan
| | - Aki Kawada
- Graduate School of Nursing Science, St Luke's International University, Tokyo, Japan
| | - Kotoko Minami
- Graduate School of Nursing Science, St Luke's International University, Tokyo, Japan
| | - Zaiya Takahashi
- Department of Medical Education, Graduate School of Medicine, Chiba University, Chiba, Japan
| | | | - Takashi Yamanaka
- Department of Home Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Noriko Yamamoto
- Department of Gerontological Homecare and Long-term Care Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuko Yamamoto
- Chiba Faculty of Nursing, Tokyo Healthcare University, Chiba, Japan
| | - Yusuke Suzuki
- Centre for Community Liaison and Patient Consultations, Nagoya University Hospital, Aichi, Japan
| | - Takamasa Watanabe
- Centre for Family Medicine Development, Japanese Health and Welfare Co-operative Federation, Tokyo, Japan
| | - Katsuya Iijima
- Institute for Future Initiatives, Institute of Gerontology, The University of Tokyo, Tokyo, Japan
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Kirvalidze M, Boström AM, Liljas A, Doheny M, Hendry A, McCormack B, Fratiglioni L, Ali S, Ebrahimi Z, Elmståhl S, Eriksdotter M, Gläske P, Gustafsson LK, Rundgren ÅH, Hvitfeldt H, Lennartsson C, Hammar LM, Nilsson GH, Nilsson P, Öhlén J, Sandgren A, Söderman A, Swedberg K, Vackerberg N, Vetrano DL, Wijk H, Agerholm J, Calderón-Larrañaga A. Effectiveness of integrated person-centered interventions for older people's care: Review of Swedish experiences and experts' perspective. J Intern Med 2024; 295:804-824. [PMID: 38664991 DOI: 10.1111/joim.13784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/15/2024]
Abstract
Older adults have multiple medical and social care needs, requiring a shift toward an integrated person-centered model of care. Our objective was to describe and summarize Swedish experiences of integrated person-centered care by reviewing studies published between 2000 and 2023, and to identify the main challenges and scientific gaps through expert discussions. Seventy-three publications were identified by searching MEDLINE and contacting experts. Interventions were categorized using two World Health Organization frameworks: (1) Integrated Care for Older People (ICOPE), and (2) Integrated People-Centered Health Services (IPCHS). The included 73 publications were derived from 31 unique and heterogeneous interventions pertaining mainly to the micro- and meso-levels. Among publications measuring mortality, 15% were effective. Subjective health outcomes showed improvement in 24% of publications, morbidity outcomes in 42%, disability outcomes in 48%, and service utilization outcomes in 58%. Workshop discussions in Stockholm (Sweden), March 2023, were recorded, transcribed, and summarized. Experts emphasized: (1) lack of rigorous evaluation methods, (2) need for participatory designs, (3) scarcity of macro-level interventions, and (4) importance of transitioning from person- to people-centered integrated care. These challenges could explain the unexpected weak beneficial effects of the interventions on health outcomes, whereas service utilization outcomes were more positively impacted. Finally, we derived a list of recommendations, including the need to engage care organizations in interventions from their inception and to leverage researchers' scientific expertise. Although this review provides a comprehensive snapshot of interventions in the context of Sweden, the findings offer transferable perspectives on the real-world challenges encountered in this field.
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Affiliation(s)
- Mariam Kirvalidze
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Solna, Sweden
| | - Anne-Marie Boström
- Department of Neurobiology, Care Sciences, and Society, Division of Nursing, Karolinska Institutet, Huddinge, Sweden
- Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden
- Research and Development Unit, Stockholms Sjukhem, Stockholm, Sweden
| | - Ann Liljas
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Solna, Sweden
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
| | - Megan Doheny
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Solna, Sweden
| | - Anne Hendry
- International Foundation for Integrated Care (IFIC), Glasgow, Scotland, UK
- School of Health and Life Sciences, University of the West of Scotland, Glasgow, Scotland, UK
| | - Brendan McCormack
- Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, Sydney Nursing School, The University of Sydney, Sydney, Australia
| | - Laura Fratiglioni
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Solna, Sweden
- Stockholm Gerontology Research Center, Stockholm, Sweden
| | - Sulin Ali
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Solna, Sweden
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- Institute for Sociology, University of Duisburg-Essen, Duisburg, Germany
| | - Zahra Ebrahimi
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg Centre for Person-Centred Care - GPCC, Gothenburg, Sweden
| | - Sölve Elmståhl
- Department of Clinical Sciences, Division of Geriatric Medicine, Lund University, Lund, Sweden
| | - Maria Eriksdotter
- Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Clinical Geriatrics, Karolinska Institutet, Huddinge, Sweden
| | - Pascal Gläske
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Solna, Sweden
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- Institute for Sociology, University of Duisburg-Essen, Duisburg, Germany
| | - Lena-Karin Gustafsson
- School of Health, Care and Social Welfare, Mälardalen University, Eskilstuna, Sweden
| | | | | | - Carin Lennartsson
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Solna, Sweden
- Swedish Institute for Social Research (SOFI), Stockholm University, Stockholm, Sweden
| | - Lena Marmstål Hammar
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
- School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Gunnar H Nilsson
- Department of Neurobiology, Care Sciences, and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Huddinge, Sweden
| | - Peter Nilsson
- Myndigheten för vård- och omsorgsanalys, Stockholm, Sweden
| | - Joakim Öhlén
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg Centre for Person-Centred Care - GPCC, Gothenburg, Sweden
- Palliative Care Centre, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| | - Annika Söderman
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nicoline Vackerberg
- Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Davide Liborio Vetrano
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Solna, Sweden
- Stockholm Gerontology Research Center, Stockholm, Sweden
| | - Helle Wijk
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg Centre for Person-Centred Care - GPCC, Gothenburg, Sweden
- Department of Architecture and Civil Engineering, Chalmers University of Technology, Gothenburg, Sweden
- Department of Quality Assurance and Patient Safety, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Janne Agerholm
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Solna, Sweden
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
| | - Amaia Calderón-Larrañaga
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Solna, Sweden
- Stockholm Gerontology Research Center, Stockholm, Sweden
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Long SO, Hope SV. What patient-reported outcome measures may be suitable for research involving older adults with frailty? A scoping review. Eur Geriatr Med 2024:10.1007/s41999-024-00964-5. [PMID: 38532081 DOI: 10.1007/s41999-024-00964-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/14/2024] [Indexed: 03/28/2024]
Abstract
INTRODUCTION The need to develop and evaluate frailty-related interventions is increasingly important, and inclusion of patient-reported outcomes is vital. Patient-reported outcomes can be defined as measures of health, quality of life or functional status reported directly by patients with no clinician interpretation. Numerous validated questionnaires can thus be considered patient-reported outcome measures (PROMs). This review aimed to identify existing PROMs currently used in quantitative research that may be suitable for older people with frailty. METHOD PubMed and Cochrane were searched up to 24/11/22. Inclusion criteria were quantitative studies, use of a PROM, and either measurement of frailty or inclusion of older adult participants. Criteria were created to distinguish PROMs from questionnaire-based clinical assessments. 197 papers were screened. PROMs were categorized according to the domain assessed, as derived from a published consensus 'Standard Set of Health Outcome Measures for Older People'. RESULTS 88 studies were included. 112 unique PROMs were used 289 times, most frequently the SF-36 (n = 21), EQ-5D (n = 21) and Barthel Index (n = 14). The most frequently assessed outcome domains included Mood and Emotional Health and Activities of Daily Living, with fewer assessments of Participation in Decision-Making and Carer Burden. CONCLUSIONS PROM usage in frailty research is highly heterogeneous. Frequently used PROMs omit important outcomes identified by older adults. Further research should evaluate the importance of specific outcomes and identify PROMs relevant to people at different stages of frailty. Consistent and appropriate PROM use in frailty research would facilitate more effective comparisons and meaningful evaluation of frailty interventions.
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Affiliation(s)
- S O Long
- University of Exeter, Exeter, UK
| | - S V Hope
- University of Exeter, Exeter, UK.
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK.
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Taylor-Rowan M, Hafdi M, Drozdowska B, Elliott E, Wardlaw J, Quinn TJ. Physical and brain frailty in ischaemic stroke or TIA: Shared occurrence and outcomes. A cohort study. Eur Stroke J 2023; 8:1011-1020. [PMID: 37421136 PMCID: PMC10683729 DOI: 10.1177/23969873231186480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/20/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND There is increasing interest in the concept of frailty in stroke, including both physical frailty and imaging-evidence of brain frailty. We aimed to establish the prevalence of brain frailty in stroke survivors as well as the concurrent and predictive validity of various frailty measures against long-term cognitive outcomes. METHODS We included consecutively admitted stroke or transient ischaemic attack (TIA) survivors from participating stroke centres. Baseline CT scans were used to generate an overall brain frailty score for each participant. We measured frailty via the Rockwood frailty index, and a Fried frailty screening tool. Presence of major or minor neurocognitive disorder at 18-months following stroke or TIA was established via a multicomponent assessment. Prevalence of brain frailty was established based upon observed percentages within groups defined by frailty status (robust, pre-frail, frail). We assessed the concurrent validity of brain frailty and frailty scales via Spearman's rank correlation. We conducted multivariable logistic regression analyses, controlling for age, sex, baseline education and stroke severity, to evaluate association between each frailty measure and 18-month cognitive impairment. RESULTS Three-hundred-forty-one stroke survivors participated. Three-quarters of people who were frail had moderate-severe brain frailty and prevalence increased according to frailty status. Brain frailty was weakly correlated with Rockwood frailty (Rho: 0.336; p < 0.001) and with Fried frailty (Rho: 0.230; p < 0.001). Brain frailty (OR: 1.64, 95% CI = 1.17-2.32), Rockwood frailty (OR: 1.05, 95% CI = 1.02-1.08) and Fried frailty (OR: 1.93, 95% CI = 1.39-2.67) were each independently associated with cognitive impairment at 18 months following stroke. CONCLUSIONS There appears to be value in the assessment of both physical and brain frailty in patients with ischaemic stroke and TIA. Both are associated with adverse cognitive outcomes and physical frailty remains important when assessing cognitive outcomes.
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Affiliation(s)
| | - Melanie Hafdi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Bogna Drozdowska
- Institute of Cardiovascular and Metabolic Sciences, University of Glasgow, Glasgow, UK
| | - Emma Elliott
- Institute of Cardiovascular and Metabolic Sciences, University of Glasgow, Glasgow, UK
| | - Joanna Wardlaw
- Centre for Clinical Brain Sciences, Edinburgh Center in the UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Metabolic Sciences, University of Glasgow, Glasgow, UK
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Edney LC, Haji Ali Afzali H, Visvanathan R, Toson B, Karnon J. An exploration of healthcare use in older people waiting for and receiving Australian community-based aged care services. Geriatr Gerontol Int 2023; 23:899-905. [PMID: 37860887 DOI: 10.1111/ggi.14703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 09/21/2023] [Accepted: 09/28/2023] [Indexed: 10/21/2023]
Abstract
AIM Home care packages (HCPs) facilitate older individuals to remain at home, with longer HCP wait times associated with increased mortality risk. We analyze healthcare cost data pre- and post-HCP access to inform hypotheses around the effects of healthcare use and mortality risk. METHODS Regression models were used to assess the impact of delayed HCP access on healthcare costs and to compare costs whilst waiting and in the 6- and 12 month periods post-HCP access for 16 629 older adults. RESULTS Average wait time for a HCP was 89.7 days (SD = 125.6) during the study period. Wait-time length had no impact on any healthcare cost category or time period. However, total per day healthcare costs were higher in the 6 and 12 months post-receipt of a HCP (AU$61.5, AU$63, respectively) compared with those in the time waiting for a HCP (AU$48.1). Inpatient care accounted for a higher proportion of total healthcare costs post-HCP (AU$45.1, AU$46.3, respectively) compared with in the wait time (AU$30.6), whilst spending on medical services and pharmaceuticals reduced slightly in the 6 month (AU$7.1, AU$6.3) and 12 month (AU$7.2, AU$6.3) post-HCP periods compared with in the wait time (AU$7.9, AU$7.1). CONCLUSIONS Increased spending post-HCP on inpatient care or non-health support afforded by HCPs may offer protective effects for mortality and risk of admission to aged care. Further research should explore the association between delayed access to inpatient care for geriatric syndromes and mortality to inform recommendations on extensions to residential care outreach services into the community to improve the timely identification of the need for inpatient care. Geriatr Gerontol Int 2023; 23: 899-905.
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Affiliation(s)
- Laura C Edney
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Hossein Haji Ali Afzali
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Renuka Visvanathan
- Aged and Extended Care Services, Queen Elizabeth Hospital and Basil Hetzel Institute, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
- Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Barbara Toson
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Jonathan Karnon
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
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Yen PC, Lo YT, Lai CC, Lee CC, Fang CJ, Chang CM, Yang YC. Effectiveness of outpatient geriatric evaluation and management intervention on survival and nursing home admission: a systematic review and meta-analysis of randomized controlled trials. BMC Geriatr 2023; 23:414. [PMID: 37420187 PMCID: PMC10329350 DOI: 10.1186/s12877-023-04036-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/11/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND The benefit of inpatient comprehensive geriatric assessment on patient survival and function has been demonstrated among frail older patients. However, the influence of outpatient geriatric evaluation and management (GEM) on clinical outcomes remains debated. This study aimed to update the research evidence detailing the effect of outpatient GEM on survival and nursing-home admission through a comparison with conventional care. METHODS Cochrane Library, EMBASE, and MEDLINE databases were searched up to January 29th, 2022, to identify randomized controlled trials (RCTs) including older people over age 55 that compared outpatient GEM with conventional care on mortality (primary outcome) and nursing-home admission (secondary outcome) during a follow-up period of 12 to 36 months. RESULTS Nineteen reports from 11 studies that recruited 7,993 participants (mean age 70-83) were included. Overall, outpatient GEM significantly reduced mortality (risk ratio (RR) = 0.87, 95% confidence interval (CI) = 0.77-0.99, I2 = 12%). For the subgroup analysis categorized by different follow-up periods, its prognostic benefit was only disclosed for 24-month mortality (RR = 0.68, 95% CI = 0.51-0.91, I2 = 0%), but not for 12- or 15 to 18-month mortality. Furthermore, outpatient GEM had significantly trivial effects on nursing-home admission during the follow-up period of 12 or 24 months (RR = 0.91, 95% CI = 0.74-1.12, I2 = 0%). CONCLUSIONS Outpatient GEM led by a geriatrician with a multidisciplinary team improved overall survival, specifically during the 24-month follow-up period. This trivial effect was demonstrated in rates of nursing-home admission. Future research on outpatient GEM involving a larger cohort is warranted to corroborate our findings.
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Affiliation(s)
- Pei-Chia Yen
- Department of Family Medicine, Kuo General Hospital, No.22, Sec.2, Min Sheng Road, West Central Dist, Tainan, 700, Taiwan
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, North Dist, Tainan, 704, Taiwan
| | - Yu-Tai Lo
- Department of Family Medicine, Kuo General Hospital, No.22, Sec.2, Min Sheng Road, West Central Dist, Tainan, 700, Taiwan.
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, North Dist, Tainan, 704, Taiwan.
- Department of Geriatrics and Gerontology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, North Dist, Tainan, 704, Taiwan.
| | - Chih-Cheng Lai
- Department of Internal Medicine, Chi-Mei Medical Center, No.901, Zhong Hua Road, Yongkang Dist, Tainan, 710, Taiwan
| | - Ching-Chi Lee
- Clinical Medicine Research Centre, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, North Dist, Tainan, 704, Taiwan
| | - Ching-Ju Fang
- Department of Secretariat, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, North Dist, Tainan, 704, Taiwan
- Medical Library, National Cheng Kung University, No. 1, University Road, East Dist, Tainan, 701, Taiwan
| | - Chia-Ming Chang
- Department of Geriatrics and Gerontology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, North Dist, Tainan, 704, Taiwan
- Department of Medicine & Institute of Gerontology, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, North Dist, Tainan, 704, Taiwan
| | - Yi-Ching Yang
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, North Dist, Tainan, 704, Taiwan
- Department of Geriatrics and Gerontology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, North Dist, Tainan, 704, Taiwan
- Department of Family Medicine, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, North Dist, Tainan, 704, Taiwan
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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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Westerling U, Hellgren M, Hermansson L, Strid EN. In safe hands: a qualitative study on older adults' experiences of a tailored primary health care unit. Scand J Prim Health Care 2022; 40:271-280. [PMID: 35837795 PMCID: PMC9397434 DOI: 10.1080/02813432.2022.2097611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Objective: Today's health care system faces challenges in meeting the needs of older people with multimorbidity. To better cope with these needs, tailored primary health care with geriatric competence and person-centred care has been suggested. The aim of this study was to explore older patients' experiences of a tailored primary health care unit.Design: This was a qualitative study using semi-structured individual interviews and qualitative content analysis.Setting and patients: Nineteen patients were recruited from a tailored PHC unit for people aged 75 years or older in a region in central Sweden.Methods: The interview data were analysed using inductive category development.Results: In the analysis, the theme In safe hands when in need of primary health care emerged. The interviewees expressed a desire to participate in their own care. Easy access, enough consultation time and a calm environment, along with the PHC professionals' welcoming and attentive approach enhanced their feeling of being in safe hands. PHC professionals were perceived as having geriatric knowledge and taking responsibility for the care of older patients. Although the interviewees experienced that they received attention for their health conditions, a need for a more preventive approach to care emerged.Conclusion: Older patients highly appreciated their tailored PHC unit and they emphasised that it was an improvement compared to the ordinary PHC centre. This study provides insights into older patients' experiences, which may be helpful in the ongoing process of improving care for older patients in PHC.KEY POINTSOlder patients attending a tailored Primary health care (PHC) unit felt acknowledged, unlike in the ordinary PHC centre, which facilitated their participation in their care.The calm environment, specialist geriatric competence and ample patient contact time enabled them to feel secure and taken care of.Older patients expressed a need for an incorporation of social services and health promotion visits at the tailored PHC unit.
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Affiliation(s)
- Ulrika Westerling
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Kumla Primary Health Care Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- CONTACT Ulrika Westerling University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Kumla Primary Health Care Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mikko Hellgren
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Kumla Primary Health Care Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Liselotte Hermansson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Emma Nilsing Strid
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Ketelaers SHJ, Jacobs A, Verrijssen ASE, Cnossen JS, van Hellemond IEG, Creemers GJM, Schreuder RM, Scholten HJ, Tolenaar JL, Bloemen JG, Rutten HJT, Burger JWA. A Multidisciplinary Approach for the Personalised Non-Operative Management of Elderly and Frail Rectal Cancer Patients Unable to Undergo TME Surgery. Cancers (Basel) 2022; 14:2368. [PMID: 35625976 PMCID: PMC9139821 DOI: 10.3390/cancers14102368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 02/07/2023] Open
Abstract
Despite it being the optimal curative approach, elderly and frail rectal cancer patients may not be able to undergo a total mesorectal excision. Frequently, no treatment is offered at all and the natural course of the disease is allowed to unfold. These patients are at risk for developing debilitating symptoms that impair quality of life and require palliative treatment. Recent advancements in non-operative treatment modalities have enhanced the toolbox of alternative treatment strategies in patients unable to undergo surgery. Therefore, a proposed strategy is to aim for the maximal non-operative treatment, in an effort to avoid the onset of debilitating symptoms, improve quality of life, and prolong survival. The complexity of treating elderly and frail patients requires a patient-centred approach to personalise treatment. The main challenge is to optimise the balance between local control of disease, patient preferences, and the burden of treatment. A comprehensive geriatric assessment is a crucial element within the multidisciplinary dialogue. Since limited knowledge is available on the optimal non-operative treatment strategy, these patients should be treated by dedicated multidisciplinary rectal cancer experts with special interest in the elderly and frail. The aim of this narrative review was to discuss a multidisciplinary patient-centred treatment approach and provide a practical suggestion of a successfully implemented clinical care pathway.
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Affiliation(s)
- Stijn H. J. Ketelaers
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Anne Jacobs
- Department of Gerontology and Geriatrics, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - An-Sofie E. Verrijssen
- Department of Radiation Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (A.-S.E.V.); (J.S.C.)
| | - Jeltsje S. Cnossen
- Department of Radiation Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (A.-S.E.V.); (J.S.C.)
| | - Irene E. G. van Hellemond
- Department of Medical Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (I.E.G.v.H.); (G.-J.M.C.)
| | - Geert-Jan M. Creemers
- Department of Medical Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (I.E.G.v.H.); (G.-J.M.C.)
| | - Ramon-Michel Schreuder
- Department of Gastroenterology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - Harm J. Scholten
- Department of Anaesthesiology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - Jip L. Tolenaar
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Johanne G. Bloemen
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Harm J. T. Rutten
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
- GROW, School for Oncology and Reproduction, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Jacobus W. A. Burger
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
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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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Health outcomes and implementation barriers and facilitators of comprehensive geriatric assessment in community settings: a systematic integrative review [PROSPERO registration no.: CRD42021229953]. BMC Geriatr 2022; 22:379. [PMID: 35488198 PMCID: PMC9052611 DOI: 10.1186/s12877-022-03024-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 03/29/2022] [Indexed: 11/20/2022] Open
Abstract
Background Comprehensive geriatric assessment (CGA) addresses the bio-psycho-social needs of older adults through multidimensional assessments and management. Synthesising evidence on quantitative health outcomes and implementation barriers and facilitators would inform practice and policy on CGA for community-dwelling older adults. Methods We systematically searched four medical and social sciences electronic databases for quantitative, qualitative, and mixed methods studies published from 1 January 2000 to 31 October 2020. Due to heterogeneity of articles, we narratively reviewed the synthesis of evidence on health outcomes and implementation barriers and facilitators. Results We screened 14,151 titles and abstracts and 203 full text articles, and included 43 selected articles. Study designs included controlled intervention studies (n = 31), pre-post studies without controls (n = 4), case-control (n = 1), qualitative methods (n = 3), and mixed methods (n = 4). A majority of articles studied populations aged ≥75 years (n = 18, 42%). CGAs were most frequently conducted in the home (n = 25, 58%) and primary care settings (n = 8, 19%). CGAs were conducted by nurses in most studies (n = 22, 51%). There was evidence of improved functional status (5 of 19 RCTs, 2 of 3 pre-post), frailty and fall outcomes (3 of 6 RCTs, 1 of 1 pre-post), mental health outcomes (3 of 6 RCTs, 2 of 2 pre-post), self-rated health (1 of 6 RCTs, 1 of 1 pre-post), and quality of life (4 of 17 RCTs, 3 of 3 pre-post). Barriers to implementation of CGAs involved a lack of partnership alignment and feedback, poor acceptance of preventive work, and challenges faced by providers in operationalising and optimising CGAs. The perceived benefits of CGA that served to facilitate its implementation included the use of highly skilled staff to provide holistic assessments and patient education, and the resultant improvements in care coordination and convenience to the patients, particularly where home-based assessments and management were performed. Conclusion There is mixed evidence on the quantitative health outcomes of CGA on community-dwelling older adults. While there is perceived positive value from CGA when carried out by highly skilled staff, barriers such as bringing providers into a partnership, greater acceptance of preventive care, and operational issues could impede its implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03024-4.
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12
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Eriksen CU, Kamstrup–Larsen N, Birke H, Helding SAL, Ghith N, Andersen JS, Frølich A. Models of care for improving health-related quality of life, mental health, or mortality in persons with multimorbidity: A systematic review of randomized controlled trials. JOURNAL OF MULTIMORBIDITY AND COMORBIDITY 2022; 12:26335565221134017. [PMID: 36325259 PMCID: PMC9618762 DOI: 10.1177/26335565221134017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To categorize and examine the effectiveness regarding health-related quality of life (HRQoL), mental health, and mortality of care models for persons with multimorbidity in primary care, community care, and hospitals through a systematic review. METHODS We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials up to May 2020. One author screened titles and abstracts, and to validate, a second author screened 5% of the studies. Two authors independently extracted data and assessed risk of bias using the tool by the Cochrane Effective Practice and Organisation of Care group. Study inclusion criteria were (1) participants aged ≥ 18 years with multimorbidity; (2) referred to multimorbidity or two or more specific chronic conditions in the title or abstract; (3) randomized controlled design; and (4) HRQoL, mental health, or mortality as primary outcome measures. We used the Foundation Framework to categorize the models and the PRISMA-guideline for reporting. RESULTS In this study, the first to report effectiveness of care models in patients with multimorbidity in hospital settings, we included 30 studies and 9,777 participants with multimorbidity. 12 studies were located in primary care, 9 in community care, and 9 in hospitals. HRQoL was reported as the primary outcome in 12 studies, mental health in 17 studies, and mortality in three studies-with significant improvements in 5, 14, and 2, respectively. The studies are presented according to settings. CONCLUSIONS Although 20 of the care models reported positive effects, the variations in populations, settings, model elements, and outcome measures made it difficult to conclude on which models and model elements were effective.
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Affiliation(s)
- Christian U Eriksen
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region of Denmark, Denmark
| | - Nina Kamstrup–Larsen
- The Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; AND Innovation and Research Center for Multimorbidity, Slagelse Hospital, Region Zealand, Denmark
| | - Hanne Birke
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region of Denmark, Denmark
| | - Sofie A L Helding
- Rigshospitalet and DanTrials ApS, Juliane Marie Centre, Kobenhavn, Denmark; Zero Phase 1 Unit, Bispebjerg and Frederiksberg Hospital, The Capital Region of Denmark, Denmark
| | - Nermin Ghith
- Research Group for Genomic Epidemiology, National Food Institute, Technical University of Denmark, Denmark
| | - John S Andersen
- The Research Unit for General Practice, Department of Public Health, University of Copenhagen, Denmark
| | - Anne Frølich
- The Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; AND Innovation and Research Center for Multimorbidity, Slagelse Hospital, Region Zealand, Denmark
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"To be seen" - older adults and their relatives' care experiences given by a geriatric mobile team (GerMoT). BMC Geriatr 2021; 21:636. [PMID: 34742233 PMCID: PMC8572495 DOI: 10.1186/s12877-021-02587-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/22/2021] [Indexed: 11/10/2022] Open
Abstract
Background The proportion of older people in the population has increased globally and has thus become a challenge in health and social care. There is good evidence that care based on comprehensive geriatric assessment (CGA) is superior to the usual care found in acute hospital settings; however, the evidence is scarcer in community-dwelling older people. This study is a secondary outcome of a randomized controlled trial of community-dwelling older people in which the intervention group (IG) received CGA-based care by a geriatric mobile geriatric team (GerMoT). The aim of this study is to obtain a better understanding, from the patients’ perspective, the experience of being a part of the IG for both the participants and their relatives. Methods Qualitative semistructured interviews of twenty-two community dwelling participants and eleven of their relatives were conducted using content analysis for interpretation. Results The main finding expressed by the participants and their relatives was in the form of feelings related to safety and security and being recognized. The participants found the care easily accessible, and that contacts could be taken according to needs by health care professionals who knew them. This is in accordance with person-centred care as recommended by the World Health Organisation (WHO) for older people in need of integrated care. Other positive aspects were recurrent health examinations and being given the time needed when seeking health care. Not all participants were positive as some found the information about the intervention to be unclear especially regarding whom to contact when in different situations. Conclusions CGA-based care of community-dwelling older people shows promising results as the participants in GerMoT found the care was giving a feeling of security and safety. They found the care easily accessible and that it was provided by health care professionals who knew them as a person and knew their health care problems. They found this to be in contrast to the usual care provided, but GerMoT care did not fulfill some people’s expectations.
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Tannou T, Godard-Marceau A, Joubert S, Daneault S, Kergoat MJ, Magnin E, Comte A, Gabriel D, Vidal C, Pazart L, Aubry R. Added value of functional neuroimaging to assess decision-making capacity of older adults with neurocognitive disorders: protocol for a prospective, monocentric, single-arm study (IMAGISION). BMJ Open 2021; 11:e053549. [PMID: 34588264 PMCID: PMC8483026 DOI: 10.1136/bmjopen-2021-053549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Assessment of decision-making capacity (DMC) is essential in daily life as well as for defining a person-centred care plan. Nevertheless, in ageing, especially if signs of dementia appear, it becomes difficult to assess decision-making ability and raises ethical questions. Currently, the assessment of DMC is based on the clinician's evaluation, completed by neuropsychological tests. Functional MRI (fMRI) could bring added value to the diagnosis of DMC in difficult situations. METHODS AND ANALYSIS IMAGISION is a prospective, monocentric, single-arm study evaluating fMRI compared with clinical assessment of DMC. The study will begin during Fall 2021 and should be completed by Spring 2023. Participants will be recruited from a memory clinic where they will come for an assessment of their cognitive abilities due to decision-making needs to support ageing in place. They will be older people over 70 years of age, living at home, presenting with a diagnosis of mild dementia, and no exclusion criteria of MRI. They will be clinically assessed by a geriatrician on their DMC, based on the neuropsychological tests usually performed. Participants will then perform a behavioural task in fMRI (Balloon Analogue Risk Task) to analyse the activation areas. Additional semistructured interviews will be conducted to explore real life implications. The main analysis will study concordance/discordance between the clinical classification and the activation of fMRI regions of interest. Reclassification as 'capable', based on fMRI, of patients for whom clinical diagnosis is 'questionable' will be considered as a diagnostic gain. ETHICS AND DISSEMINATION IMAGISION has been authorised by a research ethics board (Comité de Protection des Personnes, Bordeaux, II) in France, in accordance with French legislation on interventional biomedical research, under the reference IDRCB number 2019-A00863-54, since 30 September 2020. Participants will sign an informed consent form. The results of the study will be presented in international peer-reviewed scientific journals, international scientific conferences and public lectures. TRIAL REGISTRATION NUMBER NCT03931148.
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Affiliation(s)
- Thomas Tannou
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive - UR LINC, Université Bourgogne Franche Comté, Besancon, France
- Inserm, CIC 1431, Centre d'Investigation Clinique, Besançon, F-25000 France, University Hospital of Besançon, Besançon, France
- Geriatrics, University Hospital of Besançon, Besancon, France
- Centre de recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Québec, Canada
| | - Aurelie Godard-Marceau
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive - UR LINC, Université Bourgogne Franche Comté, Besancon, France
- Inserm, CIC 1431, Centre d'Investigation Clinique, Besançon, F-25000 France, University Hospital of Besançon, Besançon, France
| | - Sven Joubert
- Centre de recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Québec, Canada
- Departement de psychologie, Université de Montréal, Montreal, Québec, Canada
| | - Serge Daneault
- Centre de recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Québec, Canada
| | - Marie-Jeanne Kergoat
- Centre de recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Québec, Canada
| | - Eloi Magnin
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive - UR LINC, Université Bourgogne Franche Comté, Besancon, France
| | - Alexandre Comte
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive - UR LINC, Université Bourgogne Franche Comté, Besancon, France
- Inserm, CIC 1431, Centre d'Investigation Clinique, Besançon, F-25000 France, University Hospital of Besançon, Besançon, France
| | - Damien Gabriel
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive - UR LINC, Université Bourgogne Franche Comté, Besancon, France
- Inserm, CIC 1431, Centre d'Investigation Clinique, Besançon, F-25000 France, University Hospital of Besançon, Besançon, France
| | - Chrystelle Vidal
- Inserm, CIC 1431, Centre d'Investigation Clinique, Besançon, F-25000 France, University Hospital of Besançon, Besançon, France
| | - Lionel Pazart
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive - UR LINC, Université Bourgogne Franche Comté, Besancon, France
- Inserm, CIC 1431, Centre d'Investigation Clinique, Besançon, F-25000 France, University Hospital of Besançon, Besançon, France
| | - Regis Aubry
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive - UR LINC, Université Bourgogne Franche Comté, Besancon, France
- Inserm, CIC 1431, Centre d'Investigation Clinique, Besançon, F-25000 France, University Hospital of Besançon, Besançon, France
- Geriatrics, University Hospital of Besançon, Besancon, France
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Vellani S, Cumal A, Degan C. Frailty assessment and interventions for community-dwelling older adults: a rapid review. Nurs Older People 2021; 33:28-34. [PMID: 34286521 DOI: 10.7748/nop.2021.e1327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2021] [Indexed: 11/09/2022]
Abstract
Frailty is a syndrome involving increased vulnerability that usually develops from age-related decline in physiological reserves and function in multiple organ systems, resulting in an impaired ability to respond to acute changes in health conditions. It is imperative that healthcare providers who work with older adults in primary care and community settings understand how to assess frailty and can identify appropriate interventions. This article reports the results of a rapid review that examined how frailty is assessed in community-dwelling older adults and what interventions are used to address frailty in this population.
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Affiliation(s)
- Shirin Vellani
- KITE Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Alexia Cumal
- KITE Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
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Acosta-García H, Alfaro-Lara ER, Sánchez-Fidalgo S, Sevilla-Sánchez D, Delgado-Silveira E, Juanes-Borrego A, Santos-Ramos B. Intervention effectiveness by pharmacists integrated within an interdisciplinary health team on chronic complex patients. Eur J Public Health 2021; 30:886-899. [PMID: 32052027 DOI: 10.1093/eurpub/ckz224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Nowadays, it is difficult to establish a specific method of intervention by the pharmacist and its clinical repercussions. Our aim was to identify interventions by pharmacists integrated within an interdisciplinary team for chronic complex patients (CCPs) and determine which of them produce the best results. METHODS A systematic review (SR) was performed based on PICO(d) question (2008-18): (Population): CCPs; (Intervention): carried out by health system pharmacists in collaboration with an interdisciplinary team; (Comparator): any; (Outcome): clinical and health resources usage outcomes; (Design): meta-analysis, SR and randomized clinical trials. RESULTS Nine articles were included: one SR and eight randomized clinical trials. The interventions consisted mainly in putting in order the pharmacotherapy and the review of the medication adequacy, medication reconciliation in transition of care and educational intervention for health professionals. Only one showed significant improvements in mortality (27.9% vs. 38.5%; HR = 1.49; P = 0.026), two in health-related quality of life [according to EQ-5D (European Quality of Life-5 Dimensions) and EQ-VAS (European Quality of Life-Visual Analog Scale) tests] and four in other health-related results (subjective self-assessment scales, falls or episodes of delirium and negative health outcomes associated with medication). Significant differences between groups were found in hospital stay and frequency of visits to the emergency department. No better results were observed in hospitalization rate. Otherwise, one study measured cost utility and found a cost of €45 987 per quality-adjusted life year gained due to the intervention. CONCLUSIONS It was not possible to determine with certainty which interventions produce the best results in CCPs. The clinical heterogeneity of the studies and the short follow-up of most studies probably contributed to this uncertainty.
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Affiliation(s)
| | | | - Susana Sánchez-Fidalgo
- Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | - Daniel Sevilla-Sánchez
- Pharmacy Service, Vic Hospital Consortium, Central Catalonia Chronicity Research Group (C3RG), Vic, Spain
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Yao S, Zheng P, Ji L, Ma Z, Wang L, Qiao L, Wan Y, Sun N, Luo Y, Yang J, Wang H. The effect of comprehensive assessment and multi-disciplinary management for the geriatric and frail patient: A multi-center, randomized, parallel controlled trial. Medicine (Baltimore) 2020; 99:e22873. [PMID: 33181655 PMCID: PMC7668452 DOI: 10.1097/md.0000000000022873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND A comprehensive geriatric assessment (CGA) of elderly patients is useful for detecting the patients vulnerabilities. Exercise and early rehabilitation, nutritional intervention, traditional Chinese medicine (TCM), standardized medication guidance, and patient education can, separately, improve and even reverse the physical frailty status. However, the effect of combining a CGA and multi-disciplinary management on frailty in elderly patients remains unclear. The present study assessed the effects of a CGA and multi-disciplinary management on elderly patients with frailty in China. METHODS In this study, 320 in patients with frailty ≥70 years old will be randomly divided into an intervention group and a control group. The intervention group will be given routine management, a CGA and multi-disciplinary management involving rehabilitation exercise, diet adjustment, multi-drug evaluation, acupoint massage in TCM and patient education for 12 months, and the control group will be followed up with routine management for basic diseases. The primary outcomes are the Fried phenotype and short physical performance battery (SPPB). The secondary outcomes are the clinical frailty scale (CFS), non-elective hospital readmission, basic activities of daily living (BADL), 5-level European quality of life 5 dimensions index (EQ-5D), nutrition risk screening-2002 (NRS-2002), medical insurance expenses, fall events, and all-cause mortality. In addition, a cost-effectiveness study will be carried out. DISCUSSION This paper outlines the protocol for a randomized, single-blind, parallel multi-center clinical study. This protocol, if beneficial, will demonstrate the interaction of various intervention strategies, will help improve elderly frailty patients, and will be useful for clinicians, nurses, policymakers, public health authorities, and the general population. TRIAL REGISTRATION Chinese Clinical Trials Register, ChiCTR1900022623. Registered on April 19, 2019, http://www.chictr.org.cn/showproj.aspx?proj=38141.
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Affiliation(s)
- Simin Yao
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences
- Peking University Fifth School of Clinical Medicine, Dong Dan, Beijing
| | - Peipei Zheng
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences
- Peking University Fifth School of Clinical Medicine, Dong Dan, Beijing
| | | | - Zhao Ma
- Department of Rehabilitation
| | | | - Linlin Qiao
- Department of TCM, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, PR China
| | - Yuhao Wan
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences
| | - Ning Sun
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences
| | - Yao Luo
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences
| | - Jiefu Yang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences
| | - Hua Wang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences
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18
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Hummel J, Müller-Wilmsen U, Wiloth S, Kopf D, Kessler EM, Oster P. [Outpatient care for the old and very old]. MMW Fortschr Med 2020; 162:14-20. [PMID: 32661892 DOI: 10.1007/s15006-020-0659-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/30/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Outpatient treatment of elderly patients is the responsibility of the family doctor. In addition to general practitioner care, there are some regionally different models that are currently not established and evaluated in Germany. The investigation presented here aims to contribute to the profiling of outpatient geriatric care in the future. METHOD A full survey on the attitude and acceptance of general practitioners towards outpatient geriatrics and a geriatric focus practice was carried out. At the same time, referral and advisory events were systematically recorded and compared. RESULTS AND CONCLUSION A geriatric focus practice can complement primary care. It is well accepted by many family doctors if there is a transparent exchange, pilot function and basic family doctor activities remain with the family doctor and he is relieved of the burden on complex patients.
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Affiliation(s)
- Jana Hummel
- Geriatrische und Gerontopsychotherapeutische Schwerpunktpraxis, Mannheim, Deutschland.
- Geriatrische und Gerontopsychotherapeutische Schwerpunktpraxis, Rheingoldstraße 41a, D-68199, Mannheim, Deutschland.
| | | | | | - Daniel Kopf
- Geriatrisches Zentrum Ludwigsburg-Bietigheim, Deutschland
| | | | - Peter Oster
- Geriatrisches Zentrum Bethanien a.D., Deutschland
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19
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Montano AR, Shellman J, Malcolm M, McDonald D, Rees C, Fortinsky R, Reagan L. A mixed methods evaluation of got care! Geriatr Nurs 2020; 41:822-831. [PMID: 32532562 DOI: 10.1016/j.gerinurse.2020.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 04/23/2020] [Accepted: 04/27/2020] [Indexed: 11/30/2022]
Abstract
This study aimed to assess the relationship between an Interprofessional Collaborative Practice (IPCP) intervention for community-dwelling older adults, Geriatric Outreach and Training with Care! (GOT Care!), and the observed 26% reduction in Emergency Department (ED) visits for the 51 older adult participants. A convergent parallel mixed-methods design was utilized. Demographic data and ED visit data were collected and analyzed using paired-samples t-tests, poisson regression and generalized poisson regression. Stakeholder perspectives were assessed via emailed open-ended surveys and analyzed using content analysis. The quantitative results were transformed into trends that were compared and contrasted with the qualitative themes. The results were consistent with the current literature that IPCP models may have a greater impact on older adults with certain demographic characteristics such as polypharmacy, diabetes and prior ED use, while nursing was identified as an ideal leader for IPCP teams.
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Affiliation(s)
- Anna-Rae Montano
- University of Connecticut School of Nursing, 231 Glenbrook Rd, Storrs, CT 06269, United States.
| | - Juliette Shellman
- University of Connecticut School of Nursing, 231 Glenbrook Rd, Storrs, CT 06269, United States.
| | - Millicent Malcolm
- University of Connecticut School of Nursing, 231 Glenbrook Rd, Storrs, CT 06269, United States.
| | - Deborah McDonald
- University of Connecticut School of Nursing, 231 Glenbrook Rd, Storrs, CT 06269, United States.
| | - Catherine Rees
- Middlesex Health, 28 Crescent Street, Middletown, CT 06457, United States.
| | - Richard Fortinsky
- UConn Center on Aging, UConn Health, 263 Farmington Avenue, Farmington, CT 06030-5215, United States.
| | - Louise Reagan
- University of Connecticut School of Nursing, 231 Glenbrook Rd, Storrs, CT 06269, United States.
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20
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Peña-Longobardo LM, Oliva-Moreno J, Zozaya N, Aranda-Reneo I, Trapero-Bertran M, Laosa O, Sinclair A, Rodríguez-Mañas L. Economic evaluation of a multimodal intervention in pre-frail and frail older people with diabetes mellitus: the MID-FRAIL project. Expert Rev Pharmacoecon Outcomes Res 2020; 21:111-118. [PMID: 32394757 DOI: 10.1080/14737167.2020.1766970] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: The aim of this study was to estimate the incremental cost-utility ratio (ICUR) of a multi-modal intervention in frail and pre-frail subjects aged ≥70 years with type-2 diabetes versus usual care group focused on quality adjusted life years (QALYs) in different European countries. Methods: The MID-FRAIL study was a cluster randomized multicentre trial conducted in seven European countries. A cost-utility analysis was carried out based on this study, conducted from the perspective of the health care system with a time horizon of one year. Univariate and probabilistic analysis were carried out to test the robustness of the results. Results: The cost estimation showed the offsetting health effect of the intervention program on total health care costs. The mean annual health care costs were 25% higher among patients in usual care. The mean incremental QALY gained per patient by the intervention group were 0.053 QALY compared with usual care practice. Conclusions: The MID-FRAIL intervention program showed to be the dominant option in comparison with usual care practice. It saved costs to the health care system and achieved worthwhile health gains. This finding should encourage its implementation, at least, in the trial participant countries.
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Affiliation(s)
| | - Juan Oliva-Moreno
- Department of Economic Analysis and Finance, University of Castilla-La Mancha , Toledo, Spain
| | - Neboa Zozaya
- Department of Health Economics, Weber, Madrid Spain, University of Las Palmas de Gran Canaria , Las Palmas De Gran Canaria, Spain
| | - Isaac Aranda-Reneo
- Department of Economic Analysis and Finance, University of Castilla-La Mancha , Toledo, Spain
| | - Marta Trapero-Bertran
- Research Institute for Evaluation and Public Policies (IRAPP), Universitat Internacional de Catalunya (UIC) , Barcelona, Spain
| | - Olga Laosa
- Servicio de Geriatría, Hospital Universitario de Getafe , Madrid, Spain
| | - Alan Sinclair
- Foundation for Diabetes Research in Older People, Diabetes Frail Ltd , Luton, UK
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21
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Shah R, Borrebach JD, Hodges JC, Varley PR, Wisniewski MK, Shinall MC, Arya S, Johnson J, Nelson JB, Youk A, Massarweh NN, Johanning JM, Hall DE. Validation of the Risk Analysis Index for Evaluating Frailty in Ambulatory Patients. J Am Geriatr Soc 2020; 68:1818-1824. [PMID: 32310317 DOI: 10.1111/jgs.16453] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 03/15/2020] [Accepted: 03/17/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Frailty is a marker of dependency, disability, hospitalization, and mortality in community-dwelling older adults. However, existing tools for measuring frailty are too cumbersome for rapid point-of-care assessment. The Risk Analysis Index (RAI) of frailty is validated in surgical populations, but its performance outside surgical populations is unknown. OBJECTIVE Validate the RAI in ambulatory patients. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study of outpatient surgical clinics within the University of Pittsburgh Medical Center Healthcare System between July 1, 2016, and December 31, 2016. Frailty was assessed using the RAI. Current Procedural Terminology codes following RAI assessment identified patients with and without minor office-based procedures (eg, joint injection, laryngoscopy). MAIN OUTCOMES AND MEASURES All-cause 1-year mortality, assessed by stratified Cox proportional hazard models. RESULTS Of 28,059 patients, 13,861 were matched to a minor, office-based procedure and 14,198 did not undergo any procedure. The mean (SD) age was 56.7 (17.2) years; women constituted 15,797 (56.3%) of the cohort. Median time (interquartile range 25th-75th percentile) to measure RAI was 30 (22-47) seconds. Mortality among the frail was two to five times that of patients with normal RAI scores. For example, the hazard ratio for frail ambulatory patients without a minor procedure was 3.69 (95% confidence interval [CI] = 2.51-5.41), corresponding to 30-, 180-, and 365-day mortality rates of 2.9%, 11.2%, and 17.4%, respectively, compared to 0.3%, 2.3%, and 4.0% among patients with normal RAI scores. Discrimination of mortality (overall, and censored at 30, 180, and 365 days) was excellent, ranging from c = 0.838 (95% CI = 0.773-0.902) for 30-day mortality after minor procedures to c = 0.909 (95% CI = 0.855-0.964) without a procedure. CONCLUSION RAI is a valid, easily administered tool for point-of-care frailty assessment in ambulatory populations that may help clinicians and patients make better informed decisions about care choices-especially among patients considered high risk with a potentially limited life span. J Am Geriatr Soc 68:1818-1824, 2020.
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Affiliation(s)
- Rupen Shah
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jeffrey D Borrebach
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jacob C Hodges
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Patrick R Varley
- Department of Surgery, University of Pittsburgh, Pittsburgh,, Pennsylvania, USA
| | - Mary Kay Wisniewski
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA, and Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | - Jonas Johnson
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joel B Nelson
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ada Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nader N Massarweh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center; Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jason M Johanning
- Department of Surgery, University of Nebraska Medical Center and Nebraska Western Iowa Veterans Affairs Health System, Omaha, Nebraska, USA
| | - Daniel E Hall
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Surgery, University of Pittsburgh, Pittsburgh,, Pennsylvania, USA.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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22
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Sepehri K, Braley MS, Chinda B, Zou M, Tang B, Park G, Garm A, McDermid R, Rockwood K, Song X. A Computerized Frailty Assessment Tool at Points-of-Care: Development of a Standalone Electronic Comprehensive Geriatric Assessment/Frailty Index (eFI-CGA). Front Public Health 2020; 8:89. [PMID: 32296673 PMCID: PMC7137764 DOI: 10.3389/fpubh.2020.00089] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 03/04/2020] [Indexed: 02/05/2023] Open
Abstract
Background: Frailty is characterized by loss of biological reserves and is associated with an increased risk of adverse health outcomes. Frailty can be operationalized using a Frailty Index (FI) based on the accumulation of health deficits; items under health evaluation in the well-established Comprehensive Geriatric Assessment (CGA) have been used to generate an FI-CGA. Traditionally, constructing the FI-CGA has relied on paper-based recording and manual data processing. As this can be time-consuming and error-prone, it limits widespread uptake of this proven type of frailty assessment. Here, we report the development of an electronic tool, the eFI-CGA, for use on personal computers by frontline healthcare providers, to collect CGA data and automate FI-CFA calculation. The ultimate goal is to support early identification and management of frailty at points-of-care, and make uptake in Electronic Medical Records (EMR) feasible and transparent. Methods: An electronic CGA (eCGA) form was implemented to operate on Microsoft's WinForms platform and coded using C# programming language. Users complete the eCGA form, from which items under the CGA evaluation are automatically retrieved and processed to output an eFI-CGA score. A user-friendly interface and secured data saving methods were implemented. The software was debugged and tested using systematically designed simulation data, addressing different logic, syntax, and application errors, and then tested with clinical assessment. The user manual and manual scoring were used as ground truth to compare eFI-CGA input and automated eFI score calculations. Frontline health-provider user feedback was incorporated to improve the end-user experience. Results: The Standalone eFI-CGA software tool was developed and optimized for use on personal computers. The user interface adapted the design of paper-based CGA form to facilitate familiarity for clinical users. Compared to known scores, the software tool generated eFI-CGA scores with 100% accuracy to four decimal places. The eFI-CGA allowed secure data storage and retrieval of multiple types, including user input, completed eCGA form, coded items, and calculated eFI-CGA scores. It also permitted recording of actions requiring clinical follow-up, facilitating care planning. Application bugs were identified and resolved at various stages of the implementation, resulting in efficient system performance. Discussion: Accurate, robust, and reliable computerized frailty assessments are needed to promote effective frailty assessment and management, as a key tool in health care systems facing up to frailty. Our research has enabled the delivery of the standalone eFI-CGA software technology to empower effective frailty assessment and management by various healthcare providers at points-of-care, facilitating integrated care of older adults.
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Affiliation(s)
- Katayoun Sepehri
- Health Sciences and Innovation, Surrey Memorial Hospital, Surrey, BC, Canada.,Department of Computing Science, Simon Fraser University, Burnaby, BC, Canada
| | | | - Betty Chinda
- Health Sciences and Innovation, Surrey Memorial Hospital, Surrey, BC, Canada.,Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Macy Zou
- Health Sciences and Innovation, Surrey Memorial Hospital, Surrey, BC, Canada
| | - Brandon Tang
- Health Sciences and Innovation, Surrey Memorial Hospital, Surrey, BC, Canada
| | - Grace Park
- Primary and Family Care, Fraser Health, Surrey, BC, Canada
| | - Antonina Garm
- Community Actions and Resources Empowering Seniors, Fraser Health Authority, Surrey, BC, Canada
| | - Robert McDermid
- Emergency Medicine, Surrey Memorial Hospital, Surrey, BC, Canada
| | - Kenneth Rockwood
- Division of Geriatric Medicine, Dalhousie University, Halifax, BC, Canada.,Centre for Healthcare of the Elderly, QEII Health Sciences Center, Halifax, NS, Canada
| | - Xiaowei Song
- Health Sciences and Innovation, Surrey Memorial Hospital, Surrey, BC, Canada.,Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada.,Division of Geriatric Medicine, Dalhousie University, Halifax, BC, Canada
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23
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Comprehensive Geriatric Assessment for Frail Older People in Swedish Acute Care Settings (CGA-Swed): A Randomised Controlled Study. Geriatrics (Basel) 2020; 5:geriatrics5010005. [PMID: 31991598 PMCID: PMC7151180 DOI: 10.3390/geriatrics5010005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 12/31/2022] Open
Abstract
The aim of the study is to evaluate the effects of the Comprehensive Geriatric Assessment (CGA) for frail older people in Swedish acute hospital settings – the CGA-Swed study. In this study protocol, we present the study design, the intervention and the outcome measures as well as the baseline characteristics of the study participants. The study is a randomised controlled trial with an intervention group receiving the CGA and a control group receiving medical assessment without the CGA. Follow-ups were conducted after 1, 6 and 12 months, with dependence in activities of daily living (ADL) as the primary outcome measure. The study group consisted of frail older people (75 years and older) in need of acute medical hospital care. The study design, randomisation and process evaluation carried out were intended to ensure the quality of the study. Baseline data show that the randomisation was successful and that the sample included frail older people with high dependence in ADL and with a high comorbidity. The CGA contributed to early recognition of frail older people’s needs and ensured a care plan and follow-up. This study is expected to show positive effects on frail older people’s dependence in ADL, life satisfaction and satisfaction with health and social care.
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24
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Overcash J, Ford N, Kress E, Ubbing C, Williams N. Comprehensive Geriatric Assessment as a Versatile Tool to Enhance the Care of the Older Person Diagnosed with Cancer. Geriatrics (Basel) 2019; 4:geriatrics4020039. [PMID: 31238518 PMCID: PMC6630523 DOI: 10.3390/geriatrics4020039] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/14/2019] [Accepted: 06/20/2019] [Indexed: 12/27/2022] Open
Abstract
The comprehensive geriatric assessment (CGA) is a versatile tool for the care of the older person diagnosed with cancer. The purpose of this article is to detail how a CGA can be tailored to Ambulatory Geriatric Oncology Programs (AGOPs) in academic cancer centers and to community oncology practices with varying levels of resources. The Society for International Oncology in Geriatrics (SIOG) recommends CGA as a foundation for treatment planning and decision-making for the older person receiving care for a malignancy. A CGA is often administered by a multidisciplinary team (MDT) composed of professionals who provide geriatric-focused cancer care. CGA can be used as a one-time consult for surgery, chemotherapy, or radiation therapy providers to predict treatment tolerance or as an ongoing part of patient care to manage malignant and non-malignant issues. Administrative support and proactive infrastructure planning to address scheduling, referrals, and provider communication are critical to the effectiveness of the CGA.
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Affiliation(s)
- Janine Overcash
- The College of Nursing, The Ohio State University, 1585 Neil Ave, Newton Hall, Columbus, OH 43201, USA.
| | - Nikki Ford
- Stephanie Spielman Comprehensive Breast Center, The Ohio State University, 1145 Olentangy River Road, Columbus, OH 43121, USA.
| | - Elizabeth Kress
- Stephanie Spielman Comprehensive Breast Center, The Ohio State University, 1145 Olentangy River Road, Columbus, OH 43121, USA.
| | - Caitlin Ubbing
- Stephanie Spielman Comprehensive Breast Center, The Ohio State University, 1145 Olentangy River Road, Columbus, OH 43121, USA.
| | - Nicole Williams
- Stephanie Spielman Comprehensive Breast Center, The Ohio State University, 1145 Olentangy River Road, Columbus, OH 43121, USA.
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Dahlqvist J, Ekdahl A, Friedrichsen M. Does comprehensive geriatric assessment (CGA) in an outpatient care setting affect the causes of death and the quality of palliative care? A subanalysis of the age-FIT study. Eur Geriatr Med 2019; 10:455-462. [PMID: 34652806 DOI: 10.1007/s41999-019-00198-w] [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: 01/30/2019] [Accepted: 04/23/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE The purposes of this study were to retrospectively study whether comprehensive geriatric assessment (CGA) given to community-dwelling old patients with high health care usage has effects regarding: (1) the cause of death and (2) the quality of the provided palliative care when compared to patients without CGA-based care. METHOD This study includes secondary data from a randomised controlled trial (RCT) with 382 participants that took place in the periods 2011-2013. The present study examines all electronical medical records (EMR) from the deceased patients in the original study regarding cause of death [intervention group (IG) N = 51/control group (CG) N = 66] and quality of palliative care (IG N = 33/CG N = 41). Descriptive and comparative statistics were produced and the significance level was set at p < 0.05. RESULTS The causes of death in both groups were dominated by cardiovascular and cerebrovascular diseases with no statistical difference between the groups. Patients in the intervention group had a higher degree of support from specialised palliative care teams than had the control group (p = 0.01). CONCLUSION The present study in an outpatient context cannot prove any effects of CGA on causes of death. The study shows that CGA in outpatient care means a higher rate of specialised palliative care, but the study cannot show any effects on the palliative quality parameters measured. Further studies with statistical power are needed.
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Affiliation(s)
- Jenny Dahlqvist
- Department of Geriatric Medicine, Vrinnevi Hospital, Gamla Övägen 25, 601 82, Norrköping, Sweden.
| | - Anne Ekdahl
- Geriatric Medicine, Department of Clinical Sciences Helsingborg, Helsingborg Hospital, Lund University, Charlotte Yhlens gata 10, 251 87, Helsingborg, Sweden
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institute (KI), Stockholm, Sweden
| | - Maria Friedrichsen
- Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden
- Palliative Education and Research Center, Vrinnevi Hospital, Gamla Övägen 25, 601 82, Norrköping, Sweden
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Gudnadottir GS, James SK, Andersen K, Lagerqvist B, Thrainsdottir IS, Ravn-Fischer A, Varenhorst C, Gudnason T. Outcomes after STEMI in old multimorbid patients with complex health needs and the effect of invasive management. Am Heart J 2019; 211:11-21. [PMID: 30831330 DOI: 10.1016/j.ahj.2019.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 01/29/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The aim of this study was to assess one-year outcomes of invasive and non-invasive strategies in ST-elevation myocardial infarction (STEMI) among multimorbid older people with complex health needs. METHODS We included patients, registered between 2006 and 2013 in the SWEDEHEART registry, who were 70 years old or older with STEMI, had multimorbidity and complex health needs and were discharged alive. The one-year outcomes of patients who underwent invasive strategy (examined with coronary angiography ≤14 days) were compared to those who did not. The primary event was a composite of all-cause death, admission due to new acute coronary syndrome, stroke or transient ischemic attack. RESULTS We identified patients, and 1089 were managed invasively and 570 non-invasively. The mean age was 79 years and 83 years in the 2 groups, respectively. After multivariable adjustment for baseline differences between the groups, including propensity scores, the primary event occurred in 31% of patients in the invasive group and 55% in the non-invasive group, adjusted hazard ratio (95% confidence intervals): 0.67 (0.54-0.83). One-year mortality was 18% in the invasive group and 45% in the non-invasive group, adjusted hazard ratio 0.51 (0.39-0.65). CONCLUSIONS Multimorbid older people with complex health needs and STEMI had high rates of new ischemic events and death. In this cohort of older, high risk STEMI patients, an invasive strategy was associated with lower event rates. Randomized studies are needed to clarify whether these high risk patients who might benefit from invasive care are being managed too conservatively.
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Mazya AL, Garvin P, Ekdahl AW. Outpatient comprehensive geriatric assessment: effects on frailty and mortality in old people with multimorbidity and high health care utilization. Aging Clin Exp Res 2019; 31:519-525. [PMID: 30039453 PMCID: PMC6439176 DOI: 10.1007/s40520-018-1004-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 07/06/2018] [Indexed: 10/31/2022]
Abstract
BACKGROUND Multimorbidity and frailty are often associated and Comprehensive Geriatric Assessment (CGA) is considered the gold standard of care for these patients. AIMS This study aimed to evaluate the effect of outpatient Comprehensive Geriatric Assessment (CGA) on frailty in community-dwelling older people with multimorbidity and high health care utilization. METHODS The Ambulatory Geriatric Assessment-Frailty Intervention Trial (AGe-FIT) was a randomized controlled trial (intervention group, n = 208, control group n = 174) with a follow-up period of 24 months. Frailty was a secondary outcome. Inclusion criteria were: age ≥ 75 years, ≥ 3 current diagnoses per ICD-10, and ≥ 3 inpatient admissions during 12 months prior to study inclusion. The intervention group received CGA-based care and tailored interventions by a multidisciplinary team in an Ambulatory Geriatric Unit, in addition to usual care. The control group received usual care. Frailty was measured with the Cardiovascular Health Study (CHS) criteria. At 24 months, frail and deceased participants were combined in the analysis. RESULTS Ninety percent of the population were frail or pre-frail at baseline. After 24 months, there was a significant smaller proportion of frail and deceased (p = 0.002) and a significant higher proportion of pre-frail patients in the intervention group (p = 0.004). Mortality was high, 18% in the intervention group and 26% in the control group. CONCLUSION Outpatient CGA may delay the progression of frailty and may contribute to the improvement of frail patients in older persons with multimorbidity.
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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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Chan B, Edwards ST, Devoe M, Gil R, Mitchell M, Englander H, Nicolaidis C, Kansagara D, Saha S, Korthuis PT. The SUMMIT ambulatory-ICU primary care model for medically and socially complex patients in an urban federally qualified health center: study design and rationale. Addict Sci Clin Pract 2018; 13:27. [PMID: 30547847 PMCID: PMC6295087 DOI: 10.1186/s13722-018-0128-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 12/05/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Medically complex urban patients experiencing homelessness comprise a disproportionate number of high-cost, high-need patients. There are few studies of interventions to improve care for these populations; their social complexity makes them difficult to study and requires clinical and research collaboration. We present a protocol for a trial of the streamlined unified meaningfully managed interdisciplinary team (SUMMIT) team, an ambulatory ICU (A-ICU) intervention to improve utilization and patient experience that uses control populations to address limitations of prior research. METHODS/DESIGN Participants are patients at a Federally Qualified Health Center in Portland, Oregon that serves patients experiencing homelessness or who have substance use disorders. Participants meet at least one of the following criteria: > 1 hospitalization over past 6 months; at least one medical co-morbidity including uncontrolled diabetes, heart failure, chronic obstructive pulmonary disease, liver disease, soft-tissue infection; and 1 mental health diagnosis or substance use disorder. We exclude patients if they have < 6 months to live, have cognitive impairment preventing consent, or are non-English speaking. Following consent and baseline assessment, we randomize participants to immediate SUMMIT intervention or wait-list control group. Participants receiving the SUMMIT intervention transfer care to a clinic-based team of physician, complex care nurse, care coordinator, social worker, and pharmacist with reduced panel size and flexible scheduling with emphasis on motivational interviewing, patient goal setting and advanced care planning. Wait-listed participants continue usual care plus engagement with community health worker intervention for 6 months prior to joining SUMMIT. The primary outcome is hospital utilization at 6 months; secondary outcomes include emergency department utilization, patient activation, and patient experience measures. We follow participants for 12 months after intervention initiation. DISCUSSION The SUMMIT A-ICU is an intensive primary care intervention for high-utilizers impacted by homelessness. Use of a wait-list control design balances community and staff stakeholder needs, who felt all participants should have access to the intervention, while addressing research needs to include control populations. Design limitations include prolonged follow-up period that increases risk for attrition, and conflict between practice and research; including partner stakeholders and embedded researchers familiar with the population in study planning can mitigate these barriers. Trial registration ClinicalTrials.gov NCT03224858, Registered 7/21/17 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT03224858.
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Affiliation(s)
- Brian Chan
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA.
- Central City Concern, Portland, OR, USA.
| | - Samuel T Edwards
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- Portland VA Medical Center, Portland, OR, USA
| | - Meg Devoe
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- Central City Concern, Portland, OR, USA
| | - Richard Gil
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- Central City Concern, Portland, OR, USA
| | | | - Honora Englander
- Central City Concern, Portland, OR, USA
- Division of Hospital Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Christina Nicolaidis
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- School of Social Work, Portland State University, Portland, OR, USA
| | - Devan Kansagara
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- Portland VA Medical Center, Portland, OR, USA
| | - Somnath Saha
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
- Portland VA Medical Center, Portland, OR, USA
| | - P Todd Korthuis
- Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L475, Portland, OR, 97239-3098, USA
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Delaying and reversing frailty: a systematic review of primary care interventions. Br J Gen Pract 2018; 69:e61-e69. [PMID: 30510094 DOI: 10.3399/bjgp18x700241] [Citation(s) in RCA: 190] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/18/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Recommendations for routine frailty screening in general practice are increasing as frailty prevalence grows. In England, frailty identification became a contractual requirement in 2017. However, there is little guidance on the most effective and practical interventions once frailty has been identified. AIM To assess the comparative effectiveness and ease of implementation of frailty interventions in primary care. DESIGN AND SETTING A systematic review of frailty interventions in primary care. METHOD Scientific databases were searched from inception to May 2017 for randomised controlled trials or cohort studies with control groups on primary care frailty interventions. Screening methods, interventions, and outcomes were analysed in included studies. Effectiveness was scored in terms of change of frailty status or frailty indicators and ease of implementation in terms of human resources, marginal costs, and time requirements. RESULTS A total of 925 studies satisfied search criteria and 46 were included. There were 15 690 participants (median study size was 160 participants). Studies reflected a broad heterogeneity. There were 17 different frailty screening methods. Of the frailty interventions, 23 involved physical activity and other interventions involved health education, nutrition supplementation, home visits, hormone supplementation, and counselling. A significant improvement of frailty status was demonstrated in 71% (n = 10) of studies and of frailty indicators in 69% (n=22) of studies where measured. Interventions with both muscle strength training and protein supplementation were consistently placed highest for effectiveness and ease of implementation. CONCLUSION A combination of muscle strength training and protein supplementation was the most effective intervention to delay or reverse frailty and the easiest to implement in primary care. A map of interventions was created that can be used to inform choices for managing frailty.
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Ekdahl AW, Axmon A, Sandberg M, Steen Carlsson K. Is care based on comprehensive geriatric assessment with mobile teams better than usual care? A study protocol of a randomised controlled trial (The GerMoT study). BMJ Open 2018; 8:e023969. [PMID: 30309994 PMCID: PMC6252639 DOI: 10.1136/bmjopen-2018-023969] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process used to determine the medical, psychological and functional capabilities of frail older people. The primary aim of our current study is to confirm whether CGA-based outpatient care is superior than usual care in terms of health-related outcomes, resource use and costs. METHODS AND ANALYSIS The Geriatric Mobile Team trial is designed as a single-centre randomised, controlled, assessor-blinded (at baseline) trial. All participants will be identified via local healthcare registries with the following inclusion criteria: age ≥75 years, ≥3 different diagnoses and ≥3 visits to the emergency care unit (with or without admittance to hospital) during the past 18 months. Nursing home residency will be an exclusion criterion. Baseline assessments will be done before the 1:1 randomisation. Participants in the intervention group will, after an initial CGA, have access to care given by a geriatric team in addition to usual care. The control group receives usual care only. The primary outcome is the total number of inpatient days during the follow-up period. Assessments of the outcomes: mortality, quality of life, health care use, physical functional level, frailty, dependence and cognition will be performed 12 and 24 months after inclusion. Both descriptive and analytical statistics will be used, in order to compare groups and for analyses of outcomes over time including changes therein. The primary outcome will be analysed using analysis of variance, including in-transformed values if needed to achieve normal distribution of the residuals. ETHICS AND DISSEMINATION Ethical approval has been obtained and the results will be disseminated in national and international journals and to health care leaders and stakeholders. Protocol amendments will be published in ClinicalTrials.gov as amendments to the initial registration NCT02923843. In case of success, the study will promote the implementation of CGA in outpatient care settings and thereby contribute to an improved care of older people with multimorbidity through dissemination of the results through scientific articles, information to politicians and to the public. TRIAL REGISTRATION NUMBER NCT02923843; Pre-results.
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Affiliation(s)
- Anne Wissendorff Ekdahl
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institute (KI), Stockholm, Sweden
- Department of Clinical Sciences Helsingborg, Geriatric Medicine, Lund University, Helsingborg Hospital, Stockholm, Sweden
| | - Anna Axmon
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lunds University, Lund, Sweden
| | - Magnus Sandberg
- Department of Health Sciences, Lunds Universitet, Lund, Sweden
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Predicting Hepatic Encephalopathy-Related Hospitalizations Using a Composite Assessment of Cognitive Impairment and Frailty in 355 Patients With Cirrhosis. Am J Gastroenterol 2018; 113:1506-1515. [PMID: 30267028 DOI: 10.1038/s41395-018-0243-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 07/05/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Hepatic encephalopathy (HE) is the most common potentially modifiable reason for admission in patients with cirrhosis. Cognitive and physical components of frailty have pathophysiologic rationale as risk factors for HE. We aimed to assess the utility of a composite score (MoCA-CFS) developed using the Montreal Cognitive Assessment (MoCA) and the Clinical Frailty Scale (CFS) for predicting HE admissions within 6 months. METHODS Consecutive adult patients with cirrhosis were followed for 6 months or until death/transplant. Patients with overt HE and dementia were excluded. Primary outcome was the prediction of HE-related admissions at 6 months. RESULTS A total of 355 patients were included; mean age 55.9 ± 9.6; 62.5% male; Hepatitis C and alcohol etiology in 64%. Thirty-six percent of patients had cognitive impairment according to the MoCA (≤24) and 14% were frail on the CFS (>4). The MoCA-CFS independently predicted HE hospitalization within 6 months, a MoCA-CFS score of 1 and 2 respectively increasing the odds of hospitalization by 3.3 (95% CI:1.5-7.7) and 5.7 (95% CI:1.9-17.3). HRQoL decreased with increasing MoCA-CFS. Depression and older age were independent predictors of a low MoCA. CONCLUSIONS Cognitive and physical frailty are common in patients with cirrhosis. In addition to being an independent predictor of HE admissions within 6 months, the MoCA-CFS composite score predicts impaired HRQoL and all-cause admissions within 6 months. These data support the predictive value of a "multidimensional" frailty tool for the prediction of adverse clinical outcomes and highlight the potential for a multi-faceted approach to therapy targeting cognitive impairment, physical frailty and depression.
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Mohile SG, Dale W, Somerfield MR, Schonberg MA, Boyd CM, Burhenn PS, Canin B, Cohen HJ, Holmes HM, Hopkins JO, Janelsins MC, Khorana AA, Klepin HD, Lichtman SM, Mustian KM, Tew WP, Hurria A. Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology. J Clin Oncol 2018; 36:2326-2347. [PMID: 29782209 PMCID: PMC6063790 DOI: 10.1200/jco.2018.78.8687] [Citation(s) in RCA: 882] [Impact Index Per Article: 147.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose To provide guidance regarding the practical assessment and management of vulnerabilities in older patients undergoing chemotherapy. Methods An Expert Panel was convened to develop clinical practice guideline recommendations based on a systematic review of the medical literature. Results A total of 68 studies met eligibility criteria and form the evidentiary basis for the recommendations. Recommendations In patients ≥ 65 years receiving chemotherapy, geriatric assessment (GA) should be used to identify vulnerabilities that are not routinely captured in oncology assessments. Evidence supports, at a minimum, assessment of function, comorbidity, falls, depression, cognition, and nutrition. The Panel recommends instrumental activities of daily living to assess for function, a thorough history or validated tool to assess comorbidity, a single question for falls, the Geriatric Depression Scale to screen for depression, the Mini-Cog or the Blessed Orientation-Memory-Concentration test to screen for cognitive impairment, and an assessment of unintentional weight loss to evaluate nutrition. Either the CARG (Cancer and Aging Research Group) or CRASH (Chemotherapy Risk Assessment Scale for High-Age Patients) tools are recommended to obtain estimates of chemotherapy toxicity risk; the Geriatric-8 or Vulnerable Elders Survey-13 can help to predict mortality. Clinicians should use a validated tool listed at ePrognosis to estimate noncancer-based life expectancy ≥ 4 years. GA results should be applied to develop an integrated and individualized plan that informs cancer management and to identify nononcologic problems amenable to intervention. Collaborating with caregivers is essential to implementing GA-guided interventions. The Panel suggests that clinicians take into account GA results when recommending chemotherapy and that the information be provided to patients and caregivers to guide treatment decision making. Clinicians should implement targeted, GA-guided interventions to manage nononcologic problems. Additional information is available at www.asco.org/supportive-care-guidelines .
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Affiliation(s)
- Supriya G Mohile
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - William Dale
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - Mark R Somerfield
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - Mara A Schonberg
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - Cynthia M Boyd
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - Peggy S Burhenn
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - Beverly Canin
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - Harvey Jay Cohen
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - Holly M Holmes
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - Judith O Hopkins
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - Michelle C Janelsins
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - Alok A Khorana
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - Heidi D Klepin
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - Stuart M Lichtman
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - Karen M Mustian
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - William P Tew
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
| | - Arti Hurria
- Supriya G. Mohile, Michelle C. Janelsins, and Karen M. Mustian, University of Rochester Medical Center, Rochester; Beverly Canin, Breast Cancer Options, Kingston; Stuart M. Lichtman and William P. Tew, Memorial Sloan Kettering Cancer Center, New York, NY; William Dale, Peggy S. Burhenn, and Arti Hurria, City of Hope, Duarte, CA; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Mara A. Schonberg, Beth Israel Deaconess Medical Center, Brookline, MA; Cynthia M. Boyd, Johns Hopkins University School of Medicine, Baltimore, MD; Harvey Jay Cohen, Duke University Medical Center, Durham; Judith O. Hopkins, Novant Health Oncology Specialists; Heidi D. Klepin, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC; Holly M. Holmes, McGovern Medical School, Houston, TX; and Alok A. Khorana, Cleveland Clinic, Cleveland, OH
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Ekdahl AW. Effectiveness of Intensive Primary Care. J Gen Intern Med 2018; 33:995. [PMID: 29633124 PMCID: PMC6025691 DOI: 10.1007/s11606-018-4409-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Anne W Ekdahl
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Stockholm, Sweden.
- Department of Clinical Sciences, Lund University, Helsingborg, Sweden.
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Ekerstad N, Karlson BW, Andersson D, Husberg M, Carlsson P, Heintz E, Alwin J. Short-term Resource Utilization and Cost-Effectiveness of Comprehensive Geriatric Assessment in Acute Hospital Care for Severely Frail Elderly Patients. J Am Med Dir Assoc 2018; 19:871-878.e2. [PMID: 29784592 DOI: 10.1016/j.jamda.2018.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 03/23/2018] [Accepted: 04/02/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of this study was to estimate the 3-month within-trial cost-effectiveness of comprehensive geriatric assessment (CGA) in acute medical care for frail elderly patients compared to usual medical care, by estimating health-related quality of life and costs from a societal perspective. DESIGN Clinical, prospective, controlled, 1-center intervention trial with 2 parallel groups. INTERVENTION Structured, systematic interdisciplinary CGA-based care in an acute elderly care unit. If the patient fulfilled the inclusion criteria, and there was a bed available at the CGA unit, the patient was included in the intervention group. If no bed was available at the CGA unit, the patient was included in the control group and admitted to a conventional acute medical care unit. SETTING AND PARTICIPANTS A large county hospital in western Sweden. The trial included 408 frail elderly patients, 75 years or older, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n = 206) or control group (n = 202). Mean age of the patients was 85.7 years, and 56% were female. MEASURES The primary outcome was the adjusted incremental cost-effectiveness ratio associated with the intervention compared to the control at the 3-month follow-up. RESULTS We undertook cost-effectiveness analysis, adjusted by regression analyses, including hospital, primary, and municipal care costs and effects. The difference in the mean adjusted quality-adjusted life years gained between groups at 3 months was 0.0252 [95% confidence interval (CI): 0.0082-0.0422]. The incremental cost, that is, the difference between the groups, was -3226 US dollars (95% CI: -6167 to -285). CONCLUSION The results indicate that the care in a CGA unit for acutely ill frail elderly patients is likely to be cost-effective compared to conventional care after 3 months.
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Affiliation(s)
- Niklas Ekerstad
- Department of Cardiology, NU (NÄL-Uddevalla) Hospital Group, Trollhättan-Uddevalla-Vänersborg, Sweden; Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Sweden.
| | - Björn W Karlson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - David Andersson
- Department of Management and Engineering, Division of Economics, Linköping University, Sweden
| | - Magnus Husberg
- Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Sweden
| | - Per Carlsson
- Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Sweden
| | - Emelie Heintz
- Department of Learning, Informatics, Management and Ethics (LIME), QRC Research Unit, Karolinska Institutet, Stockholm, Sweden
| | - Jenny Alwin
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Zintchouk D, Gregersen M, Lauritzen T, Damsgaard EM. Geriatrician-performed comprehensive geriatric care in older adults referred to an outpatient community rehabilitation unit: A randomized controlled trial. Eur J Intern Med 2018; 51:18-24. [PMID: 29395938 DOI: 10.1016/j.ejim.2018.01.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/01/2018] [Accepted: 01/16/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Older adults make increasing demands on all sectors of the healthcare system. We investigated the effect of geriatrician-performed comprehensive geriatric care (CGC) in older adults referred to an outpatient community rehabilitation unit. DESIGN Randomized controlled trial. SETTING Two Danish non-hospital based rehabilitation units. PARTICIPANTS Persons aged 65 or older admitted from home or hospital. INTERVENTION CGC performed by a geriatrician at the rehabilitation unit. OUTCOMES Primary outcome was number of hospital admissions and emergency department (ED) visits. Secondary outcomes were number of ambulatory contacts, general practitioner (GP) contacts, activities of daily living (ADL) and overall quality of life (OQoL). Outcomes were measured within 90 days of admission to the rehabilitation units. RESULTS 368 persons were randomized: 185 to the intervention group (IG) vs 183 to the control group (CG). Groups were comparable at baseline. The number of hospital admissions and ED visits, ambulatory contacts and out of hour GP visits or phone calls did not differ between the groups. The number of daytime GP consultations and visits or phone and email consultations was lower in the IG (P < 0.001). There were no differences in the mean between the groups for ADL and OQoL, but more participants in the IG improved their OQoL (OR 1.63, 95% CI: 1.07-2.48, P = 0.023). CONCLUSION Geriatrician-performed CGC in older adults in an outpatient community rehabilitation unit had no effect on the secondary healthcare utilization, but may reduce primary healthcare utilization and improve OQoL during the 90-day follow-up period. TRIAL REGISTRATION ClinicalTrials.govNCT01506219.
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Affiliation(s)
- Dmitri Zintchouk
- Department of Geriatrics, Aarhus University Hospital, Palle-Juul Jensens Boulevard 99, Building J, 8200 Aarhus N, Denmark.
| | - Merete Gregersen
- Department of Geriatrics, Aarhus University Hospital, Palle-Juul Jensens Boulevard 99, Building J, 8200 Aarhus N, Denmark
| | - Torsten Lauritzen
- Department of Public Health, Section of General Medical Practice, Aarhus University, Bartholins Alle 2, Building 123, 8000 Aarhus C, Denmark
| | - Else Marie Damsgaard
- Department of Geriatrics, Aarhus University Hospital, Palle-Juul Jensens Boulevard 99, Building J, 8200 Aarhus N, Denmark
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Seematter-Bagnoud L, Büla C. Brief assessments and screening for geriatric conditions in older primary care patients: a pragmatic approach. Public Health Rev 2018; 39:8. [PMID: 29744236 PMCID: PMC5928588 DOI: 10.1186/s40985-018-0086-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 02/12/2018] [Indexed: 01/12/2023] Open
Abstract
This paper discusses the rationale behind performing a brief geriatric assessment as a first step in the management of older patients in primary care practice. While geriatric conditions are considered by older patients and health professionals as particularly relevant for health and well-being, they remain too often overlooked due to many patient- and physician-related factors. These include time constraints and lack of specific training to undertake comprehensive geriatric assessment. This article discusses the epidemiologic rationale for screening functional, cognitive, affective, hearing and visual impairments, and nutritional status as well as fall risk and social status. It proposes using brief screening tests in primary care practice to identify patients who may need further comprehensive geriatric assessment or specific interventions.
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Affiliation(s)
- Laurence Seematter-Bagnoud
- 1Service of Geriatric Medicine and Geriatric Rehabilitation, University of Lausanne Hospital Center, Mont Paisible 16, CH-1011 Lausanne, Switzerland.,2Institute of Social and Preventive Medicine, University of Lausanne, Lausanne, Switzerland
| | - Christophe Büla
- 1Service of Geriatric Medicine and Geriatric Rehabilitation, University of Lausanne Hospital Center, Mont Paisible 16, CH-1011 Lausanne, Switzerland
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Hajek A, Bock JO, Saum KU, Matschinger H, Brenner H, Holleczek B, Haefeli WE, Heider D, König HH. Frailty and healthcare costs-longitudinal results of a prospective cohort study. Age Ageing 2018; 47:233-241. [PMID: 29036424 DOI: 10.1093/ageing/afx157] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 08/22/2017] [Indexed: 12/16/2022] Open
Abstract
Objective to investigate how frailty and frailty symptoms affect healthcare costs in older age longitudinally. Methods data were gathered from a prospective cohort study in Saarland, Germany (two waves with 3-year interval, n = 1,636 aged 57-84 years at baseline). Frailty was assessed by the five Fried frailty criteria. Frailty was defined as having at least three criteria, the presence of 1-2 criteria as 'pre-frail'. Healthcare costs were quantified based on self-reported healthcare use in the sectors of inpatient treatment, outpatient treatment, professional nursing care and informal care as well as the provision of pharmaceuticals, medical supplies and dental prostheses. Results while the onset of pre-frailty did not increase (log) total healthcare costs after adjusting for potential confounders including comorbidity, progression from non-frailty to frailty was associated with an increase in total healthcare costs (for example, costs increased by ~54 and 101% if 3 and 4 or 5 symptoms were present, respectively). This association of frailty onset with increased healthcare costs was in particular observed in the inpatient sector and for informal nursing care. Among the frailty symptoms, the onset of exhaustion was associated with an increase in total healthcare costs, whereas changes in slowness, weakness, weight loss and low-physical activity were not significantly associated with an increase in total healthcare costs. Conclusions our data stress the economic relevance of frailty in late life. Postponing or reducing frailty might be fruitful in order to reduce healthcare costs.
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Affiliation(s)
- André Hajek
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens-Oliver Bock
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kai-Uwe Saum
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Herbert Matschinger
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute for Social Medicine, Occupational Health and Public Health, University of Leipzig, Leipzig, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Network Aging Research, University of Heidelberg, Heidelberg, Germany
| | - Bernd Holleczek
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Saarland Cancer Registry, Saarbrücken, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Dirk Heider
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Weeks LE, Macdonald M, Martin-Misener R, Helwig M, Bishop A, Iduye DF, Moody E. The impact of transitional care programs on health services utilization in community-dwelling older adults. ACTA ACUST UNITED AC 2018; 16:345-384. [DOI: 10.11124/jbisrir-2017-003486] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Lundqvist M, Alwin J, Henriksson M, Husberg M, Carlsson P, Ekdahl AW. Cost-effectiveness of comprehensive geriatric assessment at an ambulatory geriatric unit based on the AGe-FIT trial. BMC Geriatr 2018; 18:32. [PMID: 29386007 PMCID: PMC5793378 DOI: 10.1186/s12877-017-0703-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 12/29/2017] [Indexed: 11/19/2022] Open
Abstract
Background Older people with multi-morbidity are increasingly challenging for today’s healthcare, and novel, cost-effective healthcare solutions are needed. The aim of this study was to assess the cost-effectiveness of comprehensive geriatric assessment (CGA) at an ambulatory geriatric unit for people ≥75 years with multi-morbidity. Method The primary outcome was the incremental cost-effectiveness ratio (ICER) comparing costs and quality-adjusted life years (QALYs) of a CGA strategy with usual care in a Swedish setting. Outcomes were estimated over a lifelong time horizon using decision-analytic modelling based on data from the randomized AGe-FIT trial. The analysis employed a public health care sector perspective. Costs and QALYs were discounted by 3% per annum and are reported in 2016 euros. Results Compared with usual care CGA was associated with a per patient mean incremental cost of approximately 25,000 EUR and a gain of 0.54 QALYs resulting in an ICER of 46,000 EUR. The incremental costs were primarily caused by intervention costs and costs associated with increased survival, whereas the gain in QALYs was primarily a consequence of the fact that patients in the CGA group lived longer. Conclusion CGA in an ambulatory setting for older people with multi-morbidity results in a cost per QALY of 46,000 EUR compared with usual care, a figure generally considered reasonable in a Swedish healthcare context. A rather simple reorganisation of care for older people with multi-morbidity may therefore cost effectively contribute to meet the needs of this complex patient population. Trial registration The trial was retrospectively registered in clinicaltrial.gov, NCT01446757. September, 2011. Electronic supplementary material The online version of this article (10.1186/s12877-017-0703-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Martina Lundqvist
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | - Jenny Alwin
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Martin Henriksson
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Magnus Husberg
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Per Carlsson
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Anne W Ekdahl
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical geriatrics, Karolinska Institute (KI), Stockholm, Sweden.,Institution of Clinical Sciences, Lund University, Helsingborg, Sweden
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Comprehensive Geriatric Assessment and Caring for the Older Person with Cancer. Semin Oncol Nurs 2017; 33:440-448. [DOI: 10.1016/j.soncn.2017.08.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Vigorito C, Abreu A, Ambrosetti M, Belardinelli R, Corrà U, Cupples M, Davos CH, Hoefer S, Iliou MC, Schmid JP, Voeller H, Doherty P. Frailty and cardiac rehabilitation: A call to action from the EAPC Cardiac Rehabilitation Section. Eur J Prev Cardiol 2016; 24:577-590. [PMID: 27940954 DOI: 10.1177/2047487316682579] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Frailty is a geriatric syndrome characterised by a vulnerability status associated with declining function of multiple physiological systems and loss of physiological reserves. Two main models of frailty have been advanced: the phenotypic model (primary frailty) or deficits accumulation model (secondary frailty), and different instruments have been proposed and validated to measure frailty. However measured, frailty correlates to medical outcomes in the elderly, and has been shown to have prognostic value for patients in different clinical settings, such as in patients with coronary artery disease, after cardiac surgery or transvalvular aortic valve replacement, in patients with chronic heart failure or after left ventricular assist device implantation. The prevalence, clinical and prognostic relevance of frailty in a cardiac rehabilitation setting has not yet been well characterised, despite the increasing frequency of elderly patients in cardiac rehabilitation, where frailty is likely to influence the onset, type and intensity of the exercise training programme and the design of tailored rehabilitative interventions for these patients. Therefore, we need to start looking for frailty in elderly patients entering cardiac rehabilitation programmes and become more familiar with some of the tools to recognise and evaluate the severity of this condition. Furthermore, we need to better understand whether exercise-based cardiac rehabilitation may change the course and the prognosis of frailty in cardiovascular patients.
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Affiliation(s)
- Carlo Vigorito
- 1 Department of Translational Medical Sciences, University of Naples Federico II, Italy
| | - Ana Abreu
- 2 Cardiology Department Hospital Santa Marta, Centro Hospitalar Lisboa Central, Portugal
| | - Marco Ambrosetti
- 3 Cardiovascular Rehabilitation Unit, Le Terrazze Clinic, Cunardo, Italy
| | | | - Ugo Corrà
- 5 Department of Cardiac Rehabilitation, Salvatore Maugeri Foundation, Veruno, Italy
| | - Margaret Cupples
- 6 Department of General Practice, UKCRC Centre of Excellence for Public Health Research (NI), Northern Ireland, Queens University, Belfast
| | - Constantinos H Davos
- 7 Cardiovascular Research Laboratory, Biomedical Research Foundation Academy of Athens, Greece
| | | | - Marie-Christine Iliou
- 9 Cardiac Rehabilitation Department, Hopital Corentin Celton-Assistance Publique Hôpitaux de Paris, France
| | - Jean-Paul Schmid
- 10 Cardiology Clinic, Tiefenau Hospital and University of Bern, Switzerland
| | - Heinz Voeller
- 11 Center of Rehabilitation Research, University of Potsdam, Germany; Department of Cardiology, Klinic am See, Rudersdorf
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Eckerblad J, Theander K, Ekdahl AW, Jaarsma T. Symptom trajectory and symptom burden in older people with multimorbidity, secondary outcome from the RCT AGe-FIT study. J Adv Nurs 2016; 72:2773-2783. [PMID: 27222059 DOI: 10.1111/jan.13032] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2016] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to follow the symptom trajectory of community-dwelling older people with multimorbidity and to explore the effect on symptom burden from an ambulatory geriatric care unit, based on comprehensive geriatric assessment. BACKGROUND Older community-dwelling people with multimorbidity suffer from a high symptom burden with a wide range of co-occurring symptoms often resulting to decreased health-related quality of life. There is a need to move from a single-disease model and address the complexity of older people living with multimorbidity. DESIGN Secondary outcome data from the randomized controlled Ambulatory Geriatric Assessment Frailty Intervention Trial (AGe-FIT). METHODS Symptom trajectory of 31 symptoms was assessed with the Memorial Symptom Assessment Scale. Data from 247 participants were assessments at baseline, 12 and 24 months, 2011-2013. Participants in the intervention group received care from an ambulatory geriatric care unit based on comprehensive geriatric assessment in addition to usual care. RESULTS Symptom prevalence and symptom burden were high and stayed high over time. Pain was the symptom with the highest prevalence and burden. Over the 2-year period 68-81% of the participants reported pain. Other highly prevalent and persistent symptoms were dry mouth, lack of energy and numbness/tingling in the hands/feet, affecting 38-59% of participants. No differences were found between the intervention and control group regarding prevalence, burden or trajectory of symptoms. CONCLUSIONS Older community-dwelling people with multimorbidity had a persistent high burden of symptoms. Receiving advanced interdisciplinary care at an ambulatory geriatric unit did not significantly reduce the prevalence or the burden of symptoms.
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Affiliation(s)
- Jeanette Eckerblad
- Department of Social and Welfare Studies, Faculty of Medicine and Health Sciences, Linkoping University, Sweden.
| | - Kersti Theander
- Faculty of Health, Science and Technology, Department of Health Sciences, Nursing, Karlstad University, Sweden
| | - Anne W Ekdahl
- Department of Research and Education, Helsingborg Hospital, Sweden.,Division of Clinical Geriatrics, Department of Neurobiology, Caring Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Tiny Jaarsma
- Department of Social and Welfare Studies, Faculty of Medicine and Health Sciences, Linkoping University, Sweden
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