Jenny Alwin

Long-Term Evaluation of the Ambulatory Geriatric Assessment: A Frailty Intervention Trial (AGe-FIT): Clinical Outcomes and Total Costs After 36 Months

OBJECTIVE To compare the effects of care based on comprehensive geriatric assessment (CGA) as a complement to usual care in an outpatient setting with those of usual care alone. The assessment was performed 36 months after study inclusion. DESIGN Randomized, controlled, assessor-blinded, single-center trial. SETTING A geriatric ambulatory unit in a municipality in the southeast of Sweden. PARTICIPANTS Community-dwelling individuals aged ≥ 75 years who had received inpatient hospital care 3 or more times in the past 12 months and had 3 or more concomitant medical diagnoses were eligible for study inclusion. Participants were randomized to the intervention group (IG) or control group (CG). INTERVENTION Participants in the IG received CGA-based care for 24 to 31 months at the geriatric ambulatory unit in addition to usual care. OUTCOME MEASURES Mortality, transfer to nursing home, days in hospital, and total costs of health and social care after 36 months. RESULTS Mean age (SD) of participants was 82.5 (4.9) years. Participants in the IG (n = 208) lived 69 days longer than did those in the CG (n = 174); 27.9% (n = 58) of participants in the IG and 38.5% (n = 67) in the CG died (hazard ratio 1.49, 95% confidence interval 1.05-2.12, P = .026). The mean number of inpatient days was lower in the IG (15.1 [SD 18.4]) than in the CG (21.0 [SD 25.0], P = .01). Mean overall costs during the 36-month period did not differ between the IG and CG (USD 71,905 [SD 85,560] and USD 65,626 [SD 66,338], P = .43). CONCLUSIONS CGA-based care resulted in longer survival and fewer days in hospital, without significantly higher cost, at 3 years after baseline. These findings add to the evidence of CGAs superiority over usual care in outpatient settings. As CGA-based care leads to important positive outcomes, this method should be used more extensively in the treatment of older people to meet their needs.

Support/services among family caregivers of persons with dementia-perceived importance and services received

The aim of this study was to examine what family caregivers of persons with dementia perceive as important types of support/services in relation to experienced negative impact (NI) due to the caregiver situation, and to investigate if caregivers receive the support/services perceived as important.

Differences between hypothetical and experience-based value sets for EQ-5D used in Sweden: Implications for decision makers.

Aims: A number of value sets are available today for converting EQ-5D questionnaire responses to quality-adjusted life year-weights used in health economic evaluations. The aim of this study is to analyse the differences between the commonly used hypothetical UK value set and the newly introduced Swedish experience-based value set and to evaluate health economic implications of such differences on policy decisions. Methods: Differences between the two value sets were studied using two methods: a comparison of health states and improvements as well as an empirical comparison. In the comparison of health states and improvements, the valuations of all EQ-5D states and all pure improvements were compared. In the empirical study, a database of 23,925 individuals was used to identify patient groups that could be affected by the implementation of the Swedish experience-based value set. Results: The comparison of health states and possible improvements showed that only three health states were assigned a lower quality-adjusted life year-weight and most improvements were given smaller absolute values if the experience-based value set was used. The empirical comparison showed that severe conditions were assigned higher values when using the experience-based value set. Conclusions: The Swedish experience-based value set seems to render a higher estimated level of health-related quality of life in virtually all health conditions compared to the hypothetical UK value set. In extension, health-related quality of life enhancing interventions are likely to be given higher priority in decision-making situations where hypothetical values are used to construct quality-adjusted life year-weights. In situations where experience-based quality-adjusted life year-weights are used, life-prolonging interventions would be prioritised.

Is the acute care of frail elderly patients in a comprehensive geriatric assessment unit superior to conventional acute medical care

Objective The aim of this study was to investigate whether the acute care of frail elderly patients in a comprehensive geriatric assessment (CGA) unit is superior to the care in a conventional acute medical care unit. Design This is a clinical, prospective, randomized, controlled, one-center intervention study. Setting This study was conducted in a large county hospital in western Sweden. Participants The study included 408 frail elderly patients, aged ≥75 years, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n=206) or control group (n=202). Mean age of the patients was 85.7 years, and 56% were female. Intervention This organizational form of care is characterized by a structured, systematic interdisciplinary CGA-based care at an acute elderly care unit. Measurements The primary outcome was the change in health-related quality of life (HRQoL) 3 months after discharge from hospital, measured by the Health Utilities Index-3 (HUI-3). Secondary outcomes were all-cause mortality, rehospitalizations, and hospital care costs. Results After adjustment by regression analysis, patients in the intervention group were less likely to present with decline in HRQoL after 3 months for the following dimensions: vision (odds ratio [OR] =0.33, 95% confidence interval [CI] =0.14–0.79), ambulation (OR =0.19, 95% CI =0.1–0.37), dexterity (OR =0.38, 95% CI =0.19–0.75), emotion (OR =0.43, 95% CI =0.22–0.84), cognition (OR = 0.076, 95% CI =0.033–0.18) and pain (OR =0.28, 95% CI =0.15–0.50). Treatment in a CGA unit was independently associated with lower 3-month mortality adjusted by Cox regression analysis (hazard ratio [HR] =0.55, 95% CI =0.32–0.96), and the two groups did not differ significantly in terms of hospital care costs (P>0.05). Conclusion Patients in an acute CGA unit were less likely to present with decline in HRQoL after 3 months, and the care in a CGA unit was also independently associated with lower mortality, at no higher cost.

Perception and significance of an assistive technology intervention – the perspectives of relatives of persons with dementia

Abstract Purpose: The aim of this study was to examine relatives’ perception of an assistive technology intervention aimed at persons with dementia (PwDs) and their relatives, and to examine whether, and how, experiences of the intervention process differed between relatives valuing the intervention to be of high, and relatives perceiving it to be of low significance. Method: A total of 47 relatives of PwDs within the Swedish Technology and Dementia project were interviewed telephonically using a modified version of the Patient perspective on Care and Rehabilitation process instrument. A total of 46 participants were divided into two groups depending on whether they valued the intervention to be of great significance (GS group; N = 33) or of some/no significance (SNS group; N = 13). Results: Several aspects of the intervention were perceived as highly important, e.g. being shown consideration and respect, and having somewhere to turn. The results indicate that relatives in the GS group perceived certain aspects of the intervention process as highly fulfilled to a larger extent than did relatives in the SNS group. Conclusions: This study illustrates how process evaluations can be used to increase the understanding and to identify improvement aspects of interventions. Implications for Rehabilitation Process evaluation is a good method for understanding how interventions can be improved – a keystone for quality work. Based on relatives’ ratings, a high fulfilment of the AT intervention process was associated with the perception of a significant outcome of the intervention.

A case of community-based fall prevention: Survey of organization and content of minor home help services in Swedish municipalities

Background: The aim of this study was to survey minor home help services provided by Swedish municipalities with the main purpose to prevent fall injuries. Methods: If minor home help services were presented on the homepage of a municipality, an initial telephone contact was taken. Thereafter a questionnaire was administered, including questions about target groups, aim with the services, tasks included, costs and restrictions for users, budget, and experienced gains with the services. Municipalities not providing minor home help services were asked about the reason therefore and if the municipality had previously provided the services Results: The questionnaire response rate was 92%. In 191 of Sweden’s 290 municipalities services were provided by, or in cooperation with, the municipality. Reasons for not providing the services were mainly financial and lack of demand. Services were more often provided in larger cities and in municipalities located in populous regions. In some municipalities services were performed by persons with functional disabilities or unemployed persons. Conclusions: Both providers and users expressed satisfaction with the services. Aspects expressed were that services lead to greater sense of safety and social gains. The effect of the services in terms of fall prevention is yet to be proved. With only a small fall-preventive effect services are probably cost-effective. Improved quality of life, sense of safety, and being able to offer meaningful work to otherwise unemployed persons are important aspects that might in themselves motivate the provision of minor home help services.

O3.03: Caring for elderly with multimorbidity: Evaluation of ambulatory geriatric unit (AGU) (the AGe-FIT-study) – a randomized controlled trial

Importance: The care of older persons with multimorbidity is a future challenge for the welfare sector in many countries in terms of organization of care and provision of sufficient health care resources. Objective: To determine whether an alternative with an ambulatory geriatric unit (AGU) additional to usual care based on Comprehensive Geriatric Assessment (CGA) is more effective than usual care (UC) only. Design: Randomized, controlled, assessor blinded, single center trial of community dwelling patients ≥75 years, hospitalized at least three times during the past 12 months, having at least three concomitant diagnoses [intervention (AGU) n = 208, control group (UC) n = 175]. Outcomes: Hospitalizations, mortality, health related quality of life (HRQoL) and costs of care. Results: After 24 months there was no difference in number of hospitalizations (2.1 in AGU versus 2.4 in CG (P = 0.19). However, patients in AGU had less inpatient days (11.1) compared to the UC (15.2) (P = 0.03). Further, the UC had 54% higher mortality rate than the IG (HR = 1.54 (95% CI: 1.01-2.34), P = 0.046). The cost of care was € 19,941 in the AGU and € 17,730 in the UC group. There was no difference in HRQoL between the groups. Conclusion: The superiority of the alternative with AGU in important findings such as decreased inpatient days and mortality, but to slightly higher total cost after 24 months follow up. This finding is important knowledge when organizing the care for the elderly. (Less)

The impact of service and hearing dogs on health-related quality of life and activity level: a Swedish longitudinal intervention study

BackgroundIndividuals with severe disability often require personal assistance and help from informal caregivers, in addition to conventional health care. The utilization of assistance dogs may decrease the need for health and social care and increase the independence of these individuals. Service and hearing dogs are trained to assist specific individuals and can be specialized to meet individual needs. The aim of this study was to describe and explore potential consequences for health-related quality of life, well-being and activity level, of having a certified service or hearing dog.MethodsA longitudinal interventional study with a pre-post design was conducted. At inclusion, all participants in the study had a regular (untrained) companion dog. Data were collected before training of the dog started and three months after certification of the dog. Health-related quality of life was assessed with EQ-5D-3L, EQ-VAS and RAND-36. Well-being was measured with WHO-5 and self-esteem with the Rosenberg Self-Esteem Scale. In addition, questions were asked about physical activity and time spent away from home and on social activities. Subgroups were analyzed for physical service and diabetes alert dogs.ResultsFifty-five owner-and-dog pairs completed the study (30 physical service dogs, 20 diabetes alert dogs, 2 epilepsy alert dogs, and 3 hearing dogs). Initially, study participants reported low health-related quality of life compared with the general population. At follow-up, health-related quality of life measured with the EQ-VAS, well-being and level of physical activity had improved significantly. In the subgroup analysis, physical service dog owners had lower health-related quality of life than diabetes alert dog owners. The improvement from baseline to follow-up measured with EQ-5D statistically differed between the subgroups.ConclusionsThe target population for service and hearing dogs has an overall low health-related quality of life. Our study indicates that having a certified service or hearing dog may have positive impact on health-related quality of life, well-being and activity level. Service and hearing dogs are a potentially important “wagging tail aid” for this vulnerable population, able to alleviate strain, increase independence, and decrease the risk of social isolation.Trial RegistrationThe trial was retrospectively registered in http://clinicaltrial.gov, NCT03270592. September, 2017.

Acute care of severely frail elderly patients in a CGA-unit is associated with less functional decline than conventional acute care

Background A high percentage of individuals treated in specialized acute care wards are frail and elderly. Our aim was to study whether the acute care of such patients in a comprehensive geriatric assessment (CGA) unit is superior to care in a conventional acute medical care unit when it comes to activities of daily living (ADLs), frailty, and use of municipal help services. Patients and methods A clinical, prospective, controlled trial with two parallel groups was conducted in a large county hospital in West Sweden and included 408 frail elderly patients, age 75 or older (mean age 85.7 years; 56% female). Patients were assigned to the intervention group (n=206) or control group (n=202). Primary outcome was decline in functional activity ADLs assessed by the ADL Staircase 3 months after discharge from hospital. Secondary outcomes were degree of frailty and use of municipal help services. Results After adjustment by regression analyses, treatment in a CGA unit was independently associated with lower risk of decline in ADLs [odds ratio (OR) 0.093; 95% confidence interval (CI) 0.052–0.164; P<0.0001], and with a less prevalent increase in the degree of frailty (OR 0.229; 95% CI 0.131–0.400; P<0.0001). When ADLs were classified into three strata (independence, instrumental ADL-dependence, and personal ADL-dependence), changes to a more dependence-associated stratum were less prevalent in the intervention group (OR 0.194; 95% CI 0.085–0.444; P=0.0001). There was no significant difference between the groups in increased use of municipal help services (OR 0.682; 95% CI 0.395–1.178; P=0.170). Conclusion Acute care of frail elderly patients in a CGA unit was independently associated with lesser loss of functional ability and lesser increase in frailty after 3 months.

O-098: Long-term evaluation of the Ambulatory Geriatric Assessment – a Frailty Intervention Trial (AGe-FIT) – clinical outcomes and total costs after 36 months

Objective: To compare mortality and costs of health and social care between participants with access to care based on Comprehensive Geriatric Assessment (CGA) in an out-patient care setting with a control group receiving usual care only. The comparison was done 36 months after inclusion. Methods: Randomized controlled trial. Inclusion criteria: community-dwelling, aged ≥75 years, ≥3 hospitalisations the last year and ≥3 medical diagnoses. Mean age 82.5 years. Results: A total of 208 participants in the intervention group (IG) and 174 in the control group (CG). Participants in the IG lived longer than the participants in the CG. 27.9% (n = 58) in the IG versus 38.5% (n = 67) in the CG had died. HR= 1.49; CI; 1.05-2.12; P = 0.026. Mean number of inpatient days was lower in the IG (intervention 15.1 (SD 18.4), control 21.0 (SD 25.0), P = 0.01. No differences in the overall costs between the IG and CG including costs for home-help service and nursing home. Mean cost during the 36-month period after baseline assessment expressed as USD/patient (SD) in the IG was 71905 (85560) versus 65626 (66338) in the CG: P = 0.43. Conclusion: Better survival and fewer days in hospital three years after baseline assessment without increasing costs. This strengthens the positive results of a care based on CGA not only in acute care settings but also in outpatient care. A change of to-days health care organization focused on a one organ/disease is needed to a more comprehensive and preventive care of the oldest old.