Dataset Information

Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in general practice for older people. A cluster randomised controlled trial: Integrated Systematic Care for older People--the ISCOPE study.

ABSTRACT:

Background

older people often experience complex problems. Because of multiple problems, care for older people in general practice needs to shift from a 'problem-based, disease-oriented' care aiming at improvement of outcomes per disease to a 'goal-oriented care', aiming at improvement of functioning and personal quality of life, integrating all healthcare providers. Feasibility and cost-effectiveness of this proactive and integrated way of working are not yet established.

Design

cluster randomised trial.

Participants

all persons aged ≥75 in 59 general practices (30 intervention, 29 control), with a combination of problems, as identified with a structured postal questionnaire with 21 questions on four health domains.

Intervention

for participants with problems on ≥3 domains, general practitioners (GPs) made an integrated care plan using a functional geriatric approach. Control practices: care as usual.

Outcome measures

(i) quality of life (QoL), (ii) activities of daily living, (iii) satisfaction with delivered health care and (iv) cost-effectiveness of the intervention at 1-year follow-up.

Trial registration

Netherlands trial register, NTR1946.

Results

of the 11,476 registered eligible older persons, 7,285 (63%) participated in the screening. One thousand nine hundred and twenty-one (26%) had problems on ≥3 health domains. For 225 randomly chosen persons, a care plan was made. No beneficial effects were found on QoL, patients' functioning or healthcare use/costs. GPs experienced better overview of the care and stability, e.g. less unexpected demands, in the care.

Conclusions

GPs prefer proactive integrated care. 'Horizontal' care using care plans for older people with complex problems can be a valuable tool in general practice. However, no direct beneficial effect was found for older persons.

SUBMITTER: Blom J

PROVIDER: S-EPMC4711660 | biostudies-literature | 2016 Jan

REPOSITORIES: biostudies-literature

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Publications

Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in general practice for older people. A cluster randomised controlled trial: Integrated Systematic Care for older People--the ISCOPE study.

Blom Jeanet J den Elzen Wendy W van Houwelingen Anne H AH Heijmans Margot M Stijnen Theo T Van den Hout Wilbert W Gussekloo Jacobijn J

Age and ageing 20160101 1

<h4>Background</h4>older people often experience complex problems. Because of multiple problems, care for older people in general practice needs to shift from a 'problem-based, disease-oriented' care aiming at improvement of outcomes per disease to a 'goal-oriented care', aiming at improvement of functioning and personal quality of life, integrating all healthcare providers. Feasibility and cost-effectiveness of this proactive and integrated way of working are not yet established.<h4>Design</h4> ...[more]

PMID: 26764392

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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.

Project description:IntroductionThe increasing number of older adults with multiple complex care needs has placed increased pressure on healthcare systems internationally to reorientate healthcare delivery. For many older adults, their first point of contact with the health service is with their general practitioner (GP) and GP participation with integrated care models is the foundation of a population-based approach. A knowledge gap remains in relation to the effectiveness of GP participation in community-based integrated health and social care approaches for older adults. This systematic review aims to examine the effectiveness of multidisciplinary-integrated care for community-dwelling older adults with GP participation.Methods and analysisThis systematic review will include randomised controlled trials (RCTs), quasi and cluster RCTs focusing on integrated care interventions for community-dwelling older adults by multidisciplinary teams including health and social care professionals and GPs. The databases PUBMED, EMBASE, CINAHL, Central Register of Controlled Trials in the Cochrane Library and MEDLINE will be searched. The primary outcome measure will be functional status. Secondary outcomes will include: primary healthcare utilisation, secondary healthcare utilisation, participant satisfaction with care, health-related quality of life, nursing home admission and mortality. The methodological quality of the studies will be assessed using the Cochrane Risk of Bias Tool V.2. The elements of care integration will be mapped in the individual studies using the Rainbow Model of Integrated Care taxonomy. A meta-analysis will be completed, depending on the uniformity of the data. Grading of Recommendations, Assessment, Development and Evaluation will be used to assess the certainty of evidence.Ethics and disseminationFormal ethical approval is not required as all data included are anonymous secondary data. Scientific outputs will be presented at relevant conferences and in collaboration with our public and patient involvement stakeholder panel of older adults at the Ageing Research Centre at the University of Limerick.Prospero registration numberCRD42022309744.

Project description:IntroductionFrailty poses a huge burden to individuals, their families and to healthcare systems. Several interventions have been evaluated for the improvement of outcomes for older people with frailty, including integrated care interventions. Reviews synthesising evidence on the effectiveness of integrated care for older people with frailty have treated them as a single population, without considering the heterogeneity between different frailty levels such as non-frail, mild frailty, moderate frailty and severe frailty. Findings from these studies have shown inconsistent results on the various outcomes assessed. People with different frailty status have different care needs, which should be addressed accordingly. The aim of this study is to synthesise evidence on the effectiveness of integrated care interventions on older people with different frailty status who are community dwelling or living in retirement housing or residential setting but not in care homes or in nursing homes.Methods and analysisThis is a protocol for a systematic review assessing the effectiveness of integrated chronic care interventions on older people with different frailty status. A literature search will be conducted on the databases Cochrane Central Register of Controlled Trials, PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and clinical trial registers. Two authors will independently conduct search and screening for eligible studies. Full-text screening will be used to include only studies that fulfil the inclusion criteria. Data extraction will be done on a data extraction form and methodological quality of studies will be assessed using the Effective Practice and Organisation of Care risk of bias tool. The interventions will be described following Wagner's Chronic Care Model.Ethics and disseminationEthical approval for this study was obtained from the Institute for Health Research Ethics Committee of the University of Bedfordshire (IHREC934). The results of the review will be disseminated through a peer-reviewed journal article, conferences and also with local provider and user stakeholders.Prospero registration numberCRD42020166908.

Project description:ObjectivesDizziness is common in older people. Physicians are often unable to identify a specific cause for dizziness in older people, even after an extensive diagnostic work-up. A prognosis-oriented approach, i.e. treating modifiable risk factors for an unfavourable course of dizziness, may reduce dizziness-related impairment in older people in primary care.DesignCluster randomized controlled trial.Setting45 primary care practices in The Netherlands.Participants168 participants aged ≥65y who consulted their general practitioner for dizziness and experienced significant dizziness-related impairment (Dizziness Handicap Inventory (DHI) ≥30). Participants were part of to the intervention group (n = 83) or control group (n = 85), depending on whether they were enlisted in an intervention practice or in a control practice.InterventionsThe multifactorial intervention consisted of: medication adjustment in case of ≥3 prescribed fall-risk-increasing drugs (FRIDs) and/or stepped mental health care in case of anxiety disorder and/or depression and/or exercise therapy in case of impaired functional mobility. The intervention was compared to usual care.Outcome measuresThe primary outcome was dizziness-related impairment. Secondary outcomes were quality of life (QoL), dizziness frequency, fall frequency, anxiety and depression, use of FRIDs.ResultsIntention-to-treat analysis showed no significant intervention effect on dizziness-related impairment (DHI score difference -0.69 [95% CI -5.66;4.28]; p = 0.79). The intervention proved effective in reducing the number of FRIDs (FRID difference -0.48 [95% CI -0.89;-0.06]; p = 0.02). No significant intervention effects were found on other secondary outcomes. The uptake of and adherence to the interventions was significantly lower in patients eligible for ≥2 interventions compared to patients eligible for one intervention (p<0.001).ConclusionsThe multifactorial intervention for dizziness in older patients showed no significant intervention effect on most outcomes and adherence to the multifactorial intervention was low. Although multifactorial treatment for older dizzy people seems promising in theory, we question its feasibility in daily practice. Future research could focus on a sequential treatment for dizziness, e.g. measuring effectiveness of various evidence-based therapies in a stepwise approach.

Project description:BackgroundEffectiveness of integrated care management for common, comorbid physical and mental disorders has been insufficiently examined in low- and middle-income countries (LMICs). We tested hypotheses that older adults treated in rural Chinese primary care clinics with integrated care management of comorbid depression and hypertension (HTN) would show greater improvements in depression symptom severity and HTN control than those who received usual care.Methods and findingsThe study, registered with ClinicalTrials.gov as Identifier NCT01938963, was a cluster randomized controlled trial with 12-month follow-up conducted from January 1, 2014 through September 30, 2018, with analyses conducted in 2020 to 2021. Participants were residents of 218 rural villages located in 10 randomly selected townships of Zhejiang Province, China. Each village hosts 1 primary care clinic that serves all residents. Ten townships, each containing approximately 20 villages, were randomly selected to deliver either the Chinese Older Adult Collaborations in Health (COACH) intervention or enhanced care-as-usual (eCAU) to eligible village clinic patients. The COACH intervention consisted of algorithm-driven treatment of depression and HTN by village primary care doctors supported by village lay workers with telephone consultation from centrally located psychiatrists. Participants included clinic patients aged ≥60 years with a diagnosis of HTN and clinically significant depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] score ≥10). Of 2,899 eligible village residents, 2,365 (82%) agreed to participate. They had a mean age of 74.5 years, 67% were women, 55% had no schooling, 59% were married, and 20% lived alone. Observers, older adult participants, and their primary care providers (PCPs) were blinded to study hypotheses but not to group assignment. Primary outcomes were change in depression symptom severity as measured by the Hamilton Depression Rating Scale (HDRS) total score and the proportion with controlled HTN, defined as systolic blood pressure (BP) <130 mm Hg or diastolic BP <80 for participants with diabetes mellitus, coronary heart disease, or renal disease, and systolic BP <140 or diastolic BP <90 for all others. Analyses were conducted using generalized linear mixed effect models with intention to treat. Sixty-seven of 1,133 participants assigned to eCAU and 85 of 1,232 COACH participants were lost to follow-up over 12 months. Thirty-six participants died of natural causes, 22 in the COACH arm and 14 receiving eCAU. Forty COACH participants discontinued antidepressant medication due to side effects. Compared with participants who received eCAU, COACH participants showed greater reduction in depressive symptoms (Cohen's d [±SD] = -1.43 [-1.71, -1.15]; p < 0.001) and greater likelihood of achieving HTN control (odds ratio [OR] [95% CI] = 18.24 [8.40, 39.63]; p < 0.001). Limitations of the study include the inability to mask research assessors and participants to which condition a village was assigned, and lack of information about participants' adherence to recommendations for lifestyle and medication management of HTN and depression. Generalizability of the model to other regions of China or other LMICs may be limited.ConclusionsThe COACH model of integrated care management resulted in greater improvement in both depression symptom severity and HTN control among older adult residents of rural Chinese villages who had both conditions than did eCAU.Trial registrationClinicalTrials.gov Identifier NCT01938963 https://clinicaltrials.gov/ct2/show/NCT01938963.

Dataset Information

Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in general practice for older people. A cluster randomised controlled trial: Integrated Systematic Care for older People--the ISCOPE study.

Background

Design

Participants

Intervention

Outcome measures

Trial registration

Results

Conclusions

Publications

Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in general practice for older people. A cluster randomised controlled trial: Integrated Systematic Care for older People--the ISCOPE study.

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