Dataset Information

Proactive and integrated primary care for frail older people: design and methodological challenges of the Utrecht primary care PROactive frailty intervention trial (U-PROFIT).

ABSTRACT:

Background

Currently, primary care for frail older people is reactive, time consuming and does not meet patients' needs. A transition is needed towards proactive and integrated care, so that daily functioning and a good quality of life can be preserved. To work towards these goals, two interventions were developed to enhance the care of frail older patients in general practice: a screening and monitoring intervention using routine healthcare data (U-PRIM) and a nurse-led multidisciplinary intervention program (U-CARE). The U-PROFIT trial was designed to evaluate the effectiveness of these interventions. The aim of this paper is to describe the U-PROFIT trial design and to discuss methodological issues and challenges.

Methods/design

The effectiveness of U-PRIM and U-CARE is being tested in a three-armed, cluster randomized trial in 58 general practices in the Netherlands, with approximately 5000 elderly individuals expected to participate. The primary outcome is the effect on activities of daily living as measured with the Katz ADL index. Secondary outcomes are quality of life, mortality, nursing home admission, emergency department and out-of-hours General Practice (GP), surgery visits, and caregiver burden.

Discussion

In a large, pragmatic trial conducted in daily clinical practice with frail older patients, several challenges and methodological issues will occur. Recruitment and retention of patients and feasibility of the interventions are important issues. To enable broad generalizability of results, careful choices of the design and outcome measures are required. Taking this into account, the U-PROFIT trial aims to provide robust evidence for a structured and integrated approach to provide care for frail older people in primary care.

Trial registration

NTR2288.

SUBMITTER: Bleijenberg N

PROVIDER: S-EPMC3373372 | biostudies-literature | 2012 Apr

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Proactive and integrated primary care for frail older people: design and methodological challenges of the Utrecht primary care PROactive frailty intervention trial (U-PROFIT).

Bleijenberg Nienke N Drubbel Irene I Ten Dam Valerie H VH Numans Mattijs E ME Schuurmans Marieke J MJ de Wit Niek J NJ

BMC geriatrics 20120425

<h4>Background</h4>Currently, primary care for frail older people is reactive, time consuming and does not meet patients' needs. A transition is needed towards proactive and integrated care, so that daily functioning and a good quality of life can be preserved. To work towards these goals, two interventions were developed to enhance the care of frail older patients in general practice: a screening and monitoring intervention using routine healthcare data (U-PRIM) and a nurse-led multidisciplinar ...[more]

PMID: 22533710

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Project description:BackgroundThe article reports on the cost-effectiveness of the proactive, integrated primary care program Finding and Follow-up of Frail older persons (FFF) compared with usual primary care for community-dwelling frail older persons in the Netherlands.MethodsThis study had a matched quasi-experimental design (pretest and posttest). The economic evaluation was performed from a healthcare perspective with a time horizon of 12 months. The target population consisted of community-dwelling frail older persons aged ≥ 75 years in the FFF intervention group (11 general practitioner (GP) practices) and in the control group receiving usual care (4 GP practices). The effectiveness measures for the cost-effectiveness and cost-utility analyses were subjective well-being (Social Production Function Instrument for the Level of well-being short; SPF-ILs) and QALYs (EuroQol; EQ-5D-3L), respectively. Costs were assessed using resource use questionnaires. Differences in mean effectiveness between groups were assessed using univariate, multilevel and propensity score matched analyses, with and without imputation of missing values. Differences in costs were assessed using Mann-Whitney U-tests and independent samples t-tests. Bootstrapping was performed, and predicted incremental cost-effectiveness ratios (ICERs) and incremental cost-utility ratios (ICURs) were depicted on cost-effectiveness planes.ResultsThe various analyses showed slightly different results with respect to differences in estimated costs and effects. Multilevel analyses showed a small but significant difference between the groups for well-being, in favor of the control group. No significant differences between groups in terms of QALYs were found. Imputed data showed that mean total costs were significantly higher in the intervention group at follow-up.ConclusionProactive, integrated care for community-dwelling frail older persons as provided in the FFF program is most likely not a cost-effective initiative, compared with usual primary care in the Netherlands, in terms of well-being and QALYs over a 12-month period.

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Project description:Frailty management focuses on optimizing the physical and psychological functioning of older people with frail health through early risk identification and intervention in primary care. Such care programs demand a joint effort by primary care professionals and older persons, one in which professionals are expected to promote or facilitate self-management practices and older persons are expected to adhere to the professional advice. It is known that patients and professionals hold different perspectives on frailty, but we know little about how this may affect their cooperation in frailty management. In this article, we therefore study how different perspectives of older persons and their primary care professionals play a role frailty management in practice. Nine cases of frailty management were reconstructed through semi-structured interviews with older persons, their family doctor and practice nurse. Drawing from literature on managing complex problems, we analyzed how "factual" and "normative" orientations played a role in their perspectives. We observe that the perspectives of care professionals and older persons on frailty management were substantially different. Both actors "manage" frailty, but they focus on different aspects of frailty and interestingly, care professionals' rationale is future-oriented whereas older person's rationale past-oriented. Primary care professionals employed practices to manage the medical and social factors of frailty in order to prevent future loss. Older persons employed practices to deal with the psychological, emotional and social aspects of the different types of loss they already experienced, in order to reconcile with loss from the past in the present. These findings raise fundamental questions regarding the different perceptions of and priorities around not only care for frail older people in general, but also implied professional-patient relations and the value of a risk-management approach to care for older people with frail health. The distinction between these perspectives could help care professionals to better respond to older patients' preferences and it could empower older persons to voice preferences and priorities that might not fit within the proposed care program.

Project description:The prompt identification of frailty in primary care is the first step to offer personalized care to older individuals. We aimed to detect and quantify frailty among primary care older patients, by developing and validating a primary care frailty index (PC-FI) based on routinely collected health records and providing sex-specific frailty charts. The PC-FI was developed using data from 308,280 primary care patients ≥ 60 years old part of the Health Search Database (HSD) in Italy (baseline 2013-2019) and validated in the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K; baseline 2001-2004), a well-characterized population-based cohort including 3363 individuals ≥ 60 years old. Potential health deficits part of the PC-FI were identified through ICD-9, ATC, and exemption codes and selected through an optimization algorithm (i.e., genetic algorithm), using all-cause mortality as the main outcome for the PC-FI development. The PC-FI association at 1, 3 and 5 years, and discriminative ability for mortality and hospitalization were tested in Cox models. The convergent validity with frailty-related measures was verified in SNAC-K. The following cut-offs were used to define absent, mild, moderate and severe frailty: < 0.07, 0.07-0.14, 0.14-0.21, and ≥ 0.21. Mean age of HSD and SNAC-K participants was 71.0 years (55.4% females). The PC-FI included 25 health deficits and showed an independent association with mortality (hazard ratio range 2.03-2.27; p < 0.05) and hospitalization (hazard ratio range 1.25-1.64; p < 0.05) and a fair-to-good discriminative ability (c-statistics range 0.74-0.84 for mortality and 0.59-0.69 for hospitalization). In HSD 34.2%, 10.9% and 3.8% were deemed mildly, moderately, and severely frail, respectively. In the SNAC-K cohort, the associations between PC-FI and mortality and hospitalization were stronger than in the HSD and PC-FI scores were associated with physical frailty (odds ratio 4.25 for each 0.1 increase; p < 0.05; area under the curve 0.84), poor physical performance, disability, injurious falls, and dementia. Almost 15% of primary care patients ≥ 60 years old are affected by moderate or severe frailty in Italy. We propose a reliable, automated, and easily implementable frailty index that can be used to screen the primary care population for frailty.

Dataset Information

Proactive and integrated primary care for frail older people: design and methodological challenges of the Utrecht primary care PROactive frailty intervention trial (U-PROFIT).

Background

Methods/design

Discussion

Trial registration

Publications

Proactive and integrated primary care for frail older people: design and methodological challenges of the Utrecht primary care PROactive frailty intervention trial (U-PROFIT).

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