Health risk appraisal for older people in general practice using an expert system: a pilot study

Health Risk Appraisals With Aging Adults: An Integrative Review

Identification of risk factors unique to the aging experience is vital to support health promotion efforts and prevent loss of independence for the increasing aging population. Health risk appraisals are tools capable of identifying a broad range of factors that affect health; however, these tools were designed for use with predominantly healthy working-age adults. The purpose of this integrative review was to describe uses and adaptations of health risk appraisals with aging adults. A total of 43 articles met inclusion criteria, identifying multiple adaptations necessary to effectively identify the risks faced by aging adults, including those related to activities of daily living, pain, depression, social support/network, vision, hearing, and cognitive status. Uses included support for health promotion efforts and to determine risk for depression, falls, and loss of independence. Further research needs to be done to evaluate impact when used as a health promotion and prevention tool for aging adults.

Exploring the relationship between frequent internet use and health and social care resource use in a community-based cohort of older adults: an observational study in primary care

OBJECTIVES

Given many countries' ageing populations, policymakers must consider how to mitigate or reduce health problems associated with old age, within budgetary constraints. Evidence of use of digital technology in delaying the onset of illness and reducing healthcare service use is mixed, with no clear consensus as yet. Our aim was to investigate the relationship between frequent internet use and patterns of health or social care resource use in primary care attendees who took part in a study seeking to improve the health of older adults.

METHODS

Participants recruited from primary care, aged >65 and living in semirural or urban areas in the south of England, were followed up at 3 and 6 months after completing a comprehensive questionnaire with personalised feedback on their health and well-being. We performed logistic regression analyses to investigate relationships between frequent internet use and patterns of service use, controlling for confounding factors, and clustering by general practitioner practice. Four categories of service use data were gathered: use of primary National Health Service (NHS) care; secondary NHS care; other community health and social care services; and assistance with washing, shopping and meals.

RESULTS

Our results show, in this relatively healthy population, a positive relationship (OR 1.72, 95% CI 1.33 to 2.23) between frequent internet use and use of any other community-based health services (physiotherapist, osteopath/chiropractor, dentist, optician/optometrist, counselling service, smoking cessation service, chiropodist/podiatrist, emergency services, other non-specific health services) and no relationship with the other types of care. No causal relationship can be postulated due to the study's design.

CONCLUSIONS

No observed relationship between frequent internet use and primary or secondary care use was found, suggesting that older adults without internet access are not disadvantaged regarding healthcare use. Further research should explore how older people use the internet to access healthcare and the impact on health.

Promoting independence, health and well-being for older people: a feasibility study of computer-aided health and social risk appraisal system in primary care

Background

With population ageing, research is needed into new low-cost, scalable methods of effective promotion of health and wellbeing for older people. We aimed to assess feasibility, reach and costs of implementing a new tailored computer-aided health and social risk appraisal system in primary care.

Methods

Design: Feasibility study.

Setting: Five General Practices in London (Ealing) and Hertfordshire, United Kingdom (UK)

Participants: Random sample of patients aged 65 + years.

Intervention: The Multi-dimensional Risk Appraisal for Older people (MRA-O) system includes: 1) Postal questionnaire including health, lifestyle, social and environmental domains; 2) Software system generating a personalised feedback report with advice on health and wellbeing; 3) Follow-up of people with new concerning or complex needs by GPs or practice nurses.

Evaluation: Feasibility of implementation; participant wellbeing, functional ability and quality of life; social needs, health risks, potential lifestyle changes; and costs of implementation.

Results

Response rates to initial postal invitations were low (526/1550, 34%). Of these, 454/526 (86%) completed MRA-O assessments. Compared to local UK Census data on older people, participants were younger, more were owner-occupiers and fewer were from ethnic minority groups than expected. A range of problems was identified by participants, including pain in last week (269/438, 61.4%), low physical activity (173/453, 38.2%), sedentary lifestyle (174/447, 38.3%), falls (117/439, 26.7%), incontinence (111/441 25.2%), impaired vision 116/451 (25.7%), impaired hearing (145/431, 33.6%), depressed mood (71/451, 15.7%), impaired memory (44/444 9.9%), social isolation (46/449, 10.2%) and loneliness (31/442, 7.0%). Self-rated health was good/excellent in 312/437 (71.4%), and quality of life and well-being were slightly above age-specific population norms. Implementation costs were low. Practices reviewed medical records of 143/454 (31.5%) of participants as a consequence of their responses, and actively followed up 110/454 (24.2%) of their patients.

Conclusions

A computer-aided risk appraisal system was feasible for General Practices to implement, yields useful information about health and social problems, and identifies individual needs. Participation rates were however low, particularly for the oldest old, the poorest, and ethnic minority groups, and this type of intervention may increase inequalities in access. Widespread implementation of this approach would require work to address potential inequalities.

Service use of older people who participate in primary care health promotion: a latent class analysis

BACKGROUND

Recruiting patients to health promotion programmes who will benefit is crucial to success. A key policy driver for health promotion in older people is to reduce health and social care use. Our aim was to describe service use among older people taking part in the Multi-dimensional Risk Appraisal for Older people primary care health promotion programme.

METHODS

A random sample of 1 in 3 older people (≥65 years old) was invited to participate in the Multi-dimensional Risk Appraisal for Older people project across five general practices in London and Hertfordshire. Data collected included socio-demographic characteristics, well-being and functional ability, lifestyle factors and service use. Latent class analysis (LCA) was used to identify groups based on use of the following: secondary health care, primary health care, community health care, paid care, unpaid care, leisure and local authority resources. Differences in group characteristics were assessed using univariate logistic regression, weighted by probability of class assignation and clustered by GP practice.

RESULTS

Response rate was 34% (526/1550) with 447 participants presenting sufficient data for analysis. LCA using three groups gave the most meaningful interpretation and best model fit. About a third (active well) were fit and active with low service use. Just under a third (high NHS users) had high impairments with high primary, secondary and community health care contact, but low non-health services use. Just over a third (community service users) with high impairments used community health and other services without much hospital use.

CONCLUSION

Older people taking part in the Multi-dimensional Risk Appraisal for Older people primary care health promotion can be described as three groups: active well, high NHS users, and community service users.

Health risk appraisal in older people 7: long-acting benzodiazepine use in community-dwelling older adults in London: is it related to physical or psychological factors?

Aim To investigate whether the use of long-acting benzodiazepines, in individuals aged 65 and over is mediated by physical or psychological factors.

BACKGROUND

Long-acting benzodiazepine consumption among older people has implications for mortality, morbidity and cost-effective prescribing. Two models explain benzodiazepine use in this age group, one linked to physical illness and disability and one to psychological factors.

METHODS

Secondary analysis of baseline data from a study of 1059 community-dwelling non-disabled people aged 65 years and over recruited from three general practices in London. For this analysis, use of long-acting benzodiazepines was defined as any self-reported use of diazepam or nitrazepam in the last four weeks. Associations between demographic factors, health service use, and physical and psychological characteristics and benzodiazepine use were investigated. Findings The prevalence of benzodiazepine use in this sample was 3.3% (35/1059). In univariate analyses, benzodiazepine use was associated with female gender, low income, high consultation rates, physical factors (medication for arthritis or joint pain, polypharmacy, difficulties in instrumental activities of daily living, recent pain) and psychological factors (poor self-perceived health, social isolation, and symptoms of anxiety or agitation). In a multivariate logistic regression analysis only two factors retained statistically significant independent associations with benzodiazepine use: receiving only the state pension (OR=4.0, 95% CI: 1.70, 9.80) and pain in the past four weeks (OR=3.79, 95% CI: 1.36, 10.54).

Perception, Interpretation, and Impact of Health Risk Appraisal Feedback: Pilot Studies of an Assessment Tool

One mandate of the Affordable Care Act is continued support of workplace wellness programs. A tool used to encourage behavior change is a health risk appraisal (HRA). However, research indicates there is limited benefit to HRAs unless supported by additional health interventions. The purpose of these two pilot studies was to examine effects of the individual HRA personalized feedback, including the perceived value of the feedback and its influence on behavior change. Six months after completing and receiving HRA personalized feedback, participants in two separate Indiana organizations answered survey questions about the HRA value, motivational influence, and ability to prompt behavior change. Descriptive statistics, chi-square tests, analyses of variance, and factor analysis were used to analyze the influence of various factors and test the relationship between HRA generated feedback and these characteristics. The majority of respondents indicated the HRA was helpful with 69% (Study 1, n = 51) and 63% (Study 2, n = 116) of the respondents reporting an attempted behavior change. Preliminary results indicate that completion of an HRA with feedback alone may be beneficial in prompting behavior change.

Opportunities for general practitioners to enhance disaster preparedness among vulnerable patients

Disasters occur frequently in Australia and will become more unpredictable and severe due to climate change. Some members of the Australian population, such as the elderly, the chronically ill and the socially isolated, are less likely to be prepared and more likely to be adversely affected by disasters. Although general practitioners (GPs) view the delivery of preventive health care as a priority, few preventive services focus on patients' resilience and ability to cope with unexpected stressors. This paper focuses on the individuals most vulnerable to disasters and the opportunities for GPs to facilitate the enhancement of disaster preparedness among these groups. General practitioners are ideally placed to identify vulnerable patients and refer them to services that may assist them in enhancing their disaster resilience. To reduce the burden on individual GPs, adjustments can be made to practice software systems that will use patient records to identify vulnerable individuals.

Health information technologies in geriatrics and gerontology: a mixed systematic review

OBJECTIVE

To review, categorize, and synthesize findings from the literature about the application of health information technologies in geriatrics and gerontology (GGHIT).

MATERIALS AND METHODS

This mixed-method systematic review is based on a comprehensive search of Medline, Embase, PsychInfo and ABI/Inform Global. Study selection and coding were performed independently by two researchers and were followed by a narrative synthesis. To move beyond a simple description of the technologies, we employed and adapted the diffusion of innovation theory (DOI).

RESULTS

112 papers were included. Analysis revealed five main types of GGHIT: (1) telecare technologies (representing half of the studies); (2) electronic health records; (3) decision support systems; (4) web-based packages for patients and/or family caregivers; and (5) assistive information technologies. On aggregate, the most consistent finding proves to be the positive outcomes of GGHIT in terms of clinical processes. Although less frequently studied, positive impacts were found on patients' health, productivity, efficiency and costs, clinicians' satisfaction, patients' satisfaction and patients' empowerment.

DISCUSSION

Further efforts should focus on improving the characteristics of such technologies in terms of compatibility and simplicity. Implementation strategies also should be improved as trialability and observability are insufficient.

CONCLUSIONS

Our results will help organizations in making decisions regarding the choice, planning and diffusion of GGHIT implemented for the care of older adults.

Health risk appraisal for older people 5: self-efficacy in patient-doctor interactions

OBJECTIVE

Enhancing self-efficacy is central to programmes promoting self-care and self-management. However, little is known about older people's self-efficacy in doctor-patient interactions. This paper investigates lifestyle, medical and demographic factors associated with self-efficacy in doctor-patient interactions in older people in general practice.

METHODS

A cross-sectional analysis of data from a randomised controlled trial of older people was conducted in a health risk appraisal study in London. Self-efficacy was measured using the Perceived Efficacy in Patient-Physician Interactions Questionnaire.

RESULTS

Older people with higher self-efficacy were significantly more likely to report having had recent preventive care measures such as recent blood pressure measurement and influenza immunisation. Women were less likely to have higher self-efficacy than men. Older people were significantly less likely to have high self-efficacy if they reported having poor memory, low mood, limited activities due to fear of falling, basic education, difficulties with at least one activity of daily living, reduced physical activity, living alone, or risk of social isolation.

CONCLUSION

A third of people had low self-efficacy in doctor-patient interactions. They appear to be a vulnerable group. Low self-efficacy in interactions with doctors may be a symptom or a characteristic of older people who experience social isolation and depression. Policies that depend on enhancing self-care and self-management need to consider the large number of older people with low self-efficacy in using medical services, and understanding characteristics in older people associated with lower confidence in doctor-patient interactions may be useful in clinical practice and research.

User involvement in the development of a health promotion technology for older people: findings from the SWISH project

Successive English government policies about older people's health and well-being aim to improve health and quality of life by promoting independence. Improving access to information and services that can improve health and well-being and reduce health risks is central to the modernisation of health and social care. Most recently, tailored and person-centred approaches with a strong emphasis on promoting health and well-being are central to policy, including the proposals for 'Life Checks' and the recent emphasis on commissioning 'community well-being'. We carried out a qualitative study to identify the key aspects of social situations that affect health and well-being, from the perspectives of older people and professionals, to enrich and expand an existing health risk appraisal tool so that it could be used for self-assessment of health and social well-being. This tool, Health Risk Appraisal in Older people (HRAO), has been evaluated in different European settings, including English general practice. Focus groups were recruited from general practice, older people's forums, social care and voluntary organisations in two London boroughs where the HRAO tool had previously been tested. The social factors determining health that were prioritised by older people and service providers and recommended for inclusion in the health risk appraisal tool were recent life events, housing and garden maintenance, transport, both public and private, financial management, career status & needs, the local environment and social networks and social isolation. This study has identified key social determinants of health that could usefully be added to 'Life Checks' for older people and that could also inform the commissioning of community well-being. Modified with the addition of social domains, the HRAO technology could be a suitable tool to achieve current policy objectives.

The impact of educational level on oral health-related quality of life in older people in London

There are socioeconomic inequalities in oral health, but the relationship between education and oral health-related quality of life (OHRQoL) among older adults has not been adequately studied. This study assessed whether there is an educational gradient in OHRQoL among older people in London. We employed secondary analysis of baseline data (n = 1,090) from a randomized controlled trial of health-risk appraisal on community-dwelling non-disabled people 65 yr of age and older, registered with three group medical practices in suburban London. Multiple linear regressions were used to analyze the association between OHRQoL [measured using the Geriatric Oral Health Assessment Index (GOHAI)] and education, adjusted for age, gender, pension status, and denture wearing. Overall, 30.6% reported low levels of OHRQoL. Eating discomfort was the most frequent problem (24% reported 'often/always'), while concerns about appearance were also prevalent. Significant variations in OHRQoL existed between socioeconomic groups. In adjusted analyses, there was a clear education gradient in OHRQoL, with worse perceptions at each lower level of education. Low educational level has an independent negative impact on OHRQoL in older people, which is not explained by differences in income or in denture wearing between educational groups. Policies targeting lower educated groups should be complemented with whole-population strategies for the reduction of oral health inequalities.

The relationship between pain intensity and severity and depression in older people: exploratory study

Background

Pain and depression are known to be associated in later life, and both have a negative effect on physical performance both separately and in combination. The nature of the relationships between pain intensity and depression in elderly persons experiencing pain is less clear. The objectives of this study were to explore which factors are associated with depressed mood in older people experiencing pain, and to test the hypothesis that older people experiencing pain are at risk of depressed mood according to the severity or frequency of their pain. In addition we explored whether other potentially modifiable factors might increase the risk of depressed mood in these persons.

Methods

The study is a secondary analysis of baseline data for four hundred and six community-dwelling non-disabled people aged 65 and over registered with three group practices in suburban London who had experienced pain in the past 4 weeks. Intensity and frequency of pain was measured using 24 item Geriatric Pain Measure (GPM) and the presence of depressive symptoms using the 5 item Mental Health Inventory. Risk for social isolation was measured using the 6 item Lubben Social Network scale and instrumental activities of daily living (IADL) were also measured.

Results

Overall 76 (19%) had depressed mood. Pain frequency and severity were not statistically significantly associated with depressed mood in this population. In multivariate analyses, significant predictors of the presence of depressive symptoms were difficulties with basic ADLs (OR 2.8, 95% CI 1.1.7.8), risk for social isolation (OR 4.1, 95% CI 1.8–9.3), and basic education only (OR 2.2, 95% CI 1.1–4.4).

Conclusion

Older people experiencing pain are also likely to experience depression. Among those experiencing pain, social network and functional status seem to be more important predictors of depressive symptoms than the severity of pain. Further studies should evaluate whether improvement of social network and functional status might reduce depressive symptoms in older patients.

"Living well in later life": an overview of the National Service Framework for Older People in England

The National Service Framework (NSF) for Older People is a set of standards produced by the Department of Health in England in 2001 to overhaul the health and social service delivery systems over a 10-year period aimed at optimizing the care received by older adults. The NSF arose from broader social and health care reforms that likewise sought the establishment of performance assessment, augmented consumer sovereignty, and greater coherence across health and social services. The United States shares with England similar problems with care for its older adults, strategies for improvement, and obstacles to successful implementation of change.

Promotion of health in older people: a randomised controlled trial of health risk appraisal in British general practice

BACKGROUND

there is inadequate evidence to support currently formulated NHS strategies to achieve health promotion and preventative care in older people through broad-based screening and assessment in primary care. The most extensively evaluated delivery instrument for this purpose is Health Risk Appraisal (HRA). This article describes a trial using HRA to evaluate the effect on health behaviour and preventative-care uptake in older people in NHS primary care.

METHODS

a randomised controlled trial was undertaken in three London primary care group practices. Functionally independent community-dwelling patients older than 65 years (n = 2,503) received a self-administered Health Risk Appraisal for Older Persons (HRA-O) questionnaire leading to computer-generated individualised written feedback to participants and general practitioners (GPs), integrated into practice information-technology (IT) systems. All primary care staff received training in preventative health in older people. The main outcome measures were self-reported health behaviour and preventative care uptake at 1-year follow-up.

RESULTS

of 2,503 individuals randomised, 2,006 respondents (80.1%) (intervention, n = 940, control n = 1,066) were available for analysis. Intervention group respondents reported slightly higher pneumococcal vaccination uptake and equivocal improvement in physical activity levels compared with controls. No significant differences were observed for any other categories of health behaviour or preventative care measures at 1-year follow-up.

CONCLUSIONS

HRA-O implemented in this way resulted in minimal improvement of health behaviour or uptake of preventative care measures in older people. Supplementary reinforcement involving contact by health professionals with patients over and above routine clinical encounters may be a prerequisite to the effectiveness of IT-based delivery systems for health promotion in older people.

Development, feasibility and performance of a health risk appraisal questionnaire for older persons

BACKGROUND

Health risk appraisal is a promising method for health promotion and prevention in older persons. The Health Risk Appraisal for the Elderly (HRA-E) developed in the U.S. has unique features but has not been tested outside the United States.

METHODS

Based on the original HRA-E, we developed a scientifically updated and regionally adapted multilingual Health Risk Appraisal for Older Persons (HRA-O) instrument consisting of a self-administered questionnaire and software-generated feed-back reports. We evaluated the practicability and performance of the questionnaire in non-disabled community-dwelling older persons in London (U.K.) (N = 1090), Hamburg (Germany) (N = 804), and Solothurn (Switzerland) (N = 748) in a sub-sample of an international randomised controlled study.

RESULTS

Over eighty percent of invited older persons returned the self-administered HRA-O questionnaire. Fair or poor self-perceived health status and older age were correlated with higher rates of non-return of the questionnaire. Older participants and those with lower educational levels reported more difficulty in completing the HRA-O questionnaire as compared to younger and higher educated persons. However, even among older participants and those with low educational level, more than 80% rated the questionnaire as easy to complete. Prevalence rates of risks for functional decline or problems were between 2% and 91% for the 19 HRA-O domains. Participants' intention to change health behaviour suggested that for some risk factors participants were in a pre-contemplation phase, having no short- or medium-term plans for change. Many participants perceived their health behaviour or preventative care uptake as optimal, despite indications of deficits according to the HRA-O based evaluation.

CONCLUSION

The HRA-O questionnaire was highly accepted by a broad range of community-dwelling non-disabled persons. It identified a high number of risks and problems, and provided information on participants' intention to change health behaviour.

The PRO-AGE study: an international randomised controlled study of health risk appraisal for older persons based in general practice

BACKGROUND

This paper describes the study protocol, the recruitment, and base-line data for evaluating the success of randomisation of the PRO-AGE (PRevention in Older people-Assessment in GEneralists' practices) project.

METHODS/DESIGN

A group of general practitioners (GPs) in London (U.K.), Hamburg (Germany) and Solothurn (Switzerland) were trained in risk identification, health promotion, and prevention in older people. Their non-disabled older patients were invited to participate in a randomised controlled study. Participants allocated to the intervention group were offered the Health Risk Appraisal for Older Persons (HRA-O) instrument with a site-specific method for reinforcement (London: physician reminders in electronic medical record; Hamburg: one group session or two preventive home visits; Solothurn: six-monthly preventive home visits over a two-year period). Participants allocated to the control group received usual care. At each site, an additional group of GPs did not receive the training, and their eligible patients were invited to participate in a concurrent comparison group. Primary outcomes are self-reported health behaviour and preventative care use at one-year follow-up. In Solothurn, an additional follow-up was conducted at two years. The number of older persons agreeing to participate (% of eligible persons) in the randomised controlled study was 2503 (66.0%) in London, 2580 (53.6%) in Hamburg, and 2284 (67.5%) in Solothurn. Base-line findings confirm that randomisation of participants was successful, with comparable characteristics between intervention and control groups. The number of persons (% of eligible) enrolled in the concurrent comparison group was 636 (48.8%) in London, 746 (35.7%) in Hamburg, and 1171 (63.0%) in Solothurn.

DISCUSSION

PRO-AGE is the first large-scale randomised controlled trial of health risk appraisal for older people in Europe. Its results will inform about the effects of implementing HRA-O with different methods of reinforcement.

Self-reported visual function in healthy older people in Britain: an exploratory study of associations with age, sex, depression, education and income

BACKGROUND

Tractable but undetected visual impairment in older people may be relatively common, particularly amongst the very old and in more deprived populations. Measurement of visual acuity is unlikely to be helpful in identifying this impairment, but targeted assessment of visual function may be beneficial. There is uncertainty about the defining characteristics of the target group.

OBJECTIVE

To explore factors associated with self-reported visual impairment in community dwelling older people.

DESIGN

secondary cross sectional analysis of baseline data from a randomised controlled trial.

SETTING

three large group practices in outer London.

PARTICIPANTS

older people aged 65 and over enrolled in a study of health risk appraisal.

METHOD

postal questionnaire using questions from the National Eye Institute Visual Function questionnaire.

RESULTS

Moderate or extreme visual function loss occurred in 4 to 12% of community-dwelling older people in this population reporting less than excellent vision, depending on which aspect of visual function is considered. Visual function loss in this subgroup increases in prevalence with advancing age, but is not associated with female sex, low educational attainment or low income. It is associated with depressed mood.

CONCLUSION

Questions about visual function identify a group of older people whose vision and mental state needs further investigation.