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Putrik P, Grobler L, Lalor A, Ramsay H, Gorelik A, Karnon J, Parker D, Morgan M, Buchbinder R, O'Connor D. Models for delivery and co-ordination of primary or secondary health care (or both) to older adults living in aged care facilities. Cochrane Database Syst Rev 2024; 3:CD013880. [PMID: 38426600 PMCID: PMC10905654 DOI: 10.1002/14651858.cd013880.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co-ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost-effectiveness of alternative models of providing health care to ACF residents. OBJECTIVES Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost-effectiveness of the alternative models. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA We included individual and cluster-randomised trials, and cost/cost-effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co-ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co-ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline-recommended care, health-related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work-related satisfaction and work-related stress of ACF staff. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care. MAIN RESULTS We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co-ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low-certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I2 = 53%; 8 trials, 1263 participants; low-certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low-certainty evidence) and adherence to guideline-recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health-related quality of life of ACF residents (MD -0.016, 95% CI -0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low-certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate-certainty evidence). We did not pool the cost-effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co-ordination of care), we are uncertain of the cost-effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low. AUTHORS' CONCLUSIONS Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health-related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost-effectiveness of alternative models of care due to the limited, disparate data available.
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Affiliation(s)
- Polina Putrik
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Liesl Grobler
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Aislinn Lalor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Helen Ramsay
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alexandra Gorelik
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jonathan Karnon
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Deborah Parker
- Faculty of Health, The University of Technology Sydney, Sydney, NSW, Australia
| | - Mark Morgan
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Denise O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Gayot C, Laubarie-Mouret C, Zarca K, Mimouni M, Cardinaud N, Luce S, Tovena I, Durand-Zaleski I, Laroche ML, Preux PM, Tchalla A. Effectiveness and cost-effectiveness of a telemedicine programme for preventing unplanned hospitalisations of older adults living in nursing homes: the GERONTACCESS cluster randomized clinical trial. BMC Geriatr 2022; 22:991. [PMID: 36550496 PMCID: PMC9773573 DOI: 10.1186/s12877-022-03575-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 11/01/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The GERONTACCESS trial evaluated the utility and cost-effectiveness of a gerontological telemedicine (TLM) programme for preventing unplanned hospitalisation of residents living in nursing homes (NHs) in regions lacking medical facilities and/or qualified medical providers ("medical deserts"). DESIGN GERONTACCESS was a 12-month, multicentre, prospective cluster-randomised trial conducted in NHs. The intervention group underwent TLM assessments every 3 months. The control group received the usual care. In both groups, comprehensive on-site assessments were conducted at baseline and the final visit. Care requirements were documented throughout the study. SETTING AND PARTICIPANTS NH residents aged ≥ 60 years with multiple chronic diseases. METHODS The study outcomes were the proportion of patients who experienced avoidable and unplanned hospitalisation, and the incremental cost savings per quality-adjusted life years from baseline to the 12-month follow-up. RESULTS Of the 426 randomised participants (mean ± standard deviation age, 87.2 ± 7.6 years; 311 [73.0%] women), 23.4% in the intervention group and 32.5% in the control group experienced unplanned hospitalisation (odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.43 to 0.97; p = 0.034). Each avoided hospitalisation in the intervention group saved $US 3,846. CONCLUSIONS AND IMPLICATIONS The results of GERONTACCESS revealed that our gerontological, preventative TLM program significantly reduced unplanned hospitalisations. This innovative intervention limited disease progression and promoted a healthy lifestyle among NH residents. TRIAL REGISTRATION Clinicaltrials.gov, NCT02816177, registered June 28, 2016.
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Affiliation(s)
- Caroline Gayot
- Laboratoire VieSanté - UR 24134 (Vieillissement, Fragilité, Prévention, E-Santé), Institut OMEGA HEALTH, Université de Limoges, Limoges, France
- CHU de Limoges, Pôle HU Gérontologie Clinique, 2 Avenue Martin-Luther King, Limoges, F-87042, France
- Unité de Recherche Clinique Et d'Innovation (URCI) en Gérontologie, CHU de Limoges, Pôle HU Gérontologie Clinique, Limoges, France
| | - Cécile Laubarie-Mouret
- Laboratoire VieSanté - UR 24134 (Vieillissement, Fragilité, Prévention, E-Santé), Institut OMEGA HEALTH, Université de Limoges, Limoges, France
- CHU de Limoges, Pôle HU Gérontologie Clinique, 2 Avenue Martin-Luther King, Limoges, F-87042, France
| | - Kevin Zarca
- DRCI-URC Eco Ile-de-France, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Maroua Mimouni
- DRCI-URC Eco Ile-de-France, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Noelle Cardinaud
- Laboratoire VieSanté - UR 24134 (Vieillissement, Fragilité, Prévention, E-Santé), Institut OMEGA HEALTH, Université de Limoges, Limoges, France
- CHU de Limoges, Pôle HU Gérontologie Clinique, 2 Avenue Martin-Luther King, Limoges, F-87042, France
| | - Sandrine Luce
- Centre d'Épidémiologie, de Bio Statistique Et de Méthodologie de La Recherche (CEBIMER), CHU de Limoges, 2 Avenue Martin-Luther King, Limoges, F-87042, France
| | - Isabelle Tovena
- Laboratoire VieSanté - UR 24134 (Vieillissement, Fragilité, Prévention, E-Santé), Institut OMEGA HEALTH, Université de Limoges, Limoges, France
| | | | - Marie-Laure Laroche
- Laboratoire VieSanté - UR 24134 (Vieillissement, Fragilité, Prévention, E-Santé), Institut OMEGA HEALTH, Université de Limoges, Limoges, France
| | - Pierre-Marie Preux
- Centre d'Épidémiologie, de Bio Statistique Et de Méthodologie de La Recherche (CEBIMER), CHU de Limoges, 2 Avenue Martin-Luther King, Limoges, F-87042, France
| | - Achille Tchalla
- Laboratoire VieSanté - UR 24134 (Vieillissement, Fragilité, Prévention, E-Santé), Institut OMEGA HEALTH, Université de Limoges, Limoges, France.
- CHU de Limoges, Pôle HU Gérontologie Clinique, 2 Avenue Martin-Luther King, Limoges, F-87042, France.
- Unité de Recherche Clinique Et d'Innovation (URCI) en Gérontologie, CHU de Limoges, Pôle HU Gérontologie Clinique, Limoges, France.
- Geriatric Medicine, University of Limoges, CHU Limoges, Laboratoire VieSanté - UR 24134, Limoges, France.
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Nkodo JA, Gana W, Debacq C, Aidoud A, Poupin P, Camus V, Fougère B. The Role of Telemedicine in the Management of the Behavioral and Psychological Symptoms of Dementia: A Systematic Review. Am J Geriatr Psychiatry 2022; 30:1135-1150. [PMID: 35241355 DOI: 10.1016/j.jagp.2022.01.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 01/25/2023]
Abstract
The first-line management of behavioral and psychological symptoms of dementia (BPSD) is based on nonpharmacologic interventions such as the provision of guidance and medical support to caregivers. However, accessibility to specialized care and medical resources is often scarce. The ongoing COVID-19 pandemic has compromised the delivery of outpatient care (notably in order to minimize the risk of disease transmission), thus making it essential to provide other means of accessing care for these patient populations. The use of telemedicine (TM) may be a means of increasing access to specialist care for patients with disabilities and poor access to health services, such as those with BPSD. The aim of this study is to provide a review of the literature on the use of TM for treatment and follow-up of patients with BPSD and their caregivers. We searched the PUBMED, EMBASE and CINAHL for articles published between January 1st, 2000, and December 31st, 2020, on the applicability of TM support for people with BPSD and their caregivers. We included open-label studies, qualitative studies, and randomized controlled trials . We did not include studies on the use of TM during the COVID-19 pandemic. A total of 22 publications were included and reviewed. TM was found to 1) be acceptable and feasible for both patients and caregivers, 2) decrease the frequency and intensity of BPSD, and 3) improve the caregiver's perceived wellbeing and mental health. Videoconferencing was effective for patient-centered interventions in nursing homes. Telephone-based interventions were more relevant when they were targeted at caregivers. The published studies are lacking in scope and high-quality studies are now needed to confirm these findings and assess TM's cost-effectiveness and ability to improve the management of patients with BPSD. In view of the ongoing COVID-19 pandemic, remote solutions for assessing and monitoring individuals with BPSD are urgently needed - particularly those living in rural areas and so-called "medical deserts."
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Affiliation(s)
- Jacques-Alexis Nkodo
- Division of Geriatric Medicine (JAN, WG, CD, AA, PP, BF), CHRU de Tours, Tours, France; Service de Psychiatrie Universitaire (JAN, VC), CHRU Tours, Tours, France.
| | - Wassim Gana
- Division of Geriatric Medicine (JAN, WG, CD, AA, PP, BF), CHRU de Tours, Tours, France
| | - Camille Debacq
- Division of Geriatric Medicine (JAN, WG, CD, AA, PP, BF), CHRU de Tours, Tours, France
| | - Amal Aidoud
- Division of Geriatric Medicine (JAN, WG, CD, AA, PP, BF), CHRU de Tours, Tours, France
| | - Pierre Poupin
- Division of Geriatric Medicine (JAN, WG, CD, AA, PP, BF), CHRU de Tours, Tours, France
| | - Vincent Camus
- Service de Psychiatrie Universitaire (JAN, VC), CHRU Tours, Tours, France; UMR INSERM U1253 & Université de Tours (VC), Tours, France
| | - Bertrand Fougère
- Division of Geriatric Medicine (JAN, WG, CD, AA, PP, BF), CHRU de Tours, Tours, France; Education, Ethics, Health (EA 7505) (BF), Tours University, Tours, France
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Groom LL, McCarthy MM, Stimpfel AW, Brody AA. Telemedicine and Telehealth in Nursing Homes: An Integrative Review. J Am Med Dir Assoc 2021; 22:1784-1801.e7. [PMID: 33819450 DOI: 10.1016/j.jamda.2021.02.037] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/12/2021] [Accepted: 02/21/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Telemedicine and telehealth are increasingly used in nursing homes (NHs). Their use was accelerated further by the COVID-19 pandemic, but their impact on patients and outcomes has not been adequately investigated. These technologies offer promising avenues to detect clinical deterioration early, increasing clinician's ability to treat patients in place. A review of literature was executed to further explore the modalities' ability to maximize access to specialty care, modernize care models, and improve patient outcomes. DESIGN Whittemore and Knafl's integrative review methodology was used to analyze quantitative and qualitative studies. SETTING AND PARTICIPANTS Primary research conducted in NH settings or focused on NH residents was included. Participants included clinicians, NH residents, subacute patients, and families. METHODS PubMed, Web of Science, CINAHL, Embase, PsycNET, and JSTOR were searched, yielding 16 studies exploring telemedicine and telehealth in NH settings between 2014 and 2020. RESULTS Measurable impacts such as reduced emergency and hospital admissions, financial savings, reduced physical restraints, and improved vital signs were found along with process improvements, such as expedient access to specialists. Clinician, resident, and family perspectives were also discovered to be roundly positive. Studies showed wide methodologic heterogeneity and low generalizability owing to small sample sizes and incomplete study designs. CONCLUSIONS AND IMPLICATIONS Preliminary evidence was found to support geriatrician, psychiatric, and palliative care consults through telemedicine. Financial and clinical incentives such as Medicare savings and reduced admissions to hospitals were also supported. NHs are met with increased challenges as a result of the COVID-19 pandemic, which telemedicine and telehealth may help to mitigate. Additional research is needed to explore resident and family opinions of telemedicine and telehealth use in nursing homes, as well as remote monitoring costs and workflow changes incurred with its use.
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Affiliation(s)
- Lisa L Groom
- New York University Rory Meyers College of Nursing, New York, NY, USA.
| | | | | | - Abraham A Brody
- New York University Rory Meyers College of Nursing, New York, NY, USA; Hartford Institute for Geriatric Nursing, New York, NY, USA; Division of Geriatric Medicine and Palliative Care, Department of Internal Medicine, NYU Grossman School of Medicine, New York, NY, USA
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Piau A, Vautier C, De Mauleon A, Tchalla A, Rumeau P, Nourhashemi F, Soto-Martin M. Health workers perception on telemedicine in management of neuropsychiatric symptoms in long-term care facilities: Two years follow-up. Geriatr Nurs 2020; 41:1000-1005. [PMID: 32771311 PMCID: PMC7406447 DOI: 10.1016/j.gerinurse.2020.07.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 11/18/2022]
Abstract
The management of neuropsychiatric symptoms is a challenge in long-term care facilities. Our objective was to assess the perception of telemedicine, as a useful tool to connect staff to specialized units. In this multicenter prospective study, 90 patients from ten facilities benefited from 180 sessions over two years. The primary outcome was the perception of telemedicine evaluated through semi-structured interviews at baseline and two years later. Our results revealed positive perceptions of telemedicine, confirmed after two years of real-life experience with its use. Not only do staff members believe that telemedicine is not a downgraded version of medicine, but they also believe that it could improve the quality of care. They expressed a very positive sense of recognition of their professional qualifications and indicated their need to be involved in change processes to ensure successful implementation and better adherence to telemedicine as a service.
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Affiliation(s)
- Antoine Piau
- Gérontopôle, CHU Toulouse, F-31400 Toulouse, France; UMR 1027, INSERM, F-31400 Toulouse, France.
| | - Claude Vautier
- Université des Sciences Sociales-Toulouse 1, Manufacture des Tabacs 2, rue du Doyen Gabriel Marty, 31042 Toulouse, France
| | | | - Achille Tchalla
- Université de Limoges, IFR 145 GEIST, EA 6310 HAVAE, Limoges, F-87025, France
| | | | - Fati Nourhashemi
- Gérontopôle, CHU Toulouse, F-31400 Toulouse, France; UMR 1027, INSERM, F-31400 Toulouse, France
| | - Maria Soto-Martin
- Gérontopôle, CHU Toulouse, F-31400 Toulouse, France; UMR 1027, INSERM, F-31400 Toulouse, France
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Zulfiqar AA, Hajjam A, Andrès E. Focus on the Different Projects of Telemedicine Centered on the Elderly In France. Curr Aging Sci 2019; 11:202-215. [PMID: 30836931 PMCID: PMC6635422 DOI: 10.2174/1874609812666190304115426] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/09/2019] [Accepted: 02/15/2019] [Indexed: 11/22/2022]
Abstract
Telemedicine is now in vogue, allowing computer and communication tools to be deployed in different fields of health, such as Cardiology, Dermatology, areas in which it has received interest, and in international studies. As the population ages, older people are increasingly concerned about this innovative practice. This is a narrative review of both the literature and Internet pertaining to telemedicine projects within the field of geriatric subjects in France. Since the beginning of the 2000's, several telemedicine projects and trials focused on chronic heart failure have been developed in the elderly, and also in the field of dermatology. The potential contribution of second-generation telemedicine projects in terms of mortality, morbidity, and the number of hospitalizations avoided is currently under study. Their impact in terms of health economics is likewise being investigated, taking into account that the economic and social benefits brought up by telemedicine solutions were previously validated by the original telemedicine projects. We take a look at telemedicine projects in France concerning the elderly.
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Affiliation(s)
- Abrar A. Zulfiqar
- Address correspondence to this author at the Department of Geriatrics, University Hospital of Rouen, Rouen, France; Tel: 0627102493;, E-mail:
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Telemedicine and Geriatrics in France: Inventory of Experiments. Curr Gerontol Geriatr Res 2018; 2018:9042180. [PMID: 30310388 PMCID: PMC6166386 DOI: 10.1155/2018/9042180] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/03/2018] [Accepted: 08/12/2018] [Indexed: 11/17/2022] Open
Abstract
Telemedicine is now in vogue, being deployed through computer and communication tools in various health fields, such as diabetology, nephrology, dermatology, neurology, and cardiology. With population ageing, geriatrics is coming into sharp focus. Telemedicine practices differ for home-based or institutionalized patients in long-term care homes. We take a look at telemedicine projects in France concerning the elderly.
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