Franka C. Bakker

Effects of hospital-wide interventions to improve care for frail older inpatients: a systematic review.

Background Although it is widely recognised that frail older persons need adaptation of healthcare services, it is unclear how hospital care in general can best be tailored to their frailty. Objective To systematically review the evidence for hospital-wide interventions for older patients. Methods PubMed, Cochrane CENTRAL, Cinahl and reference lists of included articles (1980–2009) were searched. Papers describing (1) randomised controlled trials, controlled clinical trials, controlled before–after studies or interrupted time series, (2) patients ≥65 years admitted to hospital, (3) hospital-wide organisational interventions, and (4) patient-related outcomes, quality of care, patient safety, resource use or costs were included. Two reviewers extracted data and assessed risk of bias independently, according to Cochrane Effective Practice and Organization of Care Review Group guidelines. Results The authors included 20 articles out of 1175. The mean age of the study populations ranged from 74.2 to 85.8 years. Interventions included multidisciplinary (consultative) teams, nursing care models, structural changes in physical environment and/or changes in site of service delivery. Small or no effects were found on patient-related outcomes such as functional performance, length of stay, discharge destination, resource use and costs compared with usual care. Methodological quality evaluation showed data incompleteness and contamination as main sources of bias. Conclusions No single best hospital-wide intervention could be identified using strict methodological criteria. However, several interventions had positive results, and may be used in hospital practice. Since strict methodological designs are not optimal for evaluating highly complex interventions and settings, the authors recommend studying hospital-wide interventions for older persons using adapted quality and research criteria.

Hospital Elder Life Program integrated in dutch hospital care: a pilot

To the Editor: Many hospitals in the Netherlands have geriatric support but still lack a hospital-wide mind-set toward proactive integrated care, prevention of functional decline in older hospitalized adults, and attention to subjective well-being in care, so the CareWell in Hospital (CWH) program was developed. CWH aims to improve functional status and attention to quality of life in hospital care by appointing trained volunteers, similar to the Hospital Elder Life Program (HELP), which is innovative in Dutch hospital care, but before disseminating and sustaining HELP in the Netherlands, it was necessary to modify the program to make it feasible for Dutch hospitals. The HELP program was introduced and adapted to the Netherlands as part of the CWH program. CWH comprises a first-stage screening of patients aged 70 and older for risk of delirium, physical decline, falls, and undernutrition by nurses, followed by a second-stage screening by a geriatric nurse, a CareWell plan including a medication review, in-hospital follow-up, and an updated CareWell plan at discharge. Additional components may include taking a medical history by proxy; having a geriatrician perform a comprehensive geriatric assessment; discussing a patient in a multidisciplinary meeting; and having trained volunteers perform therapeutic (cognitive) activities, nutritional assistance, or physical activities with patients (mobilization). The geriatric consultation team (GCT) also educates nurses and physicians. A pilot study was conducted to determine the feasibility of the CWH program and gathering the research data. The pilot consisted of a preand postintervention evaluation performed from July 2010 to May 2011 at the University Centre for Chronic Diseases Dekkerswald, Nijmegen, the Netherlands. From October 1, 2010, CWH was implemented on two wards mainly with individuals with chronic pulmonary obstructive disease (COPD). Feasibility was determined using a process evaluation of CWH program implementation and a (cost-)effectiveness evaluation. The degree of CWH program implementation was evaluated using data from records of meetings with program leaders; registered intervention elements provided to patients; and interviews conducted with patients, nurses, physicians, and the CWH intervention team (GCT and trained volunteers). To determine the feasibility of primary outcome measures for CWH effectiveness, data were gathered about delirium incidence (clinical judgment of a geriatrician), cognitive functioning (Mini-Mental State Examination), and physical functioning (Katz activities of daily living (ADLs)) at admission and discharge. To determine the feasibility of a cost-effectiveness evaluation, data on length of stay (LOS) were collected from electronic medical files and data on use of healthcare services 3 months after discharge were collected using a written questionnaire. Healthcare services included hospital admission, visits to a general practitioner, home care, institutionalization, and day care. Because of privacy concerns, it was impossible to gather data from healthcare insurers or providers. To determine the validity of Table 1. Characteristics of the Study Population: Implementation of Intervention Elements and Outcome Measures (N = 28)

Development and Validation of the Geriatric In‐Hospital Nursing Care Questionnaire

To develop a questionnaire, the Geriatric In‐hospital Nursing Care Questionnaire (GerINCQ), to measure, in an integrated way, the care that older adults receive in the hospital and nurses’ attitudes toward and perceptions about caring for older adults.

Evidence from Multicomponent Interventions: Value of Process Evaluations

1. Reimers MS, Bastiaannet E, van Herk-Sukel MPP et al. Aspirin use after diagnosis improves survival in older adults with colon cancer: A retrospective cohort study. J Am Geriatr Soc 2012;60:2232–2236. 2. Greystoke A, Mullamitha SA. How many diseases are colorectal cancer? Gastroenterol Res Pract 2012;2012:564741. 3. Liao X, Lochhead P, Nishihara R et al. Aspirin use, tumor PIK3CA mutation, and colorectal-cancer survival. N Engl J Med 2012;367:1596–1606. 4. Rothwell PM. Aspirin in prevention of sporadic colorectal cancer: Current clinical evidence and overall balance of risks and benefits. Recent Results Cancer Res 2013;191:121–142.

Uniform presentation of process evaluation results facilitates the evaluation of complex interventions: development of a graph

Rationale, aims and objectives Process evaluation is a highly essential element for the increasing number of studies regarding multi-component interventions. Yet, researchers are challenged to collect and present appropriate process outcomes in such way that it is easy and valuable to be used by other researchers and policy makers in interpreting and comparing intervention effects because of the absence of standards for conducting and publishing process evaluation. This article describes the development of a method to concisely summarize the results of process evaluations of complex multi-component interventions. Methods Development of a graph with the aim to facilitate the reporting of process evaluations results, based on a narrative review of the literature for process measures used in complex interventions for elderly people. Results Seventeen articles of process evaluations alongside effect studies of complex interventions were reviewed. From these articles, it was found that process evaluations should address whether the intervention (1) was implemented successfully; (2) was evaluated properly; and (3) can be continued in the future. A flow chart based on the essential components of an adequate process evaluation was developed. A simplified but highly informative figure reporting a summary of the results of the process evaluation is proposed and its use is explained by administering the figure to two studies including a process and effect evaluation of a complex intervention. Conclusion A graphical approach – which includes the core results of process evaluation and can be used directly in reporting effectiveness studies – will help researchers and policy makers to interpret and compare effects of complex multi-component interventions.RATIONALE, AIMS AND OBJECTIVES Process evaluation is a highly essential element for the increasing number of studies regarding multi-component interventions. Yet, researchers are challenged to collect and present appropriate process outcomes in such way that it is easy and valuable to be used by other researchers and policy makers in interpreting and comparing intervention effects because of the absence of standards for conducting and publishing process evaluation. This article describes the development of a method to concisely summarize the results of process evaluations of complex multi-component interventions. METHODS Development of a graph with the aim to facilitate the reporting of process evaluations results, based on a narrative review of the literature for process measures used in complex interventions for elderly people. RESULTS Seventeen articles of process evaluations alongside effect studies of complex interventions were reviewed. From these articles, it was found that process evaluations should address whether the intervention (1) was implemented successfully; (2) was evaluated properly; and (3) can be continued in the future. A flow chart based on the essential components of an adequate process evaluation was developed. A simplified but highly informative figure reporting a summary of the results of the process evaluation is proposed and its use is explained by administering the figure to two studies including a process and effect evaluation of a complex intervention. CONCLUSION A graphical approach - which includes the core results of process evaluation and can be used directly in reporting effectiveness studies - will help researchers and policy makers to interpret and compare effects of complex multi-component interventions.

Hospital Care for Frail Elderly Adults: From Specialized Geriatric Units to Hospital-Wide Interventions

Much of the acute care provided in hospitals is for elderly people. Frailty is a common clinical condition among these patients. Frail patients are vulnerable to undergoing adverse events, to developing geriatric syndromes and to experiencing functional decline during or due to hospitalization. The strategy for providing specialized geriatric care to these hospitalized frail elderly patients currently consists of care provision either by specialized departments or by specialized teams who adopt comprehensive geriatric assessment. Even so, financial and human resources are insufficient to meet the needs of all hospitalized frail elderly patients who require comprehensive geriatric assessment. New innovative and more efficient geriatric interventions, in which the priorities of the patients themselves should be the main focus, should be developed and implemented, and professionals in all specialties should be educated in applying the fundamentals of geriatric medicine to their frail elderly patients. In the evaluation of such interventions, patient-reported outcomes should play a major role, in addition to the more traditional outcome measures of effectiveness, quality of care and cost-effectiveness.

Eenzijdige beeldvorming vraagt om meer praktijkervaring in onderwijs

SamenvattingEen groot deel van de zorg- en dienstverlening betreft ouderen. Deze groep wordt alleen nog maar groter de komende jaren. Mede daarom is er steeds meer aandacht voor welke diensten worden aangeboden en hoe. Welke competenties zijn nodig in medische en verzorgende opleidingen om goede zorg te verlenen aan de doelgroep ouderen? Naast kennis en vaardigheden is aandacht voor de attitude ten opzichte van ouderen in opleidingen essentieel. Daarom werd vanuit de afdeling geriatrie van het Radboudumc te Nijmegen een onderzoek uitgevoerd naar de beeldvorming over ouderen tijdens het Lowlands festival.

Response to Dikken and Colleagues

1. Persoon A, Bakker FC, Wal-Huisman H et al. Development and validation of the Geriatric In-Hospital Nursing Care Questionnaire. J Am Geriatr Soc 2015;63:327–334. 2. Mokkink LB, Terwee CB, Patrick DL et al. The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: An international Delphi study. Qual Life Res 2010;19:539–549. 3. Abraham IL, Bottrell MM, Dash KR et al. Profiling care and benchmarking best practice in care of hospitalized elderly: The Geriatric Institutional Assessment Profile. Nurs Clin North Am 1999;34:237–255. 4. Malmgreen C, Graham PL, Shortridge-Baggett LM et al. Establishing content validity of a survey research instrument: The Older Patients in Acute Care Survey—United States. J Nurses Staff Dev 2009;25:E14–E18. 5. Malmgreen C, Graham PL, O’Connell M et al. Psychometrics of Older Patients in Acute Care Survey—US. Paper presented at the CANS State of the Science Congress on Nursing Research, Washington, DC, 2010. 6. Janssen KJ, Donders ART, Harrell FE et al. Missing covariate data in medical research: To impute is better than to ignore. J Clin Epidemiol 2010;63:721–727.