Judith E. Bosmans

Post-Discharge Nutritional Support in Malnourished Elderly Individuals Improves Functional Limitations

BACKGROUND Older people are vulnerable to malnutrition, which leads to negative outcomes. This study evaluates the effectiveness of nutritional supplementation in malnourished elderly patients after hospital discharge. METHODS Hospital-admitted malnourished elderly patients (≥ 60 years) were randomized to receive either nutritional supplementation (energy and protein enriched diet, oral nutritional support, calcium-vitamin D supplement, telephone counseling by a dietitian) for 3 months postdischarge or usual care. Outcomes were functional limitations, physical performance, physical activities, body weight, fat-free mass, and handgrip strength. Measurements were performed at hospital admission (baseline) and at 3 months after discharge. Data were analyzed according to the intention-to-treat principle. FINDINGS A total of 210 patients were included, 105 in each group. Body weight increased more in the intervention group than in the control group; this was significant for the highest body weight category (mean difference 3.4 kg, 95% CI 0.2-6.6). Functional limitations decreased more (mean difference -0.5 (95% CI -1.0-0.1) in the intervention group than in the control group. When excluding patients who had already received nutritional support before the start of the study, this reached significance. No significant differences could be demonstrated for physical performance, physical activities, fat-free mass, or handgrip strength. INTERPRETATION Three months of oral nutritional support to malnourished elderly decreased functional limitations and increased body weight. It can be questioned if a follow-up of only 3 months was not too short to detect differences on physical performance and physical activities as well.

Short‐Term Oral Nutritional Intervention with Protein and Vitamin D Decreases Falls in Malnourished Older Adults

To evaluate the effects of a short‐term nutritional intervention with protein and vitamin D on falls in malnourished older adults.

Potential Savings of a Program to Prevent Ankle Sprain Recurrence: Economic Evaluation of a Randomized Controlled Trial

Background The most common ankle injury is the lateral ankle sprain. Dutch annual sports-related ankle sprain costs can roughly be estimated at 187,200,000. Research has shown that proprioceptive training accounts for an approximated overall 50% reduction in ankle sprain recurrence rate. Hypothesis An unsupervised proprioceptive training program to reduce the recurrence of lateral ankle sprains will reduce overall health care costs. Design Cohort study (economic analysis); Level of evidence, 2. Methods The study included 522 male and female athletes: 256 athletes (120 female and 136 male) in the intervention group, and 266 athletes (128 female and 138 male) in the control group. Both groups received treatment according to usual care. Athletes allocated to the intervention group received an 8-week proprioceptive training program in addition to usual care. Costs per athlete and costs per injured athlete were calculated. Costs related to ankle sprain recurrences were measured from a societal perspective using cost diaries. Bootstrapping was used to analyze the cost-effectiveness data. Follow-up was 1 year. Results Mean total costs in the intervention group were 81 (standard deviation, 134) per athlete and 114 (325) per injured athlete. Mean overall costs in the control group were 149 (836) per athlete and 447 (1403) per injured athlete. Statistically significant differences in total costs were found per athlete (mean difference, —69; 95% confidence interval, -200 to -2) and per injured athlete (-332; -741 to -62) in favor of the intervention group. A cost-effectiveness plane showed the effect of the intervention was larger and the costs were lower in the intervention group than the control group. Conclusion The use of a proprioceptive training program after usual care of an ankle sprain is cost-effective for the prevention of ankle sprain recurrences in comparison with usual care alone. In the Netherlands, an estimated annual 35.9 million in medical and lost productivity costs can be saved solely by advocating a proprioceptive training program as in the present study.

Oral nutritional support in malnourished elderly decreases functional limitations with no extra costs

BACKGROUND & AIMS Older people are vulnerable to malnutrition which leads to increased health care costs. The aim of this study was to evaluate the cost-effectiveness of nutritional supplementation from a societal perspective. DESIGN This randomized controlled trial included hospital admitted malnourished elderly (≥ 60 y) patients. Patients in the intervention group received nutritional supplementation (energy and protein enriched diet, oral nutritional support, calcium-vitamin D supplement, telephone counselling by a dietician) until three months after discharge from hospital. Patients in the control group received usual care (control). Primary outcomes were Quality Adjusted Life Years (QALYs), physical activities and functional limitations. Measurements were performed at hospital admission and three months after discharge. Data were analyzed according to the intention-to-treat principle and multiple imputation was used to impute missing data. Incremental cost-effectiveness ratios were calculated and bootstrapping was applied to evaluate cost-effectiveness. Cost-effectiveness was expressed by cost-effectiveness planes and cost-effectiveness acceptability curves. RESULTS 210 patients were included, 105 in each group. After three months, no statistically significant differences in quality of life and physical activities were observed between groups. Functional limitations decreased significantly more in the intervention group (mean difference -0.72, 95% CI-1.15; -0.28). There were no differences in costs between groups. Cost-effectiveness for QALYs and physical activities could not be demonstrated. For functional limitations we found a 0.95 probability that the intervention is cost-effective in comparison with usual care for ceiling ratios > €6500. CONCLUSIONS A multi-component nutritional intervention to malnourished elderly patients for three months after hospital discharge leads to significant improvement in functional limitations and is neutral in costs. A follow-up of three months is probably too short to detect changes in QALYs or physical activities.

Effectiveness and cost-effectiveness of an internet intervention for family caregivers of people with dementia: design of a randomized controlled trial

BackgroundThe number of people with dementia is rising rapidly as a consequence of the greying of the world population. There is an urgent need to develop cost effective approaches that meet the needs of people with dementia and their family caregivers. Depression, feelings of burden and caregiver stress are common and serious health problems in these family caregivers. Different kinds of interventions are developed to prevent or reduce the negative psychological consequences of caregiving. The use of internet interventions is still very limited, although they may be a cost effective way to support family caregivers in an earlier stage and diminish their psychological distress in the short and longer run.Methods/designA pragmatic randomized controlled trial is designed to evaluate the effectiveness and cost-effectiveness of ‘Mastery over Dementia’, an internet intervention for caregivers of people with dementia. The intervention aims at prevention and decrease of psychological distress, in particular depressive symptoms. The experimental condition consists of an internet course with 8 sessions and a booster session over a maximum period of 6 months guided by a psychologist. Caregivers in the comparison condition receive a minimal intervention. In addition to a pre and post measurement, an intermediate measurement will be conducted. In addition, there will be two follow-up measurements 3 and 6 months after post-treatment in the experimental group only. To study the effectiveness of the intervention, depressive symptoms are used as the primary outcome, whereas symptoms of anxiety, role overload and caregiver perceived stress are used as secondary outcomes. To study which caregivers profit most of the internet intervention, several variables that may modify the impact of the intervention are taken into account. Regarding the cost-effectiveness, an economic evaluation will be conducted from a societal perspective.DiscussionThis study will provide evidence about the effectiveness and cost-effectiveness of an internet intervention for caregivers. If both can be shown, this might set the stage for the development of a range of internet interventions in the field of caregiving for people with dementia. This is even more important because future generations of caregivers will be more familiar with the use of internet.Trial registrationNTR-2051/RCT-DDB

Cardiometabolic risk factors and quality of life in severely obese children and adolescents in the Netherlands

BackgroundThe prevalence of severe obesity in children and adolescents is increasing. However, little is known about cardiometabolic risk factors and quality of life of children with severe obesity.Therefore, the aim of this study was to assess the demographic characteristics and the prevalence of cardiometabolic risk factors and quality of life in severely obese children and adolescents undergoing intensive inpatient treatment for obesity.MethodsData were collected between August 2009 and April 2011 on 16 children (8-13y) and 64 adolescents (13-19y) with severe obesity (SDS-BMI >= 3.0 or SDS-BMI >= 2.3 and comorbidity) participating in an RCT evaluating two intensive inpatient treatment programs for obesity. Demographic, anthropometric, clinical characteristics and two components of the EuroQol for the assessment of quality of life are described.ResultsEighty percent of participants in this study had at least one cardiometabolic risk factor in addition to severe obesity. Low HDL-cholesterol and hypertension were most prevalent (65.0% respectively 31.2%). The highest significant correlations were found between SDS-BMI and SDS-waist circumference, fasting plasma insulin and HOMA-IR (correlation coefficients respectively 0.80, 0.49, and 0.48). With regard to quality of life, the mean utility score of the participants was 0.79 on a scale of 0.0 to 1.0 on the EuroQol questionnaire and their mean individual valuation was 69.1 on a scale of 0 to100.ConclusionCardiometabolic risk factors are already highly prevalent in this group of severely obese children and adolescents. The score of 69.1 found for quality of life in this study suggests that participants experience important limitations in their quality of life. However, quality of life is not associated with the prevalence of cardiometabolic risk factors.Trial registrationNetherlands Trial Register (NTR1678, registered 20-Feb-2009)

Cost-effectiveness of tailored print communication, telephone motivational interviewing, and a combination of the two: results of an economic evaluation alongside the Vitalum randomized controlled trial

BackgroundThe aim of the present study was to evaluate the cost-effectiveness of tailored print communication (TPC), telephone motivational interviewing (TMI), a combination of the two, and no intervention on two outcomes in adults aged 45 to 70, half of them having hypertension: increasing the number of public health guidelines met for three behaviors (physical activity and fruit and vegetable consumption), and impact on quality adjusted life years (QALYs).MethodsParticipants (n = 1,629) from 23 Dutch general practices were randomized into one of four groups, which received 4 TPCs, 4 TMIs, 2 of each (combined), or no intervention (control), respectively. The self-reported outcomes, measured at baseline and 73 weeks follow-up (7 months after the last intervention component), were difference in total number of guidelines met at follow-up compared to baseline, and number of QALYs experienced over 73 weeks. The costs of implementing the intervention were estimated using a bottom-up approach.ResultsAt 73 weeks follow-up participants showed increased adherence with 0.62 (TPC), 0.40 (TMI), 0.50 (combined), and 0.26 (control) guidelines compared to baseline, and experienced 1.09, 1.08, 1.08, and 1.07 QALYs, respectively. The costs for the control group were considered to be zero. TMI was more expensive (€107 per person) than both the combined intervention (€80) and TPC (€57). The control condition was most cost-effective for lower ceiling ratios, while TPC had the highest probability of being most cost-effective for higher ceiling ratios (more than €160 per additional guideline met, and €2,851 for each individual QALY).ConclusionsFor low societys willingness to pay, the control group was most cost-effective for the number of QALYs experienced over 73 weeks. This also applied to the increase in the number of guidelines met at lower ceiling ratios, whereas at higher ceiling ratios, TPC had a higher probability of being more cost-effective than the TMI, combined or control conditions. This also seemed to apply for QALYs experienced over 73 weeks. More research is needed on the long-term efficacy of both TPC and TMI, as well as on how to increase their cost-effectiveness.Trial registrationDutch Trial Register NTR1068

Depression and anxiety, an Indicated Prevention (DIP) protocol in homes for the elderly: feasibility and (cost) effectiveness of a stepped care programme

BackgroundDepressive and anxiety disorders are a very common, serious and underdetected problem in homes for the elderly. Elderly persons in residential homes are at high risk for developing major depressive and anxiety disorders, and, therefore, deserve attention with regard to prevention.Methods/DesignThis protocol describes a randomised trial on the feasibility and (cost) effectiveness of a stepped-care programme for prevention of depressive and anxiety disorders in homes for the elderly. The main outcome measure is the incidence of depressive and anxiety disorder in one year with a two years follow up. Secondary outcomes are symptoms of depression and anxiety, quality of life, direct health care costs and satisfaction with treatment.DiscussionThe number of studies examining the effects of preventive interventions on the incidence of mental disorders in the elderly population is very small. However, indicated prevention by means of a stepped-care programme seems to be an important option for decreasing the burden of illness for residents and their caregivers. This study contributes to the body of knowledge in this field. Positive effects may contribute to further use and development of tailored, (cost-) effective and easy to use interventions in a preventive stepped-care programme.Trial RegistrationThe Dutch Cochrane Centre, ISRCTN27540731

Comparing Measurement Properties of the EQ-5D-3L, ICECAP-O, and ASCOT in Frail Older Adults

BACKGROUND The ICEpop CAPability measure for Older people (ICECAP-O) and the Adult Social Care Outcomes Toolkit (ASCOT) are preference-based measures for assessing quality of life (QOL) from a broader perspective than do traditional health-related QOL measures such as the EuroQol five-dimensional questionnaire (EQ-5D). Measurement properties of these instruments have not yet been directly compared. OBJECTIVE The purpose of this study was to compare the test-retest reliability, construct validity, and responsiveness of the three-level EQ-5D (EQ-5D-3L), ICECAP-O, and ASCOT in frail older adults living at home. METHODS Cross-sectional data and longitudinal data were used. Parameters for reliability (the intraclass correlation coefficient) and agreement (standard error of measurement) were used to assess test-retest reliability after 1 week. We formulated hypotheses about correlations with other measures and tested these to assess construct validity and responsiveness (longitudinal validity). RESULTS The reliability parameters for all three scales were considered good (intraclass correlation coefficient values above 0.70). Standard error of measurement values were less than 10% of the scale. Hypotheses regarding construct validity were in general accepted; the EQ-5D-3L was more strongly associated with physical limitations than were ICECAP-O and ASCOT and less strongly with instruments measuring aspects beyond health. Longitudinally, as hypothesized, mental health was most strongly associated with ICECAP-O, and self-perceived QOL, mastery, and client-centeredness of home care most strongly with ASCOT. CONCLUSIONS Our findings support the adoption of ICECAP-O and ASCOT as outcome measures in economic evaluations of care interventions for older adults that have a broader aim than health-related QOL because they are at least as reliable as the EQ-5D-3L and are associated with aspects of QOL broader than health.

Comparing Dutch Case management care models for people with dementia and their caregivers: The design of the COMPAS study

BackgroundDementia care in the Netherlands is shifting from fragmented, ad hoc care to more coordinated and personalised care. Case management contributes to this shift. The linkage model and a combination of intensive case management and joint agency care models were selected based on their emerging prominence in the Netherlands. It is unclear if these different forms of case management are more effective than usual care in improving or preserving the functioning and well-being at the patient and caregiver level and at the societal cost. The objective of this article is to describe the design of a study comparing these two case management care models against usual care. Clinical and cost outcomes are investigated while care processes and the facilitators and barriers for implementation of these models are considered.DesignMixed methods include a prospective, observational, controlled, cohort study among persons with dementia and their primary informal caregiver in regions of the Netherlands with and without case management including a qualitative process evaluation. Inclusion criteria for the cohort study are: community-dwelling individuals with a dementia diagnosis who are not terminally-ill or anticipate admission to a nursing home within 6 months and with an informal caregiver who speaks fluent Dutch. Person with dementia-informal caregiver dyads are followed for two years. The primary outcome measure is the Neuropsychiatric Inventory for the people with dementia and the General Health Questionnaire for their caregivers. Secondary outcomes include: quality of life and needs assessment in both persons with dementia and caregivers, activity of daily living, competence of care, and number of crises. Costs are measured from a societal perspective using cost diaries. Process indicators measure the quality of care from the participant’s perspective. The qualitative study uses purposive sampling methods to ensure a wide variation of respondents. Semi-structured interviews with stakeholders based on the theoretical model of adaptive implementation are planned.DiscussionThis study provides relevant insights into care processes, description of two case management models along with clinical and economic data from persons with dementia and caregivers to clarify important differences in two case management care models compared to usual care.