Quality of life of older frail persons receiving a post-discharge program

Health-related quality of life among older adults following acute hospitalization: longitudinal analysis of a randomized controlled trial

PURPOSE

To describe the longitudinal change of health-related quality of life (HRQoL) over 12 months from acute hospitalization in older adults ≥ 70 years (IMMENSE study), and associated factors, to investigate how a medication optimization intervention influenced this change.

METHODS

The EQ-5D-3L was used at discharge and 1, 6 and 12 months after discharge during a randomized controlled trial including 285 participants. Multilevel logistic (EQ-5D-3L dimensions) and mixed model regression (EQ-5D-3L index scores, EQ-VAS) were used to explore the longitudinal change with/without the intervention, and associations with medications, comorbidities, and socioeconomic variables. Subgroup analyses were performed for non-long and long stayers with hospitalizations < or ≥ 14 days.

RESULTS

EQ-5D-3L index scores significantly declined after 12 months (β -0.06 [95% confidence interval (CI:) -0.10--0.02], p = 0.003). Non-long stayers showed significant improvement 1 month from discharge (β 0.05 [0.00-0.09], p = 0.040). The number of medications and receiving home-care services were the main factors associated with reduced HRQoL. Being home-dwelling was the main factor associated with higher HRQoL. Non-long stayers of the intervention group reported significantly higher EQ-VAS than the control group (β 4.02 [0.11-7.93], p = 0.044).

CONCLUSION

We observed no significant difference in the longitudinal change in HRQoL between the two IMMENSE study groups over 12 months after hospitalization. However, the non-long stayer subgroup analysis indicates that the intervention may have had a long-term effect on HRQoL in some of intervention patients. The number of medications and the ability to live and care for oneself should be taken into consideration when planning future patient care and health-care services.

TRIAL REGISTRATION

The trial was registered in clinicaltrials.gov on 28/06/2016 before enrolment started (NCT02816086).

Barriers and Facilitators of a Community-Based, Slow-Stream Rehabilitation, Hospital-to-Home Transition Program for Older Adults: Perspectives of a Multidisciplinary Care Team

The purpose of this study was to examine the perspectives of support staff, health care professionals, and care coordinators working in or referring to a community-based, slow-stream rehabilitation, hospital-to-home transition program regarding gaps in services, and barriers and facilitators related to implementation and functioning of the program. This was a qualitative descriptive study. Recruitment was conducted through purposive sampling, and 23 individuals participated in a focus groups or individual semi-structured interview. Transcripts were analyzed by six researchers using inductive thematic analysis. Themes that emerged were organized based on a socio-ecological framework. Themes were categorized as: (1) macro level, meaning gaps while waiting for program, limited program capacity, and gaps in service post-program completion; (2) meso level, meaning lack of knowledge and awareness of the program, lack of specific referral process and procedures, lack of specific eligibility criteria, and need for enhanced communication among care settings; or (3) micro level, meaning services provided, program participant benefits, person-centred communication, program structure constraints, need for use of outcome measures, and follow-up or lack of follow-up. Implementation of seamless patient information sharing, documentation, use of specific referral criteria, and use of standardized outcome measures may reduce the number of unsuitable referrals and provide useful information for referral and program staff.

Investigating the effects of frailty on six-month outcomes in older trauma patients admitted to UK major trauma centres: a multi-centre follow up study

BACKGROUND

Pre-injury frailty is associated with adverse in-hospital outcomes in older trauma patients, but the association with longer term survival and recovery is unclear. We aimed to investigate post discharge survival and health-related quality of life (HRQoL) in older frail patients at six months after Major Trauma Centre (MTC) admission.

METHODS

This was a multi-centre study of patients aged ≥ 65 years admitted to five MTCs. Data were collected via questionnaire at hospital discharge and six months later. The primary outcome was patient-reported HRQoL at follow up using Euroqol EQ5D-5 L visual analogue scale (VAS). Secondary outcomes included health status according to EQ5D dimensions and care requirements at follow up. Multivariable linear regression analysis was conducted to evaluate the association between predictor variables and EQ-5D-5 L VAS at follow up.

RESULTS

Fifty-four patients died in the follow up period, of which two-third (64%) had been categorised as frail pre-injury, compared to 21 (16%) of the 133 survivors. There was no difference in self-reported HRQoL between frail and not-frail patients at discharge (Mean EQ-VAS: Frail 55.8 vs. Not-frail 64.1, p = 0.137) however at follow-up HRQoL had improved for the not-frail group but deteriorated for frail patients (Mean EQ-VAS: Frail: 50.0 vs. Not-frail: 65.8, p = 0.009). There was a two-fold increase in poor quality of life at six months (VAS ≤ 50) for frail patients (Frail: 65% vs. Not-frail: 30% p < 0.009). Frailty (β-13.741 [95% CI -25.377, 2.105], p = 0.02), increased age (β -1.064 [95% CI [-1.705, -0.423] p = 0.00) and non-home discharge (β -12.017 [95% CI [118.403, 207.203], p = 0.04) were associated with worse HRQoL at follow up. Requirements for professional carers increased five-fold in frail patients at follow-up (Frail: 25% vs. Not-frail: 4%, p = 0.01).

CONCLUSIONS

Frailty is associated with increased mortality post trauma discharge and frail older trauma survivors had worse HRQoL and increased care needs at six months post-discharge. Pre-injury frailty is a predictor of poor longer-term HRQoL after trauma and recognition should enable early specialist pathways and discharge planning.

Managing health care needs of the elderly through an elderly care manager: Thailand

Background: This mixed method research aimed to investigate health needs of older people and the attributes of the Elderly Care Managers (ECMs), and to evaluate the outcomes of two ECMs coordination. Methods: Three phases were: 1) a field survey of the health needs of 94 older persons; 2) group discussions between ten relevant persons involved in ECMs characteristics; 3) two ECMs coordinating with health-related agencies and measuring the outcomes of older people who needed assistance. Results: 63.1% of the participants had difficulties with their health, 12.8% of them had no caregiver, 26.6% of them had >1 health condition. Group talks dealt with the characteristics, role and attributes of ECMs. The two-month of ECMs coordination with health-related agencies according to older adults' needs, and made home visits encouraged the aged to acquire knowledge on their diseases. Conclusion: ECMs's coordination with health-related agencies could support the needs of those of advanced age.

Measuring What Matters-A Holistic Approach to Measuring Well-Being in Endometriosis

Endometriosis is a common condition which affects women in a number of ways and impairs their ability to live a full and meaningful life. Evaluative research has traditionally taken its cue from a medical approach which has forced women to choose one area of functioning as their primary concern, and tended to use a narrow definition of treatment success which ignores general well-being. While recent trials have included quality of life (QOL) measures as outcomes, these have not been able to capture the totality of the impact of the disease and its treatment on a woman's capability to do what she might want to do and be who she might want to be. A capability approach might overcome this barrier, but the available tools will need to be refined and validated in women with endometriosis before this can be integrated within everyday clinical and research practice.

Evaluating an integrated care pathway for frail elderly patients in Norway using multi-criteria decision analysis

Background

To provide value-based care for patients with multi-morbidity, innovative integrated care programmes and comprehensive evaluations of such programmes are required. In Norway, a new programme called “Holistic Continuity of Patient Care” (HCPC) addresses the issue of multi-morbidity by providing integrated care within learning networks for frail elderly patients who receive municipal home care services or a short-term stay in a nursing home. This study conducts a multi-criteria decision analysis (MCDA) to evaluate whether the HCPC programme performs better on a large set of outcomes corresponding to the ‘triple aim’ compared to usual care.

Methods

Prospective longitudinal survey data were collected at baseline and follow-up after 6-months. The assessment of HCPC was implemented by a novel MCDA framework. The relative weights of importance of the outcomes used in the MCDA were obtained from a discrete choice experiment among five different groups of stakeholders. The performance score was estimated using a quasi-experimental design and linear mixed methods. Performance scores were standardized and multiplied by their weights of importance to obtain the overall MCDA value by stakeholder group.

Results

At baseline in the HCPC and usual care groups, respectively, 120 and 89 patients responded, of whom 87 and 41 responded at follow-up. The average age at baseline was 80.0 years for HCPC and 83.6 for usual care. Matching reduced the standardized differences between the groups for patient background characteristics and outcome variables. The MCDA results indicated that HCPC was preferred to usual care irrespective of stakeholders. The better performance of HCPC was mostly driven by improvements in enjoyment of life, psychological well-being, and social relationships and participation. Results were consistent with sensitivity analyses using Monte Carlo simulation.

Conclusion

Frail elderly with multi-morbidity represent complex health problems at large costs for society in terms of health- and social care. This study is a novel contribution to assessing and understanding HCPC programme performance respecting the multi-dimensionality of desired outcomes. Integrated care programmes like HCPC may improve well-being of patients, be cost-saving, and contribute to the pursuit of evidence based gradual reforms in the care of frail elderly.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06805-6.

Using Patient- and Family-Reported Outcome and Experience Measures Across Transitions of Care for Frail Older Adults Living at Home: A Meta-Narrative Synthesis

BACKGROUND AND OBJECTIVES

Our aim was to create a "storyline" that provides empirical explanation of stakeholders' perspectives underlying the use of patient- and family-reported outcome and experience measures to inform continuity across transitions in care for frail older adults and their family caregivers living at home.

RESEARCH DESIGN AND METHODS

We conducted a meta-narrative synthesis to explore stakeholder perspectives pertaining to use of patient-reported outcome and experience measures (PROMs and PREMs) across micro (patients, family caregivers, and healthcare providers), meso (organizational managers/executives/programs), and macro (decision-/policy-makers) levels in healthcare. Systematic searches identified 9,942 citations of which 40 were included based on full-text screening.

RESULTS

PROMs and PREMS (54 PROMs; 4 PREMs; 1 with PROM and PREM elements; 6 unspecified PROMs) were rarely used to inform continuity across transitions of care and were typically used independently, rarely together (n = 3). Two overarching traditions motivated stakeholders' use. The first significant motivation by diverse stakeholders to use PROMs and PREMs was the desire to restore/support independence and care at home, predominantly at a micro-level. The second motivation to using PROMs and PREMs was to evaluate health services, including cost-effectiveness of programs and hospital discharge (planning); this focus was rarely at a macro-level and more often split between micro- and meso-levels of healthcare.

DISCUSSION AND IMPLICATIONS

The motivations underlying stakeholders' use of these tools were distinct, yet synergistic between the goals of person/family-centered care and healthcare system-level goals aimed at efficient use of health services. There is a missed opportunity here for PROMs and PREMs to be used together to inform continuity across transitions of care.

Factors associated with success in transition care services among older people in Australia

BACKGROUND

The Australian Transition Care Program (TCP) is a national intermediate care service aiming to optimise functional independence and delay entry to permanent care for older people leaving hospital. The aim of this study was to describe the outcomes of TCP and identify demographic and clinical factors associated with TCP 'success', to assist with clinical judgements about suitable candidates for the program.

METHOD

We conducted a descriptive cohort study of all older Australians accessing TCP for the first time between 2007 and 2015. Logistic regression models assessed demographic and clinical factors associated with change in performance on a modified Barthel Index from TCP entry to discharge and on discharge to community. Fine-Gray regression models estimated factors associated with transition to permanent care within 6 months of TCP discharge, with death as a competing event.

RESULTS

Functional independence improved from entry to discharge for 46,712 (38.4%) of 124,301 TCP users. Improvement was more common with younger age, less frailty, shorter hospital stay prior to TCP, and among women, those without a carer, living outside a major city, and without dementia. People who received TCP in a residential setting were far less likely to record improved functional impairment and more likely to be discharged to permanent care than those in a community setting. Discharge to community was more common with younger age and among women and those without dementia. Nearly 12% of community TCP and 63% of residential TCP users had transitioned to permanent care 6 months after discharge. Entry to permanent care was more common with older age, higher levels of frailty, and among those with dementia.

CONCLUSIONS

More than half of TCP users are discharged to home and remain at home after 6 months. However, residential-based TCP may have limited efficacy. Age, frailty, carer status, and dementia are key factors to consider when assessing program suitability. Future studies comparing users to a suitably matched control group will be very helpful for confirming whether the TCP program is meeting its aims.

ICECAP-O, the current state of play: a systematic review of studies reporting the psychometric properties and use of the instrument over the decade since its publication

PURPOSE

A paper reporting the development of the ICECAP-O was published in 2006. Since then, there has been increasing interest in the use of capability-based measures within health economics and the ICECAP-O has been suggested for use in economic evaluation by decision-making bodies in the Netherlands and UK.

METHODS

A systematic review of studies published between January 2006 and October 2018 which have assessed the psychometric properties of ICECAP-O or utilised the measure within economic evaluation.

RESULTS

Twenty-four studies explored the psychometric properties of ICECAP-O and 21 have utilised the measure within economic evaluation; one study reported psychometric properties as well as utilising the measure within economic evaluation. The ICECAP-O has good construct validity and responsiveness, but there is evidence of some issues relating to content validity. In the context of economic evaluation, the ICECAP-O has, to date, mainly been included as a secondary economic measure and the reporting of results is brief with minimal detail and often no discussion. Five of the economic evaluation studies combined scores from ICECAP-O with time, but each used different terminology to describe this result.

CONCLUSION

Focus, in terms of publications, appears to have shifted now from assessment of psychometric properties to the utilisation of the ICECAP-O within economic evaluation. Further research is needed with respect to a decision-rule for the ICECAP measures. This additional research should also guide users in terms of appropriate analysis, terminology and presentation of results, which are in-keeping with the conceptual framework underpinning the ICECAP-O.

Burden of disease, disability-adjusted life years and frailty prevalence

BACKGROUND

Burden of disease (BoD) using disability-adjusted life years (DALY) is a useful summary measure of population health and estimates are provided for Ireland annually. We hypothesized that BoD may be used as a predictor of frailty prevalence.

AIM

To examine the correlation between frailty measured by the accumulation of deficits (frailty index, FI) and Fried frailty phenotype (FFP) classifications and BoD, in an Irish context.

DESIGN

Cross-sectional secondary analysis.

METHODS

Data were obtained from waves two and three of The Survey of Health, Ageing and Retirement in Europe for Irish adults aged ≥65 in 2007. Frailty was defined by a 70-item FI and the FFP. Years lived with disability (YLD), years of life lost (YLL) and DALY were calculated using adapted equations from the World Health Organization and, where possible, disability weights, sequelae and durations as in the Global BoD (GBD) project (2016).

RESULTS

Of 1035 participants, 442 were ≥65 years. Mean DALY were significantly higher in those identified as frail (FI: 3.31, P < 0.0001, n = 406; FFP: 2.46, P = 0.005, n = 319). For the FI, stronger correlation was found for DALY (r = 0.5431, P < 0.0001) than for age (r = 0.275, P < 0.0001). Controlling for confounders, DALY were an independent predictor of frailty when measured with the FI (OR 1.17, 95% CI: 1.10-1.24) but not with the FFP (OR 1.079, 95%% CI 1.00-1.17).

CONCLUSIONS

Frailty correlates significantly with DALY, and more so with the FI than the FFP, reaffirming that these measures are different constructs. GBD data could represent a predictor of population-level frailty estimates, facilitating improved comparisons.

Ageing well: evaluation of social participation and quality of life tools to enhance community aged care (study protocol)

Background

Several outcome measures can be utilised to measure social participation and Quality of Life (QoL) in research and clinical practice. However there have been few large-scale trials of these tools in community care to identify their value to clients and providers. This study aims to evaluate the implementation of the Australian Community Participation Questionnaire (ACPQ) and the ICEpop CAPability measure for Older people (ICECAP-O) as tools to measure social participation and QoL for clients receiving community aged care services. The specific research questions focus on determining: (1) the levels and predictors of social participation and QoL among older adults using community aged care services; (2) the acceptability and feasibility of implementation of ACPQ and ICECAP-O tools into routine community aged care assessments; (3) if implementation of the tools change service provision and outcomes for older adults receiving community aged care services.

Methods

A mixed method design will be used to collect data from a large Australian aged care provider. Community aged care clients’ ACPQ and ICECAP-O scores, as well as other key outcomes (e.g. services used, hospitalisation and admission to permanent residential care), will be examined at baseline and 12-monthly follow-up assessments. Interviews and focus groups with community aged care clients and staff who administer the tools will also be completed. Descriptive statistics and multiple linear regression will be used to examine the levels and predictors of social participation and QoL. Thematic analysis of interviews and focus groups will be used to determine the acceptability and feasibility of implementing the ACPQ and ICECAP-O into routine needs assessments in community aged care. Case-controlled analyses will be used to determine whether the implementation of the ACPQ and ICECAP-O changes service use and outcomes.

Discussion

The novel use of the ACPQ and the ICECAP-O tools as part of routine needs assessments for community aged care clients has the potential to improve the quality and effectiveness of community aged care services and outcomes.

Trial registration

Australian and New Zealand clinical trial registry number: ACTRN12617001212347. Registered 18/08/2017

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1094-2) contains supplementary material, which is available to authorized users.

The (cost-)effectiveness of preventive, integrated care for community-dwelling frail older people: A systematic review

Integrated care is increasingly promoted as an effective and cost-effective way to organise care for community-dwelling frail older people with complex problems but the question remains whether high expectations are justified. Our study aims to systematically review the empirical evidence for the effectiveness and cost-effectiveness of preventive, integrated care for community-dwelling frail older people and close attention is paid to the elements and levels of integration of the interventions. We searched nine databases for eligible studies until May 2016 with a comparison group and reporting at least one outcome regarding effectiveness or cost-effectiveness. We identified 2,998 unique records and, after exclusions, selected 46 studies on 29 interventions. We assessed the quality of the included studies with the Effective Practice and Organization of Care risk-of-bias tool. The interventions were described following Rainbow Model of Integrated Care framework by Valentijn. Our systematic review reveals that the majority of the reported outcomes in the studies on preventive, integrated care show no effects. In terms of health outcomes, effectiveness is demonstrated most often for seldom-reported outcomes such as well-being. Outcomes regarding informal caregivers and professionals are rarely considered and negligible. Most promising are the care process outcomes that did improve for preventive, integrated care interventions as compared to usual care. Healthcare utilisation was the most reported outcome but we found mixed results. Evidence for cost-effectiveness is limited. High expectations should be tempered given this limited and fragmented evidence for the effectiveness and cost-effectiveness of preventive, integrated care for frail older people. Future research should focus on unravelling the heterogeneity of frailty and on exploring what outcomes among frail older people may realistically be expected.

Resilience, health perceptions, (QOL), stressors, and hospital admissions-Observations from the real world of clinical care of unstable health journeys in Monash Watch (MW), Victoria, Australia

RATIONALE, AIMS, AND OBJECTIVES

Monash Watch (MW) aims to reduce potentially preventable hospitalisations in a cohort above a risk "threshold" identified by Health Links Chronic Care (HLCC) algorithms using personal, diagnostic, and service data. MW conducted regular patient monitoring through outbound phone calls using the Patient Journey Record System (PaJR). PaJR alerts are intended to act as a self-reported barometer of stressors, resilience, and health perceptions with more alerts per call indicating greater risk.

AIMS

To describe predictors of PaJR alerts (self-reported from outbound phone calls) and predictors of acute admissions based upon a Theoretical Model for Static and Dynamic Indicators of Acute Admissions.

METHODS

Participants: HLCC cohort with predicted 3+ admissions/year in MW service arm for >40 days; n = 244. Baseline measures-Clinical Frailty Index (CFI); Connor Davis Resilience (CD-RISC): SF-12v2 Health Survey scores Mental (MSC) and Physical (PSC) and ICECAP-O. Dynamic measures: PaJR alerts/call in 10 869 MW records. Acute (non-surgical) admissions from Victorian Admitted Episode database.

ANALYSIS

Logistic regression, correlations, and timeseries homogeneity metrics using XLSTAT.

FINDINGS

Baseline indicators were significantly correlated except SF-12_MCS. SF12-MSC, SF12-PSC and ICECAP-O best predicted PaJR alerts/call (ROC: 0.84). CFI best predicted acute admissions (ROC: 0.66), adding CD-RISC, SF-12_MCS, SF-12_PCS and ICECAP-O with two-way interactions improved model (ROC: 0.70). PaJR alerts were higher ≤10 days preceding acute admissions and significantly correlated with admissions. Patterns in PaJR alerts in four case studies demonstrated dynamic variations signifying risk. Overall, all baseline indicators were explanatory supporting the theoretical model. Timing of PaJR alerts and acute admissions reflecting changing stressors, resilience, and health perceptions were not predicted from baseline indicators but provided a trigger for service interventions.

CONCLUSION

Both static and dynamic indicators representing stressors, resilience, and health perceptions have the potential to inform threshold models of admission risk in ways that could be clinically useful.

Quality of life in older adults following a hip fracture: an empirical comparison of the ICECAP-O and the EQ-5D-3 L instruments

Background

The purpose of this study was to empirically compare the performance of two generic preference based quality of life instruments, EQ-5D-3 L (with a health and physical function focus) and ICECAP-O (with a wellbeing and capability focus), in a population of older Australians following hip fracture.

Methods

Older adults or their family member proxies (in cases of severe cognitive impairment) following surgery to repair a fractured hip were invited to take part in this cross sectional study. Inclusion criteria included an age of 60 years or older, confirmed falls-related hip fracture and those receiving current palliative care or consented to other research studies were excluded. 87 participants completed the ICECAP-O and EQ-5D-3 L instruments between one and three weeks post-surgery.

Results

For the hip fracture population, the mean ICECAP-O score was 0.639 (SD 0.206, n = 82) and the mean EQ-5D-3 L utility score was 0.545 (SD 0.251, n = 87). There was a statistically significant positive correlation between the ICECAP-O and EQ-5D-3 L scores (r = 0.529, p = < 0.001).

Conclusions

Study findings indicate significant impairments in quality of life post hip fracture. In multiple regression analyses, age and health-related QoL (measured by the EQ-5D) were significant determinants of ICECAP-O scores, while proxy respondent status, age, and capability-related QoL (measured by the ICECAP-O) were significant determinants of EQ-5D scores. Approaches to measuring and valuing quality of life in this sample, should consider the target domains of the intervention in their choice of instrument. Studies aiming to measure the impact of interventions targeting broader domains of wellbeing and QoL should consider including a broader measure of QoL in conjunction with a HRQoL measure.

The Australian Aged Care and Its Implications for the Korean Aging Crisis

The Australian aged care system has evolved for >50 years to support frail older adults and allow them to make informed decisions about their care. Hospitals provide streamlined geriatric services from visits at the Emergency Department to discharges from acute and subacute geriatric care units. Moreover, nonhospital aged care services, including Transition Care Program, Commonwealth Home Support Program, Home Care Packages Program, and Residential Care (nursing home) are provided under the auspices of the Australian Government. These various specialized hospital and nonhospital services are integrated and coordinated by the multidisciplinary assessment team called ACAT (Aged Care Assessment Team). Korea does not have a similar amount of time to prepare a well-organized aged care system because of a rapidly increasing older population. The Korean government and aged care experts should exert vigorous efforts to improve the last journeys of the Korean older population.

Quality of life and psychological consequences in elderly patients after a hip fracture: a review

Fractures due to fragility of the bone around the hip joint have become a major public health issue, presenting with an increasing incidence due to the growth of the elderly population. The purpose of this review was to evaluate the impact of hip fractures on the quality of life (QoL), health status (HS), functioning, and psychological parameters, and factors influencing the outcome and the appropriate interventions for improvement of elderly patients. A systematic electronic search of the relevant literature was carried out using the CINAHL, Cochrane, EMBASE, Medline (OvidSP), and PubMed databases spanning the time period from their establishment up to January 2017. Forty-nine randomized controlled trials or prospective cohort studies reporting the QoL and psychological outcomes were assessed by using standardized questionnaires. Patients with a hip fracture who were older than 65 years, were included in the analysis. In the majority of elderly patients, the hip fracture seriously affected physical and mental functioning and exerted a severe impact on their HS and health-related QoL (HRQoL). Moreover, most of the patients did not return to prefracture levels of performance regarding both the parameters. The levels of mental, physical, and nutritional status, prior to the fracture, comorbidity, and female gender, in addition to the postoperative pain, complications, and the length of hospital stay, were the factors associated with the outcome. Psychosocial factors and symptoms of depression could increase pain severity and emotional distress. For the displaced femoral neck fractures, the treatment with total hip arthroplasty or hemiarthroplasty, when compared to the treatment with internal fixation, provided a better functional outcome. Supportive rehabilitation programs, complemented by psychotherapy and nutritional supplementation prior to and after surgery, provided beneficial effects on the HS and the psychosocial dimension of the more debilitated patients’ lives. Lack of consensus concerning the most appropriate HRQoL questionnaires to screen and identify those patients with more difficulties in the psychosocial functions, demonstrates the necessity for further research to assess the newer outcome measurement tools, which might improve our understanding for better care of patients with hip fractures.

Functioning and quality of life in Dutch oldest old with diverse levels of dependency

BACKGROUND

Frequently, a questionnaire like the EQ-5D is applied to investigate elderly health-related quality of life (HRQoL), but current literature suggests that inputs that go beyond these traditional health aspects might be of importance. The capability approach is a different method, which integrates several non-health-related factors to define the well-being of the oldest old.

OBJECTIVE

We propose to investigate the differences in oldest old functionings and quality of life (QoL), given different levels of dependency, using both a utility-based (EQ-5D+C) and capability-based (Currently Achieved Functioning) questionnaire.

METHODS

We interviewed 99 Dutch elderly, living in the Groningen, Veendam, and Hoogeveen areas. The average age of the elderly was 80 years, who were living independently, still looking after themselves; living semi-dependently with moderate care; or living in a nursing home requiring consistent care.

RESULTS

The utility score for the dependent group is the lowest of all three groups, across the diseases investigated in this study. The respective average utility scores calculated for the dependent, semi-dependent, and independent subgroups were 0.56 (SD ±0.10); 0.84 (SD ±0.11), and 0.69 (SD ±0.13). Mobility and pain were reported to be the major domains where problems appeared across the three groups. Additionally, dependent elderly experience deficits in the role and control functionings while the other two subgroups experience deficits in pleasure and security.

CONCLUSION

The results suggest that it is important to take note of the achievability of functionings and HRQoL, in addition to care dependency, to obtain QoL and well-being outcomes of the oldest old.

Psychometric validation of a multi-dimensional capability instrument for outcome measurement in mental health research (OxCAP-MH)

BACKGROUND

Patient reported outcome measures (PROMs) are widely used in mental healthcare research for quality of life assessment but most fail to capture the breadth of health and non-health domains that can be impacted. We report the psychometric validation of a novel, multi-dimensional instrument based on Amartya Sen's capability approach intended for use as an outcome measure in mental health research.

METHODS

The Oxford Capabilities Questionnaire for Mental Health (OxCAP-MH) is a 16-item self-complete capability measure that covers multiple domains of functioning and welfare. Data for validation of the instrument were collected through a national randomised controlled trial of community treatment orders for patients with psychosis. Complete OxCAP-MH data were available for 172 participants. Internal consistency was established with Cronbach's alpha; an interclass correlation coefficient was used to assess test-retest reliability in a sub-sample (N = 50) tested one week apart. Construct validity was established by comparing OxCAP-MH total scores with established instruments of illness severity and functioning: EuroQol (EQ-5D), Brief Psychiatric Rating Scale (BPRS), Global Assessment of Functioning (GAF) and Objective Social Outcomes Index (SIX). Sensitivity was established by calculating standard error of measurement using distributional methods.

RESULTS

The OxCAP-MH showed good internal consistency (Cronbach's alpha 0.79) and test-retest reliability (ICC = 0.86). Convergent validity was evidenced by strong correlations with the EQ-5D (VAS 0.52, p < .001) (Utility 0.45, p < .001), and divergent validity through more modest associations with the BPRS (-0.41, p < .001), GAF (0.24, p < .001) and SIX (0.12, p = ns). A change of 9.2 points on a 0-100 scale was found to be meaningful on statistical grounds.

CONCLUSIONS

The OxCAP-MH has demonstrable reliability and construct validity and represents a promising multi-dimensional alternative to existing patient-reported outcome measures for quality of life used in mental health research.

Addressing the Needs of an Aging Population in the Health System: The Australian Case

Although smaller as a proportion of total population than Western Europe or Japan, almost 15% of Australia's population is aged 65 years and over and expected to increase to nearly 22.5% by 2050. Health policy makers in Australia have tried multiple approaches to address the growing health care needs of an aging population and the related burden of noncommunicable conditions (NCDs). We assess how these interventions-in primary care, hospital services and private health insurance-have influenced outcomes and draw inferences from their successes and some of their main difficulties. Among the key lessons from the Australian experience, also relevant for the Asia Pacific region, are the challenge of aligning financial incentives in a mixed public-private health care and financing system and the difficulty of reforming a medically-centered primary care model to one that integrates care across a range of dimensions, including the services of allied health professionals and long-term care services. The clearest specific policy lessons for the region include the suggestions that public subsidy of private health insurance is unlikely to be an efficient approach to reducing the health-related cost burdens of aging populations, and that countries should build alternatives to fee-for-service payment mechanisms into their plans for achieving Universal Health Coverage. Australians might look to the experience of other countries in the region for additional models of coordination between national government and sub-national divisions and for approaches to reducing the disadvantages faced by minority groups in the health system.

Why older adults may decline offers of post-acute care services: A qualitative descriptive study

The most common post-acute care (PAC) services available to patients after hospital discharge include home care, skilled nursing facilities, nursing homes, inpatient rehabilitation, and hospice. Patients who need PAC and receive services have better outcomes, however almost one-third of those offered services decline. Little research exists on PAC decision-making and why patients may decline services. This qualitative descriptive study explored the responses of thirty older adults to the question: "Can you, from the patient point of view, tell me why someone would not want post hospital care?" Three themes emerged. Participants may decline due to 1) previous negative experiences with PAC, or 2) a preference to be home. Some participants stated, "I'd be there" and would not decline services. Participants also discussed 3) why other patients might decline PAC which included patients' past experiences, lack of understanding/preconceived ideas, and preferences. Clinical implications include assessing patients' knowledge and experience before providing recommendations.

Comparison of the HUI3 and the EQ-5D-3L in a nursing home setting

BACKGROUND

Accurately assessing changes in the quality of life of older people living permanently in nursing homes is important. The multi-attribute utility instrument most commonly used and recommended to assess health-related quality of life in the nursing home population is the three-level EuroQol EQ-5D-3L. To date, there have been no studies using the Health Utilities Index Mark III (HUI3). The purpose of this study was to compare the level of agreement and sensitivity to change of the EQ-5D-3L and HUI3 in a nursing home population.

METHODS

EQ-5D-3L and HUI3 scores were measured as part of a cluster randomised controlled trial of nurse led care coordination in a nursing home population in Perth, Western Australia at baseline and 6-month follow up.

RESULTS

Both measures were completed for 199 residents at baseline and 177 at 6-month follow-up. Mean baseline utility scores for EQ-5D-3L (0.45; 95% CI 0.41-0.49) and HUI3 (0.15; 95% CI 0.10-0.20) were significantly different (Wilcoxon signed rank test, p<0.01) and agreement was poor to moderate between absolute scores from each instrument (intra-class correlation coefficient = 0.63). The EQ-5D-3L appeared more sensitive to change over the 6-month period.

CONCLUSION

Our findings show that the EQ-5D-3L and HUI3 estimate different utility scores among nursing home residents. These differences should be taken into account, particularly when considering the implications of the cost-effectiveness of particular interventions and we conclude that the HUI3 is no better suited to measuring health-related quality of life in a nursing home population when compared to the EQ-5D-3L.

The development of capability measures in health economics: opportunities, challenges and progress

Recent years have seen increased engagement amongst health economists with the capability approach developed by Amartya Sen and others. This paper focuses on the capability approach in relation to the evaluative space used for analysis within health economics. It considers the opportunities that the capability approach offers in extending this space, but also the methodological challenges associated with moving from the theoretical concepts to practical empirical applications. The paper then examines three 'families' of measures, Oxford Capability instruments (OxCap), Adult Social Care Outcome Toolkit (ASCOT) and ICEpop CAPability (ICECAP), in terms of the methodological choices made in each case. The paper concludes by discussing some of the broader issues involved in making use of the capability approach in health economics. It also suggests that continued exploration of the impact of different methodological choices will be important in moving forward.

Quality of life after hip fracture in the elderly: A systematic literature review

BACKGROUND

With an increasing ageing population, hip fractures have become a major public health issue in the elderly. It is important to examine the health status (HS) and health-related quality of life (HRQOL) of the elderly faced with the epidemic of hip fractures.

OBJECTIVE

To provide an overview of reported HS and HRQOL in elderly patients with a hip fracture.

DESIGN

A systematic literature search was performed in Embase, Medline, Web of Science, Scopus, CINAHL, Cochrane, PsycINFO, Pubmed, and Google Scholar in July 2014. Studies which reported the HS or HRQOL based on standardised questionnaires in patients older than 65 years with a hip fracture were considered eligible for inclusion.

RESULTS

After inspecting the 2725 potentially eligible studies, 49 fulfilled the inclusion criteria. All included studies were randomised controlled trials or prospective cohort studies. The methodological quality of the studies was moderate. Patients' functioning on the physical, social, and emotional domains were affected after a hip fracture. The HS and HRQOL of the majority of patients recovered in the first 6 months after fracture. However, their HS did not return to prefracture level. Mental state, prefracture functioning on physical and psychosocial domains, comorbidity, female gender, nutritional status, postoperative pain, length of hospital stay, and complications were factors associated with HS or HRQOL. Treatment with total hip arthroplasty or hemi-arthroplasty provided better HS than treatment with internal fixation with displaced femoral neck fractures. Supportive psychotherapy in "low-functioning" patients, (home) rehabilitation programmes and nutritional supplementation appeared to have beneficial effects on HS.

CONCLUSIONS

Optimizing nutrition intake, (home) rehabilitation programmes, and the possibility for psychological counselling in patients with difficulties in the psychosocial dimensions would be recommended after hip fracture surgery. Besides HS questionnaires like EQ-5D and SF-36, adequate measurements like the WHOQOL-Bref or ICECAP-O are warranted in future studies regarding hip fracture surgery and postoperative treatment options.

Healthcare resource use in patients of the Australian Transition Care Program

OBJECTIVE

The aim of the present study was to describe, from the perspective of the healthcare funder, the cost components of the Australian Transition Care Program (TCP) and the healthcare resource use and costs for a group of transition care clients over a 6-month period following admission to the program.

METHODS

A prospective cohort observational study of 351 consenting patients entering community-based transition care at six sites in two states in Australia from November 2009 to September 2010 was performed. Patients were followed up 6 months after admission to the TCP to ascertain current living status and hospital re-admissions over the follow-up period. Cost data were collected by transition care teams and from administrative data (hospital and Medicare records).

RESULTS

The TCP provides a range of services with most costs attributed to provision of personal care support, case management, physiotherapy and occupational therapy. Most healthcare costs up to 6 months after transition care admission were incurred from the hospital admission leading to transition care and from re-admissions. Orthopaedic conditions incurred the highest costs, with many of these for elective procedures and others resulting from falls. Hospital re-admission rates in the present study were 10% lower than in a previous evaluation ofthe TCP. Over 6 months, approximately 40% of patients in the study were re-admitted to hospital at an average cost of A$7038.

CONCLUSIONS

Although the cost of the TCP is relatively high, it may have some impact on reducing hospital re-admissions and preventing or delaying residential care admissions.

Developing an Australian health and aged care research agenda: a systematic review of evidence at the subacute interface

Objective The aim of the present study was to systematically review articles describing recent interventions that aimed to improve access and outcomes for older people at the interface between health and aged care, with a focus on subacute care programs of palliative care, rehabilitation, geriatric evaluation and management (GEM) and psychogeriatrics. Methods Australian studies published between 2008 and 2013were evaluated using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and National Health and Medical Research Council of Australia (NHMRC) guidelines. Included studies were summarised according to focus areas and results discussed in the current Australian subacute health care context. Results Eleven Australian research articles were identified. Three did not achieve any NHMRC rating level because of methodological approach. Focus areas included: discharge planning; information management or communication; rehabilitation; hospital treatment in residential care; screening and intervention; and Telehealth. Interventions were primarily system centred; only three studies featured patient-level outcome measures. Conclusions There is limited high-quality research investigating the effectiveness of interventions at the health and aged care interface of subacute care. Further research is needed. What is known about the topic? Subacute care offers important healthcare programs for older people, operating at the interface between health and aged care. However, for the most part this has not been subject to research scrutiny. What does this paper add? Identified studies were predominantly hospital oriented and designed to avoid hospital admission and associated costs. Locally integrated, collaborative and multidiscipline based interventions improve system-level outcomes. Alternative and individualised models of care, particularly when provided in their home setting, yields positive outcomes for older people. What are the implications for practitioners? Health and aged care reforms and related research agenda must include the perspectives and experiences of patients and/or carers accessing subacute care programs, yet these are under-reported. The present review highlights opportunities to improve the quality of existing evidence and create a research agenda for the future.

The Relative Impacts of Disease on Health Status and Capability Wellbeing: A Multi-Country Study

BACKGROUND

Evaluations of the impact of interventions for resource allocation purposes commonly focus on health status. There is, however, also concern about broader impacts on wellbeing and, increasingly, on a person's capability. This study aims to compare the impact on health status and capability of seven major health conditions, and highlight differences in treatment priorities when outcomes are measured by capability as opposed to health status.

METHODS

The study was a cross-sectional four country survey (n = 6650) of eight population groups: seven disease groups with: arthritis, asthma, cancer, depression, diabetes, hearing loss, and heart disease and one health population 'comparator' group. Two simple self-complete questionnaires were used to measure health status (EQ-5D-5L) and capability (ICECAP-A). Individuals were classified by illness severity using condition-specific questionnaires. Effect sizes were used to estimate: (i) the difference in health status and capability for those with conditions, relative to a healthy population; and (ii) the impact of the severity of the condition on health status and capability within each disease group.

FINDINGS

5248 individuals were included in the analysis. Individuals with depression have the greatest mean reduction in both health (effect size, 1.26) and capability (1.22) compared to the healthy population. The effect sizes for capability for depression are much greater than for all other conditions, which is not the case for health. For example, the arthritis group effect size for health (1.24) is also high and similar to that of depression, whereas for the same arthritis group, the effect size for capability is much lower than that for depression (0.55). In terms of severity within disease groups, individuals categorised as 'mild' have similar capability levels to the healthy population (effect sizes <0.2, excluding depression) but lower health status than the healthy population (≥0.4).

CONCLUSION

Significant differences exist in the relative effect sizes across diseases when measured by health status and capability. In terms of treating morbidity, a shift in focus from health gain to capability gain would increase funding priorities for patients with depression specifically and severe illnesses more generally.

A systematic review of instruments for measuring outcomes in economic evaluation within aged care

BACKGROUND

This paper describes the methods and results of a systematic review to identify instruments used to measure quality of life outcomes in older people. The primary focus of the review was to identify instruments suitable for application with older people within economic evaluations conducted in the aged care sector.

METHODS

Online databases searched were PubMed, Medline, Scopus, and Web of Science, PsycInfo, CINAHL, Embase and Informit. Studies that met the following criteria were included: 1) study population exclusively above 65 years of age 2) measured health status, health related quality of life or quality of life outcomes more broadly through use of an instrument developed for this purpose, 3) used a generic preference based instrument or an older person specific preference based or non-preference based instrument or both, and 4) published in journals in the English language after 2000.

RESULTS

The most commonly applied generic preference based instrument in both the community and residential aged care context was the EuroQol - 5 Dimensions (EQ-5D), followed by the Adult Social Care Outcomes Toolkit (ASCOT) and the Health Utilities Index (HUI2/3). The most widely applied older person specific instrument was the ICEpop CAPability measure for Older people (ICECAP-O) in both community and residential aged care.

CONCLUSION

In the absence of an ideal instrument for incorporating into economic evaluations in the aged care sector, this review recommends the use of a generic preference based measure of health related quality of life such as the EQ-5D to obtain quality adjusted life years, in combination with an instrument that has a broader quality of life focus like the ASCOT, which was designed specifically for evaluating interventions in social care or the ICECAP-O, a capability measure for older people.

Assessing sufficient capability: A new approach to economic evaluation

Amartya Sen's capability approach has been discussed widely in the health economics discipline. Although measures have been developed to assess capability in economic evaluation, there has been much less attention paid to the decision rules that might be applied alongside. Here, new methods, drawing on the multidimensional poverty and health economics literature, are developed for conducting economic evaluation within the capability approach and focusing on an objective of achieving "sufficient capability". This objective more closely reflects the concern with equity that pervades the capability approach and the method has the advantage of retaining the longitudinal aspect of estimating outcome that is associated with quality-adjusted life years (QALYs), whilst also drawing on notions of shortfall associated with assessments of poverty. Economic evaluation from this perspective is illustrated in an osteoarthritis patient group undergoing joint replacement, with capability wellbeing assessed using ICECAP-O. Recommendations for taking the sufficient capability approach forward are provided.

Cost-effectiveness of integrated care in frail elderly using the ICECAP-O and EQ-5D: does choice of instrument matter?

Economic evaluations likely undervalue the benefits of interventions in populations receiving both health and social services, such as frail elderly, by measuring only health-related quality of life. For this reason, alternative preference-based instruments have been developed for economic evaluations in the elderly, such as the ICECAP-O. The aim of this paper is twofold: (1) to evaluate the cost-effectiveness using a short run time frame for an integrated care model for frail elderly, and (2) to investigate whether using a broader measure of (capability) wellbeing in an economic evaluation leads to a different outcome in terms of cost-effectiveness. We performed univariate and multivariate analyses on costs and outcomes separately. We also performed incremental net monetary benefit regressions using quality adjusted life years (QALYs) based on the ICECAP-O and EQ-5D. In terms of QALYs as measured with the EQ-5D and the ICECAP-O, there were small and insignificant differences between the instruments, due to negligible effect size. Therefore, widespread implementation of the Walcheren integrated care model would be premature based on these results. All results suggest that, using the ICECAP-O, the intervention has a higher probability of cost-effectiveness than with the EQ-5D at the same level of WTP. In case an intervention's health and wellbeing effects are not significant, as in this study, using the ICECAP-O will not lead to a false claim of cost-effectiveness of the intervention. On the other hand, if differences in capability QALYs are meaningful and significant, the ICECAP-O may have the potential to measure broader outcomes and be more sensitive to differences between intervention and comparators.

Mobility Is a Key Predictor of Change in Well-Being Among Older Adults Who Experience Falls: Evidence From the Vancouver Falls Prevention Clinic Cohort

OBJECTIVE

To determine the factors that predict change in well-being over time in older men and women presenting to the falls prevention clinic.

DESIGN

Prospective cohort study.

SETTING

Falls prevention clinic.

PARTICIPANTS

Community-dwelling older adults who were referred to the clinic after sustaining a fall (between N=244 and N=255, depending on the analysis).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The ICEpop CAPability measure for Older people, a measure of well-being or quality of life, was administered at baseline, 6 months, and 12 months. We constructed linear mixed models to determine whether baseline predictor variables were related to baseline well-being and/or changes in well-being over time. In addition, we included interactions with sex to investigate the difference between men and women. Baseline predictors included 2 measures of mobility--Short Performance Physical Battery and timed Up and Go test--and a measure of global cognitive function--Montreal Cognitive Assessment.

RESULTS

All 3 predictors were associated with well-being at baseline (P<.05). Furthermore, both the Short Performance Physical Battery and the timed Up and Go test interacted with sex (P<.05) to predict changes in well-being over time. Follow-up analyses suggested that better mobility was protective against decline in well-being in men but was generally unrelated to changes in well-being in women.

CONCLUSIONS

We found that 2 valid and reliable measures of mobility interacted with sex to predict changes in well-being over time. This is a critical research area to develop in order to appropriately tailor future intervention strategies targeting well-being in older fallers, a population at high risk of functional decline.

Comparing measurement properties of the EQ-5D-3L, ICECAP-O, and ASCOT in frail older adults

BACKGROUND

The ICEpop CAPability measure for Older people (ICECAP-O) and the Adult Social Care Outcomes Toolkit (ASCOT) are preference-based measures for assessing quality of life (QOL) from a broader perspective than do traditional health-related QOL measures such as the EuroQol five-dimensional questionnaire (EQ-5D). Measurement properties of these instruments have not yet been directly compared.

OBJECTIVE

The purpose of this study was to compare the test-retest reliability, construct validity, and responsiveness of the three-level EQ-5D (EQ-5D-3L), ICECAP-O, and ASCOT in frail older adults living at home.

METHODS

Cross-sectional data and longitudinal data were used. Parameters for reliability (the intraclass correlation coefficient) and agreement (standard error of measurement) were used to assess test-retest reliability after 1 week. We formulated hypotheses about correlations with other measures and tested these to assess construct validity and responsiveness (longitudinal validity).

RESULTS

The reliability parameters for all three scales were considered good (intraclass correlation coefficient values above 0.70). Standard error of measurement values were less than 10% of the scale. Hypotheses regarding construct validity were in general accepted; the EQ-5D-3L was more strongly associated with physical limitations than were ICECAP-O and ASCOT and less strongly with instruments measuring aspects beyond health. Longitudinally, as hypothesized, mental health was most strongly associated with ICECAP-O, and self-perceived QOL, mastery, and client-centeredness of home care most strongly with ASCOT.

CONCLUSIONS

Our findings support the adoption of ICECAP-O and ASCOT as outcome measures in economic evaluations of care interventions for older adults that have a broader aim than health-related QOL because they are at least as reliable as the EQ-5D-3L and are associated with aspects of QOL broader than health.

Quality of life of nursing home residents with dementia: validation of the German version of the ICECAP-O

Objectives

To validate the ICECAP-O capability wellbeing measure’s German translation in older people with dementia living in a nursing home, and to investigate the influence of proxy characteristics on responses.

Method

Cross-sectional study. For 95 residents living in a German nursing home, questionnaires were completed by nursing professionals serving as proxy respondents. We investigated the convergent validity of the ICECAP-O with other Quality of Life (Qol) measures, the EQ-5D extended with a cognitive dimension (EQ-5D+C), the Alzheimer’s Disease Related Quality of Life (ADRQL) measures, and the Barthel-index measure of Activities of Daily Living (ADL). Discriminant validity was investigated using bivariate and multivariate stepwise regression analysis, comparing ICECAP-O scores between subgroups varying in dementia severity, care dependency, ADL status and demographic characteristics.

Results

Convergent validity between the ICECAP-O, EQ-5D+C, ADRQL and Barthel-Index scores was moderate to good (with correlations of 0.72, 0.69 and 0.53 respectively), but differed considerably between dimensions of the instruments. Discriminant validity was confirmed by finding differences in ICECAP-O scores between subgroups based on ADL scores (0.58 below 65 points on the Barthel-index and 0.80 above 65 points) and other characteristics. The ICECAP-O scores based on available tariffs were related to proxy characteristics gender (0.52 males versus 0.65 females) and work experience (0.61 below 2 years of experience versus 0.68 above 2 years).

Discussion

The results of this study suggest that the ICECAP-O is a promising generic measure for general Qol and capability of people with dementia living in a nursing home. Validity tests generally yielded favorable results. Work experience and gender appeared to influence proxy response, which raises questions regarding appropriate proxies, especially since the ICECAP-O may be completed by proxies relatively often. Further research is necessary to validate the German version of the ICECAP-O, with specific attention to proxy completion for people with dementia.

Quality of life instruments for economic evaluations in health and social care for older people: a systematic review

Gaining health may not be the main goal of healthcare services aimed at older people, which may (also) seek to improve wellbeing. This emphasizes the need of finding appropriate outcome measures for economic evaluation of such services, particularly in long-term care, capturing more than only health-related quality of life (HrQol). This review assesses the usefulness of HrQol and wellbeing instruments for economic evaluations specifically aimed at older people, focusing on generic and preference-based questionnaires measuring wellbeing in particular. We systematically searched six databases and extracted instruments used to assess HrQol and wellbeing outcomes. Instruments were compared based on their usefulness for economic evaluation of services aimed at older people (dimensions measured, availability of utility scores, extent of validation). We identified 487 articles using 34 generic instruments: 22 wellbeing (two of which were preference-based) and 11 HrQol instruments. While standard HrQol instruments measure physical, social and psychological dimensions, wellbeing instruments contain additional dimensions such as purpose in life and achievement, security, and freedom. We found four promising wellbeing instruments for inclusion in economic evaluation: Ferrans and Powers QLI and the WHO-Qol OLD, ICECAP-O and the ASCOT. Ferrans and Powers QLI and the WHO-Qol OLD are widely validated but lack preference-weights while for ICECAP-O and the ASCOT preference-weights are available, but are less widely validated. Until preference-weights are available for the first two instruments, the ICECAP-O and the ASCOT currently appear to be the most useful instruments for economic evaluations in services aimed at older people. Their limitations are that (1) health dimensions may be captured only partially and (2) the instruments require further validation. Therefore, we currently recommend using the ICECAP-O or the ASCOT alongside the EQ-5D or SF-6D when evaluating interventions aimed at older people.