Quality of primary care delivery and productive interactions among community-living frail older persons and their general practitioners and practice nurses

Transmural collaborative care model for cardiovascular risk management and medication review in patients using antipsychotics in primary care (TACTIC): A study protocol of an incomplete stepped wedge cluster randomized trial

Background

It is well established that patients with severe mental illness and those treated with atypical antipsychotics (AAPs) are at an increased risk of cardiovascular disease. However, primary care currently lacks adequate monitoring of AAP usage, its effects, and the associated cardiovascular risk. We have developed TACTIC, a transmural collaborative care model for patients using AAPs prescribed by the general practitioner (GP) to address the issues of potential overtreatment with AAPs and undertreatment for cardiovascular risk. TACTIC comprises three steps: an informative video for patients, a multidisciplinary meeting, and a shared decision-making consultation with the GP.

Objectives

To evaluate TACTIC's effectiveness on cardiovascular risk and mental health and its cost-effectiveness.

Methods

We will conduct an incomplete stepped wedge cluster randomized trial in the Netherlands.40 GP-nurse clusters are randomized into four waves. Each cluster recruits adult patients (25-85 years), without prior diagnoses of dementia, delirium, or cardiovascular disease, for whom the GP prescribes AAPs. Every five months, a new wave starts with TACTIC. Measurements are taken before the intervention starts and every 5 months until the study concludes. Primary outcomes are cardiovascular risk and mental health as measured with the QRISK3 score and MHI5, respectively. The economic evaluation consists of two cost-utility analyses, one on the data collected alongside the trial and one based on a model extrapolating the trial data to a 10-year horizon. We will also evaluate the process of delivering TACTIC.

Conclusion

This study will assess TACTIC's (cost)effectiveness and provide insights for successful delivery in general practice.

Clinical trials registration

clinicaltrials.gov NCT05647980.

Attributes of family physician encounters valued by older adults: a systematic review

BACKGROUND

Older adults (aged ≥ 65) are frequent users of primary care services, often presenting with unique values, needs, expectations, and preferences for family physician encounters compared to patients of younger ages. This review identified and synthesized the attributes of family physician encounters that older patients prioritize, spanning the time of accessing primary care to post-visit.

METHODS

We conducted a systematic search of three electronic databases (MEDLINE, Ovid Embase, Web of Science) to identify peer-reviewed research articles of any design. Seven reviewers screened and extracted information using a standardized template. We narratively synthesized findings across the included studies. Older adult patient partners provided strategic input throughout the key phases of this review, including developing the research question, literature screening and synthesis, and interpreting the findings to enhance relevance and applicability.

RESULTS

We identified 28,461 articles for screening after duplicate removal. Title and abstract screening resulted in 463 retained articles, with 62 articles included for analysis after full-text screening. We identified six key attributes of family physician encounters that older adults value before, during, and after visits: trust in providers, feeling heard, effective information exchange, affective behaviours, continuity of care (longitudinal relationships), and foresight/future planning.

CONCLUSIONS

Our findings synthesizing international evidence highlight which attributes matter most to older primary care patients as they age and increasingly access family physicians. These attributes can guide primary care planning, organization, and physician education/training to promote high-quality care for older adults.

REGISTRATION

Our systematic review was prospectively registered with PROSPERO (CRD42024555970).

An examination of primary health care nursing service evaluation using the Donabedian model: A systematic review

Nurses are key to the delivery of global primary health care services. However, there appears to be a lack of evaluation of primary health care nursing delivery models in the published literature. This evaluation is vital to the improvement of patient experiences, national and global health outcomes, and the justification of future investment in primary health care nursing services. The purpose of this review was to explore and analyze the literature that reports on the evaluation of primary health care nursing services, to ascertain the nature and utility of these evaluation methods, and identify opportunities for future research in this area. A systematic review of the published literature was conducted following PRISMA guidelines, using the databases CINAHL, Joanna Briggs Institute, MEDLINE, and Proquest. Thirty-two articles published between 2010 and 2022 were selected. Results were organized using the Donabedian model. A paucity of research into the evaluation of nurse-led primary health care services was noted. Where evident, evaluation of primary health care nursing services tended to reflect the medical model. Medical outcomes measures dominated evaluation criteria including diagnosis rates, prescription costs, and disease outcomes. Primary health care principles such as service accessibility, cultural appropriateness, and availability were rarely used. The perspectives and experiences of nurses were not sought in service evaluation, including most of the nurse-led services. Development of an evidence-base of nursing primary health care services that are informed by the nursing experience and apply a framework of universal primary health care principles across the structure, process, and outcomes aspects of the service is recommended.

Understanding the implementation of interventions to improve the management of frailty in primary care: a rapid realist review

OBJECTIVE

Identifying and managing the needs of frail people in the community is an increasing priority for policy makers. We sought to identify factors that enable or constrain the implementation of interventions for frail older persons in primary care.

DESIGN

A rapid realist review.

DATA SOURCES

Cochrane Library, SCOPUS and EMBASE, and grey literature. The search was conducted in September 2019 and rerun on 8 January 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We considered all types of empirical studies describing interventions targeting frailty in primary care.

ANALYSIS

We followed the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and publication criteria for our synthesis to systematically analyse and synthesise the existing literature and to identify (intervention-context-mechanism-outcome) configurations. We used normalisation processes theory to illuminate mechanisms surrounding implementation.

RESULTS

Our primary research returned 1755 articles, narrowed down to 29 relevant frailty intervention studies conducted in primary care. Our review identified two families of interventions. They comprised: (1) interventions aimed at the comprehensive assessment and management of frailty needs; and (2) interventions targeting specific frailty needs. Key factors that facilitate or inhibit the translation of frailty interventions into practice related to the distribution of resources; patient engagement and professional skill sets to address identified need.

CONCLUSION

There remain challenges to achieving successful implementation of frailty interventions in primary care. There were a key learning points under each family. First, targeted allocation of resources to address specific needs allows a greater alignment of skill sets and reduces overassessment of frail individuals. Second, earlier patient involvement may also improve intervention implementation and adherence.

PROSPERO REGISTRATION NUMBER

The published protocol for the review is registered with PROSPERO (CRD42019161193).

Generalist-Specialist Collaboration in Primary Care for Frail Older Persons: A Promising Model for the Future

OBJECTIVES

The complex care needs of frail older persons living at home is a major challenge for health care systems worldwide. One possible solution is to employ a primary care physician (PCP) with additional geriatric expertise. In the Netherlands, elderly care physicians (ECPs), who traditionally work in nursing homes, are increasingly encouraged to utilize their expertise within primary care. However, little is known about how PCPs and ECPs collaborate. Therefore, we aimed to unravel the nature of the current PCP-ECP collaboration in primary care for frail older persons, and to identify key concepts for success.

DESIGN

A qualitative multiple case study with semistructured interviews.

SETTING AND PARTICIPANTS

A selection of 22 participants from 7 "established collaboration practices" within the primary care setting in the Netherlands, including at least 1 ECP, 1 PCP, and 1 other health care professional for every included established collaboration practice.

METHODS

Transcripts of individual interviews were analyzed using largely double and independent open and axial coding, and formulation of themes and subthemes.

RESULTS

Data analysis revealed 4 key concepts for success: (1) clarification of roles and expectations (ie, patient-centered care and embedding in existing care networks), (2) trust, respect, and familiarity as drivers for collaboration (ie, mutual trust through knowing each other and having shared goals); (3) framework for regular communication (ie, structural meetings and a shared vision); and (4) government, payer, and organization support (ie, financial support and emphasis on the collaboration's urgency by organizations and national policy makers).

CONCLUSIONS AND IMPLICATIONS

For a successful generalist-specialist collaboration, health care professionals need to invest in building relationships and mutual trust, and incorporating their efforts in the existing care networks to guarantee patient-centeredness. When provided with reimbursement and appreciation, this collaboration is a promising change in general practice to improve the care and outcomes of frail older persons.

[Quality of care in family practice and quality of life from the point of view of older patients with gon- and coxosteoarthritis - results from the MobilE-TRA cohort study]

BACKGROUND

A central role in the care of patients with osteoarthritis has the family practice. The aim of this analysis is to assess the association between the quality of family practice care from the osteoarthritis patients' perspectives and their health-related quality of life, disease-specific symptoms, and physical function.

METHOD

111 patients suffering from cox- and/or gonosteoarthritis at the age of 65 or older had been recruited from family practices in Saxony and Bavaria. The participants received a paper-based questionnaire that assessed their sociodemographic data, the patients' level of depression (PHQ-9), physical activity, health-related quality of life (EQ-5D with EQ-VAS), as well as the quality of care in family practice from the patients' perspectives (PACIC short form). Furthermore, disease-specific symptoms (pain, stiffness) and physical function of patients with osteoarthritis were investigated (WOMAC). The analysis was performed with multiple linear regression models.

RESULTS

A greater extent of depression was associated with stronger pain (beta=0,378; 95% CI [0,180; 0,576]), more stiffness of the joints (beta=0,223; 95% CI [0,135; 0,310]), and worse physical function (beta=1,628; 95% CI [0,908; 2,348]). The analysis also showed that older (beta=-0,901; 95% CI [-1,705; -0,097]), more depressive (beta=-1,654; 95% CI [-2,820; -0,488]) osteoarthritis patients were associated with a lower health-related quality of life. A statistically significant association between the quality of family practice care from the patients' perspectives and their health-related quality of life, disease-specific symptoms, and physical function could not be detected.

CONCLUSIONS

Previous literature provides evidence for an association between the quality of care of patients with a chronic illness and their quality of life or other health outcomes. The results of this research work did not align with these findings. Since depression was associated with decreased health-related quality of life and more severe complaints of patients suffering from osteoarthritis, potential depressive comorbidity should not be disregarded in the health care of this patient group and should be treated if necessary.

A cross-sectional study investigating the relationships between self-management abilities, productive patient-professional interactions, and well-being of community-dwelling frail older people

Worldwide, the maintenance of well-being in ageing populations with associated frailty has become increasingly important. To maintain well-being during ageing, investment in frail older people’s self-management abilities and the fostering of productive interactions with healthcare professionals may lead to higher levels of well-being. The aim of this study was to investigate the relationships between community-dwelling frail older people’s self-management abilities, productive patient-professional interactions and well-being, while controlling for socio-demographic characteristics. This cross-sectional study included 588 community-dwelling frail older people (aged ≥ 75 years) from 15 general practitioner (GP) practices in the Netherlands. Well-being (Social Production Function Instrument for the Level of well-being short), productivity of interactions with GPs (relational coproduction instrument), and self-management abilities (Self-Management Ability Scale short) were measured during in-home face-to-face interviews by trained interviewers. Data were analysed using descriptive statistics, correlation analyses, and linear mixed-effects models. Significant relationships were detected between self-management abilities and the overall, social, and physical well-being of older people, and between productive interactions with GPs and overall and social well-being, but not physical well-being. In a time of ageing populations with associated frailty, investment in frail older people’s self-management abilities and the productivity of patient-professional interactions may be beneficial for this population’s well-being.

Co-Production Performance Evaluation in Healthcare. A Systematic Review of Methods, Tools and Metrics

Co-produced practices and publications in the healthcare sector are gaining momentum, since they can be a useful tool in addressing the sustainability and resilience challenges of health systems. However, the investigation of positive and, mainly, negative outcomes is still confused and fragmented, and above all, a comprehensive knowledge of the metrics used to assess these outcomes is lacking. To fill this gap, this study aims to systematically review the extant literature to map the methods, tools and metrics used to empirically evaluate co-production in health services. The search took place in six databases: Scopus, Web of Science, Psych INFO, PubMed, Cochrane and CINAHL. A total of 2311 articles were screened and 203 articles were included in the analysis, according to PRISMA guidelines. Findings show that outcomes are mainly investigated through qualitative methods and from the lay actor or provider perspective. Moreover, the detailed categorisation of the quantitative measures found offers a multidimensional performance measurement system and highlights the impact areas where research is needed to develop and test new measures. Findings should also promote improvements in empirical data collection on the multiple faceted co-produced activities and spur the consciousness of the adoption of sustainable co-productive initiatives.

Care for frail older adults in the community: an integrative review

Abstract Objective: to identify scientific evidence regarding the care of frail older adults in the community, from the perspective of the older adults themselves. Method: a descriptive, integrative review study was performed. The search for articles was carried out in the Medline, Lilacs, Web of Science, Scopus and SciELO databases. The inclusion criteria were complete available articles; published between 2014 and 2019; written in Portuguese, English, Spanish or French; which had older adults as participants. Results: four categories of analysis emerged from the results: frailty from the perspective of frail older adults; priorities from the perspective of the older adults; the older adults’ perspectives on care by services; and interpersonal relationships in the care of frail older adults. The perception of the older adults has specific characteristics, has maintaining their independence as a focus of care, signals the need to maintain interpersonal relationships, improve communication, and for actions of health education and people-centered services. Conclusion: these points demand the attention of care providers and policy services to improve care delivery and provide actions that are welcomed by this public.

Cost-effectiveness of a proactive, integrated primary care approach for community-dwelling frail older persons

BACKGROUND

The article reports on the cost-effectiveness of the proactive, integrated primary care program Finding and Follow-up of Frail older persons (FFF) compared with usual primary care for community-dwelling frail older persons in the Netherlands.

METHODS

This study had a matched quasi-experimental design (pretest and posttest). The economic evaluation was performed from a healthcare perspective with a time horizon of 12 months. The target population consisted of community-dwelling frail older persons aged ≥ 75 years in the FFF intervention group (11 general practitioner (GP) practices) and in the control group receiving usual care (4 GP practices). The effectiveness measures for the cost-effectiveness and cost-utility analyses were subjective well-being (Social Production Function Instrument for the Level of well-being short; SPF-ILs) and QALYs (EuroQol; EQ-5D-3L), respectively. Costs were assessed using resource use questionnaires. Differences in mean effectiveness between groups were assessed using univariate, multilevel and propensity score matched analyses, with and without imputation of missing values. Differences in costs were assessed using Mann-Whitney U-tests and independent samples t-tests. Bootstrapping was performed, and predicted incremental cost-effectiveness ratios (ICERs) and incremental cost-utility ratios (ICURs) were depicted on cost-effectiveness planes.

RESULTS

The various analyses showed slightly different results with respect to differences in estimated costs and effects. Multilevel analyses showed a small but significant difference between the groups for well-being, in favor of the control group. No significant differences between groups in terms of QALYs were found. Imputed data showed that mean total costs were significantly higher in the intervention group at follow-up.

CONCLUSION

Proactive, integrated care for community-dwelling frail older persons as provided in the FFF program is most likely not a cost-effective initiative, compared with usual primary care in the Netherlands, in terms of well-being and QALYs over a 12-month period.