Cost-Effectiveness of a Proactive Primary Care Program for Frail Older People: A Cluster-Randomized Controlled Trial

Background

A proactive integrated approach has shown to preserve daily functioning among older people in the community. The aim is to determine the cost-effectiveness of a proactive integrated primary care program.

Open Trial of Integrated Primary Care Consultation for Medically Unexplained Symptoms

Within primary care settings, patients with medically unexplained symptoms (MUS) are common, often present with comorbid psychopathology, and have high rates of healthcare utilization. Despite increased healthcare utilization, these patients often have poor outcomes that frustrate patients and providers alike. A behavioral consultation intervention for primary care patients with MUS (n?=?10) was developed and assessed. All participants completed all intervention and assessment sessions and rated the intervention favorably. Participants self-report scores revealed statistically significant improvements from baseline to 3-month follow-up on physical functioning, mental functioning, and physical symptoms. Notwithstanding the limitations of open trial designs, these findings demonstrate high feasibility for a behavioral health consultation treatment model for patients with MUS and highlight the need for further research.     

Practice Facilitation to Improve Diabetes Care in Primary Care: A Report From the EPIC Randomized Clinical Trial

PURPOSE

We investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing self-directed (SD) practices with model information and resources, without facilitation.

METHODS

We conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys.

RESULTS

Although measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices.

CONCLUSIONS

Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture.     

The Effectiveness and Cost-effectiveness of a Parenting Intervention Integrated with Primary Health Care on Early Childhood Development: a Cluster-Randomized Controlled Trial

Prevention Science - Developing countries require interventions that can sustainably improve early childhood development (ECD) at scale because hundreds of millions of children are at risk of poor...     

Consultations for Influenza-Like Illness in Primary Care in The Netherlands: A Regression Approach

ObjectivesTo estimate the general practitioner (GP) consultation rate attributable to influenza in The Netherlands.MethodsRegression analysis was performed on the weekly numbers of influenza-like illness (ILI) GP consultations and laboratory reports for influenza virus types A and B and 8 other pathogens over the period 2003–2014 (11 influenza seasons; week 40–20 of the following year).ResultsIn an average influenza season, 27% and 11% of ILI GP consultations were attributed to infection by influenza virus types A and B, respectively. Influenza is therefore responsible for approximately 107 000 GP consultations (651/100 000) each year in The Netherlands. GP consultation rates associated with influenza infection were highest in children under 5 years of age, at 667 of 100 000 for influenza A and 258 of 100 000 for influenza B. Influenza virus infection was found to be the predominant cause of ILI-related GP visits in all age groups except children under 5, in which respiratory syncytial virus (RSV) infection was found to be the main contributor.ConclusionsThe burden of influenza in terms of GP consultations is considerable. Overall, influenza is the main contributor to ILI. Although ILI symptoms in children under 5 years of age are most often associated with RSV infection, the majority of visits related to influenza occur among children under 5 years of age.     

Annals Journal Club: Physician Satisfaction with Chronic Care Processes: A Cluster-Randomized Trial of Guided Care

PURPOSE Chronically ill older patients with multiple conditions are challenging to care for, and new models of care for this population are needed. This study evaluates the effect of the Guided Care model on primary care physicians’ impressions of processes of care for chronically ill older patients.METHODS In Guided Care a specially educated registered nurse works at the practice with 2 to 5 primary care physicians, performing 8 clinical activities for 50 to 60 chronically ill older patients. The care model was tested in a cluster-randomized controlled trial between 2006 and 2009. All eligible primary care physicians in 14 pods (teams of physicians and their chronically ill older patients) agreed to participate (n = 49). Pods were randomly assigned to provide either Guided Care or usual care. Physicians were surveyed at baseline and 1 year later. We assessed the effects of Guided Care using responses from 38 physicians who completed both survey questionnaires. We measured physicians’ satisfaction with chronic care processes, time spent on chronic care, knowledge of their chronically ill older patients, and care coordination provided by physicians and office staff.RESULTS Compared with the physicians in the control group, those in the Guided Care group rated their satisfaction with patient/family communication and their knowledge of the clinical characteristics of their chronically ill older patients significantly higher (ρ<0.05 in linear regression models). Other differences did not reach statistical significance.CONCLUSIONS Based on physician report, Guided Care provides important benefits to physicians by improving communication with chronically ill older patients and their families and in physicians’ knowledge of their patients’ clinical conditions.     

Association of Deprescribing With Reduction in Mortality and Hospitalization: A Pragmatic Stepped-Wedge Cluster-Randomized Controlled Trial

ObjectivesDeprescribing has gained awareness recently, but the clinical benefits observed from randomized trials are limited. The aim of this study was to examine the effectiveness of a pharmacist-led 5-step team-care deprescribing intervention in nursing homes to reduce falls (fall risks and fall rates). Secondary aims include reducing mortality, number of hospitalized residents, pill burden, medication cost, and assessing the deprescribing acceptance rate.DesignPragmatic multicenter stepped-wedge cluster randomized controlled trial.Setting and ParticipantsResidents across 4 nursing homes in Singapore were included if they were aged 65 years and above, and taking 5 or more medications.MethodsThe intervention involved a 5-step deprescribing intervention, which involved a multidisciplinary team-care medication review with pharmacists, physicians, and nurses (in which pharmacists discussed with other team members the feasibility of deprescribing and implementation using the Beers and STOPP criteria) or to an active waitlist control for the first 3 months.ResultsTwo hundred ninety-five residents from 4 nursing homes participated in the study from February 2017 to March 2018. At 6 months, the deprescribing intervention did not reduce falls. Subgroup analysis showed that intervention reduced fall risk scores within the deprescribing-naïve group by 0.18 (P = .04). Intervention was associated with a reduction in mortality [hazard ratio (HR) 0.16, 95% confidence interval 0.07, 0.41; P < .001] and number of hospitalized residents (HR 0.16, 95% CI 0.10, 0.26; P < .001). Pre-post analysis witnessed a reduction in pill burden at the end of the study, and a conservative daily cost saving estimate of US$11.42 (SG$15.65) for the study population. Approximately three-quarters of deprescribing interventions initiated by the pharmacists were accepted by the physicians.Conclusions and ImplicationsMultidisciplinary medication review–directed deprescribing was associated with reductions in mortality and number of hospitalized residents in nursing homes and should be considered for all nursing home residents.     

Effects of the FIT-HIP Intervention for Fear of Falling After Hip Fracture: A Cluster-Randomized Controlled Trial in Geriatric Rehabilitation

ObjectivesFear of falling (FoF) is common after hip fracture and can impede functional recovery because of activity restriction. The Fear of falling InTervention in HIP fracture geriatric rehabilitation (FIT-HIP intervention) was designed to target FoF and consequently to improve mobility. The aim of this study was to evaluate the effect of the FIT-HIP intervention in patients with FoF in geriatric rehabilitation (GR) after hip fracture.Design, setting, and participantsThis cluster-randomized controlled trial was performed in 11 post-acute GR units in the Netherlands (2016-2017). Six clusters were assigned to the intervention group, 5 to the usual care group. We included 78 patients with hip fracture and FoF (aged ≥65 years; 39 per group).Intervention(s)The FIT-HIP intervention is a multicomponent cognitive behavioral intervention conducted by physiotherapists, embedded in usual care in GR. The FIT-HIP intervention was compared to usual care in GR.MeasurementsFoF was assessed with the Falls Efficacy Scale–International (FES-I) and mobility, with the Performance Oriented Mobility Assessment (POMA). Data were collected at baseline, discharge, and 3 and 6 months postdischarge from GR. Primary endpoints were change scores at discharge. Linear mixed models were used to evaluate the treatment effect.ResultsNo significant between-group differences were observed for primary outcome measures. With the usual care group as reference, the FES-I estimated difference between mean change scores was 3.3 [95% confidence interval (CI) ?1.0, 7.5, P = .13] at discharge from GR; ?4.1 (95% CI –11.8, 3.6, P = .29) after 3 months; and ?2.8 (95% CI –10.0, 4.4, P = .44) after 6 months. POMA estimated difference was ?0.3 (95% CI –6.5, 5.8, P = .90).Conclusion/ImplicationsThe FIT-HIP intervention was not effective in reducing FoF. Possibly FoF (shortly) after hip fracture can to some extent be appropriate. This may imply the study was not able to accurately identify and accordingly treat FoF that is maladaptive (reflective of disproportionate anxiety).     

Challenges to Effective Primary Care-Specialty Communication and Coordination in the Mental Health Referral and Care Process for Publicly Insured Children

Publicly insured children needing referral to mental health (MH) services often do not access or receive services. The objective of this study was to identify gaps in communication and coordination between primary care providers (PCPs) and MH providers during the MH referral and care process for publicly insured children. Thirteen semi-structured interviews were conducted with 10 PCPs and staff from a federally qualified health center (FQHC) and 6 MH providers and staff from two local MH clinics. Interview participants identified multiple gaps in communication throughout the care process and different phases as priorities for improvement. PCPs described primary care-MH communication challenges during early phases, while MH providers described coordination challenges in transferring patients back to primary care for ongoing mental health management. Strategies are needed to improve primary care-specialty MH communication and coordination throughout all phases of the referral and care process, particularly at initial referral and transfer back to primary care.     

Post-Acute Care for Older People Following Injury: A Randomized Controlled Trial

ObjectivesThe study sought to determine whether older people, on discharge from hospital and on referral to a supported discharge team (SDT), will have: (1) reduced length of stay in hospital; (2) reduced risk of hospital readmission; and (3) reduced healthcare costs.Design/InterventionRandomized controlled trial with follow-up at 4 and 12 months of post-acute home-based rehabilitation team (SDT). Programs were delivered by trained healthcare assistants, up to 4 times a day, 7 days a week, under the guidance of registered nurses, allied health, and geriatricians for up to 6 weeks.Participants/SettingA total of 303 older women and 100 older men (mean age 81) in hospital because of injury, were randomized to either SDT (n = 201) or usual care (n = 202). The intervention was operated from Waikato hospital, a regional hospital in New Zealand.MethodsDays spent in hospital in the year following randomization and healthcare costs were collected from hospital datasets, and functional status assessed using the interRAI Contact Assessment was gathered by health professional research associates.ResultsParticipants randomized to the SDT spent less time in hospital in the period immediately prior to discharge (mean 20.9 days) in comparison to usual care (mean 26.6 days) and spent less time in hospital in the 12 months following discharge home. Healthcare costs were lower in the SDT group in the 12 months following randomization.Conclusions/ImplicationsSDT can provide an important role in reducing hospital length of stay and readmissions of older people following an injury. Almost a million older people (65+ years of age) a year in the US are hospitalized as a consequence of falls-related injuries, most often fractured hip. Hospitals are not always the best location to provide care for older people. SDTs can help with the transition from hospital to home, while reducing hospital length-of-stay.     

Consultative Care Coordination Through the Medical Home for CSHCN: A Randomized Controlled Trial

The purpose of this study was to examine the impact of a care coordination intervention aimed at improving the medical home for children with special health care needs (CSHCN). 100 CSHCN referred by a Medicaid managed care plan were randomly assigned to a care coordination intervention or to a wait list comparison group that received standard care. For the intervention group, a care coordinator supported the medical home by consulting with primary care providers at multiple practices to develop an integrated, individualized plan to meet child and family needs. During the second phase of the study, the wait list comparison group received the 6-month intervention. At the end of 12 months, the two groups were combined to examine within subject differences (n = 61). Compared to the control group, participants in the initial intervention group reported a decreased need for information and improved satisfaction with mental health services and specialized therapies. This effect was replicated when the wait list control group received the intervention. Additional benefits were observed in the within subject analysis, including a decline in unmet needs, improved satisfaction with specialty care and care coordination, and improved ratings of child health and family functioning. This intervention improved outcomes for CSHCN and their families by supporting the efforts of primary care physicians to provide comprehensive and coordinated care through the medical home. The consulting care coordinator may provide an efficient and cost effective approach to enhancing the quality of care for CSHCN.     

A Community-Adapted Approach to SARS-CoV-2 Testing for Medically Underserved Populations,Rhode Island,USA

We developed a testing program for severe acute respiratory syndrome coronavirus 2 in an urban Latinx neighborhood in Providence, Rhode Island, USA. Approximately 11% of Latinx participants (n = 180) tested positive. Culturally tailored, community-based programs that reduce barriers to testing help identify persons at highest risk for coronavirus disease.     

Effectiveness of an HIV/STD Risk-Reduction Intervention for Adolescents When Implemented by Community-Based Organizations: A Cluster-Randomized Controlled Trial

Objectives. We evaluated the effectiveness of an HIV/STD risk-reduction intervention when implemented by community-based organizations (CBOs).Methods. In a cluster-randomized controlled trial, 86 CBOs that served African American adolescents aged 13 to 18 years were randomized to implement either an HIV/STD risk-reduction intervention whose efficacy has been demonstrated or a health-promotion control intervention. CBOs agreed to implement 6 intervention groups, a random half of which completed 3-, 6-, and 12-month follow-up assessments. The primary outcome was consistent condom use in the 3 months prior to each follow-up assessment, averaged over the follow-up assessments.Results. Participants were 1707 adolescents, 863 in HIV/STD-intervention CBOs and 844 in control-intervention CBOs. HIV/STD-intervention participants were more likely to report consistent condom use (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.06, 1.84) than were control-intervention participants. HIV/STD-intervention participants also reported a greater proportion of condom-protected intercourse (β = 0.06; 95% CI = 0.00, 0.12) than did the control group.Conclusions. This is the first large, randomized intervention trial to demonstrate that CBOs can successfully implement an HIV/STD risk-reduction intervention whose efficacy has been established.The HIV/AIDS pandemic has had a particularly devastating effect on young people throughout the world.¹ Those aged 15 to 24 years account for half of all new HIV infections.² Young people are also at high risk for other STDs. In the United States, although youths aged 15 to 24 years constitute only 25% of the sexually active population, they account for about half of new STD cases.³Controlled studies have identified developmentally appropriate interventions that reduce self-reported sexual-risk behavior^4–10 and rates of biologically confirmed STDs^11,12 among adolescents. Less well-documented is whether efficacious HIV/STD interventions retain their ability to reduce sexual risks when implemented under more realistic real-world circumstances.¹³ This has led to calls for evidence from different types of studies—not studies of the efficacy of HIV/STD risk-reduction interventions under highly controlled circumstances, but studies of their effectiveness in real-world settings.^13–15We conducted a cluster-randomized controlled trial testing the effectiveness of the “Be Proud! Be Responsible!” HIV/STD risk-reduction intervention¹⁶ when implemented by community-based organizations (CBOs). Several randomized controlled trials have demonstrated this intervention''s efficacy. One reported that African American adolescents who received the intervention reported less sexual-risk behavior at 3-month follow-up than did the control group and that the facilitators'' gender did not moderate the intervention''s efficacy. ¹⁷ Another found that African American adolescents who received the intervention reported less sexual-risk behavior at 6-month follow-up than did the control group and that the intervention''s efficacy did not vary by the facilitators'' race or gender, the participants'' gender, or the gender composition of the intervention groups. ¹⁸ A randomized controlled trial found that a culturally adapted version of the intervention reduced sexual risk in Latino adolescents, including monolingual Spanish speakers, at 12-month follow-up.¹⁹ Moreover, the intervention was included in the Centers for Disease Control and Prevention dissemination initiative “Programs that Work” and distributed to US schools and CBOs. An economic analysis suggests that the intervention is cost-effective.²⁰We employed a cluster design with CBOs as the unit of randomization to allow us to draw conclusions about effectiveness of implementation by CBOs. CBOs have played a central role in the fight against HIV since the beginning of the epidemic^21–24 and are seen as an essential component of any multisectoral national strategy to curtail the spread of HIV.² Although previous research has examined factors that increase the likelihood that CBOs will adopt evidence-based HIV risk-reduction strategies,^24–26 no large, randomized, controlled trials have tested the effectiveness of evidence-based interventions when implemented by CBOs.We hypothesized that adolescents in CBOs randomly assigned to implement “Be Proud! Be Responsible!” would be more likely to report consistent condom use than those in CBOs implementing a health-promotion control intervention. A secondary hypothesis was that the intervention''s effectiveness would increase with increases in the amount of training the CBOs received, which varied as follows: only the intervention packet; the packet and 2 days of training; or the packet, the training, a practice intervention-implementation session, and 2 days of additional training incorporating videotapes of trainees'' practice sessions.     

Effects of Training on Use of Stimulant Diversion Prevention Strategies by Pediatric Primary Care Providers: Results from a Cluster-Randomized Trial

Prevention Science - Pediatric primary care is a promising setting for reducing diversion of stimulant medications for ADHD. We tested if training pediatric primary care providers (PCPs) increased...     

The Effect of a School-Based Intervention on Sunbed Use in Danish Pupils at Continuation Schools: A Cluster-Randomized Controlled Trial

PurposeTo examine the effect of an educational intervention on sunbed use and intentions and attitudes toward sunbed use in 14- to 18-year-olds at continuation schools.MethodsWe randomized 33 continuation schools either to receive the educational intervention (n = 16) or to be controls (n = 17). Intervention schools received an e-magazine addressing the health risks of sunbed use. Information on behavior and intentions and attitudes toward sunbed use was gathered through self-administrated questionnaires before the intervention and at 6 months as a follow-up. The effect of the intervention was examined by multilevel linear regression and logistic regression.ResultsSunbed use was significantly lower at follow-up among pupils at intervention schools versus pupils at control schools (girls: odds ratio .60, 95% confidence interval .42–.86; Boys: odds ratio .58, 95% confidence interval .35–.96). The intervention had no effect on intention to use sunbeds or attitudes toward sunbed use. The analyses revealed a significant impact of school on attitudes toward sunbed; the intraclass correlation coefficient was estimated to be 6.0% and 7.8% for girls and boys, respectively.ConclusionsThe findings from the present study provide new evidence of a positive effect of an educational intervention on sunbed use among pupils aged 14–18 years at continuation schools.