Effectiveness and cost-effectiveness of proactive and multidisciplinary integrated care for older people with complex problems in general practice: an individual participant data meta-analysis

Purpose

to support older people with several healthcare needs in sustaining adequate functioning and independence, more proactive approaches are needed. This purpose of this study is to summarise the (cost-) effectiveness of proactive, multidisciplinary, integrated care programmes for older people in Dutch primary care.

Methods design

individual patient data (IPD) meta-analysis of eight clinically controlled trials.

Setting

primary care sector.

Interventions

combination of (i) identification of older people with complex problems by means of screening, followed by (ii) a multidisciplinary integrated care programme for those identified.

Main outcome

activities of daily living, i.e. a change on modified Katz-15 scale between baseline and 1-year follow-up.

Secondary outcomes

quality of life (visual analogue scale 0–10), psychological (mental well-being scale Short Form Health Survey (SF)-36) and social well-being (single item, SF-36), quality-adjusted life years (Euroqol-5dimensions-3level (EQ-5D-3L)), healthcare utilisation and cost-effectiveness.

Analysis

intention-to-treat analysis, two-stage IPD and subgroup analysis based on patient and intervention characteristics.

Results

included were 8,678 participants: median age of 80.5 (interquartile range 75.3; 85.7) years; 5,496 (63.3%) women. On the modified Katz-15 scale, the pooled difference in change between the intervention and control group was −0.01 (95% confidence interval −0.10 to 0.08). No significant differences were found in the other patient outcomes or subgroup analyses. Compared to usual care, the probability of the intervention group to be cost-effective was less than 5%.

Conclusion

compared to usual care at 1-year follow-up, strategies for identification of frail older people in primary care combined with a proactive integrated care intervention are probably not (cost-) effective.

The frail older person does not exist: development of frailty profiles with latent class analysis

Background

A fundamental issue in elderly care is targeting those older people at risk and in need of care interventions. Frailty is widely used to capture variations in health risks but there is no general consensus on the conceptualization of frailty. Indeed, there is considerable heterogeneity in the group of older people characterized as frail. This research identifies frailty profiles based on the physical, psychological, social and cognitive domains of functioning and the severity of the problems within these domains.

Methods

This research was a secondary data-analysis of older persons derived from The Older Person and Informal Caregiver Minimum Dataset. Selected respondents were 60 years and older (n = 43,704; 59.6% female). The following variables were included: self-reported health, cognitive functioning, social functioning, mental health, morbidity status, and functional limitations. Using latent class analysis, the population was divided in subpopulations that were subsequently discussed in a focus group with older people for further validation.

Results

We distinguished six frailty profiles: relatively healthy; mild physically frail; psychologically frail; severe physically frail; medically frail and multi-frail. The relatively healthy had limited problems across all domains. In three profiles older people mostly had singular problems in either the physical or psychological domain and the severity of the problems differed. Two remaining profiles were multidimensional with a combination of problems that extended to the social and cognitive domains.

Conclusions

Our research provides an empirical base for meaningful frailty profiles. The profiles showed specific patterns underlying the problems in different domains of functioning. The heterogeneous population of frail older people has differing needs and faces different health issues that should be considered to tailor care interventions. Evaluation research of these interventions should acknowledge the heterogeneity of frailty by profiling.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0776-5) contains supplementary material, which is available to authorized users.

Unravelling complex primary-care programs to maintain independent living in older people: a systematic overview

OBJECTIVES

Complex interventions are criticized for being a "black box", which makes it difficult to determine why they succeed or fail. Recently, nine proactive primary-care programs aiming to prevent functional decline in older adults showed inconclusive effects. The aim of this study was to systematically unravel, compare, and synthesize the development and evaluation of nine primary-care programs within a controlled trial to further improve the development and evaluation of complex interventions.

STUDY DESIGN AND SETTING

A systematic overview of all written data on the nine proactive primary-care programs was conducted using a validated item list. The nine proactive primary-care programs involved 214 general practices throughout the Netherlands.

RESULTS

There was little or no focus on the (1) context surrounding the care program, (2) modeling of processes and outcomes, (3) intervention fidelity and adaptation, and (4) content and evaluation of training for interventionists.

CONCLUSIONS

An in-depth analysis of the context, modeling of the processes and outcomes, measurement and reporting of intervention fidelity, and implementation of effective training for interventionists is needed to enhance the development and replication of future complex interventions.

The Importance of Trust in Successful Home Visit Programs for Older People

Outcomes of proactive home visit programs for frail, older people might be influenced by aspects of the caregiver-receiver interaction. We conducted a naturalistic case study to explore the interactional process between a nurse and an older woman during two home visits. Using an ethics of care, we posit that a trusting relationship is pivotal for older people to accept care that is proactively offered to them. Trust can be build when nurses meet the relational needs of older people. Nurses can achieve insight in these needs by exploring older people's value systems and life stories. We argue that a strong focus on older people's relational needs might contribute to success of proactive home visits for frail, older people.

Cost-effectiveness of a nurse-led intervention to optimise implementation of guideline-concordant continence care: Study protocol of the COCON study

Background

Guidelines on urinary incontinence recommend that absorbent products are only used as a coping strategy pending definitive treatment, as an adjunct to ongoing therapy, or for long-term management after all treatment options have been explored. However, these criteria are rarely met and a significant share of long-term product users could still benefit from therapeutic interventions recommended in guidelines for urinary incontinence. Better implementation of these guidelines can potentially result in both health benefits for women and long-term cost savings for society. The aim of the COCON study is to evaluate the (cost-)effectiveness of a nurse-led intervention to optimise implementation of guideline-concordant continence care in comparison with usual care for urinary incontinent women aged 55 years and over who use absorbent products.

Methods

This randomised clinical trial compares usual care with a nurse-led intervention to optimise implementation of guideline-concordant continence care. Women (anticipated N = 160) are recruited in 12 community pharmacies in three Dutch regions, and are eligible for trial entry when they are 55 years and over, community-dwelling and long-term users of absorbent products (≥4 months) reimbursed by health insurance. Measurements are administered at baseline, 3, 6 and 12 months. Primary outcome is severity of urinary incontinence (ICIQ-UI SF); other outcomes include health related quality of life (EQ-5D-5 L), use of absorbent products (in accordance with the recommended criteria in guidelines) (yes/no), and societal costs. Mixed model analysis will be performed to compare (the course) of outcomes between groups. The economic evaluation will be performed from a societal perspective. The implementation process is investigated using the Tailored Implementation for Chronic Diseases (TICD) framework.

Discussion

Results will add to current knowledge of the (cost-)effectiveness of nurse-led primary healthcare to improve guideline-concordant care for older women with urinary incontinence. In addition, the results will provide more insight into care needs and health service utilization of this group of women, as well as into use of absorbent products in accordance with the recommended criteria in guidelines. Finally, results will increase our understanding of the intervention’s uptake and could provide useful insights for future dissemination and sustenance.

Trial registration

Dutch Trial Register NTR4396, registered 13-January-2014

Electronic supplementary material

The online version of this article (doi:10.1186/s12912-017-0204-8) contains supplementary material, which is available to authorized users.

Effectiveness of insulin therapy in people with Type 2 diabetes in the Hoorn Diabetes Care System

AIMS

To identify HbA1c trajectories after the start of insulin treatment and to identify clinically applicable predictors of the response to insulin therapy.

METHODS

The study population comprised 1203 people with Type 2 diabetes included in the Hoorn Diabetes Care System (n = 9849). Inclusion criteria were: age ≥ 40 years; initiation of insulin during follow-up after failure to reach HbA1c levels ≤ 53 mmol/mol (7%) with oral glucose-lowering agents; and a follow up ≥ 2 years after initiating insulin. Latent class growth modelling was used to identify trajectories of HbA1c . Subjects considered to be 'off target' had HbA1c levels ≥ 53 mmol/mol (7.0%) during one-third or more of the follow-up time, and those considered to be 'on target' had HbA1c levels ≥ 53 mmol/mol (7.0%) during less than one-third of the follow-up time.

RESULTS

Four HbA1c trajectories were identified. Most people (88.7%) were classified as having a stable HbA1c trajectory of ~57 mmol/mol (7.4%). Only 24.4% of the people were on target in response to insulin; this was associated with lower HbA1c levels and a higher age at the start of insulin treatment.

CONCLUSIONS

Using latent class growth modelling, four HbA1c trajectories were identified. A quarter of the people starting insulin were on target. Low HbA1c levels and advanced age at the start of insulin therapy were associated with better response to insulin therapy. Initiating insulin earlier improves the likelihood of achieving and sustaining glycaemic control.

Expanding access to pain care for frail, older people in primary care: a cross-sectional study

Background

Although untreated pain has a negative impact on quality of life and health outcomes, research has shown that older people do not always have access to adequate pain care. Practice nurse-led, comprehensive geriatric assessments (CGAs) may increase access to tailored pain care for frail, older people who live at home. To explore this, we investigated whether new pain cases were identified by practice nurses during CGAs administered as part of an intervention with the Geriatric Care Model, a comprehensive care model based on the Chronic Care Model, and whether the intervention led to tailored pain action plans in care plans of frail, older people.

Methods

We used cross-sectional data from the older Adults: Care in Transition (ACT) study, a 2-year clinical trial carried out in two regions of the Netherlands. Practice nurses proactively visited older people at home and administered an in-home CGA that included an assessment of pain. Pain care-related agreements and actions (pain action plans) based on CGA results were described in a tailored care plan. We analyzed care plans of 781 older people who received a first-time CGA by a practice nurse for the presence of pain, pain location and cause, new pain cases, and pain action plans. We used descriptive statistics to analyze our data.

Results

We found that 315 (40.3 %) older people experienced any type of pain. Practice nurses identified 20 (10.6 %) new pain cases, and 188 (59.7 %) older people with pain formulated at least one therapeutic or non-therapeutic pain action plan together with a practice nurse. More than half of the older people whose pain had already been identified by a primary care physician wanted a pain action plan. Most pain action plans consisted of actions or agreements related to continuity of care.

Discussion and conclusion

Practice nurses in primary care can contribute to expanding older people's access to tailored pain care. Future researchers should continue to direct their focus at ways to overcome the barriers that restrict older people’s access to pain care.

Effectiveness of a Geriatric Care Model for frail older adults in primary care: Results from a stepped wedge cluster randomized trial

BACKGROUND

Primary care-based comprehensive care programs have the potential to improve outcomes in frail older adults. We evaluated the impact of the Geriatric Care Model (GCM) on the quality of life of community-dwelling frail older adults.

METHODS

A 24-month stepped wedge cluster randomized controlled trial was conducted between May 2010 and March 2013 in 35 primary care practices in the Netherlands, and included 1147 frail older adults. The intervention consisted of a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Reassessment occurred every six months. Nurses worked together with primary care physicians and were supervised and trained by geriatric expert teams. Complex patients were reviewed in multidisciplinary consultations. The primary outcome was quality of life (SF-12). Secondary outcomes were health-related quality of life, functional limitations, self-rated health, psychological wellbeing, social functioning and hospitalizations.

RESULTS

Intention-to-treat analyses based on multilevel modeling showed no significant differences between the intervention group and usual care regarding SF-12 and most secondary outcomes. Only for IADL limitations we found a small intervention effect in patients who received the intervention for 18months (B=-0.25, 95%CI=-0.43 to -0.06, p=0.007), but this effect was not statistically significant after correction for multiple comparisons.

CONCLUSION

The GCM did not show beneficial effects on quality of life in frail older adults in primary care, compared to usual care. This study strengthens the idea that comprehensive care programs add very little to usual primary care for this population.

TRIAL REGISTRATION

The Netherlands National Trial Register NTR2160.

[Clinical medication reviews in elderly patients with polypharmacy: a cross-sectional study in Dutch community pharmacies]

OBJECTIVE

To investigate the nature and prevalence of drug related problems (DRPs) in older patients with polypharmacy identified by community pharmacists in daily practice through means of a clinical medication review (CMR) and assess the implementation rate of proposed interventions to solve DRPs.

DESIGN

A cross-sectional study METHOD: We analysed the CMR data of 3,807 older patients (≥ 65 years) with polypharmacy (≥ 5 drugs) completed in January-August 2012. Using the "Service Apotheek Medicatie Review Tool" (SAMRT, Service Pharmacy Medication Review Tool), pharmacists in 258 community pharmacies registered the patients' year of birth, gender, dispensing data, DRPs, and proposed and implemented interventions.

RESULTS

Pharmacists identified a median of two DRPs (interquartile range 1-4; mean 3.0) per patient. The DRP categories overtreatment (25.5 %) and undertreatment (15.9 %) were found to occur most frequently. On average, 46.2 % of the proposed interventions to address DRPs were implemented as proposed. In 22.4 % of cases the intervention differed from the proposal, whereas in 31.3 % of cases no intervention was implemented.

CONCLUSION

In daily practice, community pharmacists identified a mean of three DRPs in older patients with polypharmacy, a number comparable to that found in controlled studies. Over- or undertreatment caused nearly half of the identified DRPs. The majority (69.9%) of the proposed interventions led to an intervention for the patient.

Cost-Effectiveness of a Chronic Care Model for Frail Older Adults in Primary Care: Economic Evaluation Alongside a Stepped-Wedge Cluster-Randomized Trial

OBJECTIVES

To evaluate the cost-effectiveness of the Geriatric Care Model (GCM), an integrated care model for frail older adults based on the Chronic Care Model, with that of usual care.

DESIGN

Economic evaluation alongside a 24-month stepped-wedge cluster-randomized controlled trial.

SETTING

Primary care (35 practices) in two regions in the Netherlands.

PARTICIPANTS

Community-dwelling older adults who were frail according to their primary care physicians and the Program on Research for Integrating Services for the Maintenance of Autonomy case-finding tool questionnaire (N = 1,147).

INTERVENTION

The GCM consisted of the following components: a regularly scheduled in-home comprehensive geriatric assessment by a practice nurse followed by a customized care plan, management and training of practice nurses by a geriatric expert team, and coordination of care through community network meetings and multidisciplinary team consultations of individuals with complex care needs.

MEASUREMENTS

Outcomes were measured every 6 months and included costs from a societal perspective, health-related quality of life (Medical Outcomes Study 12-item Short-Form Survey (SF-12) physical (PCS) and mental component summary (MCS) scales), functional limitations (Katz activities of daily living and instrumental activities of daily living), and quality-adjusted life years based on the EQ-5D.

RESULTS

Multilevel regression models adjusted for time and baseline confounders showed no significant differences in costs ($356, 95% confidence interval = -$488-1,134) and outcomes between intervention and usual care phases. Cost-effectiveness acceptability curves showed that, for the SF-12 PCS and MCS, the probability of the intervention being cost-effective was 0.76 if decision-makers are willing to pay $30,000 per point improvement on the SF-12 scales (range 0-100). For all other outcomes the probability of the intervention being cost-effective was low.

CONCLUSION

Because the GCM was not cost-effective compared to usual care after 24 months of follow-up, widespread implementation in its current form is not recommended.

Clinical medication reviews in elderly patients with polypharmacy: a cross-sectional study on drug-related problems in the Netherlands

Background Knowledge of drug-related problems (DRPs) identified in the medication of home-dwelling elderly patients with polypharmacy has been based predominantly on medication reviews conducted in research settings rather than in daily practice. Objective To evaluate the prevalence of DRPs identified by means of a clinical medication review (CMR) and the implementation rate of proposed interventions in a large group of older patients with polypharmacy in the daily practice of community pharmacies. Setting 318 Dutch community pharmacies. Method A cross-sectional study based on CMR-data of 3807 older patients (≥65 years) with polypharmacy (≥5 drugs) completed between January and August 2012. Data were extracted from community pharmacists’ databases and entailed: year of birth, gender, dispensing data, number and nature of identified DRPs, consultations performed, proposed and implemented interventions. Main outcome measure Prevalence of DRPs, drug classes involved in overtreatment and undertreatment, and proposed and implemented interventions. Results A median of two DRPs (interquartile range 1–4; mean 3.0) was identified per patient. The DRP-categories overtreatment (25.5 %) and undertreatment (15.9 %) were found most frequently. 46.2 % of the proposed interventions to solve DRPs were implemented as proposed, in 22.4 % of cases, the intervention differed from the proposal. In 31.3 % of cases no intervention was implemented. Conclusion By conducting a CMR community pharmacists identified a median of two DRPs in older patients with polypharmacy. Overtreatment and undertreatment accounted for 41.4 % of the DRPs identified. In dealing with DRPs, pharmacists proposed a variety of interventions of which the majority (69.9 %) was either implemented or led to alternative interventions. A set of explicit criteria should be applied during a CMR to solve and prevent DRPs.

Exploration of the content validity and feasibility of the EQ-5D-3L, ICECAP-O and ASCOT in older adults

Background

In economic evaluations of care services for older adults health-related quality of life (QoL) measures such as the EQ-5D are increasingly replaced by the ICECAP-O and ASCOT, which cover a broader scope of QoL than health alone. Little is known about the content validity and feasibility of these measures. The purpose of this study was to explore the content validity and feasibility of the EQ-5D-3L, ICECAP-O and ASCOT in older adults.

Methods

Ten older adults were purposively sampled using a maximum variation principle. Think-aloud and verbal probing techniques were used to identify response issues encountered during the interpretation of items and the selection of response options. We used constant comparative methods to analyse the data.

Results

Two types of response issues were identified for various items in all three measures: interpretation issues and positive responses. Issues with the mapping of a response on one of the response options were least often encountered for the EQ-5D-3L items. Older adults considered the items of the ICECAP-O and ASCOT valuable though more abstract than the EQ-5D-3L.

Conclusions

Researchers who intend to use the EQ-5D, ICECAP-O or ASCOT in economic evaluations of care services for older adults, should be aware of the response issues that occur during the administration of these measures. Older adults perceived none of the measures as providing a comprehensive picture of their QoL. A preference from older adults for one of the measures depends on the extent to which the items reflect current personal concerns in life.

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.

What can local authorities do to improve the social care-related quality of life of older adults living at home? Evidence from the Adult Social Care Survey

Local authorities spend considerable resources on social care at home for older adults. Given the expected growth in the population of older adults and budget cuts on local government, it is important to find efficient ways of maintaining and improving the quality of life of older adults. The ageing in place literature suggests that policies in other functions of local authorities may have a significant role to play. This study aims to examine the associations between social care-related quality of life (SCRQoL) in older adults and three potential policy targets for local authorities: (i) accessibility of information and advice, (ii) design of the home and (iii) accessibility of the local area. We used cross-sectional data from the English national Adult Social Care Survey (ASCS) 2010/2011 on service users aged 65 years and older and living at home (N=29,935). To examine the association between SCRQoL, as measured by the ASCOT, and three single-item questions about accessibility of information, design of the home and accessibility of the local area, we estimate linear and quantile regression models. After adjusting for physical and mental health factors and other confounders our findings indicate that SCRQoL is significantly lower for older adults who find it more difficult to find information and advice, for those who report that their home design is inappropriate for their needs and for those who find it more difficult to get around their local area. In addition, these three variables are as strongly associated with SCRQoL as physical and mental health factors. We conclude that in seeking to find ways to maintain and improve the quality of life of social care users living at home, local authorities could look more broadly across their responsibilities. Further research is required to explore the cost-effectiveness of these options compared to standard social care services.

[Frailty, disability and multi-morbidity: the relationship with quality of life and healthcare costs in elderly people]

OBJECTIVE

To assess the independent and combined impact of frailty, multi-morbidity, and activities of daily living (ADL) limitations on self-reported quality of life and healthcare costs in elderly people.

DESIGN

Cross-sectional, descriptive study.

METHOD

Data came from The Older Persons and Informal Caregivers Minimum DataSet (TOPICS-MDS), a pooled dataset with information from 41 projects across the Netherlands from the Dutch national care for the Elderly programme. Frailty, multi-morbidity and ADL limitations, and the interactions between these domains, were used as predictors in regression analyses with quality of life and healthcare costs as outcome measures. Analyses were stratified by living situation (independent or care home). Directionality and magnitude of associations were assessed using linear mixed models.

RESULTS

A total of 11,093 elderly people were interviewed. A substantial proportion of elderly people living independently reported frailty, multi-morbidity, and/or ADL limitations (56.4%, 88.3% and 41.4%, respectively), as did elderly people living in a care home (88.7%, 89.2% and 77,3%, respectively). One-third of elderly people living at home (31.9%) reported all three conditions compared with two-thirds of elderly people living in a care home (68.3%). In the multivariable analysis, frailty had a strong impact on outcomes independently of multi-morbidity and ADL limitations. Elderly people experiencing problems across all three domains reported the poorest quality-of-life scores and the highest healthcare costs, irrespective of their living situation.

CONCLUSION

Frailty, multi-morbidity and ADL limitations are complementary measurements, which together provide a more holistic understanding of health status in elderly people. A multi-dimensional approach is important in mapping the complex relationships between these measurements on the one hand and the quality of life and healthcare costs on the other.

The development of the Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS): a large-scale data sharing initiative

Introduction

In 2008, the Ministry of Health, Welfare and Sport commissioned the National Care for the Elderly Programme. While numerous research projects in older persons’ health care were to be conducted under this national agenda, the Programme further advocated the development of The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS) which would be integrated into all funded research protocols. In this context, we describe TOPICS data sharing initiative (www.topics-mds.eu).

Materials and Methods

A working group drafted TOPICS-MDS prototype, which was subsequently approved by a multidisciplinary panel. Using instruments validated for older populations, information was collected on demographics, morbidity, quality of life, functional limitations, mental health, social functioning and health service utilisation. For informal caregivers, information was collected on demographics, hours of informal care and quality of life (including subjective care-related burden).

Results

Between 2010 and 2013, a total of 41 research projects contributed data to TOPICS-MDS, resulting in preliminary data available for 32,310 older persons and 3,940 informal caregivers. The majority of studies sampled were from primary care settings and inclusion criteria differed across studies.

Discussion

TOPICS-MDS is a public data repository which contains essential data to better understand health challenges experienced by older persons and informal caregivers. Such findings are relevant for countries where increasing health-related expenditure has necessitated the evaluation of contemporary health care delivery. Although open sharing of data can be difficult to achieve in practice, proactively addressing issues of data protection, conflicting data analysis requests and funding limitations during TOPICS-MDS developmental phase has fostered a data sharing culture. To date, TOPICS-MDS has been successfully incorporated into 41 research projects, thus supporting the feasibility of constructing a large (>30,000 observations), standardised dataset pooled from various study protocols with different sampling frameworks. This unique implementation strategy improves efficiency and facilitates individual-level data meta-analysis.

Environmental interventions in low-SES neighbourhoods to promote healthy behaviour: enhancing and impeding factors

BACKGROUND

Social and physical environments are important drivers of socioeconomic inequalities in health behaviour. Although many interventions aiming to improve such environments are being implemented in underprivileged neighbourhoods, implementation processes are rarely studied. Acquiring insight into successful implementation may improve future interventions. The present study aimed to investigate factors influencing the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of social and physical environmental interventions aimed at promoting healthy behaviour in underprivileged neighbourhoods in The Netherlands.

METHODS

A large set of theory-based factors of successful implementation was assessed for 18 implemented interventions in three underprivileged neighbourhoods. Expert and target group panels scored the RE-AIM dimensions for each intervention. We analyzed the statistical significance of associations between theory-based factors and the actual RE-AIM in a statistical model, to identify factors associated with increased RE-AIM.

RESULTS

Six factors were identified: effectiveness and implementation success were higher when the target group was involved in the planning process, whereas maintenance increased in the absence of competition with other projects. If the current situation was inventoried during intervention development, the effectiveness, adoption and implementation were higher. These dimensions were also higher when the target group was informed before implementation. Involvement of the target group during implementation resulted in higher reach, effectiveness and adoption. Finally, lack of intervention staff worsened the reach.

DISCUSSION

This study contributes to the evidence base for effective implementation of environmental measures aimed at promoting healthy behaviours. In particular, interventions in which the target group was involved in the implementation process were associated with higher RE-AIM outcomes.

The identification of frail older adults in primary care: comparing the accuracy of five simple instruments

BACKGROUND

many instruments are available to identify frail older adults who may benefit from geriatric interventions. Most of those instruments are time-consuming and difficult to use in primary care.

OBJECTIVE

to select a valid instrument to identify frail older adults in primary care, five simple instruments were compared.

METHODS

instruments included clinical judgement of the general practitioner, prescription of multiple medications, the Groningen frailty indicator (GFI), PRISMA-7 and the self-rated health of the older adult. Fried's frailty criteria and a clinical judgement by a multidisciplinary expert panel were used as reference standards. Data were used from the cross-sectional Dutch Identification of Frail Elderly Study consisting of 102 people aged 65 and over from a primary care practice in Amsterdam. In this study, frail older adults were oversampled. We estimated the accuracy of each instrument by calculating the area under the ROC curve. The agreement between the instruments and the reference standards was determined by kappa.

RESULTS

frailty prevalence rates in this sample ranged from 11.6 to 36.4%. The accuracy of the instruments ranged from poor (AUC = 0.64) to good (AUC = 0.85).

CONCLUSION

PRISMA-7 was the best of the five instruments with good accuracy. Further research is needed to establish the predictive validity and clinical utility of the simple instruments used in this study.

Implementing the chronic care model for frail older adults in the Netherlands: study protocol of ACT (frail older adults: care in transition)

BACKGROUND

Care for older adults is facing a number of challenges: health problems are not consistently identified at a timely stage, older adults report a lack of autonomy in their care process, and care systems are often confronted with the need for better coordination between health care professionals. We aim to address these challenges by introducing the geriatric care model, based on the chronic care model, and to evaluate its effects on the quality of life of community-dwelling frail older adults.

METHODS/DESIGN

In a 2-year stepped-wedge cluster randomised clinical trial with 6-monthly measurements, the chronic care model will be compared with usual care. The trial will be carried out among 35 primary care practices in two regions in the Netherlands. Per region, practices will be randomly allocated to four allocation arms designating the starting point of the intervention.

PARTICIPANTS

1200 community-dwelling older adults aged 65 or over and their primary informal caregivers. Primary care physicians will identify frail individuals based on a composite definition of frailty and a polypharmacy criterion. Final inclusion criterion: scoring 3 or more on a disability case-finding tool.

INTERVENTION

Every 6 months patients will receive a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Expert teams will manage and train practice nurses. Patients with complex care needs will be reviewed in interdisciplinary consultations.

EVALUATION

We will perform an effect evaluation, an economic evaluation, and a process evaluation. Primary outcome is quality of life as measured with the Short Form-12 questionnaire. Effect analyses will be based on the "intention-to-treat" principle, using multilevel regression analysis. Cost measurements will be administered continually during the study period. A cost-effectiveness analysis and cost-utility analysis will be conducted comparing mean total costs to functional status, care needs and QALYs. We will investigate the level of implementation, barriers and facilitators to successful implementation and the extent to which the intervention manages to achieve the transition necessary to overcome challenges in elderly care.

DISCUSSION

This is one of the first studies assessing the effectiveness, cost-effectiveness and implementation process of the chronic care model for frail community-dwelling older adults.

TRIAL REGISTRATION

The Netherlands National Trial Register NTR2160.

Effectiveness of case management among older adults with early symptoms of dementia and their primary informal caregivers: a randomized clinical trial

BACKGROUND

It is believed that timely recognition and diagnosis of dementia is a pre-condition for improving care for both older adults with dementia and their informal caregivers. However, diagnosing dementia often occurs late in the disease. This means that a significant number of patients with early symptoms of dementia and their informal caregivers may lack appropriate care.

OBJECTIVES

To compare the effects of case management and usual care among community-dwelling older adults with early symptoms of dementia and their primary informal caregivers.

DESIGN

Randomized controlled trial with measurements at baseline and after 6 and 12 months.

SETTING

Primary care in West-Friesland, the Netherlands.

PARTICIPANTS

99 pairs of community-dwelling older adults with dementia symptoms (defined as abnormal screening for symptoms of dementia) and their primary informal caregivers.

INTERVENTION

12 months of case management by district nurses for both older adults and informal caregivers versus usual care.

MEASUREMENTS

PRIMARY OUTCOME

informal caregiver's sense of competence.

SECONDARY OUTCOMES

caregiver's quality of life, depressive symptoms, and burden, and patient's quality of life. Process measurements: intervention fidelity and caregiver's satisfaction with the quality of case management.

RESULTS

Linear mixed model analyses showed no statistically significant and clinically relevant differences over time between the two groups. The process evaluation revealed that intervention fidelity could have been better. Meanwhile, informal caregivers were satisfied with the quality of case management.

CONCLUSION

This study shows no benefits of case management for older adults with dementia symptoms and their primary informal caregivers. One possible explanation is that case management, which has been recommended among diagnosed dementia patients, may not be beneficial if offered too early. However, on the other hand, it is possible that: (1) case management will be effective in this group if more fully implemented and adapted or aimed at informal caregivers who experience more severe distress and problems; (2) case management is beneficial but that it is not seen in the timeframe studied; (3) case management might have undetected small benefits. This has to be established. Trial registration ISCRTN83135728.

Self-reports on the IQCODE in older adults: a psychometric evaluation

The Informant Questionnaire on Cognitive Decline (IQCODE) has been successful in identifying demented persons in a general population. In this study, this questionnaire was used as a self-report screening for dementia symptoms. The object was to investigate the feasibility, homogeneity, and construct validity of self-reports on the IQCODE. Participants were 4823 community-dwelling older adults who received an IQCODE-SR. Feasibility was assessed on the basis of response rate, the proportion of missing data for each item, and the number of persons who received help in completing the questionnaire. Homogeneity was checked with Cronbach's alpha. To investigate construct validity, hypotheses on performance of the IQCODE-SR were tested. Feasibility was acceptable, with a response rate of 58.9%. Missing answers per item ranged from 2.5% to 7.3%, and 915 of 2841 participants received help in completing the questionnaire. Homogeneity was good, with Cronbach's alpha = .94. The majority of hypotheses on construct validity were confirmed. It was concluded that the IQCODE-SR meets the basic requirements of a good measurement instrument.

Depression in old age (75+), the PIKO study

BACKGROUND

Old people (75+) are underrepresented in studies on the prevalence of and risk factors for depression while the number of elderly people suffering from this mood disorder may be considerably higher than previously assumed. The role--if any--of age and gender in 'Geriatric Depression' is still unclear.

METHODS

In this community-based study, prevalence of depressive symptomatology and risk indicators were assessed in 2850 participants aged 75 years or more. A clinically relevant level of depressive symptoms was defined as a score of > or =16 on the Centre for Epidemiologic Studies Depression scale (CES-D). Demographic data and questions related to physical and psychological health were recorded. Simple and multiple logistic regression techniques were used to determine the risk indicators (Odds Ratios, OR, with 95% confidence intervals, CI) with apparent importance to this population.

RESULTS

The prevalence of depressive symptoms was assessed to be 31.1%. This is considerably higher than what has been found in younger elderly samples. The bivariate age effect was OR 1.05 (95% CI=1.03 to 1.07). Controlling for confounding, the effect of gender and age on depressive symptoms disappeared.

CONCLUSIONS

Depressive symptoms are highly prevalent in the elderly population and increase with age. This increase seems to be attributable to age-related changes in risk factors rather than to ageing itself. With regard to the risk factors found, attention should perhaps be paid to functional disability, loneliness and apprehensiveness for falling since these risk indicators are amenable for improvement.

Yield of a new method to detect cognitive impairment in general practice

OBJECTIVE

To examine whether a new screening method that identified patients with cognitive impairment who needed further examination on the presence of dementia yielded patients who were not detected by their general practitioner (GP), and to identify factors associated with GPs' awareness of patients identified by the screening.

METHODS

Cross-sectional comparison between two methods used to identify dementia symptoms: (1) usual identification of dementia by GPs; (2) a two-stage screening to identify cognitive impairment. The two methods were implemented on the same older general practice population. The study was set in primary care practices in the Netherlands. The participants were 44 GPs and 2,101 general practice patients aged 75+ who lived at home. The following measurements were used: (1) yield of the screening; (2) determinants of GPs' awareness of patients identified by the screening.

RESULTS

The two-stage screening yielded 117 patients with cognitive impairment who needed further examination; in most cases (n = 82, 70.1%) their GP was unaware of the symptoms. Among patients identified by the screening, GPs' awareness was associated with co-morbidity of chronic diseases [odds ratio (OR) = 3.19; 95% Confidence Interval (CI) = 1.25 to 8.15], depressive symptoms (OR = 0.41; 95% CI = 0.17 to 0.99), and cognitive functioning (per point on the MMSE, OR = 0.88; 95% CI = 0.79 to 0.98).

CONCLUSION

A two-stage screening method and increased alertness for cognitive impairment and dementia among patients with depressive symptoms may improve detection rate of dementia in general practice.