Comprehensive geriatric assessment, multifactorial interventions and nurse-led care coordination to prevent functional decline in community-dwelling older persons: protocol of a cluster randomized trial

Development and testing of the Geriatric Care Assessment Practices (G-CAP) survey

Background

While the Resident Assessment Instrument-Home Care (RAI-HC) tool was designed to support comprehensive geriatric assessment in home care, it is more often used for service allocation and little is known about how point-of-care providers collect the information they need to plan and provide care. The purpose of this pilot study was to develop and test a survey to explore the geriatric care assessment practices of nurses, occupational therapists (OTs) and physiotherapists (PTs) in home care.

Methods

Literature review and expert consultation informed the development of the Geriatric Care Assessment Practices (G-CAP) survey—a 33 question, online, self-report tool exploring assessment and information-sharing methods, attitudes, knowledge, experience and demographic information. The survey was pilot tested at a single home care agency in Ontario, Canada (N = 27). Test-retest reliability (N = 20) and construct validity were explored.

Results

The subscales of the G-CAP survey showed fair to good test-retest reliability within a population of interdisciplinary home care providers [ICC2 (A,1) (M ICC = 0.58) for continuous items; weighted kappa (M kappa = 0.63) for categorical items]. Statistically significant differences between OT, PT and nurse responses [M t = 3.0; M p = 0.01] and moderate correlations between predicted related items [M r = |0.39|] provide preliminary support for our hypotheses around survey construct validity in this population. Pilot participants indicated that they use their clinical judgment far more often than standardized assessment tools. Client input was indicated to be the most important source of information for goal-setting. Most pilot participants had heard of the RAI-HC; however, few used it. Pilot participants agreed they could use assessment information from others but also said they must conduct their own assessments and only sometimes share and rarely receive information from other providers.

Conclusions

The G-CAP survey shows promise as a measure of the geriatric care assessment practices of interdisciplinary home care providers. Findings from the survey have the potential to inform improvements to integrated care planning. Next steps include making adaptations to the G-CAP survey to further improve the reliability and validity of the tool and a broad administration of the survey in Ontario home care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02073-5.

Core components and impact of nurse-led integrated care models for home-dwelling older people: A systematic review and meta-analysis

BACKGROUND

Integrated care models are highly recommended to overcome care fragmentation in the multimorbid older population. Nurses are potentially ideally situated to fulfil the role as care coordinator to guide integrated care. No systematic review has been conducted specifically focusing on the impact of nurse-led integrated care models for older people in community settings.

OBJECTIVES

To identify core components of nurse-led integrated care models for the home-dwelling older population; to describe patient, service and process outcomes; and to evaluate the impact of these care models on quality of life, activities of daily living, hospitalisation, emergency department visits, nursing home admissions and mortality.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

English, Dutch, French, German and Spanish articles selected from PubMed and CINAHL, hand-search of reference lists of the included articles and grey literature.

REVIEW METHODS

A systematic search was conducted to identify prospective experimental or quasi-experimental studies detailing nurse-led integrated care models in the older home-dwelling population. Study characteristics and reported outcomes were tabulated. The core components of the models were mapped using the Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE (SELFIE) framework. A random effects meta-analysis was conducted to study the overall effectiveness of the included care models on health-related quality of life, activities of daily living, hospitalisation, emergency department visits, nursing home admissions or mortality. Risk of bias was appraised using the revised Cochrane risk-of-bias tool for randomized trials and ROBINS-I tool for non-randomized studies.

RESULTS

Nineteen studies were included studying a total of 22,168 patients. Core components of integrated care for multimorbid patients such as the involvement of a multidisciplinary team, high risk screening, tailored holistic assessment and an individualized care plan, were performed in a vast majority of the studies; however variability was observed in their operationalisation. Twenty-seven different patient, provider and service outcomes were reported, ranging from 1 to 13 per study. The meta-analyses could not demonstrate a beneficial impact on any of the predefined outcomes. Most included studies were of high risk for several biases.

CONCLUSION

The summarized evidence on nurse-led integrated care models in home-dwelling older people is inconclusive and of low quality. Future studies should include key components of implementation research, such as context analyses, process evaluations and proximal outcomes, to strengthen the evidence-base of nurse-led integrated care.

Addressing safety risks in integrated care programs for older people living at home: a scoping review

BACKGROUND

Many older people live at home, often with complex and chronic health and social care needs. Integrated care programs are increasingly being implemented as a way to better address these needs. To support older people living at home, it is also essential to maintain their safety. Integrated care programs have the potential to address a wide range of risks and problems that could undermine older people's ability to live independently at home. The aim of this scoping review is to provide insight into how integrated care programs address safety risks faced by older people living at home - an area that is rather underexplored.

METHODS

Safety was conceptualised as preventing or reducing the risk of problems, associated with individual functioning and behaviour, social and physical environments, and health and social care management, which could undermine older people's ability to live independently at home. For this scoping review a systematic literature search was performed to identify papers describing integrated care programs where at least one intervention component addressed safety risks. Data were extracted on the programs' characteristics, safety risks addressed, and the activities and interventions used to address them.

RESULTS

None of the 11 programs included in this review explicitly mentioned safety in their goals. Nevertheless, following the principles of our conceptual framework, the programs appeared to address risks in multiple domains. Most attention was paid to risks related to older people's functioning, behaviour, and the health and social care they receive. Risks related to people's physical and social environments received less attention.

CONCLUSION

Even though prevention of safety risks is not an explicit goal of integrated care programs, the programs address a wide range of risks on multiple domains. The need to address social and environmental risks is becoming increasingly important given the growing number of people receiving care and support at home. Prioritising a multidimensional approach to safety in integrated care programs could enhance the ability of health and social care systems to support older people to live safely at home.

Comprehensive geriatric assessments in integrated care programs for older people living at home: A scoping review

In many integrated care programs, a comprehensive geriatric assessment (CGA) is conducted to identify older people's problems and care needs. Different ways for conducting a CGA are in place. However, it is still unclear which CGA instruments and procedures for conducting them are used in integrated care programs, and what distinguishes them from each other. Furthermore, it is yet unknown how and to what extent CGAs, as a component of integrated care programs, actually reflect the main principles of integrated care, being comprehensiveness, multidisciplinarity and person-centredness. Therefore, the objectives of this study were to: (a) describe and compare different CGA instruments and procedures conducted within integrated care programs for older people living at home, and (b) describe how the principles of integrated care were applied in these CGAs. A scoping review of the scientific literature on CGAs in the context of integrated care was conducted for the period 2006-2018. Data were extracted on main characteristics of the identified CGA instruments and procedures, and on how principles of integrated care were applied in these CGAs. Twenty-seven integrated care programs were included in this study, of which most were implemented in the Netherlands and the United States. Twenty-one different CGAs were identified, of which the EASYcare instrument, RAI-HC/RAI-CHA and GRACE tool were used in multiple programs. The majority of CGAs seemed to reflect comprehensiveness, multidisciplinarity and person-centredness, although the way and extent to which principles of integrated care were incorporated differed between the CGAs. This study highlights the high variability of CGA instruments and procedures used in integrated care programs. This overview of available CGAs and their characteristics may promote (inter-)national exchange of CGAs, which could enable researchers and professionals in choosing from the wide range of existing CGAs, thereby preventing them from unnecessarily reinventing the wheel.

Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology

Purpose To provide guidance regarding the practical assessment and management of vulnerabilities in older patients undergoing chemotherapy. Methods An Expert Panel was convened to develop clinical practice guideline recommendations based on a systematic review of the medical literature. Results A total of 68 studies met eligibility criteria and form the evidentiary basis for the recommendations. Recommendations In patients ≥ 65 years receiving chemotherapy, geriatric assessment (GA) should be used to identify vulnerabilities that are not routinely captured in oncology assessments. Evidence supports, at a minimum, assessment of function, comorbidity, falls, depression, cognition, and nutrition. The Panel recommends instrumental activities of daily living to assess for function, a thorough history or validated tool to assess comorbidity, a single question for falls, the Geriatric Depression Scale to screen for depression, the Mini-Cog or the Blessed Orientation-Memory-Concentration test to screen for cognitive impairment, and an assessment of unintentional weight loss to evaluate nutrition. Either the CARG (Cancer and Aging Research Group) or CRASH (Chemotherapy Risk Assessment Scale for High-Age Patients) tools are recommended to obtain estimates of chemotherapy toxicity risk; the Geriatric-8 or Vulnerable Elders Survey-13 can help to predict mortality. Clinicians should use a validated tool listed at ePrognosis to estimate noncancer-based life expectancy ≥ 4 years. GA results should be applied to develop an integrated and individualized plan that informs cancer management and to identify nononcologic problems amenable to intervention. Collaborating with caregivers is essential to implementing GA-guided interventions. The Panel suggests that clinicians take into account GA results when recommending chemotherapy and that the information be provided to patients and caregivers to guide treatment decision making. Clinicians should implement targeted, GA-guided interventions to manage nononcologic problems. Additional information is available at www.asco.org/supportive-care-guidelines .

Cost-effectiveness of nurse-led multifactorial care to prevent or postpone new disabilities in community-living older people: Results of a cluster randomized trial

Objective

To evaluate the cost-effectiveness of nurse-led multifactorial care to prevent or postpone new disabilities in community-living older people in comparison with usual care.

Methods

We conducted cost-effectiveness and cost-utility analyses alongside a cluster randomized trial with one-year follow-up. Participants were aged ≥ 70 years and at increased risk of functional decline. Participants in the intervention group (n = 1209) received a comprehensive geriatric assessment and individually tailored multifactorial interventions coordinated by a community-care registered nurse with multiple follow-up visits. The control group (n = 1074) received usual care. Costs were assessed from a healthcare perspective. Outcome measures included disability (modified Katz-Activities of Daily Living (ADL) index score), and quality-adjusted life-years (QALYs). Statistical uncertainty surrounding Incremental Cost-Effectiveness Ratios (ICERs) was estimated using bootstrapped bivariate regression models while adjusting for confounders.

Results

There were no statistically significant differences in Katz-ADL index score and QALYs between the two groups. Total mean costs were significantly higher in the intervention group (EUR 6518 (SE 472) compared with usual care (EUR 5214 (SE 338); adjusted mean difference €1457 (95% CI: 572; 2537). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective was 0.14 at a willingness to pay (WTP) of EUR 50,000 per one point improvement on the Katz-ADL index score and 0.04 at a WTP of EUR 50,000 per QALY gained.

Conclusion

The current intervention was not cost-effective compared to usual care to prevent or postpone new disabilities over a one-year period. Based on these findings, implementation of the evaluated multifactorial nurse-led care model is not to be recommended.

Identifying Patients at Risk of High Healthcare Utilization

Objective. To develop a systematic and reproducible way to identify patients at increased risk for higher healthcare costs. Methods. Medical records were analyzed for 9,581 adults who were primary care patients in the University of Missouri Health System and who were enrolled in Medicare or Medicaid. Patients were categorized into one of four risk tiers as of October 1, 2013, and the four tiers were compared on demographic characteristics, number of healthcare episodes, and healthcare charges in the year before and the year after cohort formation. Results. The mean number of healthcare episodes and the sum of healthcare charges in the year following cohort formation were higher for patients in the higher-risk tiers. Conclusions. Retrospective information that is easily extracted from medical records can be used to create risk tiers that provide highly useful information about the prospective risk of healthcare utilization and costs.

Minimal Important Change and Minimal Detectable Change in Activities of Daily Living in Community-Living Older People

OBJECTIVE

To estimate the minimal important change (MIC) and the minimal detectable change (MDC) of the Katz-activities of daily living (ADL) index score and the Lawton instrumental activities of daily living (IADL) scale.

DESIGN

Data from a cluster-randomized clinical trial and a cohort study.

SETTING

General practices in the Netherlands.

PARTICIPANTS

3184 trial participants and 51 participants of the cohort study with a mean age of 80.1 (SD 6.4) years.

MEASUREMENTS

At baseline and after 6 months, the Katz-ADL index score (0-6 points), the Lawton IADL scale (0-7 points), and self-perceived decline in (I)ADL were assessed using a self-reporting questionnaire. MIC was assessed using anchor-based methods: the (relative) mean change score; and using distributional methods: the effect size (ES), the standard error of measurement (SEM), and 0.5 SD. The MDC was estimated using SEM, based on a test-retest study (2-week interval) and on the anchor-based method.

RESULTS

Anchor-based MICs of the Katz-ADL index score were 0.47 points, while distributional MICs ranged from 0.18 to 0.47 points. Similarly, anchor-based MICs of the Lawton IADL scale were between 0.31 and 0.54 points and distributional MICs ranged from 0.31 to 0.77 points. The MDC varies by sample size. For the MIC to exceed the MDC at least 482 patients are needed.

CONCLUSION

The MIC of both the Katz-ADL index and the Lawton IADL scale lie around half a point. The certainty of this conclusion is reduced by the variation across calculational methods.

Comprehensive geriatric assessment: recognition of identified geriatric conditions by community-dwelling older persons

OBJECTIVES

to study (i) the prevalence of geriatric conditions in community-dwelling older persons at increased risk of functional decline and (ii) the extent to which older persons recognise comprehensive geriatric assessment (CGA)-identified conditions as relevant problems.

METHODS

trained registered nurses conducted a CGA in 934 out of 1209 older persons at increased risk of functional decline participating in the intervention arm of a randomised trial in the Netherlands. After screening for 32 geriatric conditions, participants were asked which of the identified geriatric conditions they recognised as relevant problems.

RESULTS

at baseline, the median age of participants was 82.9 years (interquartile range (IQR) 77.3-87.3 years). The median number of identified geriatric conditions per participant was 8 (IQR 6-11). The median number of geriatric conditions that were recognised was 1 (IQR 0-2). Functional dependency and (increased risk of) alcohol and drug dependency were the most commonly identified conditions. Pain was the most widely recognised problem.

CONCLUSION

CGA identified many geriatric conditions, of which few were recognised as a problem by the person involved. Further study is needed to better understand how older persons interact with identified geriatric conditions, in terms of perceived relevance. This may yield a more efficient CGA and further improve a patient-centred approach.

Effects of Nurse-Led Multifactorial Care to Prevent Disability in Community-Living Older People: Cluster Randomized Trial

BACKGROUND

To evaluate the effects of nurse-led multifactorial care to prevent disability in community-living older people.

METHODS

In a cluster randomized trail, 11 practices (n = 1,209 participants) were randomized to the intervention group, and 13 practices (n = 1,074 participants) were randomized to the control group. Participants aged ≥ 70 years were at increased risk of functional decline based on a score ≥ 2 points on the Identification of Seniors at Risk- Primary Care, ISAR-PC. Participants in the intervention group received a systematic comprehensive geriatric assessment, and individually tailored multifactorial interventions coordinated by a trained community-care registered nurse (CCRN) with multiple follow-up home visits. The primary outcome was the participant's disability as measured by the modified Katz activities of daily living (ADL) index score (range 0-15) at one year follow-up. Secondary outcomes were health-related quality of life, hospitalization, and mortality.

RESULTS

At baseline, the median age was 82.7 years (IQR 77.0-87.1), the median modified Katz-ADL index score was 2 (IQR 1-5) points in the intervention group and 3 (IQR 1-5) points in the control group. The follow-up rate was 76.8% (n = 1753) after one year and was similar in both trial groups. The adjusted intervention effect on disability was -0.07 (95% confidence interval -0.22 to 0.07; p = 0.33). No intervention effects were found for the secondary outcomes.

CONCLUSIONS

We found no evidence that a one-year individualized multifactorial intervention program with nurse-led care coordination was better than the current primary care in community-living older people at increased risk of functional decline in The Netherlands.

TRIAL REGISTRATION

Netherlands Trial Register NTR2653.

Effectiveness of a Proactive Primary Care Program on Preserving Daily Functioning of Older People: A Cluster Randomized Controlled Trial

OBJECTIVES

To determine the effectiveness of a proactive primary care program on the daily functioning of older people in primary care.

DESIGN

Single-blind, three-arm, cluster-randomized controlled trial with 1-year follow-up.

SETTING

Primary care setting, 39 general practices in the Netherlands.

PARTICIPANTS

Community-dwelling people aged 60 and older (N = 3,092).

INTERVENTIONS

A frailty screening intervention using routine electronic medical record data to identify older people at risk of adverse events followed by usual care from a general practitioner; after the screening intervention, a nurse-led care program consisting of a comprehensive geriatric assessment, evidence-based care planning, care coordination, and follow-up; usual care.

MEASUREMENTS

Primary outcome was daily functioning measured using the Katz-15 (6 activities of daily living (ADLs), 8 instrumental activities of daily living (IADLs), one mobility item (range 0-15)); higher scores indicate greater dependence. Secondary outcomes included quality of life, primary care consultations, hospital admissions, emergency department visits, nursing home admissions, and mortality.

RESULTS

The participants in both intervention arms had less decline in daily functioning than those in the usual care arm at 12 months (mean Katz-15 score: screening arm, 1.87, 95% confidence interval (CI) = 1.77-1.97; screening and nurse-led care arm, 1.88, 95% CI = 1.80-1.96; control group, 2.03, 95% CI = 1.92-2.13; P = .03). No differences in quality of life were observed.

CONCLUSION

Participants in both intervention groups had less decline than those in the control group at 1-year follow-up. Despite the statistically significant effect, the clinical relevance is uncertain at this point because of the small differences. Greater customizing of the intervention combined with prolonged follow-up may lead to more-robust results.

Assessment of the quality of fall detection and management in primary care in the Netherlands based on the ACOVE quality indicators

We determined adherence to nine fall-related ACOVE quality indicators to investigate the quality of management of falls in the elderly population by general practitioners in the Netherlands. Our findings demonstrate overall low adherence to these indicators, possibly indicating insufficiency in the quality of fall management. Most indicators showed a positive association between increased risk for functional decline and adherence, four of which with statistical significance.

INTRODUCTION

This study aims to investigate the quality of detection and management of falls in the elderly population by general practitioners in the Netherlands, using the Assessing Care of Vulnerable Elders (ACOVE) quality indicators.

METHODS

Community-dwelling persons aged 70 years or above, registered in participating general practices, were asked to fill in a questionnaire designed to determine general practitioner (GP) adherence to fall-related indicators. We used logistic regression to estimate the association between increased risk for functional decline-quantified by the Identification of Seniors At Risk for Primary Care score-and adherence. We then cross-validated the self-reported falls with medical records.

RESULTS

Of the 950 elders responding to our questionnaire, only 10.6 % reported that their GP proactively asked them about falls. Of the 160 patients who reported two or more falls, or one fall for which they visited the GP, only 23.1 % had fall documentation in their records. Adherence ranged between 13.6 and 48.6 %. There was a significant positive association between the ISAR-PC scores and adherence in four QIs. Documentation of falls was highest (36.7 %) in patients whom the GP had proactively asked about falls.

CONCLUSION

Based on patient self-reports, adherence to the ACOVE fall-related indicators was poor, suggesting that the quality of evaluation and management of falls in community-dwelling older persons in the Netherlands is poor. The documentation of falls and fall-related risk factors was also poor. However, for most QIs, adherence to them increased with the increase in the risk of functional decline.

Factors associated with recognition and prioritization for falling, and the effect on fall incidence in community dwelling older adults

BACKGROUND

Recent trials have shown that multifactorial fall interventions vary in effectiveness, possibly due to lack of adherence to the interventions. The aim of this study was to examine what proportion of older adults recognize their falls risk and prioritize for fall-preventive care, and which factors are associated with this prioritization.

METHODS

Observational study within the intervention arm of a cluster randomized controlled trial (RCT) on the effect of preventive interventions for geriatric problems in older community-dwellers at risk of functional decline.

SETTING

 general practices in the Netherlands. Participants were community dwellers (70+) in whom falling was identified as a condition. A comprehensive geriatric assessment (CGA) was performed by a registered community care nurse. Participants were asked which of the identified conditions they recognized and prioritized for in a preventive care plan, and subsequent interventions were started. Multivariable logistic regression was performed to identify which factors were associated with this prioritization. Fall-incidence was measured during one-year follow-up.

RESULTS

The RCT included 6668 participants, 3430 were in the intervention arm. Of those, 1209 were at risk of functional decline, of whom 936 underwent CGA. In 380 participants (41 %), falling was identified as a condition; 62 (16 %) recognized this and 37 (10 %) prioritized for it. Factors associated with prioritization for falls-prevention were: recurrent falls in the past year (OR 2.2 [95 % CI 1.1-4.4]), severe fear-of-falling (OR 2.7 [1.2-6.0]) and use of a walking aid (2.3 [1.1-5.0]). Sixty participants received a preventive intervention for falling; 29 had prioritized for falling. Incidence of falls was higher in the priority group than the non-priority group (67 % vs. 37 % respectively) during first six months of follow-up, but similar between groups after 12 months (40.7 % vs. 44.4 %).

CONCLUSIONS

The proportion of community-dwellers at risk of falls that recognizes this risk and prioritizes for preventive care is small. Recurrent falls in the past year, severe fear-of-falling and use of a walking aid were associated with prioritization. Prioritization was associated with a greater fall-risk during first six months, which appeared to level out at one-year follow-up. These results could aid in the identification of community-dwellings likely to benefit from fall-preventive interventions.

TRIAL REGISTRATION

NTR2653 , 17 December 2010.

Initiatives on early detection and intervention to proactively identify health and social problems in older people: experiences from the Netherlands

Background

Over the last years, several initiatives on early detection and intervention have been put in place to proactively identify health and social problems in (frail) older people. An overview of the initiatives currently available in the Netherlands is lacking, and it is unknown whether they meet the preferences and needs of older people. Therefore, the objectives of this study were threefold: 1. To identify initiatives on early detection and intervention for older people in the Netherlands and compare their characteristics; 2. To explore the experiences of professionals with these initiatives; and 3. To explore to what extent existing initiatives meet the preferences and needs of older people.

Methods

We performed a qualitative descriptive study in which we conducted semi-structured interviews with seventeen experts in preventive elderly care and three group interviews with volunteer elderly advisors. Data were analysed using the framework analysis method.

Results

We identified eight categories of initiatives based on the setting (e.g. general practitioner practice, hospital, municipality) in which they were offered. Initiatives differed in their aims and target groups. The utilization of peers to identify problems and risks, as was done by some initiatives, was seen as a strength. Difficulties were experienced with identifying the target group that would benefit from proactive delivery of care and support most, and with addressing prevalent issues among older people (e.g. psychosocial issues, self-reliance issues).

Conclusion

Although there is a broad array of initiatives available, there is a discrepancy between supply and demand. Current initiatives insufficiently address needs of (frail) older people. More insight is needed in “what should be done by whom, for which target group and at what moment”, in order to improve current practice in preventive elderly care.

Initiatives on early detection and intervention to proactively identify health and social problems in older people: experiences from the Netherlands

BACKGROUND

Over the last years, several initiatives on early detection and intervention have been put in place to proactively identify health and social problems in (frail) older people. An overview of the initiatives currently available in the Netherlands is lacking, and it is unknown whether they meet the preferences and needs of older people. Therefore, the objectives of this study were threefold: 1. To identify initiatives on early detection and intervention for older people in the Netherlands and compare their characteristics; 2. To explore the experiences of professionals with these initiatives; and 3. To explore to what extent existing initiatives meet the preferences and needs of older people.

METHODS

We performed a qualitative descriptive study in which we conducted semi-structured interviews with seventeen experts in preventive elderly care and three group interviews with volunteer elderly advisors. Data were analysed using the framework analysis method.

RESULTS

We identified eight categories of initiatives based on the setting (e.g. general practitioner practice, hospital, municipality) in which they were offered. Initiatives differed in their aims and target groups. The utilization of peers to identify problems and risks, as was done by some initiatives, was seen as a strength. Difficulties were experienced with identifying the target group that would benefit from proactive delivery of care and support most, and with addressing prevalent issues among older people (e.g. psychosocial issues, self-reliance issues).

CONCLUSION

Although there is a broad array of initiatives available, there is a discrepancy between supply and demand. Current initiatives insufficiently address needs of (frail) older people. More insight is needed in "what should be done by whom, for which target group and at what moment", in order to improve current practice in preventive elderly care.

Older patients' perceived burdens of their health problems: a cross-sectional analysis in 74 German general practices

BACKGROUND

Older patients often experience the burden of multiple health problems. Physicians need to consider them to arrive at a holistic treatment plan. Yet, it has not been systematically investigated as to which personal burdens ensue from certain health conditions.

OBJECTIVE

The objective of this study is to examine older patients' perceived burden of their health problems.

PATIENTS AND METHODS

The study presents a cross-sectional analysis in 74 German general practices; 836 patients, 72 years and older (mean 79±4.4), rated the burden of each health problem disclosed by a comprehensive geriatric assessment. Patients rated each burden using three components: importance, emotional impact, and impact on daily activities. Cluster analyses were performed to define patterns in the rating of these components of burden. In a multilevel logistic regression analysis, independent factors that predict high and low burden were explored.

RESULTS

Patients had a median of eleven health problems and rated the burden of altogether 8,900 health problems. Four clusters provided a good clustering structure. Two clusters describe a high burden, and a further two, a low burden. Patients attributed a high burden to social and psychological health problems (especially being a caregiver: odds ratio [OR] 10.4, 95% confidence interval [CI] 4.4-24.4), to specific symptoms (eg, claudication: OR 2.3, 95% CI 1.3-4.0; pain: OR 2.3, 95% CI 1.6-3.1), and physical disabilities. Patients rated a comparatively low burden for most of their medical findings, for cognitive impairment, and lifestyle issues (eg, hypertension: OR 0.2, 95% CI 0.2-0.3).

CONCLUSION

The patients experienced a relatively greater burden for physical disabilities, mood, or social issues than for diseases themselves. Physicians should interpret these burdens in the individual context and consider them in their treatment planning.

[Identification of seniors at risk--primary care: a validated questionnaire predicting functional decline]

OBJECTIVES

To modify and validate in primary healthcare the Identification of Seniors At Risk (ISAR) screening questionnaire to identify older persons at increased risk of functional decline and to compare this strategy with risk stratification by age alone.

STUDY DESIGN AND SETTING

Prospective development (n=790) and validation cohorts (n=2,573) of community-dwelling persons aged ≥70 years. Functional decline at 12 months was defined as an increase of at least one point on the modified Katz-activities of daily living index score compared with baseline or death.

RESULTS

Three items were independently associated with functional decline: age (odds ratio [OR] 1.06 per year; 95% confidence interval [CI] 1.02, 1.10) dependence in instrumental activities of daily living (OR: 2.17; 95% CI: 1.46, 3.22), and impaired memory (OR: 2.22; 95% CI: 1.41, 3.51). The area under the receiver operating characteristics curve (AUC) range of the ISAR-primary care model was 0.67-0.70 and 40.6% was identified at increased risk. Validation yielded an AUC range of 0.63-0.64. Age≥75 years alone yielded an AUC range of 0.56-0.57 and identified 65.0% at increased risk in the validation cohort.

CONCLUSION

Although the ISAR-Primary Care (ISAR-PC) has moderate predictive value, application of the ISAR-PC is more efficient than selection based on age alone in identifying persons at increased risk of functional decline. This paper is a translated and adjusted version based on a publication in Journal of Clinical Epidemiology, 67 (2014) 1121-1130.

Validity and reliability of the Katz-15 scale to measure unfavorable health outcomes in community-dwelling older people

OBJECTIVES

To predict the risk of future unfavourable health outcomes in older people it is common to assess the level of both basic and instrumental activities of daily living. To accomplish this, the commonly used Katz-6 and the Lawton IADL questionnaires can be combined to form the 'Modified Katz ADL' scale, also known as the Katz-15 scale. So far, the validity and reliability of the Katz-15 scale is unknown. The objective of the current study is to investigate how well the Katz-15 is able to predict future unfavorable health outcomes and how this is related to the existing Katz-6 scale.

DESIGN

We performed a follow-up study using data from a group of 60 year and older participants from a large Dutch clinical trial.

PARTICIPANTS

We included 2321 participants in the analysis. The average age of the study population was 74 years and 44% was male.

MEASUREMENTS

We studied the relation between the Katz-15 scale and a number of unfavourable health outcomes, such as hospitalization, admission to a nursing home, admission to a home for the aged and death within one year of follow-up.

RESULTS

We found the Katz-15 to be both internally consistent and strongly associated with quality of life measures. We observed moderate to strong associations between the Katz-15 and the unfavourable health outcomes All associations studied were stronger for the Katz-15 scale as compared to the Katz-6 scale.

CONCLUSION

The results of our study indicate that the Katz-15 scale is able to reliably and validly predict future unfavorable health outcomes. This makes the scale a valuable measure in determining both basic and instrumental activities of daily living.

A simple validated questionnaire predicted functional decline in community-dwelling older persons: prospective cohort studies

OBJECTIVES

To modify and validate in primary health care the Identification of Seniors At Risk (ISAR) screening questionnaire to identify older persons at increased risk of functional decline and to compare this strategy with risk stratification by age alone.

STUDY DESIGN AND SETTING

Prospective development (n = 790) and validation cohorts (n = 2,573) of community-dwelling persons aged ≥70 years. Functional decline at 12 months was defined as an increase of at least one point on the modified Katz-activities of daily living index score compared with baseline or death.

RESULTS

Three items were independently associated with functional decline: age (odds ratio [OR]: 1.06 per year; 95% confidence interval [CI]: 1.02, 1.10), dependence in instrumental activities of daily living (OR: 2.17; 95% CI: 1.46, 3.22), and impaired memory (OR: 2.22; 95% CI: 1.41, 3.51). The area under the receiver operating characteristics curve (AUC) range of the ISAR-primary care model was 0.67-0.70, and 40.6% was identified at increased risk. Validation yielded an AUC range of 0.63-0.64. Age ≥75 years alone yielded an AUC range of 0.56-0.57 and identified 55.4% at increased risk in the development cohort.

CONCLUSION

Although the ISAR-Primary Care (ISAR-PC) has moderate predictive value, application of the ISAR-PC is more efficient than selection based on age alone in identifying persons at increased risk of functional decline.

Improving care for older adults: a model to segment the senior population

CONTEXT

Risk stratification and tailored interventions are key population-level care management strategies among older adults, whose needs range from screening and prevention to end-of-life care.

OBJECTIVE

To validate the Senior Segmentation Algorithm, a tool using administrative and clinical data from the electronic health record to identify each member aged 65 years and older as belonging to 1 of 4 Care Groups with similar needs: those without chronic conditions, with one or more chronic conditions, with advanced illness or end-organ failure, or with extreme frailty or nearing the end of life.

DESIGN

Multiple validation methods.

MAIN OUTCOME MEASURES

Concordance with physician judgment, stability of segmentation over time, convergence with mortality, hospitalization, and readmission rates, and costs of care.

RESULTS

Concordance of the algorithm with physician-assessed segmentation of 1615 Medicare recipients was 85%. After 1 year, approximately 85% of 86,140 surviving seniors remained in the same care group; 3.9% moved to a lower need group; and 11% moved to a higher need group. Six-month and 12-month mortality rates varied substantially across care groups. The algorithm performed similarly to the likelihood of hospitalization score in predicting hospitalization and readmissions.

CONCLUSIONS

The Senior Segmentation Algorithm accurately identifies older adults in care groups with similar needs, trajectories, and utilization patterns. It is being implemented in all Kaiser Permanente Regions, with the goal of determining key elements of care for members in each group. In addition, future efforts will aim to slow progression to higher need care groups and to identify necessary improvements in delivery system design.

Self-report of healthcare utilization among community-dwelling older persons: a prospective cohort study

Background

Self-reported data are often used for estimates on healthcare utilization in cost-effectiveness studies.

Objective

To analyze older adults’ self-report of healthcare utilization compared to data obtained from the general practitioners’ (GP) electronic medical record (EMR) and to study the differences in healthcare utilization between those who completed the study, those who did not respond, and those lost to follow-up.

Methods

A prospective cohort study was conducted among community-dwelling persons aged 70 years and above, without dementia and not living in a nursing home. Self-reporting questionnaires were compared to healthcare utilization data extracted from the EMR at the GP-office.

Results

Overall, 790 persons completed questionnaires at baseline, median age 75 years (IQR 72–80), 55.8% had no disabilities in (instrumental) activities of daily living. Correlations between self-report data and EMR data on healthcare utilization were substantial for ‘hospitalizations’ and ‘GP home visits’ at 12 months intraclass correlation coefficient 0.63 (95% CI; 0.58–0.68). Compared to the EMR, self-reported healthcare utilization was generally slightly over-reported. Non-respondents received more GP home visits (p<0.05). Of the participants who died or were institutionalized 62.2% received 2 or more home visits (p<0.001) and 18.9% had 2 or more hospital admissions (p<0.001) versus respectively 18.6% and 3.9% of the participants who completed the study. Of the participants lost to follow-up for other reasons 33.0% received 2 or more home visits (p<0.01) versus 18.6 of the participants who completed the study.

Conclusions

Self-report of hospitalizations and GP home visits in a broadly ‘healthy’ community-dwelling older population seems adequate and efficient. However, as people become older and more functionally impaired, collecting healthcare utilization data from the EMR should be considered to avoid measurement bias, particularly if the data will be used to support economic evaluation.

Diabetes predicts long-term disability in an elderly urban cohort: the Northern Manhattan Study

PURPOSE

There are limited data on vascular predictors of long-term disability in Hispanics. We hypothesized that (1) functional status declines over time and (2) vascular risk factors predict functional decline.

METHODS

The Northern Manhattan Study contains a population-based study of 3298 stroke-free individuals aged 40 years or older, followed for median 11 years. The Barthel Index (BI) was assessed annually. Generalized estimating equations and Cox models were adjusted for demographic, medical, and social risk factors. Stroke and myocardial infarction occurring during follow-up were censored in sensitivity analysis. Secondarily, motor and nonmotor domains of the BI were analyzed.

RESULTS

Mean age (standard deviation) of the cohort (n = 3298) was 69.2 (10) years, 37% were male, 52% Hispanic, 22% diabetic, and 74% hypertensive. There was a mean annual decline of 1.02 BI points (P < .0001). Predictors of decline in BI included age, female sex, diabetes, depression, and normocholesterolemia. Results did not change with censoring. We found similar predictors of BI for motor and nonmotor domains.

CONCLUSION

In this large, population-based, multiethnic study with long-term follow-up, we found a 1% mean decline in function per year that did not change when vascular events were censored. Diabetes predicted functional decline in the absence of clinical vascular events.

Is comprehensive geriatric assessment recognized and applied in Southwest China? A survey from Sichuan Association of Geriatrics

OBJECTIVES

To investigate how health care providers in Southwest China conducted comprehensive geriatric assessment (CGA) in their clinical practices.

METHODS

One hundred twenty-two medical care providers who attended the 2012 Sichuan Association of Geriatrics (SAG) Continuing Medical Education participated in this cross-sectional survey. The instrument was divided into 2 parts, including respondents' demographics and information on their application of CGA.

RESULTS

Of the total 122 participants, 120 (73 physicians and 47 nurses) responded. Three-quarters of the respondents reported that they evaluated at least 1 item of CGA separately. Among them, 30/32 respondents from university-affiliated hospitals reported having performed CGA compared with 18/22 from community hospitals or retirement/nursing facilities and 42/66 from provincial or county hospitals (P < .001), respectively. Respondents who attended the SAG Continuing Medical Education were more likely to complete the CGA (86.5% vs 66.2%, P = .011) and the integrated CGA (48.9% vs 20.0%, P < .001). Physicians were more likely to assess the instrument daily living capacity and communication capacity. Nurses were more focused on the basic activities of daily living, economic support, and caregiver.

CONCLUSIONS

These findings showed that the application of CAG in the mainland of China is not adequate. The training program related to CGA held by the SAG was helpful in improving the proportion of effective use of CGA. More efforts should be made in the future to build the CGA work team.