The Effects of Guided Care on the Perceived Quality of Health Care for Multi-morbid Older Persons: 18-Month Outcomes from a Cluster-Randomized Controlled Trial

BACKGROUND

The quality of health care for older Americans with chronic conditions is suboptimal.

OBJECTIVE

To evaluate the effects of “Guided Care” on patient-reported quality of chronic illness care.

DESIGN

Cluster-randomized controlled trial of Guided Care in 14 primary care teams.

PARTICIPANTS

Older patients of these teams were eligible to participate if, based on analysis of their recent insurance claims, they were at risk for incurring high health-care costs during the coming year. Small teams of physicians and their at-risk older patients were randomized to receive either Guided Care (GC) or usual care (UC).

INTERVENTION

“Guided Care” is designed to enhance the quality of health care by integrating a registered nurse, trained in chronic care, into a primary care practice to work with 2–5 physicians in providing comprehensive chronic care to 50–60 multi-morbid older patients.

MEASUREMENTS

Eighteen months after baseline, interviewers blinded to group assignment administered the Patient Assessment of Chronic Illness Care (PACIC) survey by telephone. Logistic and linear regression was used to evaluate the effect of the intervention on patient-reported quality of chronic illness care.

RESULTS

Of the 13,534 older patients screened, 2,391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 18 months, 95.3% and 92.2% of the GC and UC recipients who remained alive and eligible completed interviews. Compared to UC recipients, GC recipients had twice greater odds of rating their chronic care highly (aOR = 2.13, 95% CI = 1.30–3.50, p = 0.003).

CONCLUSION

Guided Care improves self-reported quality of chronic health care for multi-morbid older persons.KEY WORDS: quality of care, chronic illness, older     

Parenting Style and the Vulnerable Child Syndrome

TOPIC:  Vulnerable child syndrome (VCS) refers to the combination of the parental view that their child is at increased risk for death despite the child's objective health and the resulting behavior problems in the child. Although risk factors for the development of the syndrome have been outlined, the variability in the development of VCS has not been explained.
PURPOSE:  A theoretical explanation for the variability in the development of VCS utilizing Susan Calkins' model is explored. By considering the development of VCS in light of Calkins' model, variability may be explained and preventative interventions may be instituted.
SOURCES USED:  Relevant literature pertaining to child development and VCS was reviewed.
CONCLUSIONS:  By recognizing the risk of the role that parenting sensitivity plays in the development of VCS, team-based interventions involving a developmental approach may be employed, and the long-term behavioral sequelae of the disorder may be prevented or alleviated.     

Video as an Effective Method to Deliver Pretest Information for Rapid Human Immunodeficiency Testing

Objectives: Video‐based delivery of human immunodeficiency virus (HIV) pretest information might assist in streamlining HIV screening and testing efforts in the emergency department (ED). The objectives of this study were to determine if the video “Do you know about rapid HIV testing?” is an acceptable alternative to an in‐person information session on rapid HIV pretest information, in regard to comprehension of rapid HIV pretest fundamentals, and to identify patients who might have difficulties in comprehending pretest information. Methods: This was a noninferiority trial of 574 participants in an ED opt‐in rapid HIV screening program who were randomly assigned to receive identical pretest information from either an animated and live‐action 9.5‐minute video or an in‐person information session. Pretest information comprehension was assessed using a questionnaire. The video would be accepted as not inferior to the in‐person information session if the 95% confidence interval (CI) of the difference (Δ) in mean scores on the questionnaire between the two information groups was less than a 10% decrease in the in‐person information session arm’s mean score. Linear regression models were constructed to identify patients with lower mean scores based upon study arm assignment, demographic characteristics, and history of prior HIV testing. Results: The questionnaire mean scores were 20.1 (95% CI = 19.7 to 20.5) for the video arm and 20.8 (95% CI = 20.4 to 21.2) for the in‐person information session arm. The difference in mean scores compared to the mean score for the in‐person information session met the noninferiority criterion for this investigation (Δ = 0.68; 95% CI = 0.18 to 1.26). In a multivariable linear regression model, Blacks/African Americans, Hispanics, and those with Medicare and Medicaid insurance exhibited slightly lower mean scores, regardless of the pretest information delivery format. There was a strong relationship between fewer years of formal education and lower mean scores on the questionnaire. Age, gender, type of insurance, partner/marital status, and history of prior HIV testing were not predictive of scores on the questionnaire. Conclusions: In terms of patient comprehension of rapid HIV pretest information fundamentals, the video was an acceptable substitute to pretest information delivered by an HIV test counselor. Both the video and the in‐person information session were less effective in providing pretest information for patients with fewer years of formal education.