Determinants of Post-acute Care Costs in Acutely Hospitalized Older Adults: The Hospital-ADL Study

ObjectivesAfter hospitalization, many older adults need post-acute care, including rehabilitation or home care. However, post-acute care expenses can be as high as the costs for the initial hospitalization. Detailed information on monthly post-acute health care expenditures and the characteristics of patients that make up for a large share of these expenditures is scarce. We aimed to calculate costs in acutely hospitalized older patients and identify patient characteristics that are associated with high post-acute care costs.DesignProspective multicenter cohort study (between October 2015 and June 2017).Setting and participants401 acutely hospitalized older persons from internal medicine, cardiology, and geriatric wards.MeasurementsOur primary outcome was mean post-acute care costs within 90 days postdischarge. Post-acute care costs included costs for unplanned readmissions, home care, nursing home care, general practice, and rehabilitation care. Three costs categories were defined: low [0-50th percentile (p0-50)], moderate (p50-75), and high (p75-100). Multinomial logistic regression analyses were conducted to assess the associations between costs and frailty, functional impairment, health-related quality of life, cognitive impairment, and depressive symptoms.ResultsCosts were distributed unevenly in the population, with the top 10.0% (n = 40) accounting for 52.1% of total post-acute care costs. Mean post-acute care costs were €4035 [standard deviation (SD) 4346] or $4560 (SD 4911). Frailty [odds ratio (OR) 3.44, 95% confidence interval (CI) 1.78-6.63], functional impairment (OR 1.80, 95% CI 1.03-3.16), and poor health-related quality of life (OR 1.89, 95% CI 1.09-3.28) at admission were associated with classification in the high-cost group, compared with the low-cost group.Conclusions/ImplicationsPost-acute care costs are substantial in a small portion of hospitalized older adults. Frailty, functional impairment, and poor health-related quality of life are associated with higher post-acute care costs and may be used as an indicator of such costs in practice.     

Effects of Unstructured Mobility Programs in Older Hospitalized General Medicine Patients: A Systematic Review and Meta-Analysis

ObjectiveMobility interventions have been shown to mitigate functional decline in various clinical populations; however, the effects of mobility programs in older hospitalized patients are unclear. The objective of this study was to determine the effects of unstructured mobility programs on physical activity, physical function, length of stay (LOS), and quality of life (QOL) in older (≥60 years) general medicine inpatients.DesignIn this systematic review and meta-analysis, we systematically searched MEDLINE, Embase, CINAHL, and AMED databases from inception to March 2020, plus hand screening references of relevant studies.Setting and ParticipantsWe included randomized controlled trials (RCTs) and quasi-experimental studies assessing the effects of mobility programs compared to usual care in older adults admitted to general medicine units.MeasuresTeams of 2 reviewers independently extracted data, assessed risk of bias, and evaluated quality of evidence. Where study population, intervention, and outcomes were similar, results from RCTs were combined by meta-analysis.ResultsThree RCTs and 10 quasi-experimental studies met eligibility criteria. Interventions mainly included ambulation and staff, patient, or caregiver education. Meta-analyses showed that mobility interventions had a moderate effect on physical activity [step count standardized mean difference 0.60, 95% confidence interval (CI) 0.23-0.97] and a nonsignificant effect on LOS (mean difference –0.36, 95% CI –1.92 to 1.21), both favoring mobility. Narrative synthesis showed consistent evidence for improvement in physical function, potential decrease in LOS, and no increase in adverse events with mobility interventions.Conclusions and ImplicationsUnstructured mobility interventions in general medicine units may improve older hospitalized patients’ physical activity and physical function; however, the quality of evidence was low. More RCTs are needed to evaluate the effectiveness of mobility interventions, particularly on LOS and QOL.     

Efectividad de las intervenciones basadas en telemedicina sobre resultados en salud en pacientes con multimorbilidad en atención primaria: revisión sistemática

ObjectiveTo evaluate the effectiveness of telemedicine interventions to improve health outcomes in patients with multiple morbidities in Primary Health Care.DesignA systematic review.Data sourcesINAHTA, Health Guidelines, NICE, Cochrane Library, Medline/PubMed and EMBASE up to April 2018.Study selectionInclusion criteria: patients (adults with 2 or more chronic diseases or a Charlson index greater than three); intervention (telemedicine intervention developed entirely in Primary Health Care); comparator (usual care); health outcomes (mortality, hospital admissions, emergency department visits, health-related quality of life, and satisfaction); study design(clinical practice guideline, systematic review, meta-analysis, randomised controlled clinical trial),and quasi-experimental design). English and Spanish language publication. A total of236 references were located.Data extractionDuplicated articles were removed. Titles, abstracts, and full text of references identified were assessed using the selection criteria; methodological quality assessment; data extraction, and qualitative analysis.ResultsFive articles, corresponding to 3 studies, were included, with 2 randomised controlled clinical trials and one quasi-experimental design. No significant results were observed in reducing mortality or improving health-related quality of life. The effectiveness of telemedicine on the number of hospital admissions or emergency visits showed contradictory results. Satisfaction was not measured in the studies included.ConclusionsThe relatively small number of studies, heterogeneity characteristics, and methodological limitations did not confirm the effectiveness of telemedicine intervention on the improvement of mortality, number of hospital admissions, emergency department visits, and health-related quality of life, compared to usual care.     

Physical Exercise Improves Function in Acutely Hospitalized Older Patients: Secondary Analysis of a Randomized Clinical Trial

ObjectivesTo evaluate the effects of an exercise intervention on physical function, maximal muscle strength, and muscle power in very old hospitalized patients.DesignIn a randomized controlled trial, 130 hospitalized patients were allocated to an exercise intervention (n = 65) or a control group (n = 65). The intervention consisted of a multicomponent exercise training program performed during 5-7 consecutive days (2 sessions/d). The usual care group received habitual hospital care, which included physical rehabilitation when needed.Setting and participantsAcute care for elderly unit. Older adults age >75 years.MeasuresPhysical function, assessed with the Short Physical Performance Battery test and the Gait Velocity Test (GVT), were the primary endpoints. The GVT was also administered under dual-task conditions (ie, verbal and arithmetic GVT). The functional tasks were recorded using an inertial sensor unit to determine the movement pattern. The secondary endpoints were maximal muscle strength and muscle power output.ResultsThe exercise intervention program provided significant benefits over usual care. At discharge (primary time point), the exercise group showed a mean increase of 1.7 points in the Short Physical Performance Battery scale (95% confidence interval [CI] 0.98, 2.42) and 0.14 m·s-1 in the GVT (95% CI 0.086, 0.194) over the usual care group. The intervention also improved the verbal (0.151; 95% CI 0.119, 0.184 vs ?0.001; 95% CI –0.025, 0.033 in the control group) and arithmetic GVT (0.115; 95% CI 0.077, 0.153 vs ?0.004; 95% CI –0.044, 0.035). Significant benefits were also observed in the intervention group in movement pattern, as well as in muscle strength and muscle power.Conclusions and implicationsAn individualized multicomponent exercise training program improves physical function, maximal muscle strength, and muscle power in acutely hospitalized older patients. These findings support the importance of physical exercise for avoiding the loss of physical functional capacity that frequently occurs during hospitalization in older adults.     

Do Exercises Prevent Falls Among Older Adults: Where Are We Now? A Systematic Review

ObjectiveTo determine whether single interventions (SI), multifactorial interventions (MI), or multiple component interventions (MCI) including vitamin D supplementation prevent the incidence of falls and fall risk factors among older adults who are community-dwelling or living in long-term care facilities.DesignSystematic review.MethodsPubMed, Scopus, MEDLINE, and Cochrane were searched with restrictions applied to publication year (2015‒2019) and language (limited to studies published in English). After duplicate removal and title and abstract screening, 2 authors independently identified eligible studies on the basis of inclusion criteria. Risk of bias and quality of evidence were assessed.ResultsThirty-four studies were included after screening titles and abstracts from 855 citations and 129 full-text articles. Thirteen randomized-controlled trials and clinical trials (5 on MI, 1 on MCI, and 7 on SI) including 2232 participants and 21 systematic reviews (assessing SI, MI, MCI, or all) were extracted for qualitative synthesis. Fifteen out of 20 studies that reported outcomes on falls rate found a significant reduction. Seventeen out of 23 studies with outcomes on fall risk factors concluded a significant improvement. Five studies found no significant differences in falls incidence, and 5 studies found no significant differences in fall risks. One study reported worsened outcomes, including poorer balance.Conclusion and ImplicationsAlthough results are inconclusive, SI, MI, and MCI involving exercises may prevent falls. Vitamin D supplementation may be beneficial alongside exercise; however, whether vitamin D use consistently reduces falls incidence or fall risks remains uncertain. Exercises that are individually tailored to participants’ capabilities and risks may be the most effective falls prevention interventions. Implementation may reduce medical costs and improve quality of life for older adults who are community-dwelling or are living in long-term care facilities.     

Integration of depression and hypertension treatment: a pilot, randomized controlled trial

PURPOSE We wanted to examine whether integrating depression treatment into care for hypertension improved adherence to antidepressant and antihypertensive medications, depression outcomes, and blood pressure control among older primary care patients.METHODS Older adults prescribed pharmacotherapy for depression and hypertension from physicians at a large primary care practice in West Philadelphia were randomly assigned to an integrated care intervention or usual care. Outcomes were assessed at baseline, 2, 4, and 6 weeks using the Center for Epidemiologic Studies Depression Scale (CES-D) to assess depression, an electronic monitor to measure blood pressure, and the Medication Event Monitoring System to assess adherence.RESULTS In all, 64 participants aged 50 to 80 years participated. Participants in the integrated care intervention had fewer depressive symptoms (CES-D mean scores, intervention 9.9 vs usual care 19.3; P <.01), lower systolic blood pressure (intervention 127.3 mm Hg vs usual care 141.3 mm Hg; P <.01), and lower diastolic blood pressure (intervention 75.8 mm Hg vs usual care 85.0 mm Hg; P <.01) compared with participants in the usual care group at 6 weeks. Compared with the usual care group, the proportion of participants in the intervention group who had 80% or greater adherence to an antidepressant medication (intervention 71.9% vs usual care 31.3%; P <.01) and to an antihypertensive medication (intervention 78.1% vs usual care 31.3%; P <.001) was greater at 6 weeks.CONCLUSION A pilot, randomized controlled trial integrating depression and hypertension treatment was successful in improving patient outcomes. Integrated interventions may be more feasible and effective in real-world practices, where there are competing demands for limited resources.     

Impact of Interventions on Medication Adherence and Blood Pressure Control in Patients with Essential Hypertension: A Systematic Review by the ISPOR Medication Adherence and Persistence Special Interest Group

ObjectivesTo systematically review the evidence on the impact of interventions to improve medication adherence in adults prescribed antihypertensive medications.MethodsAn electronic search was undertaken of articles published between 1979 and 2009, without language restriction, that focused on interventions to improve antihypertensive medication adherence among patients (≥18 years) with essential hypertension. Studies must have measured adherence as an outcome of the intervention. We followed standard guidelines for the conduct and reporting of the review and conducted a narrative synthesis of reported data.ResultsNinety-seven articles were identified for inclusion; 35 (35 of 97, 36.1%) examined interventions to directly improve medication adherence, and the majority (58 of 97, 59.8%) were randomized controlled trials. Thirty-four (34 of 97, 35.1%) studies reported a statistically significant improvement in medication adherence.Discussion/ConclusionsInterventions aimed at improving patients’ knowledge of medications possess the greatest potential clinical value in improving adherence with antihypertensive therapy. However, we identified several limitations of these studies, and advise future researchers to focus on using validated adherence measures, well-designed randomized controlled trials with relevant adherence and clinical outcomes, and guidelines on the appropriate design and analysis of adherence research.     

A Systematic Review of Nursing Home Palliative Care Interventions: Characteristics and Outcomes

BackgroundDespite recommendations to integrate palliative care into nursing home care, little is known about the most effective ways to meet this goal.ObjectiveTo examine the characteristics and effectiveness of nursing home interventions that incorporated multiple palliative care domains (eg, physical aspects of care—symptom management, and ethical aspects—advance care planning).DesignSystematic review.MethodsWe searched MEDLINE via PubMed, Embase, CINAHL, and Cochrane Library's CENTRAL from inception through January 2019. We included all randomized and nonrandomized trials that compared palliative care to usual care and an active comparator. We assessed the type of intervention, outcomes, and the risk of bias.ResultsWe screened 1167 records for eligibility and included 13 articles. Most interventions focused on staff education and training strategies and on implementing a palliative care team. Many interventions integrated advance care planning initiatives into the intervention. We found that palliative care interventions in nursing homes may enhance palliative care practices, including processes to assess and manage pain and symptoms. However, inconsistent outcomes and high or unclear risk of bias among most studies requires results to be interpreted with caution.Conclusions and ImplicationsHeterogeneity in methodology, findings, and study bias within the existing literature revealed limited evidence for nursing home palliative care interventions. Findings from a small group of diverse clinical trials suggest that interventions enhanced nursing home palliative care and improved symptom assessment and management processes.     

Effect of a Simple Exercise Program on Hospitalization-Associated Disability in Older Patients: A Randomized Controlled Trial

ObjectiveHospitalization-associated disability [HAD, ie, the loss of ability to perform ≥1 basic activities of daily living (ADLs) independently at discharge] is a frequent condition among older patients. The present study assessed whether a simple inpatient exercise program decreases HAD incidence in acutely hospitalized very old patients.DesignIn this randomized controlled trial (Activity in Geriatric Acute Care) participants were assigned to a control or intervention group and were assessed at baseline, admission, discharge, and 3 months thereafter.Setting and ParticipantsIn total, 268 patients (mean age 88 years, range 75–102) admitted to an acute care for older patients unit of a public hospital were randomized to a control (n = 125) or intervention (exercise) group (n = 143).MethodsBoth groups received usual care, and patients in the intervention group also performed simple supervised exercises (walking and rising from a chair, for a total duration of ∼20 minutes/day). We measured ADL function (Katz index) and incident HAD at discharge and after 3 months (primary outcome) and Short Physical Performance Battery, ambulatory capacity, number of falls, rehospitalization, and death during a 3-month follow-up (secondary outcomes).ResultsMedian duration of hospitalization was 7 days (interquartile range 4 days). The intervention group had a lower risk of HAD with reference to both baseline [odds ratio (OR) 0.36; 95% confidence interval (CI) 0.17–0.76, P = .007] and admission (OR 0.29; 95% CI 0.10–0.89, P = .030). A trend toward an improved ADL function at discharge vs admission was found in the intervention group compared with controls (OR 0.32; 95% CI ‒0.04 to 0.68; P = .083). No between-group differences were noted for the other endpoints (all P > .05).Conclusion and ImplicationsA simple inpatient exercise program decreases risk of HAD in acutely hospitalized, very old patients.     

Is Dietetic Treatment for Undernutrition in Older Individuals in Primary Care Cost-Effective?

ObjectivesUndernutrition in older age is associated with adverse clinical outcomes and high health care costs. This study aimed to evaluate the cost-effectiveness of a dietetic treatment in primary care compared with usual care in older, undernourished, community-dwelling individuals.DesignA parallel randomized controlled trial.SettingPrimary care.ParticipantsA total of 146 undernourished, independently living older (≥65 years) individuals.InterventionDietetic treatment.MeasurementsMain outcomes were change in kilogram body weight compared with baseline and quality-adjusted life years (QALYs) after 6 months. Costs were measured from a societal perspective. The main analysis was performed according to the intention-to-treat principle. Multiple imputation was used to impute missing data and bootstrapping was used to estimate uncertainty surrounding cost differences and incremental cost-effectiveness ratios. Cost-effectiveness planes and cost-effectiveness acceptability curves were estimated.ResultsThe participants were randomized to receive either dietetic treatment (n = 72) or usual care (n = 74). After 6 months, no statistically significant differences were found between the dietetic treatment and usual care group in body weight change (mean difference 0.78 kg, 95% CI −0.26–1.82), QALYs (mean difference 0.001, 95% CI −0.04–0.04) and total costs (mean difference €1645, 95% CI −525–3547). The incremental cost-utility ratio (ICUR) for QALYs was not interpretable. The incremental cost-effectiveness ratio (ICER) for body weight gain was 2111. The probability that dietetic treatment is cost-effective compared with usual care was 0.78 for a ceiling ratio of €5000 for body weight and 0.06 for a ceiling ratio of €20.000 for QALY.ConclusionIn this study, dietetic treatment in older, undernourished, community-dwelling individuals was not cost-effective compared with usual care.     

Interventions to Improve Clinical Outcomes in Older Adults Admitted to a Surgical Service: A Systematic Review and Meta-analysis

ObjectivesManaging older patients with surgical conditions is a major challenge for hospitals. There is therefore a growing interest in providing geriatric perioperative services. The aim of this systematic review and meta-analysis was to characterize and assess the impact of targeted perioperative geriatric interventions on clinical outcomes of older adults admitted to nonorthopedic surgical teams.Design, Setting and ParticipantsA systematic review and meta-analysis of studies of perioperative geriatric interventions in older adults hospitalized under nonorthopedic surgical teams.MethodsOvid MEDLINE, EMBASE, PsycINFO, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and trial registry databases were searched. Primary outcomes were change in functional status and length of stay (LOS).ResultsFifteen randomized controlled trials (RCTs) and 9 prospective before-and-after studies met the inclusion criteria (n = 3026 participants). Perioperative geriatric interventions included preoperative comprehensive geriatric assessment and management (CGA) (5 studies), multicomponent inpatient geriatric programs (8 studies), cognitive training (1 study), exercise (5 studies), and prehabilitation (5 studies). Exercise therapy [mean difference (MD) −1.90, 95% confidence interval (CI) −3.01, −0.80], multicomponent inpatient geriatric programs (MD –1.98, 95% CI –3.09, −0.88), and prehabilitation (MD –1.32, 95% CI –2.75, 0.11) reduced LOS. Functional decline was highly heterogeneous, with 4 of 8 studies reporting significantly less functional decline. Geriatric perioperative interventions reduced complications [exercise therapy risk ratio (RR) 0.74, 95% CI 0.48, 1.15; prehabilitation RR 0.61, 95% CI 0.47, 0.80] and delirium (multicomponent inpatient geriatric programs RR 0.49, 95% CI 0.27, 0.90; preoperative CGA RR 0.54, 95% CI 0.33, 0.89). There was no significant impact on mortality or readmissions.Conclusions and ImplicationsPerioperative geriatric interventions targeted at older nonorthopedic surgical patients improve some clinically relevant outcomes. There is a need for these interventions to be further evaluated in high-quality studies, and future research should explore how to effectively implement these interventions within complex health care systems.     

Urinary Incontinence and Indwelling Urinary Catheters in Acutely Admitted Elderly Patients: Relationship With Mortality,Institutionalization, and Functional Decline

ObjectivesTo study differences in functional status at admission in acutely hospitalized elderly patients with urinary incontinence, a catheter, or without a catheter or incontinence (controls) and to determine whether incontinence or a catheter are independent risk factors for death, institutionalization, or functional decline.DesignProspective cohort study conducted between 2006 and 2008 with a 12-month follow-up.SettingEleven medical wards of 2 university teaching hospitals and 1 teaching hospital in the Netherlands.ParticipantsParticipants included 639 patients who were 65 years and older, acutely hospitalized for more than 48 hours.MeasurementsBaseline characteristics, functional status, presence of urinary incontinence or catheter, length of hospital stay, mortality, institutionalization, and functional decline during admission and 3 and 12 months after admission were collected. Regression analyses were done to study a possible relationship between incontinence, catheter use, and adverse outcomes at 3 and 12 months.ResultsOf all patients, 20.7% presented with incontinence, 23.3% presented with a catheter, and 56.0% were controls. Patients with a catheter scored worst on all baseline characteristics. A catheter was an independent risk factor for mortality at 3 months (odds ratio [OR] = 1.73, 95% confidence interval [CI] 1.10–2.70), for institutionalization at 12 months (OR = 4.03, 95% CI 1.67–9.75), and for functional decline at 3 (OR = 2.17, 95% CI 1.32–3.54) and 12 months (OR = 3.37, 95% CI 1.81–6.25). Incontinence was an independent risk factor for functional decline at 3 months (OR = 1.84, 95% CI 1.11–3.04).ConclusionThere is an association between presence of a catheter, urinary incontinence, and development of adverse outcomes in hospitalized older patients.     

Cognitive Function Improvements Mediate Exercise Intervention Effects on Physical Performance in Acutely Hospitalized Older Adults

ObjectivesAn individualized, multicomponent exercise program is effective to reverse the functional and cognitive decline that frequently occur during acute care hospitalization in older patients. The aim was to determine whether improvements in cognition mediate improvements in physical function in acutely hospitalized older patients.DesignA single-center, single-blind randomized clinical trial.Setting and ParticipantsAcute care for elderly (ACE) unit in a tertiary public hospital in Navarre (Spain). Hospitalized patients were randomly assigned to an exercise intervention (n = 185) or usual-care group (n = 185). The intervention consisted of a multicomponent exercise-training program performed during 5 to 7 consecutive days (2 sessions/day). The usual-care group received habitual hospital care, which included physical rehabilitation when needed.MeasuresThe main endpoints were changes in cognitive function assessed by the Mini-Mental State Examination test and verbal fluency ability, and changes in physical performance by the Short Physical Performance Battery from baseline to discharge. Mediation regression models were generated using ordinary least squares with the PROCESS version 3.2 to determine links between exercise-induced improvements.ResultsMediation regression model analysis indicated a significant and direct beneficial effect of physical exercise on physical function (β = 2.14; P < .0001), and a significant indirect effect of global cognitive function on the direct effect (indirect effect = 0.26; 0.10 to 0.49). Verbal fluency ability also had an indirect effect (0.32; 0.16 to 0.53) on the positive effect of exercise-training on physical function.Conclusions and ImplicationsCognitive function enhancements mediate physical function improvements in acutely hospitalized older adults after an individualized, multicomponent exercise-training program.ClinicalTrials.gov registration (NCT02300896)     

The use of incentives to reinforce medication adherence

ObjectivePoor medication adherence is a longstanding problem, and is especially pertinent for individuals with chronic conditions or diseases. Adherence to medications can improve patient outcomes and greatly reduce the cost of care. The purpose of the present review is to describe the literature on the use of incentives as applied to the problem of medication adherence.MethodsWe conducted a systematic review of peer-reviewed empirical evaluations of incentives provided to patients contingent upon medication adherence.ResultsThis review suggests that incentive-based medication adherence interventions can be very effective, but there are few controlled studies. The studies on incentive-based medication adherence interventions most commonly feature patients taking medication for drug or alcohol dependence, HIV, or latent tuberculosis. Across studies that reported percent adherence comparisons, incentives increased adherence by a mean of 20 percentage points, but effects varied widely. Cross-study comparisons indicate a positive relationship between the value of the incentive and the impact of the intervention. Post-intervention evaluations were rare, but tended to find that adherence effects diminish after the interventions are discontinued.ConclusionsIncentive-based medication adherence interventions are promising but understudied. A significant challenge for research in this area is the development of sustainable and cost-effective long-term interventions.     

Effect of Clinical Care Pathways on Quality of Life and Physical Function After Fragility Fracture: A Meta-analysis

ObjectivesTo evaluate the effect of clinical care pathways (CCPs) on health-related quality of life (HRQoL) and physical function following fragility fracture and identify the specific characteristics of CCPs that are associated with improved outcomes.DesignSystematic review and meta-analysis.Setting and participantsRandomized controlled studies and nonrandomized studies that involved participants aged ≥50 years who sustained a fragility fracture, evaluated the effects of a CCP compared to usual care, and reported outcomes of HRQoL or physical function.MethodsWe systematically searched Ovid Medline, CINAHL, Embase, and the Cochrane Central Register of Controlled Trials from the earliest records to July 25, 2018. Two reviewers independently extracted study data and assessed methodologic quality.ResultsOverall, 22 studies (17 randomized controlled trials, 5 nonrandomized studies) were included, comprising 5842 participants. Twenty-one studies included hip fracture patients, and 1 included wrist fracture patients. Majority of studies (82%) were assessed as high quality. Meta-analyses showed moderate improvements in the CCP group for HRQoL [standardized mean difference (SMD) = 0.24, 95% confidence interval (CI) 0.12, 0.35] and physical function (SMD 0.21, 95% CI 0.10, 0.33) compared with usual care post hip fracture. Inpatient CCPs that extended to the outpatient setting showed greater improvements in HRQoL and physical function compared to CCPs that were only inpatient or outpatient. CCPs that included a care coordinator, geriatric assessment, rehabilitation, prevention of inpatient complications, nutritional advice, or discharge planning also showed greater improvements in outcomes.Conclusions and ImplicationsTreatment with CCPs following fragility fracture showed greater improvements in HRQoL and physical function compared with usual care. Further research is warranted to assess the combination of CCP components that provide the most beneficial results, evaluate the effect of CCPs in patients with nonhip fractures, and determine which patient groups are more likely to benefit from CCPs.     

Dementia Care in the General Practice Setting: A Cluster Randomized Trial on the Effectiveness and Cost Impact of Three Management Strategies

ObjectiveTo compare a complex nondrug intervention including actively approaching counseling and caregiver support groups with differing intensity against usual care with respect to time to institutionalization in patients with dementia.MethodsWithin this three-armed cluster-randomized controlled trial, 390 community-dwelling patients aged 65 years or older with physician-diagnosed mild to moderate dementia and their caregivers were enrolled via 129 general practitioners in Middle Franconia, Germany. The intervention included general practitioners' training in dementia care and their recommendation of support groups and actively approaching caregiver counseling. Primary study end point was time to institutionalization over 2 years. In addition, long-term intervention effects were assessed over a time horizon of 4 years. Secondary end points included cognitive functioning, (instrumental) activities of daily living, burden of caregiving, and health-related quality of life after 2 years. Frailty models with strict intention-to-treat approach and mixed linear models were applied to account for cluster randomization. Health care costs were assessed from the societal perspective.ResultsAfter 2 (4) years, 12% (24%) of the patients were institutionalized and another 21% (35%) died before institutionalization. No significant differences between study groups were observed with respect to time to institutionalization after 2 and 4 years (P 0.25 and 0.71, respectively). Secondary end points deteriorated, but differences were not significant between study groups. Almost 80% of the health care costs were due to informal care. Total annual costs amounted to more than €47,000 per patient and did not differ between study arms.ConclusionThe intervention showed no effects on time to institutionalization and secondary outcomes.     

La prevención de las caídas de las personas mayores y sus familiares: una síntesis cualitativa

ObjectiveTo analyse and synthesize the evidence on fall prevention of people older than 65 years and their family care providersMethodQualitative synthesis, which is a part of a convergent systematic integrative review. Forty-one qualitative studies were retained for full text scrutiny. Nine studies on family care providers were selected for this synthesis.ResultsCare providing, and kinship relationships mediated family care providers’ interventions to prevent falls in older people. The fall of the dependent relative constitutes a turning point in these relationships. Family care providers are vulnerable to having a fall themselves and therefore receivers of preventive interventions.ConclusionsTaking into account the context of care and family relations will improve the effectiveness of preventive interventions and will facilitate adherence. Fall prevention policy and programmes must pay better attention to the health and wellbeing of family care providers.     

A multicenter randomized controlled trial to compare subacute 'treatment as usual' with and without mental practice among persons with stroke in Dutch nursing homes

ObjectiveSystematic reviews suggest that mental practice as an additional therapy for people with stroke might be effective and suggest that more trials with better defined interventions are needed. This study investigated whether imagining the skilled movement systematically can contribute to a quicker and/or better recovery of stroke patients in long term care.DesignA multicenter randomized controlled trial.SettingDutch nursing homes.ParticipantsStroke patients in the subacute phase of recovery.InterventionsStudy participants were randomly assigned to the control or experimental group. Over a 6-week intervention period, both groups received multi professional therapy as usual. Additionally, patients in the experimental group had instruction on mental practice with a 4-step framework embedded in regular therapy time.Main OutcomeOutcomes were assessed at 6 weeks and 6 months with the patient-perceived effect on performance of daily activities (10-point Numeric Rating Scale). Six secondary outcomes on impairment and activity level were also assessed. Primary analyses were performed according to the intention-to-treat principle. Generalized estimating equations (GEE) were used to analyze effects.ResultsThirty-six adult stroke patients (average age 77.8, ±7.2 years) participated in the trial. No effect in favor of the mental practice intervention on any outcome measure could be detected at either measuring points.ConclusionsThis study could not show differences between embedded mental practice and current standard of care. However, stroke pathways in Dutch nursing homes select specific and frail patients, which might have reduced the effects of training.     

Modeling Early Warning Systems: Construction and Validation of a Discrete Event Simulation Model for Heart Failure

ObjectivesDeveloping and validating a discrete event simulation model that is able to model patients with heart failure managed with usual care or an early warning system (with or without a diagnostic algorithm) and to account for the impact of individual patient characteristics in their health outcomes.MethodsThe model was developed using patient-level data from the Trans-European Network – Home-Care Management System study. It was coded using RStudio Version 1.3.1093 (version 3.6.2.) and validated along the lines of the Assessment of the Validation Status of Health-Economic decision models tool. The model includes 20 patient and disease characteristics and generates 8 different outcomes. Model outcomes were generated for the base-case analysis and used in the model validation.ResultsPatients managed with the early warning system, compared with usual care, experienced an average increase of 2.99 outpatient visits and a decrease of 0.02 hospitalizations per year, with a gain of 0.81 life years (0.45 quality-adjusted life years) and increased average total costs of €11 249. Adding a diagnostic algorithm to the early warning system resulted in a 0.92 life year gain (0.57 quality-adjusted life years) and increased average costs of €9680. These patients experienced a decrease of 0.02 outpatient visits and 0.65 hospitalizations per year, while they avoided being hospitalized 0.93 times. The model showed robustness and validity of generated outcomes when comparing them with other models addressing the same problem and with external data.ConclusionsThis study developed and validated a unique patient-level simulation model that can be used for simulating a wide range of outcomes for different patient subgroups and treatment scenarios. It provides useful information for guiding research and for developing new treatment options by showing the hypothetical impact of these interventions on a large number of important heart failure outcomes.