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Gotanda H, Ikesu R, Walling AM, Zhang JJ, Xu H, Reuben DB, Wenger NS, Damberg CL, Zingmond DS, Jena AB, Gross N, Tsugawa Y. Association between physician age and patterns of end-of-life care among older Americans. J Am Geriatr Soc 2024; 72:2070-2081. [PMID: 38721884 PMCID: PMC11226372 DOI: 10.1111/jgs.18939] [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: 01/11/2024] [Revised: 04/03/2024] [Accepted: 04/15/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND End-of-life (EOL) care patterns may differ by physician age given differences in how physicians are trained or changes associated with aging. We sought to compare patterns of EOL care delivered to older Americans according to physician age. METHODS We conducted a cross-sectional study of a 20% sample of Medicare fee-for-service beneficiaries aged ≥66 years who died in 2016-2019 (n = 487,293). We attributed beneficiaries to the physician who had >50% of primary care visits during the last 6 months of life. We compared beneficiary-level outcomes by physician age (<40, 40-49, 50-59, or ≥60) in two areas: (1) advance care planning (ACP) and palliative care; and (2) high-intensity care at the EOL. RESULTS Beneficiaries attributed to younger physicians had slightly higher proportions of billed ACP (adjusted proportions, 17.1%, 16.1%, 15.5%, and 14.0% for physicians aged <40, 40-49, 50-59, and ≥60, respectively; p-for-trend adjusted for multiple comparisons <0.001) and palliative care counseling or hospice use in the last 180 days of life (64.5%, 63.6%, 61.9%, and 60.8%; p-for-trend <0.001). Similarly, physicians' younger age was associated with slightly lower proportions of emergency department visits (57.4%, 57.0%, 57.4%, and 58.1%; p-for-trend <0.001), hospital admissions (51.2%, 51.1%, 51.4%, and 52.1%; p-for-trend <0.001), intensive care unit admissions (27.8%, 27.9%, 28.2%, and 28.3%; p-for-trend = 0.03), or mechanical ventilation or cardiopulmonary resuscitation (14.2, 14.9%, 15.2%, and 15.3%; p-for-trend <0.001) in the last 30 days of life, and in-hospital death (20.2%, 20.6%, 21.3%, and 21.5%; p-for-trend <0.001). CONCLUSIONS We found that differences in patterns of EOL care between beneficiaries cared for by younger and older physicians were small, and thus, not clinically meaningful. Future research is warranted to understand the factors that can influence patterns of EOL care provided by physicians, including initial and continuing medical education.
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Affiliation(s)
- Hiroshi Gotanda
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ryo Ikesu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Anne M. Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Jessica J. Zhang
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Haiyong Xu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Neil S. Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - David S. Zingmond
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Anupam B. Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
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Sato N, Fujita K, Okada H, Kushida K, Chen TF. Validation of quality indicators for evaluating geriatric pharmacotherapy services in primary care: a mixed methods study. BMJ Open 2023; 13:e066665. [PMID: 36958785 PMCID: PMC10040050 DOI: 10.1136/bmjopen-2022-066665] [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: 03/25/2023] Open
Abstract
OBJECTIVE To assess measurement properties of 121 face and content validated quality indicators (QIs) for medication safety in geriatric pharmacotherapy in primary care. DESIGN A mixed methods study: a 6-month observational study in primary care (July-December 2020) and in-depth semistructured online interviews with participants (February-March 2021). SETTING Sixty community pharmacies in Japan. PARTICIPANTS Patients aged 75 years and older who were regularly taking six or more prescription medicines for ˃4 weeks were eligible. The observational study included 457 patients. The interviews were undertaken with 26 community pharmacists, including pharmacy managers and owners. PRIMARY AND SECONDARY OUTCOME MEASURES Five measurement properties of QIs (applicability, improvement potential, acceptability, implementation issues and sensitivity to change) were evaluated. A web application was developed for data reporting and data visualisation. RESULTS This study showed that 53 QIs met the measurement properties of applicability, improvement potential, acceptability and implementation issues. Of 53 QIs, 17 also had a high sensitivity to change. Interviews identified eight themes (indicator characteristics, web application, policy, patient, time, competence, pharmacy administration and collaboration) in relation to the consequence of implementation of QIs. CONCLUSIONS A set of 121 QIs for geriatric pharmacotherapy was field tested for their five measurement properties. This QI set can be used to identify patients who may benefit from clinician reviews of their medicines. These QIs may be applied at different levels within the healthcare system: patient, pharmacy, regional and national levels. Further mechanisms to automatically collect and report data should be established to facilitate sustainable quality improvement initiatives.
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Affiliation(s)
- Noriko Sato
- Faculty of Medicine and Health, The University of Sydney School of Pharmacy, Sydney, New South Wales, Australia
| | - Kenji Fujita
- Kolling Institute, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Hiroshi Okada
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Kazuki Kushida
- Faculty of Pharmacy, Showa Pharmaceutical University, Machida, Tokyo, Japan
| | - Timothy F Chen
- Faculty of Medicine and Health, The University of Sydney School of Pharmacy, Sydney, New South Wales, Australia
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McCullough K, Andrew L, Genoni A, Dunham M, Whitehead L, Porock D. An examination of primary health care nursing service evaluation using the Donabedian model: A systematic review. Res Nurs Health 2023; 46:159-176. [PMID: 36566361 PMCID: PMC10107523 DOI: 10.1002/nur.22291] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/04/2022] [Accepted: 11/03/2022] [Indexed: 12/26/2022]
Abstract
Nurses are key to the delivery of global primary health care services. However, there appears to be a lack of evaluation of primary health care nursing delivery models in the published literature. This evaluation is vital to the improvement of patient experiences, national and global health outcomes, and the justification of future investment in primary health care nursing services. The purpose of this review was to explore and analyze the literature that reports on the evaluation of primary health care nursing services, to ascertain the nature and utility of these evaluation methods, and identify opportunities for future research in this area. A systematic review of the published literature was conducted following PRISMA guidelines, using the databases CINAHL, Joanna Briggs Institute, MEDLINE, and Proquest. Thirty-two articles published between 2010 and 2022 were selected. Results were organized using the Donabedian model. A paucity of research into the evaluation of nurse-led primary health care services was noted. Where evident, evaluation of primary health care nursing services tended to reflect the medical model. Medical outcomes measures dominated evaluation criteria including diagnosis rates, prescription costs, and disease outcomes. Primary health care principles such as service accessibility, cultural appropriateness, and availability were rarely used. The perspectives and experiences of nurses were not sought in service evaluation, including most of the nurse-led services. Development of an evidence-base of nursing primary health care services that are informed by the nursing experience and apply a framework of universal primary health care principles across the structure, process, and outcomes aspects of the service is recommended.
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Affiliation(s)
- Kylie McCullough
- School of Nursing and MidwiferyEdith Cowan UniversityJoondalupWestern AustraliaAustralia
| | - Lesley Andrew
- School of Nursing and MidwiferyEdith Cowan UniversityJoondalupWestern AustraliaAustralia
| | - Angela Genoni
- School of Medical and Health SciencesEdith Cowan UniversityJoondalupWestern AustraliaAustralia
| | - Melissa Dunham
- School of Nursing and MidwiferyEdith Cowan UniversityJoondalupWestern AustraliaAustralia
| | - Lisa Whitehead
- School of Nursing and MidwiferyEdith Cowan UniversityJoondalupWestern AustraliaAustralia
| | - Davina Porock
- School of Nursing and MidwiferyEdith Cowan UniversityJoondalupWestern AustraliaAustralia
- Centre for Research in Aged CareEdith Cowan UniversityJoondalupWestern AustraliaAustralia
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Schneberk T, Bolshakova M, Sloan K, Chang E, Stal J, Dinalo J, Jimenez E, Motala A, Hempel S. Quality Indicators for High-Need Patients: a Systematic Review. J Gen Intern Med 2022; 37:3147-3161. [PMID: 35260956 PMCID: PMC9485370 DOI: 10.1007/s11606-022-07454-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/03/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Healthcare systems are increasingly implementing programs for high-need patients, who often have multiple chronic conditions and complex social situations. Little, however, is known about quality indicators that might guide healthcare organizations and providers in improving care for high-need patients. We sought to conduct a systematic review to identify potential quality indicators for high-need patients. METHODS This systematic review (CRD42020215917) searched PubMed, CINAHL, and EMBASE; guideline clearing houses ECRI and GIN; and Google scholar. We included publications suggesting, evaluating, and utilizing indicators to assess quality of care for high-need patients. Critical appraisal of the indicators addressed the development process, endorsement and adoption, and characteristics, such as feasibility. We standardized indicators by patient population subgroups to facilitate comparisons across different indicator groups. RESULTS The search identified 6964 citations. Of these, 1382 publications were obtained as full text, and 53 studies met inclusion criteria. We identified over 1700 quality indicators across studies. Quality indicator characteristics varied widely. The scope of the selected indicators ranged from detailed criterion (e.g., "annual eye exam") to very broad categories (e.g., "care coordination"). Some publications suggested disease condition-specific indicators (e.g., diabetes), some used condition-independent criteria (e.g., "documentation of the medication list in the medical record available to all care agencies"), and some publications used a mixture of indicator types. DISCUSSION We identified and evaluated existing quality indicators for a complex, heterogeneous patient group. Although some quality indicators were not disease-specific, we found very few that accounted for social determinants of health and behavioral factors. More research is needed to develop quality indicators that address patient risk factors.
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Affiliation(s)
- Todd Schneberk
- Gehr Center for Health Systems Science and Innovation, Keck School of Medicine, University of Southern California, GNH 1011, 1200 N State Street Rm 1011, Los Angeles, CA, 90033, USA.
| | - Maria Bolshakova
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kylie Sloan
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Evelyn Chang
- VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Julia Stal
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jennifer Dinalo
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Elvira Jimenez
- VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Aneesa Motala
- Gehr Center for Health Systems Science and Innovation, Keck School of Medicine, University of Southern California, GNH 1011, 1200 N State Street Rm 1011, Los Angeles, CA, 90033, USA
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Susanne Hempel
- Gehr Center for Health Systems Science and Innovation, Keck School of Medicine, University of Southern California, GNH 1011, 1200 N State Street Rm 1011, Los Angeles, CA, 90033, USA
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Egry EY, Fornari LF, Taminato M, Vigeta SMG, Fonseca RMGSD. Indicators of Good Nursing Practices for Vulnerable Groups in Primary Health Care: A Scoping Review. Rev Lat Am Enfermagem 2021; 29:e3488. [PMID: 34730764 PMCID: PMC8570252 DOI: 10.1590/1518-8345.5203.3488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/14/2021] [Indexed: 11/30/2022] Open
Abstract
Objective: to map the indicators of Good Nursing Practices in Primary Health Care, from
the perspective of Collective Health, reported to the vulnerable social
groups. Method: this is a scoping review according to the PRISMA Extension for Scoping
Reviews. The searches were carried out in2020 in six databases and in a
virtual library. Independent reviewers performed the reading of the full
texts, as well as treatment, analysis and synthesis of the content. Results: a total of 13 articles were found, the first from 2007 and the last from
2020. The data were classified according to the following empirical
categories: assessment and control of health conditions(3 indicators);
assessment of knowledge about health(3 indicators); use of sociodemographic
characteristics to estimate risks or vulnerabilities(3 indicators);
assessment and monitoring of health needs(5 indicators); promotion of safety
and trust in health services(6 indicators); and assessment of the care
process(4 indicators). Conclusion: the articles showed a variety of indicators that assess the interventions
carried out in the context of Nursing in Primary Care with vulnerable social
groups. These indicators are related to health conditions, especially those
of the biopsychological body, reported to vulnerable populations, especially
women, children, adolescents and older adults.
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Affiliation(s)
- Emiko Yoshikawa Egry
- Universidade de São Paulo, Escola de Enfermagem, São Paulo, SP, Brazil.,Universidade Federal de São Paulo, Escola Paulista de Enfermagem, São Paulo, SP, Brazil.,Scholarship holder at the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil
| | - Lucimara Fabiana Fornari
- Universidade de São Paulo, Escola de Enfermagem, São Paulo, SP, Brazil.,Scholarship holder at the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil
| | - Monica Taminato
- Universidade Federal de São Paulo, Escola Paulista de Enfermagem, São Paulo, SP, Brazil
| | | | - Rosa Maria Godoy Serpa da Fonseca
- Universidade de São Paulo, Escola de Enfermagem, São Paulo, SP, Brazil.,Scholarship holder at the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil
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Burholt V, Davies J, Boyd M, Mullins JM, Shoemark EZ. A research agenda for promoting continence for people living with dementia in the community: Recommendations based on a critical review and expert-by-experience opinion. J Clin Nurs 2020; 31:1933-1946. [PMID: 33091190 PMCID: PMC9292568 DOI: 10.1111/jocn.15537] [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: 07/20/2020] [Revised: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 12/03/2022]
Abstract
Aims and objectives To identify research undertaken in the last decade addressing continence for people living with dementia (PLWD) in the community. To highlight gaps and develop recommendations for future research, taking into account the experiences and priorities of PLWD, caregivers and healthcare professionals. Methods A critical review with an Expert Review Group (ERG) comprising researchers, PLWD and facing continence issues, caregivers and other professional stakeholders. Findings are reported in line with the COREQ and Preferred Reporting Items for Systematic reviews and Meta‐Analyses extension for Scoping Reviews checklists. Background Caregivers rate the independent use of the toilet as the most important activity for PLWD to retain. However, in 2009 a review identified shortfalls in knowledge and praxis around promoting continence and managing incontinence for PLWD in the community. As absolute numbers of people with dementia are predicted to increase, it is imperative to examine whether these deficits have been addressed. Results Of 3,563 records identified, 57 full‐text articles were reviewed. The ERG developed a conceptual model to summarise research evidence according to the extent of the challenge (neuropathology and clinicopathology, prevalence and incidence), gateways to continence services, effectiveness of interventions, outcomes and the potential influences of personal resources, socio‐cultural factors and environmental contexts. Conclusions Research on (in)continence for PLWD in the community is under‐developed and has not increased substantially over the last decade. ERG recommendations for future research included user involvement to identify appropriate quality indicators to assess the effectiveness of interventions. Relevance to clinical practice There is insufficient evidence on which to base decisions on continence care for PLWD in the community. Omission from continence care guidelines has the effect of marginalising and silencing this population. User involvement in clinical research and developing practice guidelines has the potential for positive systems change.
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Affiliation(s)
- Vanessa Burholt
- Faculty of Medical and Health Sciences, School of Nursing, University of Auckland, Auckland, New Zealand.,Centre for Innovative Ageing, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Johanna Davies
- Centre for Innovative Ageing, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Michal Boyd
- School of Nursing and Freemasons' Department of Geriatric Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Jane M Mullins
- Centre for Innovative Ageing, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - E Zoe Shoemark
- Centre for Innovative Ageing, College of Human and Health Sciences, Swansea University, Swansea, UK
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Joling KJ, van Eenoo L, Vetrano DL, Smaardijk VR, Declercq A, Onder G, van Hout HPJ, van der Roest HG. Quality indicators for community care for older people: A systematic review. PLoS One 2018; 13:e0190298. [PMID: 29315325 PMCID: PMC5760020 DOI: 10.1371/journal.pone.0190298] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 12/12/2017] [Indexed: 11/22/2022] Open
Abstract
Background Health care systems that succeed in preventing long term care and hospital admissions of frail older people may substantially save on their public spending. The key might be found in high-quality care in the community. Quality Indicators (QIs) of a sufficient methodological level are a prerequisite to monitor, compare, and improve care quality. This systematic review identified existing QIs for community care for older people and assessed their methodological quality. Methods Relevant studies were identified by searches in electronic reference databases and selected by two reviewers independently. Eligible publications described the development or application of QIs to assess the quality of community care for older people. Information about the QIs, the study sample, and specific setting was extracted. The methodological quality of the QI sets was assessed with the Appraisal of Indicators through Research and Evaluation (AIRE) instrument. A score of 50% or higher on a domain was considered to indicate high methodological quality. Results Searches resulted in 25 included articles, describing 17 QI sets with 567 QIs. Most indicators referred to care processes (80%) and measured clinical issues (63%), mainly about follow-up, monitoring, examinations and treatment. About two-third of the QIs focussed on specific disease groups. The methodological quality of the indicator sets varied considerably. The highest overall level was achieved on the domain ‘Additional evidence, formulation and usage’ (51%), followed by ‘Scientific evidence’ (39%) and ‘Stakeholder involvement’ (28%). Conclusion A substantial number of QIs is available to assess the quality of community care for older people. However, generic QIs, measuring care outcomes and non-clinical aspects are relatively scarce and most QI sets do not meet standards of high methodological quality. This study can support policy makers and clinicians to navigate through a large number of QIs and select QIs for their purposes. PROSPERO Registration: 2014:CRD42014007199
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Affiliation(s)
- Karlijn J. Joling
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
- * E-mail:
| | | | - Davide L. Vetrano
- Department of Geriatrics, Centro Medicina dell’Invecchiamento, Universita`Cattolica Sacro Cuore, Rome, Italy
- Aging Research Center, Karolinska Institutet, Stockholm, Sweden
- Stockholm University, Stockholm, Sweden
| | - Veerle R. Smaardijk
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Anja Declercq
- LUCAS, KU Leuven, University of Leuven, Leuven, Belgium
| | - Graziano Onder
- Department of Geriatrics, Centro Medicina dell’Invecchiamento, Universita`Cattolica Sacro Cuore, Rome, Italy
| | - Hein P. J. van Hout
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Henriëtte G. van der Roest
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
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Shier V, Trieu E, Ganz DA. Implementing exercise programs to prevent falls: systematic descriptive review. Inj Epidemiol 2016; 3:16. [PMID: 27747553 PMCID: PMC4932138 DOI: 10.1186/s40621-016-0081-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 06/20/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The United States Preventive Services Task Force recommends exercise to prevent falls in community-dwelling adults aged ≥ 65 years at increased fall risk. However, little is known about how best to implement exercise programs in routine care when a patient's need for exercise is identified within the healthcare system. METHODS Using a qualitative approach, we reviewed the literature to determine how exercise programs to prevent falls are implemented from the vantage point of a health care setting. We synthesized descriptive information about each program with data on program features and implementation difficulties and facilitators. RESULTS We found that programs sponsored by primary care providers (PCPs) or specialists may help with recruitment into exercise programs. PCPs have the opportunity to identify people at risk and promote participation since most older adults regularly visit, and inquire about exercise from, their physicians. In terms of referral options, both home-based and group-based exercise programs have been shown effective in preventing falls; however, each approach carries strengths and limitations. Home-based programs can include participants who are reluctant or unable to attend group classes and can be individually tailored, but provide less opportunity for supervision and socialization than classes. Adherence to programs can be encouraged, and attrition minimized, through positive reinforcement. Successful programs ranged in expense for exercise sessions: a weekly class combined with exercises at home cost < $2 per participant per week, while frequent individual sessions cost > $100 per participant per week. CONCLUSIONS With increasing attention to population-based health management in the United States, clinicians and health system leaders need a deeper understanding of how to link patients in their healthcare systems with appropriate community programs. This review identifies key characteristics of successful fall prevention exercise programs that can be used to determine which local options conform to clinical evidence. In addition, we highlight tradeoffs between program options, such as home versus group exercise programs, to allow referrals to be tailored to local conditions and patient preferences. Finally, our work highlights the key role of the PCP in recruiting patients to participate in exercise programs, and identifies options, such as registries, to support referrals to the community.
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Affiliation(s)
- Victoria Shier
- Pardee RAND Graduate School, RAND Corporation, 1776 Main St, Santa Monica, CA 90407 USA
| | - Eric Trieu
- Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048 USA
| | - David A. Ganz
- VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, RAND Corporation, 11301 Wilshire Blvd., Building 158, Room 128, Los Angeles, CA 90073 USA
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10
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Jennings LA, Tan Z, Wenger NS, Cook EA, Han W, McCreath HE, Serrano KS, Roth CP, Reuben DB. Quality of Care Provided by a Comprehensive Dementia Care Comanagement Program. J Am Geriatr Soc 2016; 64:1724-30. [PMID: 27355394 DOI: 10.1111/jgs.14251] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Multiple studies have shown that quality of care for dementia in primary care is poor, with physician adherence to dementia quality indicators (QIs) ranging from 18% to 42%. In response, the University of California at Los Angeles (UCLA) Health System created the UCLA Alzheimer's and Dementia Care (ADC) Program, a quality improvement program that uses a comanagement model with nurse practitioner dementia care managers (DCM) working with primary care physicians and community-based organizations to provide comprehensive dementia care. The objective was to measure the quality of dementia care that nurse practitioner DCMs provide using the Assessing Care of Vulnerable Elders (ACOVE-3) and Physician Consortium for Performance Improvement QIs. Participants included 797 community-dwelling adults with dementia referred to the UCLA ADC program over a 2-year period. UCLA is an urban academic medical center with primarily fee-for-service reimbursement. The percentage of recommended care received for 17 dementia QIs was measured. The primary outcome was aggregate quality of care for the UCLA ADC cohort, calculated as the total number of recommended care processes received divided by the total number of eligible quality indicators. Secondary outcomes included aggregate quality of care in three domains of dementia care: assessment and screening (7 QIs), treatment (6 QIs), and counseling (4 QIs). QIs were abstracted from DCM notes over a 3-month period from date of initial assessment. Individuals were eligible for 9,895 QIs, of which 92% were passed. Overall pass rates of DCMs were similar (90-96%). All counseling and assessment QIs had pass rates greater than 80%, with most exceeding 90%. Wider variation in adherence was found among QIs addressing treatments for dementia, which patient-specific criteria triggered, ranging from 27% for discontinuation of medications associated with mental status changes to 86% for discussion about acetylcholinesterase inhibitors. Comprehensive dementia care comanagement with a nurse practitioner can result in high quality of care for dementia, especially for assessment, screening, and counseling. The effect on treatment QIs is more variable but higher than previous reports of physician-provided dementia care.
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Affiliation(s)
- Lee A Jennings
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Zaldy Tan
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Erin A Cook
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Weijuan Han
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Heather E McCreath
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Katherine S Serrano
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | | | - David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
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Lichtenstein BJ, Reuben DB, Karlamangla AS, Han W, Roth CP, Wenger NS. Effect of Physician Delegation to Other Healthcare Providers on the Quality of Care for Geriatric Conditions. J Am Geriatr Soc 2016; 63:2164-70. [PMID: 26480977 DOI: 10.1111/jgs.13654] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The quality of care of older adults in the United States has been consistently shown to be inadequate. This gap between recommended and actual care provides an opportunity to improve the value of health care for older adults. Prior work from the Assessing Care of Vulnerable Elders (ACOVE) investigators first defined, and then sought to improve, clinical practice for common geriatric conditions. A critical component of the ACOVE intervention for practice improvement was an emphasis on the delegation of specific care processes, but the independent effect of delegation on the quality of care has not been evaluated. This study analyzed the pooled results of prior ACOVE projects from 1998 to 2010. Totaled, these studies included 4,776 individuals aged 65 and older of mixed demographic backgrounds and 16,204 ACOVE quality indicators (QIs) for three geriatric conditions: falls, urinary incontinence, and dementia. In unadjusted analyses, QI pass probabilities were 0.36 for physician-performed tasks, 0.55 for nurse practitioner (NP)-, physician assistant (PA)-, and registered nurse (RN)-performed tasks; and 0.61 for medical assistant- and licensed vocational nurse-performed tasks. In multiply adjusted models, the independent pass-probability effect of delegation to NPs, PAs, and RNs was 1.37 (P = .05). These findings suggest that delegation of selected tasks to nonphysician healthcare providers is associated with higher quality of care for these geriatric conditions in community practices and supports the value of interdisciplinary team management for common outpatient conditions in older adults.
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Affiliation(s)
- Brian J Lichtenstein
- Department of Medicine, Section of Hospital Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Arun S Karlamangla
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Weijuan Han
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | | | - Neil S Wenger
- RAND Health, Santa Monica, California.,Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
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Hall WJ. Assessing Care of Vulnerable Elders to the Rescue. J Am Geriatr Soc 2015; 63:2171-2. [PMID: 26480978 DOI: 10.1111/jgs.13653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- William J Hall
- Division of Geriatrics, School of Medicine and Dentistry, University of Rochester, Rochester, New York
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13
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Keller SC, Yehia BR, Momplaisir FO, Eberhart MG, Share A, Brady KA. Assessing the overall quality of health care in persons living with HIV in an urban environment. AIDS Patient Care STDS 2014; 28:198-205. [PMID: 24654969 DOI: 10.1089/apc.2014.0001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Ensuring high quality primary care for people living with HIV (PLWH) is important. We studied factors associated with meeting Health Resources and Services Administration-identified HIV performance measures, among a population-based sample of 376 PLWH in care at 24 Philadelphia clinics. Quality of care was assessed by a patient-level composite of 15 performance measures, focusing on HIV-specific care, vaccinations, and co-morbid condition screening. Adjusted incidence rate ratios (IRR) demonstrated relationships between patient and clinic factors and the performance measures score. The mean number of measures met was 8.52. Older age groups met more measures than 18- to 29-year-olds (age 40-49: adjusted IRR: 1.19, 95% CI: 1.05-1.35; age ≥50: adjusted IRR: 1.19, 95% CI: 1.03-1.35). Higher CD4 counts were associated with meeting more measures compared to CD4 <200 cells/μL (CD4 350-499 cells/μL: adjusted IRR: 1.14, 95% CI: 1.02-1.28; ≥500 cells/μL: adjusted IRR: 1.12, 95% CI: 1.01-1.26). PLWH attending clinics that provide adherence counseling or case management met more measures (adjusted IRR: 1.12, 95% CI: 1.04-1.21; adjusted IRR: 1.08, 95% CI: 1.02-1.14; respectively) than those attending clinics without these services. Limitations include potentially poor performance measure documentation and equal treatment of measures. Future work should focus on improving compliance with performance measures.
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Affiliation(s)
- Sara C. Keller
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Baligh R. Yehia
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Florence O. Momplaisir
- Division of Infectious Diseases, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Michael G. Eberhart
- AIDS Activities Coordinating Office, City of Philadelphia Department of Public Health, Philadelphia, Pennsylvania
| | - Amanda Share
- AIDS Activities Coordinating Office, City of Philadelphia Department of Public Health, Philadelphia, Pennsylvania
| | - Kathleen A. Brady
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
- AIDS Activities Coordinating Office, City of Philadelphia Department of Public Health, Philadelphia, Pennsylvania
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14
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Roth CP, Ganz DA, Nickles L, Martin D, Beckman R, Wenger NS. Nurse care manager contribution to quality of care in a dual-eligible special needs plan. J Gerontol Nurs 2012; 38:44-54. [PMID: 22833891 DOI: 10.3928/00989134-20120606-10] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We evaluated the quality of care provided to older patients with complex needs in a dual-eligible, community-based Medicare Special Needs Plan that used a nurse care manager model. Care provided by physicians was substantially supplemented by nurse care managers, as measured by Assessing Care of Vulnerable Elders quality indicators. We describe selected nurse care manager activities for six geriatric conditions (falls, dementia, depression, nutrition, urinary incontinence, and end-of-life care) during provision of patient care coordination and management for patients in the highest decile of clinical complexity. We identify areas of high nurse performance (i.e., falls screening, functional assessment, behavioral interventions for dementia problems, advance care planning) and areas of potential missed opportunities (i.e., follow up for new memory problems, targeted dementia counseling, nutrition, and behavioral approaches to urinary incontinence). Increasing the collaborative interaction between nurses providing care in this model and physicians has the potential to enhance nurses' contributions to primary care for vulnerable older adults.
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Miake-Lye IM, Amulis A, Saliba D, Shekelle PG, Volkman LK, Ganz DA. Formative evaluation of the telecare fall prevention project for older veterans. BMC Health Serv Res 2011; 11:119. [PMID: 21605438 PMCID: PMC3127979 DOI: 10.1186/1472-6963-11-119] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 05/23/2011] [Indexed: 11/25/2022] Open
Abstract
Background Fall prevention interventions for community-dwelling older adults have been found to reduce falls in some research studies. However, wider implementation of fall prevention activities in routine care has yielded mixed results. We implemented a theory-driven program to improve care for falls at our Veterans Affairs healthcare facility. The first project arising from this program used a nurse advice telephone line to identify patients' risk factors for falls and to triage patients to appropriate services. Here we report the formative evaluation of this project. Methods To evaluate the intervention we: 1) interviewed patient and employee stakeholders, 2) reviewed participating patients' electronic health record data and 3) abstracted information from meeting minutes. We describe the implementation process, including whether the project was implemented according to plan; identify barriers and facilitators to implementation; and assess the incremental benefit to the quality of health care for fall prevention received by patients in the project. We also estimate the cost of developing the pilot project. Results The project underwent multiple changes over its life span, including the addition of an option to mail patients educational materials about falls. During the project's lifespan, 113 patients were considered for inclusion and 35 participated. Patient and employee interviews suggested support for the project, but revealed that transportation to medical care was a major barrier in following up on fall risks identified by nurse telephone triage. Medical record review showed that the project enhanced usual medical care with respect to home safety counseling. We discontinued the program after 18 months due to staffing limitations and competing priorities. We estimated a cost of $9194 for meeting time to develop the project. Conclusions The project appeared feasible at its outset but could not be sustained past the first cycle of evaluation due to insufficient resources and a waning of local leadership support due to competing national priorities. Future projects will need both front-level staff commitment and prolonged high-level leadership involvement to thrive.
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Affiliation(s)
- Isomi M Miake-Lye
- VA Greater Los Angeles HSR&D Center of Excellence, 16111 Plummer Street, Sepulveda, CA 91343, USA.
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