Andrea Steiner

A Trial of Annual in-Home Comprehensive Geriatric Assessments for Elderly People Living in the Community

BACKGROUND AND METHODS The prevention of disability in elderly people poses a challenge for health care and social services. We conducted a three-year, randomized, controlled trial of the effect of annual in-home comprehensive geriatric assessment and follow-up for people living in the community who were 75 years of age or older. The 215 people in the intervention group were seen at home by gerontologic nurse practitioners who, in collaboration with geriatricians, evaluated problems and risk factors for disability, gave specific recommendations, and provided health education. The 199 people in the control group received their regular medical care. The main outcome measures were the prevention of disability, defined as the need for assistance in performing the basic activities of daily living (bathing, dressing, feeding, grooming, transferring from bed to chair, and moving around inside the house) or the instrumental activities of daily living (e.g., cooking, handling finances and medication, housekeeping, and shopping), and the prevention of nursing home admissions. RESULTS At three years, 20 people in the intervention group (12 percent of 170 surviving participants) and 32 in the control group (22 percent of 147 surviving participants) required assistance in performing the basic activities of daily living (adjusted odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.8; P = 0.02). The number of persons who were dependent on assistance in performing the instrumental activities of daily living but not the basic activities did not differ significantly between the two groups. Nine people in the intervention group (4 percent) and 20 in the control group (10 percent) were permanently admitted to nursing homes (P = 0.02). Acute care hospital admissions and short-term nursing home admissions did not differ significantly between the two groups. In the second and third years of the study, there were significantly more visits to physicians among the participants in the intervention group than among those in the control group (mean number of visits per month, 1.41 in year 2 and 1.27 in year 3 in the intervention group, as compared with 1.11 and 0.92 visits, respectively, in the control group; P = 0.007 and P = 0.001, respectively). The cost of the intervention for each year of disability-free life gained was about

Mobility and dementia: is physiotherapy treatment during respite care effective?

46,000. CONCLUSIONS A program of in-home comprehensive geriatric assessments can delay the development of disability and reduce permanent nursing home stays among elderly people living at home.

Economic evaluation of nurse led intermediate care versus standard care for post-acute medical patients: cost minimisation analysis of data from a randomised controlled trial

Mobility problems experienced by elderly people with a dementia are associated with falls, fractures and admission to long‐term care. A hospital respite care admission is therefore often seen as an opportunity to provide physiotherapy treatment.

Economic Evaluation and the Shifting Balance Towards Primary Care: Definitions, Evidence and Methodological Issues

Abstract Objective To undertake an economic evaluation of nurse led intermediate care compared with standard hospital care for post-acute medical patients. Design Cost minimisation analysis from an NHS perspective, comprising secondary care, primary care, and community care, using data from a pragmatic randomised controlled trial. Setting Nurse led unit and acute general medical wards in large, urban, UK teaching hospital. Participants 238 patients. Outcome measure Costs to acute hospital trusts and to the NHS over six months. Results On an intention to treat basis, nurse led care was associated with higher costs during the initial admission period (nurse led care £7892 (

Accreditation: what can we learn from the Anglophone model?

14 970; €11 503), standard care £4810, difference £3082 (95% confidence interval £1161 to £5002)). During the readmission period, costs were similar (nurse led care £1444, standard care £1879, difference -£435, -£1406 to £536). Total costs at six months were significantly higher (nurse led care £10 529, standard care £7819, difference £2710, £518 to £4903). Sensitivity analyses suggested that the trend for nurse led care to be more expensive was maintained even with substantial cost reductions, although differences were no longer significant. Conclusion Acute hospitals may not be cost effective settings for nurse led intermediate care. Both inpatient and total costs were significantly higher for nurse led care than for standard care of post-acute medical patients, suggesting that this model of care should not be pursued unless clinical or organisational benefits justify the increased investment.

Managed care: drawing lessons from the USA

Current UK government policy places considerable emphasis on shifting the balance of health care provision from secondary towards primary care. Despite this emphasis, however, there has been very little economic evaluation of initiatives designed to achieve this shift. In view of this deficiency, our article has three main aims. First, it offers a working definition of shifts in the balance of care at the primary-secondary care interface. Second, it systematically reviews the existing literature on the cost-effectiveness of initiatives designed to shift the balance of care. Third, it identifies a range of methodological issues that need to be addressed if future economic evaluations in this area are to be carried out satisfactorily.

Does It Matter How You Slice It? The Relationship Between Population Ageing and Use of Hospital and Posthospital Care in the United States

There is growing interest in the development and application of standards for the health care to both promote quality assurance but also to improve the processes by which health services are held accountable to the public. This paper maps the development of organisational accreditation systems in the USA, Canada, Australia and the United Kingdom. In the USA, accreditation, which began as a means of ensuring the correct environment for clinical practice has developed into a form of public regulation. In the United Kingdom, many different approaches to the setting of standards and their assessment has created a variety of accreditation systems. The case studies demonstrate that as the concept of accreditation diffuses into the health care systems of different countries, it is being adapted to meet the wider policy needs of different national circumstances.

Inappropriate medication use in community-residing older persons.

Many pharmaceutical companies, management consultants and health policy analysts claim that managed care is the way forward for the UK National Health Service. 1 These claims are often justified by reference to the achievements of managed care in the USA as a method for controlling costs without compromising the quality of care. At the same time, there are other commentators who are less impressed by the record of managed care. They point to restricted access to health care in managed care organizations (MCOs~ and also raise concerns about the equity of treatment. On close scrutiny, however, it becomes clear that most of the US evidence cited in this context whether claims ofsuccess or concerns about failure is based on anecdotal or partial accounts of the performance of managed care. Faced with this deficiency, The Institute for Health Policy Studies was commissioned by the Department of Health to carry out a systematic review of the high-quality US research literature on managed care, and to consider its lessons for the NHS. 3 In this paper, we review some of the main messages to emerge from the US evidence and highlight a number of the problems associated with drawing lessons from abroad. We conclude with some outline recommendations for drawing on the US experience in the development of managed care approaches in the UK.

Appropriateness of acute medical care for the elderly: an analysis of the literature

In the context of demographic transition, one would expect public health planners to allocate resources according to changing needs. This paper explores the effects that definitions of population ageing have on the images of, and subsequent responses to, demographic transition in the United States. Data are drawn from the 1988 U.S. Census and from a 20-percent national random sample of Medicare patients during the same period (n = 1.9 million). Main findings are that supply and use of acute services do differ according to definitions and the way in which population ageing has occurred; that, regardless of definition, older people in high-ageing states make far greater use of posthospital home health care than in low-ageing states; and that, although individual-level clinical factors appear central to rehabilitative decisions, all states seem to use very old age (85-plus) as a proxy to determine who goes where, with low-ageing states also affected by structural constraints at the hospital and market levels.