Effectiveness of interdisciplinary primary care approach to reduce disability in community dwelling

12 Pages·2013·0.73 MB·English

BMJ2013;347:f5264doi:10.1136/bmj.f5264(Published10September2013) Page1of12
Research
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Effectiveness of interdisciplinary primary care .1
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approach to reduce disability in community dwelling /b
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frail older people: cluster randomised controlled trial j.f5
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OPENACCESS on
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Silke F Metzelthin scientific researcher1, Erik van Rossum lecturer in innovations in care for frail ep
te
elderly2,LucPdeWitteprofessoroftechnologyincare3,AntoniusWAmbergenstatistician4,Sjoerd m
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O Hobma general practitioner5, Walther Sipers geriatrician6, Gertrudis I J M Kempen professor of er 2
social gerontology1 01
3
. D
1DepartmentofHealthServicesResearch-FocusingonChronicCareandAgeing,CAPHRISchoolforPublicHealthandPrimaryCare,Maastricht ow
University,POBox616,6200MDMaastricht,Netherlands;2CentreofResearchonAutonomyandParticipation,ZuydUniversityofAppliedSciences, nlo
POBox550,6400ANHeerlen,Netherlands;3CentreofResearchonTechnologyinCare,ZuydUniversityofAppliedSciences;4Departmentof a
d
MethodologyandStatistics,CAPHRISchoolforPublicHealthandPrimaryCare,MaastrichtUniversity;5DepartmentofGeneralPractice,CAPHRI ed
SchoolforPublicHealthandPrimaryCare,MaastrichtUniversity;6OrbisMedicalCentre,POBox5500,6130MBSittard,Netherlands fro
m
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Abstract ConclusionsThisstudyfoundnoevidencefortheeffectivenessofthe ://w
ObjectiveToevaluatewhetheraninterdisciplinaryprimarycareapproach PoCapproach.Thestudycontributestotheemergingbodyofevidence w
forcommunitydwellingfrailolderpeopleismoreeffectivethanusual thatcommunitybasedcareinfrailolderpeopleisachallengingtask. w.b
careinreducingdisabilityandpreventing(further)functionaldecline. Moreresearchinthisfieldisneeded. m
DesignClusterrandomisedcontrolledtrial. TrialregistrationCurrentControlledTrialsISRCTN31954692. j.co
m
Setting12generalpracticesinthesouthoftheNetherlands Introduction o/
n
PInadritciactiopra)nwtesr3e4in6cflruadileodl;d2e7r0pe(7o8p%le)(sccoomrepl≥e5teodnthGerostnuindgy.enFrailty Icnhaolulernaggeesinignshoecailetthyc,acraer.e12foErvoidldeenrcpeesoupglgeeisstosntehaotfctohmegmreuantietsyt 15 J
a
InterventionsGeneralpracticeswererandomisedtotheintervention basedcareincomparisonwithinstitutionalisationmayachieve nu
orcontrolgroup.Practicesinthecontrolgroupdeliveredcareasusual. betteroutcomesatlowercostsandispreferredbyolderpeople ary
Practicesintheinterventiongroupimplementedthe“PreventionofCare” themselves.34Consequently,anincreasingdemandexistsfor 2
(PoC)approach,inwhichfrailolderpeoplereceivedamultidimensional innovativeinitiativestoprovidecosteffectivecommunitybased 02
3
assessmentandinterdisciplinarycarebasedonatailormadetreatment care.56InmostWesterncountries,suchastheUnitedKingdom b
planandregularevaluationandfollow-up. andtheNetherlands,generalpractitionershaveacentralposition y g
u
MainoutcomemeasuresTheprimaryoutcomewasdisability,assessed intheprovisionofcommunitycare,astheyaregatekeepersto e
s
at24monthsbymeansoftheGroningenActivityRestrictionScale. specialisedandhospitalcare.7IntheUK,generalpractitioners t. P
Secondaryoutcomesweredepressivesymptomatology,socialsupport havebeenrequiredsince1990toofferanannual ro
interactions,fearoffalling,andsocialparticipation.Outcomeswere multidimensionalassessmenttotheirpatientsaged75yearsand te
measuredatbaselineandat6,12,and24months’follow-up. over.8Inaddition,generalpractitioners’geographicalproximity cte
d
Results193olderpeopleintheinterventiongroup(sixpractices) toolderpeopleandtheirintenseandlonglastingrelationship b
receivedthePoCapproach;153olderpeopleinthecontrolgroup(six withtheirpatientsmaycontributetoeffectivecareinolder y c
people.7However,communitybasedcareoffrailolderpeople o
practices)receivedcareasusual.Follow-upratesforpatientswere91% p
(2n4=m31o6n)thast.sMixixmeodnmthosd,e8l6m%u(lntil=e2v9e8l)aanta1ly2semsosnhthosw,eadndno78si%gn(infi=ca2n7t0)at ihdseecafihlntahelcdleaanresgindneigfef.dicFsu,ralwtiylhoioclrdhdeoerfppteeennodpleelnaedchytaovineditmshaeubleitlxiipteylce.u9-at1in1oDdnicosoafmbdipaliiltleyyxis yright.
differencesbetweenthetwogroupswithregardtodisability(primary
activitiesthatareessentialforindependentliving.9Asdisability
outcome)andsecondaryoutcomes.Pre-plannedsubgroupanalyses
isconsideredadynamicprocess,olderpeoplecanrecovertoa
confirmedtheseresults.
Correspondence to: S F Metzelthin [email protected]
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RESEARCH
lessdisabledornon-disabledstate.12Regardless,preventive andsystematicpolicyforthedetectionandfollow-upoffrail
actionshavetobetakentoimprovetheabilitiesoffrailolder olderpeopletotakepartinthestudy.Intotal,24practiceswere
B
peopletoremainathomeaslongaspossible.13 interested,ofwhichwerandomlyselected12forthestudyon M
J
Dedxiastnaebinëisllisivtyaeniodnvcceoorvlmlieemawguuonefitsyedxdiidswtiaenlnglianirngrtaeftrriavvieelnortelidvoeinerswpfeotoorppplrreeo.v1v4eiTdnhetieoannof tfyhoeecaurbssa)es.siTsohonoftshaeecwiorhmcoopmwutmeerruegnteeitnrymedriawntaeeldlllyilniisgltl,ofrwfaenilrueomlcdboeenrrfspi.naTetidheentotsstbu(e≥ddy7,0 : first pu
identifiedinterventions,mostofwhichwereinthefieldof hadseverecognitiveorpsychologicalimpairments,orwere blis
comprehensivegeriatricassessmentandphysicalexercise unabletocommunicateinDutchwereexcludedonthebasisof h
e
programmes,showedalargediversityintermsofcontent, theadviceofthegeneralpractitioner.Theremainingotherolder d a
disciplinesinvolved,duration,intensity,andsetting.Onlya people(n=3498)inthe12practicesreceivedapostal s
smallnumberhaveshownbeneficialeffectswithregardto questionnaire,includingtheGroningenFrailtyIndicator.18In 10
disability,andmoststudiesdidnotreportonanylongterm theliterature,ascoreof4orhigher(range0-15)isproposedas .11
effects.14Onthebasisofthisreview,theauthorssuggestedthat thecut-offpointformoderatelytoseverelyfrailolderpeople.18 36
communitycareinterventionsforfrailolderpeopleshouldbe However,thisstudyfocusedonpeoplewhowereconsiderably /bm
cinodnidvuidcuteadlisbeydaanssienstsemrdeisnctsipalnindairnyteprrvimenatiroyncsa(rteaitleoarmmiandveoclavrien)g, fdreavile,lorapnignigndgisfraobmilitpyetoopdleiswabhloedhaovldeearnpeinocprleea.sTehderriesfkorfeo,rolder j.f52
6
selfmanagementsupport,engagementinmeaningfulactivities, peoplewhosignedtheinformedconsentformandhada 4
casemanagement,andlongtermfollow-up.Inaneffortto GroningenFrailtyIndicatorscoreof5orhigherwereincluded on
reducedisabilityandprevent(further)functionaldeclinein inthestudy.Forpracticalreasons,therecruitmentoffrailolder 10
communitydwellingfrailolderpeople,wehavecombinedthese peopletookplaceinthreecycles.Thefirstcyclestartedin S
e
ealpepmroeancths.inTthoisonaepparpoparcohacfohc:uthsees“oPnrebvoetnhtioolndeorfpCeaorpel”e(wPoitCh)an DMeacrecmhb2e0r1200.0T9h,ethinetesrevceonntdioinnaFnedbrtuhaercyo2ll0e1c0ti,oannodftdhaettahairldsoin ptem
increasedriskfordevelopingdisabilityandolderpeoplewho tookplaceinthreecycles.Allincludedolderpeoplegavewritten be
arealreadydisabled.15Apreviouspilotstudy(n=41)usingthe informedconsentbeforecollectionofthebaselinemeasure. r 2
0
PoCapproachhasshownpromisingresults.15Olderpeople 1
appreciatedtheattentiontheygotandfeltsupportedinreaching Intervention 3. D
theirgoalsandinhandlingfuturedisability.Healthcare Intheinterventiongroup(sixpractices),frailolderpeople ow
professionalsreportedthattheapproachprovidedauseful receivedthePoCapproach.Thegeneralpractitionerandpractice nlo
structureforgeriatricprimarycare.Inaddition,theapproach nursebuiltthecoreteamoftheinterdisciplinarycareapproach. a
d
stimulatedinterdisciplinarycollaboration,afocusonmeaningful In2001theprofessionofpracticenursewasintroducedinthe ed
activities,andselfmanagementsupport.15However,the NetherlandstoreducetheworkloadofDutchgeneral fro
effectivenesswithregardtodisabilityandvariousrelated practitioners,whoarethegatekeepertospecialisedandhospital m
otohunitsvctoarmriiaoelustsohpainsavtnieeosntttyigleeatvtbeeeltehoneustetcufofdemiceetdisv.CceonomensspseaoqrfueedthnwetlyiPt,howCuesaucpaoplnrcdoauarcceth.e1d6 cgmaearnene.ar1g9alePmprareacnctittc,itemionenunertrsa,eloshnoefadtlietshneaswesoervrpkicr,eeuvsn,edanestisroetnshs,emcsheurnpotensriovcficsfiaroraneiloofldtheer http://w
w
Wechoseaclusterrandomiseddesignforpracticalreasonsand people,andcareoffamilieswithyoungchildren.20Withinthe w
toavoidcontaminationbias.17 PoCapproach,thegeneralpractitionerandpracticenurse .bm
cooperatecloselywithoccupationalandphysicaltherapists.If j.c
Methods needed,otherinpatientandoutpatienthealthcareprofessionals, om
Study design suchasapharmacistorageriatrician,areinvolvedaswell. o/
n
ThePoCapproachaimstoreducedisabilityandprevent(further) 1
Wedidatwoarmclusterrandomisedcontrolledtrialamong12 functionaldeclinebyusingasixstepapproach(fig1⇓).21After 5 J
generalpracticesinthesouthoftheNetherlands.Beforethe thepostalscreeningforfrailtyusingtheGroningenFrailty an
screeningprocedureforidentifyingfrailolderpeoplestarted, Indicator(step1),frailolderpeopleandtheirinformalcaregiver, ua
wsixerparnadctoimcelsytoallcoocnattienduesicxapreraacstiucseusatlo.BtheefoProeCraanpdpormoaicshatiaonnd, iafmavualitliadbimlee,nrescioenivaelaashsoemssemveinstitfboycuthsienpgraocntiecxeisntuinrsgepwrohboldemoess ry 20
2
thepracticeswerepre-stratifiedintofourstratabasedonnumber inperformingdailyactivitiesandonriskfactorsfordisability 3
ofolderpatients(<350versus≥350patients)andlocation(urban (step2).Thefocusisonactivitiesthataremeaningfultothe by
versusruralarea).Weassumedthatgeneralpractitioners olderperson.Examplesofmeaningfulactivitiesaregardening, gu
workinginapracticewithalargenumberofolderpatientshave visitingfamily/friends,readingabook,takingawalk,playing es
moreexperiencewithgeriatriccareandthatolderpeopleliving games,andjoiningreligiousactivities.Afterthehomevisit,the t. P
inaruralareareceivemoresupportfromtheinformalcare generalpractitionerandpracticenursediscusswhether ro
systemthandothoselivinginanurbanarea.Westratifiedthe additionalassessmentsbyotherinpatientoroutpatienthealthcare tec
practicesinpairsandusedacomputergeneratedrandomisation professionalsareneeded.Onthebasisoftheassessmentphase, ted
listtorandomisethemintoeithertheinterventionorcontrol apreliminarytreatmentplanisformulated(step3),eitherina by
group.Topromoteextrapolationoftheresults,practicesinan bilateralmeeting(generalpractitionerandpracticenurse)orin c
o
urbanareawithalargenumberofolderpeoplehadtwicethe anextendedteammeetingconsistingofageneralpractitioner, py
chanceofbeingallocatedtotheinterventiongroupthandid practicenurse,occupationalandphysicaltherapist,and,if rig
practicesintheotherthreestrata.Theclusterrandomised necessary,otherhealthcareprofessionals. ht.
controlledtrialwasperformedasplanned.Moredetailsofthe
Duringasecondhomevisitbythepracticenurse(step4),afinal
studydesignhavebeenpublishedelsewhere.16
treatmentplanisformulated,includingalistofgoals,strategies,
andactionsthatmeettheolderperson’sneeds.Dependingon
Participants
theselfmanagementskillsandpreferencesoftheolderperson,
WeinvitedallgeneralpracticesintheregionofSittard(the strategiesandactionsareeitherfocusedontheolderpersonor
Netherlands)anditssurroundingareathathadnocurrentactive moreon(supportof)thesocialandphysicalenvironment.On
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thebasisofthe5AsBehaviouralChangeModel,22and alimitof25%missingvalues.Multilevelanalysesarequite
motivationalinterviewingtechniques,23thepracticenurse robustagainstmissingvaluesatthemeasurementlevel.
B
encouragesactiveinvolvementindecisionmakingand Therefore,weneededatleastthebaselinemeasurementand M
J
eosldtaebrlpisehressonaacnodopthereaitnivfeorwmoarlkcinargegreivlaetri.oSnsuhbispeqwuiethnttlhye,tfhraeil oinnethoeuatnoafltyhsreese.fFoollroawll-uapnamlyesaessu,rewmeeunstesdtoainstcalnuddaerodldmeordpeelople : firs
treatmentstarts(step5).Theinterventionprotocoloffers includingsixindependentvariables.Wecorrectedoutcome t p
u
recommendationsandguidelinesfortheexecutionofthe estimatesofthemultilevelanalysesforage,sex,educational b
lis
treatmentplan.Forexample,atoolboxofinterventionsis level,significantdifferencesatbaseline(frailtyanddisability), h
e
availablethatfocusesonfivetopics:“enhancingmeaningful andthebaselinestatusoftheoutcomevariable(inthecaseof d
a
activities,”“dailyphysicalactivity,”“socialnetworkandsocial secondaryoutcomes)byincludingthesevariablesascovariates s
activities,”“adaptingtheenvironment,activities,orskills,”and ineachmodel.Weobtainedinsightintotheeffectivenessofthe 10
“stimulatinghealth.”Thepracticenurseisalsothecasemanager PoCapproachincomparisonwithusualcareatvarious .1
1
and,alongwiththefrailolderpersonandtheinformalcaregiver, follow-uptimesbyexaminingfixedeffectsforgroupbytime 3
6
regularlyevaluatestheachievementofgoals,theimplementation interaction.Weevaluatedthetrendintimebyremovingthe /b
m
ofoflslotrwatienggiepseriniodda(islytelpif6e),.aTnhdethperonfeeesdsiofonralssuipnpvoorltviendthaere ionntleyrafcixtieodnetfefremcts(gfororugprobuyptaimndet)imfroem.Inthaefemwodimelpaunteddtedsattiansgets, j.f52
6
updatedabouttheprogressandtheagreementsmade.Thebox varianceofpracticeiteratedtozero.Consequently,weexamined 4
illustrateshowtheapproachworks. inabasicmodelofdisability,includingonlybaselinestatusof on
Theremainingsixpractices(controlgroup)continuedtodeliver disabilityasacovariate,whetherpracticehadaneffecton 10
careasusual. outcomes.Theanalysesofthebasicmodelwithandwithout S
e
practiceasarandomeffectshowedthattheresultswerehighly p
Measurements similarforthetwoanalyses.Therefore,wedecidedtoexclude tem
practiceasanextralevel. b
e
Wemeasureddatafortheeffectivenessanalysisatthelevelof Wedidseveralsubgroupanalyses.Firstly,wedividedolder r 2
thepatientatbaselineandafter6,12,and24monthsbyusing 0
peopleintheinterventiongroupintotwosubgroupsonthebasis 1
postalquestionnairesandtelephoneinterviews.Whereasolder 3
peopleandhealthcareprofessionalswereawareoftheallocated oftheirexposuretothePoCapproach.Wecomparedolder . D
peoplewhoreceivedonlyassessment(s)(exposuregrouplow) o
arm(interventionorcontrol),outcomeassessorswerekept w
withthosewhoreceivedinterventions,follow-upvisits,orboth n
blindedtotheallocation. lo
(exposuregrouphigh).Wetestedfixedeffectsforexposure a
d
groupbytimeinteractionsforsignificance.Inaddition,wedid e
Outcome measures d
pre-plannedsubgroupanalysesforthepotentialeffectmodifiers fro
Wemeasuredtheprimaryoutcome,disability,at24monthsby baselinestatusoffrailtyandmastery.16Wecreatedtwogroups m
meansoftheGroningenActivityRestrictionScale.24Thisisan foreacheffectmodifierbasedonthemedianscores:lowfrailty h
easytoadminister,comprehensive,reliable,hierarchical,and (GroningenFrailtyIndicatorscore5-6)versushighfrailty(score ttp
validmeasureforassessingdisabilityinolderpeople.Itconsists 7-14)andlowmastery(PearlinMasteryScalescore23-32) ://w
w
oftwosubscales.Thefirstsubscaleisaboutactivitiesofdaily versushighmastery(score10-22).Again,wetestedfixedeffects w
living(11items),andthesecondsubscalerelatestoinstrumental foreffectmodifierbygroupinteractionsforsignificance. .b
m
activitiesofdailyliving(sevenitems).Thescoresforthetotal Thesamplesizecalculationwasbasedonourprimaryoutcome j.c
scalerangefrom18to72,withhigherscoresindicatingmore o
(disability).Onthebasisofapowerof80%andanαof0.05 m
(addnisedapbsroeilscistiyaio.l2nf4uAsnuscbtdsioicsnaalibenigoli,ft2y5thwiesesHctrhooosnpsgeitladylerAperlneaxstesieidvtyteoaspynsmdyDpchteoopmlroeagstiosciloaolngy (ltehtwaesortet2qa.ui0lierpdeodtiensstastminopgnl)et,hasenizdGerawonnaeisnx8gp0eencpteAerdcgttirrvoeiauttypmR(e1en6st0tdriiicnfftietoornetanSlc)c.eaolef,2a4t on 15/
Scale),26socialsupportinteractions(SocialSupport J
Accountingforadropoutrateof30%andaclustereffectof a
List—Interactionversion),27fearoffalling(ShortFallsEfficacy 1.73(intraclasscorrelationcoefficient0.05),16assumingequal nu
Scale—International),28andsocialparticipation(Maastricht clustersizes,thefinalsamplesizehadtobe180pergroup(360 ary
SocialParticipationProfile,subscaleA)29assecondary intotal).16WeusedthesoftwarepackageSPSSforWindows, 20
outcomes.Inaddition,weusedthePearlinMasteryScaleto 2
version20.0,forallstatisticalanalyses. 3
determinethefeelingsofcompetenceandcontrolinolder b
y
people,30feelingscrucialforselfmanagementandcoping,31 Results gu
whichbelongtotheimportantunderlyingmechanismsofthe e
s
PoCapproach. Weallocated12generalpracticesatrandomtothecontrol(six t. P
practices)orinterventiongroup(sixpractices).Halfofthe ro
Statistical analysis practiceshadlessthan350patientsandhalfhadatleast350 te
c
Weuseddescriptivetechniquestodescribethestudygroups. patients.Inaddition,sixpracticeswerelocatedinanurbanarea ted
Wecomparedbaselinevariablestodetectdifferencesbetween andsixinaruralarea.Theseclustercharacteristicswereequally b
y
theinterventionandcontrolgroupsatthestartofthestudy. distributedamongthegroups.Asshowninfigure2⇓,3498 c
o
Becauseoftheclusterrandomiseddesignofthestudyincluding communitydwellingolderpatients(≥70years)ofthe12 p
y
threelevels(generalpractices,participants,andrepeated practicesreceivedthescreeningquestionnaire.Theresponse rig
measurements),weappliedamixedmodelmultilevelanalysis. ratewas80%(n=2790).Non-respondersweresignificantly ht.
Weanalysedtheprimaryandsecondaryoutcomes,measured youngerthanresponders(meanage76.75v77.62years;
atthelevelofthepatient,accordingtotheintentiontotreat P<0.05),andslightlymorenon-respondersweremen(42.9%v
principle.Weimputedmissingvaluesatthelevelofthescale 39.1%;P=0.07).Olderpeoplewhocompletedthequestionnaire
bymeansofmultipleimputations.Webasedthemaximum andwerewillingtoparticipateinthestudy(n=1101)were
numberofmissingvalueswithinascaleontheguidelinesgiven significantlyfrailerthanrespondentswhocompletedthe
bythedevelopers.Ifnoguidelineswereavailable,weaccepted questionnairebutdeclinedparticipation(n=1634)(meanscore
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RESEARCH
Casesummary
B
M
AKisa75yearoldwomanlivingindependentlyinasmallflat.Shehasfourchildren,wholiveinthesamecity.Herhusbandhasbeenliving J
iAnKarneucersivinegdhaolmetetefrofrrotwmohyeeragresn.eralpractitioner,whoaskedhertofillintheGroningenFrailtyIndicator(step1).Shehadatotalfrailtyscore : firs
of7,andthepracticenursecalledhertoofferahomevisitforamultidimensionalassessment(step2).Theassessmentfocusedonexisting t p
problemsinperformingdailyactivitiesandriskfactorsfordevelopingdisability.ThepracticenursealsodiscussedwithAKherindividual u
neexpeedrsieanncdedgoparolsbalenmdshweritmhocotivoaktiniogn,tsohompapkinegc,haanndgevissiitninhgehrelirfeh.uAsKba’snmdoinstthimepnourrtsainntgghooamlwe.aTshtoeslatasytoinfdtheepseendweanstlpyainrtihcuelrahrloymmee.aSnhinegful blis
h
toher.Sheoftenfeltexhaustedandhadafearoffalling.Inaddition,memorydeficitsaffectedherparticipationindailylife.Herchronic e
diseases(diabetesandheartfailure)wereundercontrol. d
a
Afterthehomevisit,thepracticenursediscussedtheresultsoftheassessmentwiththegeneralpractitioneranddecidedtoreferAKtoa s
geriatricianforfurthercognitiveassessment.Inaddition,theyagreedthatinvolvinganoccupationaltherapistandphysiotherapistwouldalso 1
0
beuseful,asAKhadproblemswithdailyactivities.Aninterdisciplinaryteammeeting,consistingofthegeneralpractitioner,practicenurse, .1
occupationaltherapist,andphysiotherapisttookplacetoformulateapreliminarytreatmentplanbasedontheresultsoftheassessment 1
(step3).Theassessmentofthegeriatricianshowednosignsofdementia.Regardingherfearoffalling,theteamassumedthatAKneeded 3
6
tochangeherattitudesandselfefficacybeliefswithregardtofalling,leadingtowardsimprovedparticipationindailyactivitiessuchas /b
shoppingandvisitingherhusband.Anincreaseinphysicalactivitywassupposedtopositivelyaffectherfearoffallingaswell.Inaddition, m
sAifmteprlethsetrtaetaemgiemseaentidnga,ftehwephrealpcitnicgeanidusrsweevriesitdeidscAuKssaegdationhtoelfpinAalKisewitthhectoreoakitnmgeanntdplhaann(dsltienpg4h)e.rWmheicmhotroyodlbeofixciptsa.rtscouldbeusedwas j.f52
alsodiscussed.ForthetreatmentofAKthetoolboxes“adaptingtheenvironment,activities,orskills”and“dailyphysicalactivity”werechosen 6
4
(step5).Duringthetreatment,thepracticenursevisitedAKfourtimestoevaluatetheachievementofgoalsandtheimplementationof o
strategiesindailylife(step6).Fourmonthslater,duringthelastvisit,AKreportedthatshehadfewerproblemswithcookingandvisiting n
herhusband.Shehadincreasedherphysicalactivityindailylifeandhadlessfearoffalling.However,thestrategieslearntforhandlingher 1
memorydeficitswerestilldifficulttoapplyindailylife.Afewhelpingaidsandastoolplacedinthekitchenhelpedhertocookmoreefficiently. 0
ThepracticenursewillvisitAKeverysixmonthstofollow-upwithher. S
e
p
te
onGroningenFrailtyIndicator3.64v2.96;P<0.05).Several Secondary outcomes m
b
participantsdeclinedparticipationandthequestionnairewas e
not(completely)filledin(n=55),sowewerenotabletoobtain Table3⇓showstheresultsofthesecondaryoutcomes.Again, r 2
wefoundnosignificantgroupbytimeinteractioneffectsofthe 0
frailtyscoresandhavenoinformationabouttheleveloffrailty. 1
interventiongrouponanyoftheseoutcomes. 3
Oftheolderpeoplewhowerewillingtoparticipate,34% . D
(n=179)inthecontrolgroupand38%(n=214)inthe o
Subgroup analyses w
interventiongroupwerefrailaccordingtotheirfrailtyscore n
lo
(score≥5).Ofthe393olderpeoplewhowereeligibleforthe Thefixedeffectsforexposuregroups(lowversushigh)bytime a
d
study(werefrailandgavewritteninformedconsent),47were interactionswerenotsignificant(P>0.05).Wefoundno e
d
notincludedinthestudy,astheyhadnotcompletedthebaseline significant(P>0.05)mediatingeffectsforahigherlevelof fro
measurement(fig2⇓).Finally,346olderpeoplewereincluded masteryoralowerleveloffrailty(datanotshown). m
inthestudy,193(56%)ofwhomreceivedthePoCapproach. h
T(nh=e1m99e)awneargeefoemfpaalert,i4ci9p%an(tns=w1a7s0)77w.e2r(eSlDivi5n.g1)alyoenaer,s,an5d8%58% Discussion ttp://w
Ourstudyhasprovidednoevidencefortheeffectivenessofa w
(n=202)hadalowlevelofeducation. w
proactiveprimarycareapproach,consistingofa .b
Wefoundsignificantdifferencesbetweeninterventionand multidimensionalassessmentwithinterdisciplinarycarebased m
controlgroupparticipantswithregardtofrailty(Groningen onatailormadetreatmentplanandregularevaluationand j.co
FrailtyIndicator)anddisability(GroningenActivityRestriction m
follow-up,amongfrailolderpeople.Wefoundnosignificant
Scale)scores.Theinterventiongroupparticipantswere differencesbetweentheinterventiongroupandthecontrolgroup o/
n
significantlyfrailer(score7.13v6.72;P<0.05)andmore (careasusual)withregardtodisability(primaryoutcome)or 1
disabled(score33.09v30.58;P<0.05).Allothercharacteristics oursecondaryoutcomes:depressivesymptomatology,social 5 J
weresimilarbetweenthegroupsatbaseline(table1⇓).Intotal, a
supportinteractions,fearoffalling,andsocialparticipation. n
76olderpeoplewerelosttofollow-upduringthetrial, Pre-plannedsubgroupanalysesconfirmedtheseresults. ua
significantlymoreofthemintheinterventiongroup(26%v ry
2
17%;P<0.05). Strengths and weaknesses of study 02
3
Primary outcome Thestrengthsofthisclusterrandomisedtrialincludealong by
follow-upperiodwithrelativelyfewmissingdataandhigh g
All12clusters,consistingof310frailolderpeoplewitha follow-uprates.Inaddition,weusedoutcomemeasureswith ue
s
bmaesaesliunreemdiesnatbsi,liwtyersecoinreclaunddedatinletahsetomniexeodutmoofdtherlemeufoltlilloewve-lup goodpsychometricproperties,whichwereassessedbyblinded t. P
datacollectors.Thisstudyalsohassomeweaknesses.Firstly, ro
analyses.Withregardtodisability,weidentifiednosignificant significantbaselinedifferencesexistedbetweentheintervention te
c
differencebetweenthecontrolandinterventiongroupsat24 andcontrolgroupswithregardtofrailtyanddisability,andthe te
months’follow-up.Wefoundnosignificantgroupbytime samplesizedistributionwasskewed.Thesedifferenceswerea d b
interactioneffectsforthetotalGroningenActivityRestriction y
resultoftheclusterrandomiseddesignofthestudy,whichisa c
Scalescoresorfortheactivitiesofdailylivingandinstrumental o
commonapproachwiththiskindofinterventiontoavoid p
ainctteivraitciteisonoftedramilyfrloivmintghesumbosdcaelle,wsceotreesst.eAdfttheertrreemndovfionrgtitmhee. cdoifnftearmenicneastiionnobuirasa.n17aAlylstehso,utghhiswmeaaydsjtuislltehdavfoerabffaescetleindeour yrigh
Bothgroupsincreasedsignificantly(P<0.05)indisabilityover t.
findingstosomeextent.Secondly,significantlymore
aperiodof24months,butnosignificantdifferencesbetween
participantswerelosttofollow-upintheinterventiongroup
thegroupswithrespecttotheirincreaseexisted.Table2⇓gives
thaninthecontrolgroup(26%v17%).Wecannotfullyexplain
asummaryoftheseresults.
thisfinding,butolderpeopleintheinterventiongroupwere
significantlymorefrailanddisabledthanthoseinthecontrol
group,whichmighthaveaffectedthecompletionrate.Thirdly,
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RESEARCH
thePoCapproachwasevaluatedinareallifesettingin12 group,insufficientimplementationofthePoCapproach,and
generalpractices.Althoughwedidacomprehensiveprocess currenthealthcaredeliveryintheNetherlands.
B
evaluationalongsidethetrial,32wehavelimitedinsightinto Firstly,thePoCapproachfocusesonfrailolderpeople M
J
woirlrhdeaestrphepaceptoipvpeelenoewfdethirneeipprrasattciuetdincytespfoaofrrttishceeivpireartgiaeolnnre.erCaasloonpnsrsae.cqPtuiateirnotitnclyeipr,amtiankging (shGcigorhroeenriinnthgoaeunnrtfhFraraatiliilnstayamIcnopdmleicp(aamtroaerbanslec3os2are.m0≥,pSl5eD).(≥T171h0.e2y)bewaasaressl)isnouefbtdshtieasanDbtiuialtilctlyhy : first pu
adistinctionbetweenusualcareactivitiesandcontactsrelated generalpopulation(mean24.9,SD9.3).41Someofthe blis
tothePoCapproachwasdifficult,resultinginanoverlapin participantsinourstudymayhavebeentoofrail,assome h
e
timespentindeliveringusualcareversusthenewapproach. previousreviewsinthefieldofpreventivehomevisiting d a
Also,practicenurseshadtroubleindeterminingaclearendpoint programmessuggestthatinterventionsmaybemoreeffective s
ofthePoCapproach,becauseolderpeopleremainedpatients inlowrisk,non-disabledolderpeople.2533Thisisinlinewith 10
oftheirgeneralpractitionersafterthePoCapproachhadbeen amorerecentreviewreportingthatfrailolderpeoplehaveto .11
delivered,resultingincontinuousmonitoringofolderpeople. beidentifiedatarelativelyearlystagewhennegativehealth 36
Inaddition,olderpeoplewerereferredtootherhealthcare outcomescanstillbeavoided.42Incontrast,practicenursesand /bm
pmruocfehstsiimoneawlsaassswpeenllt.iAnsdaelrievseurlitn,gwtehedoPonCotakpnporwoaecxhaacntldyhhooww gmeennetriaolnperdatchtaittioanlaerrgseinntuemrvbieewroefdpdaurrtiincigptahnetspwroecreesisnetvhaeliuravtiieown j.f52
6
forlongtheseactivitieswerecontinued.However,theprocess noteligibleforthePoCapproach,astheyhadhardlyany 4
evaluationshowedthatslightlymorethanonethirdofthe disabilityintermsofactivitiesofdailylivingandinstrumental on
participantsintheinterventiongroup(34%)hadonlythe activitiesofdailyliving.32Ineffortstoreducedisabilityand 10
multidimensionalassessmentconductedbythepracticenurse prevent(further)functionaldecline,whicholderpeoplewould S
e
dautariinlogramnaindietiatrlehaotmmeenvtisfiotl.lTohweerdembyaiunpintgooflidveerfpoelloopwle-urepceviivsietds bisesnteilflitntohtecmleoasr.tfrominterventionssuchasthePoCapproach ptem
bythepracticenurse. b
Comparison with other studies Sinetceorvnednlyti,otnheprportoocceoslswevearelunaotitoinmsphloewmeednttehdatassopmlaenpnaerdts.32oTfthhee er 20
1
problemanalysisandthedevelopmentofapreliminarytreatment 3
Duringthepastdecades,muchresearchtargetingcommunity plan(step3)wasoftennotdoneinabilateralmeetingoran . D
o
dwelling(frail)olderpeoplehasbeendone,withmanystudies extendedteammeeting,andonlyhalfofthetreatmentplans w
inthefieldofpreventivehomevisitingprogrammes.Since werediscussedwiththefrailolderperson(step4).Also,the nlo
2000,severalmeta-analyses,systematicreviews,andliterature toolboxpartswerenotfrequentlyusedinthetreatmentphase ad
reviewshavebeenpublished.121333-37Thestudiesevaluateda (step5),andtheextentofevaluationandfollow-up,especially ed
rangeofinterventions(suchasmultidimensionalgeriatric amongthehealthcareprofessionals,waslimited(step6).32 fro
assessment,careplanning,organisationandmonitoring,health Insufficientimplementationisawellknownproblem,especially m
promotion,selfmanagementsupport,nursingservices,and inthefieldofpreventiveandbehaviouralchangeinterventions.43 http
r(egfeenreraralslptoraoctthiteironseerrvs,icneusr)sceas,rraileldieoduptrboyfevsasiroionuaslsp).roTfheessaiiomnaolsf Dsoumriengpatrhtesopfrotcheesisnetevravleunattiioonn,pprrootfoecsosliownearles(mtoeon)titoimneedthat ://w
w
theseinterventionsistoproactivelydetectmodifiableriskfactors consumingordifficulttoapply32;thismayhavebeenareason w
andworseninghealthconditionstoreduceorpreventdisability, forinsufficientimplementation.43Inaddition,professionals .bm
healthcareuse,andrelatedcosts.Resultsregardingthe expressedaneedformoretrainingonthejobandmore j.c
effectivenessoftheseinterventionshavebeeninconsistentand opportunitiestoexchangeexperienceswitheachother. om
conflicting.Afewstudieshaveshownfavourableeffectson Educationandexperienceofprofessionalsandtheintensityof o/
disability.Forexample,Bernabeiandcolleaguesdida providedtrainingactivitiesarestronglyrelatedtobeneficial n 1
randomisedcontrolledtrialshowingthatamodelofintegrated outcomes.12Despiteanextensivedevelopmentperiodanda 5
J
careandcasemanagementhadfavourableeffectsondisability comprehensivetrainingprogrammewithregardtothe a
n
incommunitydwellingolderpeople.38Serviceswereprovided interventionprotocol,weprobablyfailedinproviding u
a
bythegeneralpractitionerandacommunitygeriatricevaluation professionalswiththenecessarycompetenciesandfeasibletools ry
unit,consistingofageriatrician,asocialworker,andseveral toapplyrathercomplexconcepts,suchasinterdisciplinary 20
2
nurses.Gillandcolleagueshavereportedasuccessful collaboration,tailormadecare,andselfmanagementsupport, 3
randomisedcontrolledtrialevaluatinganintenseexercise intodailypractice.32Forexample,thedevelopmentof by
programmeforphysicallyfrailolderpeoplelivinginthe individualisedgoals,aprerequisitefortailormadecareandself gu
community.39Theprogrammeisbasedontheoutcomesofan managementsupport,isachallengingtask,aspatientstendto es
extensiveassessment;itfocusesontheindividualneedsofolder adoptapassiveroleingoalsetting.44Encouragementofactive t. P
peoplebutalsotakestheirenvironmentalconditionsinto involvementisevenmoredifficultwitholderpeopleowingto ro
account.Moststudies,however,reportednooronlymodest highlyprevalentcognitiveimpairments,communication tec
effectsoftheirinterventions.Also,thelargesttrialinthisfield, difficulties,andcomorbiditiesandassuchrequiresauniqueset te
d
byFletcherandcolleagues,comparingdifferentstrategiesfor ofcompetencies.45Goalidentificationtools,suchasthe b
y
assessment(targetedversusuniversal)andevaluationand CanadianOccupationalPerformanceMeasureorGoal c
o
management(primarycareversusmultidisciplinarygeriatric AttainmentScaling,4647maybeusefulintheprocessofgoal p
y
team)inmorethan40000olderpeople,didnotresultin setting.Inaddition,moreattentionhastobepaidtothe rig
convincingeffectsoradequateevidencethatonestrategyis implementationofevaluationandfollow-upactivities,asa ht.
betterthananother.40 minimumintensityandlengthoffollow-upisneededtoreach
favourableeffects.2534
Meaning of study: explanations and clinical
Thirdly,standardhealthcaredeliveryintheNetherlandsis
implications
alreadyatarelativelyhighlevel.Nearlyallpeoplearecovered
Besidesthemethodologicaldrawbacks,someotherexplanations byhealthcareinsurance,healthcareiseasilyaccessible,andits
forthelackofeffectsarepossible.Theserelatetothetarget qualityisoftenconsideredtobegood.48Moreover,thecontrast
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RESEARCH
betweenthePoCapproachandcareasusualwasprobablytoo 1 BergmanH,BélandF,PerraultA.Theglobalchallengeofunderstandingandmeeting
theneedsofthefrailolderpopulation.AgingClinExpRes2002;14:223-5.
smalltodetectsubstantialeffects.Thenon-effectiveresultsof
2 ColemanEA.Challengesofsystemsofcareforfrailolderpersons:theUnitedStatesof B
thisstudyandthecomplexityofeffectiveinterventions(or Americaexperience.AgingClinExpRes2002;14:233-8. M
ecloenmcleunstiso)ndseasbcroiubtewdhinicthhesplietceirfaitcusretramteegainesthwatodurldawreinsugltina 34 WPUlnooieoteglhdaJS,ntBdalrteaerzsSila,KnC,daHCmuatpcnbhaeidsllaoT.n,NBH,EimKnagmclezJlosMrteoeiwndsD2k0iU0J.,3CD;3oa4sl9bts:y7o6Df8Mh-7e,5aG.ltohldcsamreithadCmHin,iesttraalt.ioEnffeinctthoef J: firs
surpluseffectinwhichtargetgroupisdifficult. preventiveprimarycareoutreachonhealthrelatedqualityoflifeamongolderadultsat t p
riskoffunctionaldecline:randomisedcontrolledtrial.BMJ2010;340:c1480. u
b
Future research 5 KofeiantfionrgmNal,nOettfwinoorwksskoifPfr,aWilseenngieorrsC:,aFcaassteJ,foDrecrakrseenneLtw.Uonrkdse.rAsgtaenindginSgothce20ca0r3in;2g3c:1a1p5a-c2i7ty. lish
6 Markle-ReidM,BrowneG,WeirR,GafniA,RobertsJ,HendersonSR.Theeffectiveness e
Althoughthisstudyhasnotshownanybeneficialeffectsofa alitnedraetuffricei.eMnceydoCfahroemRee-bsaRseevd2n0u0rs6i;n6g3:h5e3a1l-th69p.romotionforolderpeople:reviewofthe d as
proactiveprimarycareapproach,includingamultidimensional 7 StijnenMMN,Duimel-PeetersIGP,JansenMWJ,VrijhoefHJM.Earlydetectionofhealth 1
assessmentandinterdisciplinarycarebasedonatailormade p[Gro]OblLeDm:sdienspigonteonftiaallloynfgraitiulcdoinmaml,quunaitys-i-dewxeplelirnimgeolndtearlspteuodpyl.eBbMyCgeGneerriaaltprr2a0c1ti3c;e1s3—(7p):r1o-j1e0ct. 0.1
treatmentplanandregularevaluationandfollow-up,infrail 1
8 FletcherAE,JonesDA,BulpittCJ,TullochAJ.TheMRCtrialofassessmentand 3
olderpeople,itaddstotheevidencebaseforclinicaldecision managementofolderpeopleinthecommunity:objectives,designandinterventions 6
[ISRCTN23494848].BMCHealthServRes2002;2(1):21. /b
makingandfutureresearchregardingcommunitybasedcare m
9 FriedLP,FerrucciL,DarerJ,WilliamsonJD,AndersonG.Untanglingtheconceptsof
forsuchpeople.Thepublicationofnon-effectivestudiesis disability,frailty,andcomorbidity:implicationsforimprovedtargetingandcare.Gerontol j.f5
highlyrelevanttopreventanoverestimationofthebenefitsof 10 MAaBrikolleS-RceiMideMd,SBcrio2w0n0e4;G5.9C:2o5n5c-6e3p.tualizationsoffrailtyinrelationtoolderadults.JAdv 264
interventionsandawasteofhealthcareresources.Thisstudy Nurs2003;44:58-68. o
contributestotheemergingbodyofevidencethatmoreresearch 11 PmeelaLsiuttreinlgREo,faScchounucrempat.nJsNMuJt,rEHmeamltehloAtgVinognk20M0H9;,1V3e:3rh9a0a-4r.HJJ.Frailty:definingand n 1
isneededtoimprovetheeffectivenessofinterventionsforfrail 12 LiebelDV,FriedmanB,WatsonNM,PowersBA.Reviewofnursehomevisiting 0 S
olderpeople. interventionsforcommunity-dwellingolderpersonswithexistingdisability.MedCareRes e
Rev2009;66:119-46. p
13 HallbergIR,KristenssonJ.Preventivehomecareoffrailolderpeople:areviewofrecent te
Wethanktheparticipantsinthestudy;theparticipatinghealthcare casemanagementstudies.JClinNurs2004;13(6B):112-20. m
b
p(MroEfeMsIsCio):nAanlsi;tathLeegCteenntbreerfgo,rADlfaotnasaSncdhIrnoftoernm,aatniodnMMaarlnèangeeRmoennnter;the 14 D2p0rae1nv0iee;n7lst:3Rd7i,s-5Ma5be.itliztyelitnhifnraSil,cVoamnmRuonsistyu-mdwEe,llDinegWolidtteerLp,eVrsaonndse:nanHoevuevrevlieWw..InEtuerrvJeAngtioeninsgto er 20
15 DanielsR,vanRossumE,MetzelthinS,SipersW,HabetsH,HobmaS,etal.Adisability 1
membersoftheresearchgroup:LiloCrasborn(MCCOmnes),Simone 3
Denis(MCCOmnes),MarlouWolters(MCCOmnes),HerbertHabets p2r0e1v1e;n2t5io:9n6p3r-o7g4r.ammeforcommunity-dwellingfrailolderpersons.ClinRehabil . D
(OrbisMedicalCentre),andRamonDaniels(ZuydUniversityofApplied 16 MetzelthinSF,vanRossumE,deWitteLP,HendriksMR,KempenGI.Thereductionof ow
disabilityincommunity-dwellingfrailolderpeople:designofatwo-armclusterrandomized n
Sciences,Heerlen);theirresearchassistants:FloorKoomen,Ine controlledtrial.BMCPublicHealth2010;10:511. lo
Hesdahl,andAstridDello;andtheirsponsors:theNetherlands 17 CampbellMK,ElbourneDR,AltmanDG,CONSORTGroup.CONSORTstatement: ad
extensiontoclusterrandomisedtrials.BMJ2004;328:702-8. e
OrganisationforHealthResearchandDevelopment(ZonMw),the 18 SteverinkN,SlaetsJPJ,SchuurmansH,vanLisM.Measuringfrailty:developmentand d
Hague,theNetherlands,andtheNetherlandsOrganisationforScientific testingoftheGroningenFrailtyIndicator(GFI).TheGerontologist2001;41(1):236-37. fro
19 DerckxE.Eerstenursepractitionersmetdifferentiatiehuisartsenzorg.Tijdschriftvoor m
Research(NWO),theHague,theNetherlands.
Verpleegkundigen2006;3:26-30. h
Ccoonncteripbtuiotonrsa:nSdFdMes,iEgnvRo,ftLhPedsWtu,dayn.SdFGMIJ,MEKvRw,eLrPedrWes,pAoWnsAib,SleOfoHr,tWheS, 2201 VDMaaenndiWe2l0se1eR2l.;C2F,5rSa(sicluhepelpdrlse1rHl)y:,S—T1iim2d-em7n.etirfmicaatniosnAa.nHdeadlitshacbailirteyipnrethveenNteiothneinrlapnrdims.aJryAcmarBeo[aPrhdDFam ttp://w
andGIJMKwereinvolvedintheanalysisandinterpretationofthedata. Thesis].MaastrichtUniversity,2011. w
22 GlasgowRE,EmontS,MillerDC.Assessingdeliveryofthefive‘As’forpatient-centred w
SFMcreatedthefirstdraftofthispaper.Theotherauthorscommented counseling.HealthPromotInt2006;21:245-55. .b
onitandapprovedthefinalversion.Allauthorshadfullaccesstoallof 23 MillerWR,RollnikS.Motivationalinterviewing:preparingpeopleforchange.Guildford m
thedataandcantakeresponsibilityfortheintegrityofthedataandthe Publications,2002. j.c
24 KempenGIJM,MiedemaI,OrmelJ,MolenaarW.Theassessmentofdisabilitywiththe o
accuracyofthedataanalysis.SFMistheguarantor. GroningenActivityRestrictionScale:conceptualframeworkandpsychometricproperties. m
Funding:ThisresearchisfundedbytheDutchNationalCareforthe SocSciMed1996;43:1601-10. o/
25 StuckAE,WalthertJM,NikolausT,BulaCJ,HohmannC,BeckJC.Riskfactorsfor n
ElderlyProgrammebyTheNetherlandsOrganisationforHealth functionalstatusdeclineincommunity-livingelderlypeople:asystematicliteraturereview. 1
ResearchandDevelopment(ZonMw311070301).Itisaninitiativeof 26 SSpoicnhSocvieMnePd,1O99rm9;e4l8J:,4S45lo-e6k9e.rsPPA,KempenGIJM,SpeckensAEM,vanHemertAM. 5 Ja
theDutchMinistryofHealth,WelfareandSporttoimprovethequality AvalidationstudyoftheHospitalAnxietyandDepressionScale(HADS)indifferentgroups n
u
ofcareforfrailolderpeople(www.nationaalprogrammaouderenzorg. ofDutchsubjects.PsycholMed1997;27:363-70. a
27 KempenGIJM,vanEijkLM.ThepsychometricpropertiesoftheSSL12-l,ashortscale ry
nl).OpenaccessofthispublicationwasfinancedbytheNetherlands formeasuringsocialsupportintheelderly.SocIndicRes1995;35:303-12. 2
OrganisationforScientificResearch(NWO). 28 KempenGIJM,YardleyL,vanHaastregtJCM,ZijlstraGAR,BeyerN,HauerK,etal.The 02
ShortFES-I:ashortenedversionofthefallsefficacyscale-internationaltoassessfearof 3
Competinginterests:AllauthorshavecompletedtheICMJEuniform falling.AgeAgeing2008;37:45-50. b
disclosureformatwww.icmje.org/coi_disclosure.pdf(availableon 29 MsoacrisalGpMarJti,cKipeamtiopnenpGroIfJilMe:,dPeovsetlMopWmMen,tParonodtcIMlin,imMeetsrtiecrpsrIo,pvearntieEsijkinJTolMde.rTahdeuMltsaawsittrhicaht y gu
requestfromthecorrespondingauthor)anddeclare:thisresearchis chronicphysicalillness.QualLifeRes2009;18:1207-18. e
fundedbytheDutchNationalCarefortheElderlyProgrammebyThe 3301 PKeeamrplinenLIG,SIJcMh.oPorleerveCn.tTieheenstoruucdteurrewoorfdceonp:inmgo.gJeHlijekahlethdeSnovcoBoerhzaevlfm19a7n8a;g1e9m:2e-2n1t.. st. P
NetherlandsOrganisationforHealthResearchandDevelopment;no Epidemiologischbulletin2006;41(2):27-32. ro
financialrelationshipswithanyorganisationsthatmighthaveaninterest 32 MetzelthinSF,DanielsR,VanRossumE,CoxK,HabetsH,deWitteLP,etal.Anurse-led te
interdisciplinarycareapproachtopreventdisabilityamongcommunity-dwellingfrailolder c
inthesubmittedworkinthepreviousthreeyears;nootherrelationships people:alarge-scaleprocessevaluation.IntJNursStud2013;50:1184-96. te
d
oractivitiesthatcouldappeartohaveinfluencedthesubmittedwork. 33 ElkanR,KendrickD,DeweyM,HewittM,RobinsonJ,BlairM,etal.Effectivenessof b
homebasedsupportforolderpeople:systematicreviewandmeta-analysis.BMJ y
Ethicalapproval:ThestudywasapprovedbytheMedicalEthical 2001;323:719-25. c
CommitteeoftheMaastrichtUniversity/AcademicHospitalMaastricht 34 StuckAE,EggerM,HammerA,MinderCE,BeckJC.Homevisitstopreventnursing op
homeadmissionandfunctionaldeclineinelderlypeople:systematicreviewand y
intheNetherlandsin2009(MEC09-3-067).Betweenrandomisation meta-regressionanalysis.JAMA2002;287:1022-8. rig
andbaselinemeasurement,allincludedparticipantsgavewritten 35 BoumanA,vanRossumE,NelemansP,KempenGIJM,KnipschildP.Effectsofintensive h
homevisitingprogramsforolderpeoplewithpoorhealthstatus:asystematicreview. t.
informedconsent.
BMCHealthServRes2008;8:74.
Datasharing:Additionaldatafromthestudydatabaseareavailableon 36 HussA,StuckAE,RubensteinLZ,EggerM,Clough-GorrKM.Multidimensionalpreventive
homevisitprogramsforcommunity-dwellingolderadults:asystematicreviewandmeta
requestfromthecorrespondingauthorat
analysisofrandomizedcontrolledtrials.JGerontolABiolSciMedSci2008;63:298-307.
[email protected] 37 VanHaastregtJC,DiederiksJP,vanRossumE,deWitteLP,CrebolderHF.Effectsof
preventivehomevisitstoelderlypeoplelivinginthecommunity:systematicreview.BMJ
level,asparticipants’consenttosharetheirdatawasnotobtained.
2000;320:754-8.
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RESEARCH
Whatisalreadyknownonthistopic
B
M
Comparedwithinstitutionalisation,communitybasedcareofolderpeoplemayachievebetteroutcomesatlowercostsandisalso J
pVraerfieorursedcobmymoludneirtypeboapseledthinetemrsveelnvteiosnsaimingatreductionofdisabilityhavebeendevelopedduringthepastdecades : firs
However,onlyasmallnumberofinterventionshaveshownbeneficialeffectsondisability,andmoststudiesdidnotreportonthelong t p
u
termeffects b
lis
Whatthisstudyadds h
e
d
Noevidencewasfoundfortheeffectivenessofaproactiveprimarycareapproach,includingamultidimensionalassessment, a
interdisciplinarycarebasedonatailormadetreatmentplan,andregularevaluationandfollow-up,infrailolderpeople s
1
Effectiveeducationandtrainingprogrammesareneededtoprovidehealthcareprofessionalswithadequatecompetenciesandfeasible 0
toolstofacethechallengesofcommunitybasedcareinfrailolderpeople .1
1
3
Thenon-effectiveresultsofthisstudymeanthatmoreresearchisneededtooptimisetheeffectivenessofcommunitybasedinterventions 6
forfrailolderpeople /b
m
j.f5
38 BernabeiR,LandiF,GambassiG,SgadariA,ZuccalaG,MorV,etal.Randomisedtrial 46 LawM,BaptisteS,McCollM,OpzoomerA,PolatajkoH,PollockN.TheCanadian 2
ofimpactofmodelofintegratedcareandcasemanagementforolderpeoplelivinginthe OccupationalPerformanceMeasure:anoutcomemeasureforoccupationaltherapy.Can 6
4
community.BMJ1998;316:1348-51. JOccupTher1990;57:82-7. o
39 GillTM,BakerDI,GottschalkM,PeduzziPN,AlloreH,ByersA.Aprogramtoprevent 47 KiresukTJ,ShermanRE.Goalattainmentscaling:ageneralmethodforevaluating n
functionaldeclineinphysicallyfrail,elderlypersonswholiveathome.NEnglJMed comprehensivecommunitymentalhealthprograms.CommunityMentHealth 1
40 F20le0tc2h;3e4r7A:1E0,6P8ri-c7e4.GM,NgESW,StirlingSL,BulpittCJ,BreezeE,etal.Population-based 48 1S9m6e8u;1ld:e4r4s3E-5S3T.F,vanHaastregtJCM,AmbergenT,Uszko-LencerNHKM,Janssen-Boyne 0 S
e
multidimensionalassessmentofolderpeopleinUKgeneralpractice:acluster-randomised JJJ,GorgelsAPM,etal.Nurse-ledself-managementgroupprogrammeforpatientswith p
factorialtrial.Lancet2004;364:1667-77. congestiveheartfailure:randomizedcontrolledtrial.JAdvNurs2010;66:1487-99. te
41 DanielsR,VanRossumHIJ,BeurskensA,VandenHeuvelW,DeWitteL.Thepredictive m
validityofthreeself-reportscreeninginstrumentsforidentifyingfrailolderpeopleinthe Accepted:15August2013 b
e
42 cPoijmpemrsuEni,tyF.eBrrMeiCraPI,uSbtleichoHuewaelthrC2D01A2,;N1i2e:u6w9.enhuijzenKrusemanAC.Thefrailtydilemma: r 2
Citethisas:BMJ2013;347:f5264 0
reviewofthepredictiveaccuracyofmajorfrailtyscores.EurJInternMed2012;23:118-23. 1
43 GTylapsegsoowfeRvEid,eEnmcemnoenesdKeMd..AHnonwucRaenvwPeuibnlcicreHaesaeltthra2n0s0la7t;i2o8n:4o1f3re-3se3a.rchintopractice? ThisisanOpenAccessarticledistributedinaccordancewiththeCreativeCommons 3. D
AttributionNonCommercial(CCBY-NC3.0)license,whichpermitsotherstodistribute,
44 SiegertRJ,TaylorWJ.Theoreticalaspectsofgoal-settingandmotivationinrehabilitation. o
DisabilRehabil2004;26:1-8. remix,adapt,builduponthisworknon-commercially,andlicensetheirderivativeworks wn
45 ParsonsJGM,ParsonsMJG.Theeffectofadesignatedtoolonperson-centredgoal ondifferentterms,providedtheoriginalworkisproperlycitedandtheuseis lo
identificationandserviceplanningamongolderpeoplereceivinghomecareinNewZealand. non-commercial.See:http://creativecommons.org/licenses/by-nc/3.0/. a
HealthSocCareCommunity2012;20:653-62. de
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BMJ2013;347:f5264doi:10.1136/bmj.f5264(Published10September2013) Page8of12
RESEARCH
Tables
B
M
J
Table1|Baselinecharacteristicsofparticipantsincontrolgroupandinterventiongroup.Valuesarenumbers(percentages)unlessstated : firs
otherwise t p
u
Characteristics Control(n=153) Intervention(n=193) b
lis
Mean(SD)age(years) 76.80(4.92) 77.49(5.28) h
e
d
Femalesex 93(61) 106(55) a
s
Livingalone 80(52) 90(47) 1
0
Loweducation 94(61) 108(56) .1
1
Mean(SD)scores: 36
/b
GARStotal 30.58*(10.62) 33.09*(11.52) m
GARSADLscale 16.54*(5.35) 17.97*(6.14) j.f5
2
GARSIADLscale 14.03(5.86) 15.12(5.96) 6
4
MSPP-CP-D 1.90(1.63) 1.63(1.48) o
n
MSPP-CP-F 0.46(0.44) 0.36(0.35) 10
MSPP-FSP-D 0.73(0.88) 0.610.84 S
e
p
MSPP-FSP-F 0.45(0.63) 0.38(0.55) te
m
ShortFES-I 12.38(4.72) 13.24(5.39) b
e
HADS-D 6.69(4.35) 6.54(3.77) r 2
0
SSL-I12 27.46(6.06) 27.17(6.30) 1
3
GFI 6.72*(1.71) 7.13*(1.89) . D
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PMS 21.41(4.25) 21.97(4.01) w
n
lo
GARS=GroningenActivityRestrictionScale(rangetotalscale18-78,rangeactivitiesofdailyliving(ADL)scale11-44,rangeinstrumentalADL(IADL)scale7-28; a
d
higherscoresindicatemoredisability);MSPP=MaastrichtSocialParticipationProfile;MSPP-CP-D=MSPPconsumptiveparticipation,diversityscore(range0-7; e
d
higherscoreindicatesmorediverseconsumptiveparticipation);MSPP-CP-F=MSPPconsumptiveparticipation,frequencyscore(range0-3;higherscoreindicates fro
morefrequentconsumptiveparticipation);MSPP-FSP-D=MSPPformalsocialparticipation,diversityscore(range0-7;higherscoreindicatesmorediverseformal m
socialparticipation);MSPP-FSP-F=MSSPformalsocialparticipation,frequencyscore(range0-3;higherscoreindicatesmorefrequentformalsocialparticipation); h
SShcaolret—FEdSep-Ir=eSshsoiorntFsaulblsscEaffleica(rcaynSgeca0le-2—1,Inhtiegrhneartisocnoarle(rianndgiceat7e-s28m;ohrieghdeerpsrecossreivien)d;iScaStLe-sI1m2o=rSeofceiaalrSoufpfaplloinrtgL);isHt—ADInSte-Dra=cHtioosnpvitearlsAionnxi(eratyngaend12D-e4p8r;ehsisgihoenrscore ttp://w
w
indicatesmoresocialsupport);GFI=GroningenFrailtyIndicator(range0-15;higherscoreindicatesmoreseverefrailty);PMS=PearlinMasteryScale(higherscore w
indicateslessowncontrol). .b
m
*Significantdifferences:P<0.05. j.c
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No commercial reuse: See rights and reprints http://www.bmj.com/permissions Subscribe:http://www.bmj.com/subscribe
BMJ2013;347:f5264doi:10.1136/bmj.f5264(Published10September2013) Page9of12
RESEARCH
Table2|Multilevelanalysesfordifferencesbetweencontrolgroup(CG)andinterventiongroup(IG)forprimaryoutcomemeasuresat6,
12,and24months’follow-up(n=310) B
M
J
Mea6nm(oSnDt)hs’follow-upMean Me1a2nm(SoDn)ths’follow-upMean Me2a4nm(SoDn)ths’follow-upMean : firs
difference* difference* difference* t p
u
(95%CI);P (95%CI);P (95%CI);P b
Outcome CG IG value CG IG value CG IG value lis
h
GARS 30.16 32.83 0.41(−0.80to 30.81 33.08 0.47(−0.81to 31.50 34.39 1.18(−0.35to ed
(10.07) (10.98) 1.62);0.51 (10.29) (11.34) 1.76);0.47 (10.92) (11.58) 2.71);0.35 a
s
GARS 16.17(5.13) 17.54(5.82) 0.25(−0.44to 16.30(5.31) 17.81(5.90) 0.59(−0.14to 16.73(5.73) 18.31(5.82) 0.77(−0.05to 1
0
ADL 0.94);0.48 1.33);0.11 1.59);0.07 .1
1
GARS 14.00(5.51) 15.29(5.92) 0.17(−0.63to 14.51(5.69) 15.28(6.03) −0.12(−0.93to 14.77(5.86) 16.08(6.35) 0.40(−0.54to 3
6
IADL 0.97);0.67 0.68);0.76 1.34);0.41 /b
m
GARS=GroningenActivityRestrictionScale(rangetotalscale18-78;higherscoresindicatemoredisability);GARSADL=GroningenActivityRestrictionScale—activities j.f5
ofdailyliving(ADL)subscale(rangetotalscale11-44;higherscoresindicatemoredisability);GARSIADL=GroningenActivityRestrictionScale—instrumental 2
6
ADLsubscale(rangetotalscale7-28;higherscoresindicatemoredisability). 4 o
*Adjustedforage,sex,education,andsignificantdifferencesatbaseline(frailtyanddisability). n
1
0
S
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r 2
0
1
3
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No commercial reuse: See rights and reprints http://www.bmj.com/permissions Subscribe:http://www.bmj.com/subscribe
BMJ2013;347:f5264doi:10.1136/bmj.f5264(Published10September2013) Page10of12
RESEARCH
Table3|Multilevelanalysesfordifferencesbetweencontrolgroup(CG)andinterventiongroup(IG)forsecondaryoutcomemeasuresat
6,12,and24months’follow-up B
M
J
Me6anm(oSnDt)hs’follow-upMean Me1a2nm(SoDn)ths’follow-upMean Me2a4nm(SoDn)ths’follow-upMean : firs
difference* difference* difference* t p
u
(95%CI);P (95%CI);P (95%CI);P b
Outcome CG IG value CG IG value CG IG value lis
h
MSPP-CP-D 2.10(1.63) 1.92(1.57) −0.06(−0.21to 2.10(1.64) 1.73(1.45) −0.22(−0.48to 1.94(1.70) 1.61(1.33) −0.13(−0.43to ed
(n=310) 0.09);0.71 0.03);0.09 0.16);0.38 a
s
MSPP-CP-F 0.46(0.40) 0.40(0.36) 0.00(−0.04to 0.45(0.40) 0.35(0.32) −0.05(−0.11to 0.44(0.45) 0.33(0.31) −0.04(−0.11to 1
0
(n=310) 0.03);0.96 0.01);0.12 0.04);0.32 .1
1
MSPP-FSP-D 0.69(0.88) 0.64(0.79) 0.03(−0.05to 0.73(0.91) 0.60(0.81) −0.06(−0.14to 0.71(0.87) 0.58(0.77) −0.04(−0.12to 3
6
(n=310) 0.10);0.73 0.02);0.43 0.04);0.57 /b
m
MSPP-FSP-F 0.41(0.59) 0.39(0.55) 0.03(−0.02to 0.43(0.62) 0.35(0.51) −0.03(−0.08to 0.45(0.64) 0.34(0.51) −0.05(−0.11to
(n=310) 0.08);0.52 0.01);0.47 0.00);0.31 j.f5
2
HADS-D 5.82(3.88) 5.72(3.49) −0.11(−0.80to 5.68(3.92) 6.36(4.13) 0.78(0.04to 6.10(3.78) 5.97(4.18) −0.07(−0.90to 64
(n=305) 0.58);0.76 1.53);0.04 0.77);0.87 o
n
SSL-I12 26.94(5.53) 27.03(6.36) 0.18(−079to 27.27(6.54) 27.10(6.09) −0.12(−1.22to 27.35(6.27) 26.76(5.98) −0.29(−1.37to 1
0
(n=312) 1.15);0.71 0.99);0.84 0.79);0.60 S
e
ShortFES-I 12.37(4.90) 12.66(5.25) −0.67(−1.48to 12.15(5.24) 13.42(5.43) 0.34(−0.54to 12.95(5.29) 13.73(5.75) −0.04(−1.01to p
(n=306) 0.14);0.11 1.22);0.44 0.93);0.94 te
m
b
MSPP=MaastrichtSocialParticipationProfile,MSPP-CP-D=MSPPconsumpativeparticipationdiversityscore(range0-7;higherscoreindicatesmorediverse e
consumptiveparticipation);MSPP-CP-F=MSPPconsumptiveparticipation,frequencyscore(range0-3;higherscoreindicatesmorefrequentconsumptive r 2
0
participation);MSPP-FSP-D=MSPPformalsocialparticipation,diversityscore(range0-7;higherscoreindicatesmorediverseformalsocialparticipation); 13
MSPP-FSP-F=MSPPformalsocialparticipation,frequencyscore(range0-3;higherscoreindicatesmorefrequentformalsocialparticipation);HADS-D=Hospital . D
o
AnxietyandDepressionScale—depressionsubscale(range0-21,higherscoreindicatesmoredepressive);SSL-I12=SocialSupportList—Interactionversion w
(range12-48;higherscoreindicatesmoresocialsupport);ShortFES-I=ShortFallsEfficacyScale—International(range7-28;higherscoreindicatesmorefearof nlo
falling). a
d
*Adjustedforage,sex,education,significantdifferencesatbaseline(frailtyanddisability),andbaselinestatusoutcomemeasure. ed
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