Effect of health risk assessment and counselling on health behaviour and survival in older people: a pragmatic randomised trial.

Andreas E Stuck,Stephan Born,André Moser,Joseph Wyser,Marcel Zwahlen,Steve Iliffe,John C Beck,Danielle Harari,Gerhard Gillmann,Urban Wirz,Matthias Egger,Ueli Morf,Cameron Swift

doi:10.1371/journal.pmed.1001889

Abstract

BackgroundPotentially avoidable risk factors continue to cause unnecessary disability and premature death in older people. Health risk assessment (HRA), a method successfully used in working-age populations, is a promising method for cost-effective health promotion and preventive care in older individuals, but the long-term effects of this approach are unknown. The objective of this study was to evaluate the effects of an innovative approach to HRA and counselling in older individuals for health behaviours, preventive care, and long-term survival.Methods and FindingsThis study was a pragmatic, single-centre randomised controlled clinical trial in community-dwelling individuals aged 65 y or older registered with one of 19 primary care physician (PCP) practices in a mixed rural and urban area in Switzerland. From November 2000 to January 2002, 874 participants were randomly allocated to the intervention and 1,410 to usual care. The intervention consisted of HRA based on self-administered questionnaires and individualised computer-generated feedback reports, combined with nurse and PCP counselling over a 2-y period. Primary outcomes were health behaviours and preventive care use at 2 y and all-cause mortality at 8 y. At baseline, participants in the intervention group had a mean ± standard deviation of 6.9 ± 3.7 risk factors (including unfavourable health behaviours, health and functional impairments, and social risk factors) and 4.3 ± 1.8 deficits in recommended preventive care. At 2 y, favourable health behaviours and use of preventive care were more frequent in the intervention than in the control group (based on z-statistics from generalised estimating equation models). For example, 70% compared to 62% were physically active (odds ratio 1.43, 95% CI 1.16–1.77, p = 0.001), and 66% compared to 59% had influenza vaccinations in the past year (odds ratio 1.35, 95% CI 1.09–1.66, p = 0.005). At 8 y, based on an intention-to-treat analysis, the estimated proportion alive was 77.9% in the intervention and 72.8% in the control group, for an absolute mortality difference of 4.9% (95% CI 1.3%–8.5%, p = 0.009; based on z-test for risk difference). The hazard ratio of death comparing intervention with control was 0.79 (95% CI 0.66–0.94, p = 0.009; based on Wald test from Cox regression model), and the number needed to receive the intervention to prevent one death was 21 (95% CI 12–79). The main limitations of the study include the single-site study design, the use of a brief self-administered questionnaire for 2-y outcome data collection, the unavailability of other long-term outcome data (e.g., functional status, nursing home admissions), and the availability of long-term follow-up data on mortality for analysis only in 2014.ConclusionsThis is the first trial to our knowledge demonstrating that a collaborative care model of HRA in community-dwelling older people not only results in better health behaviours and increased use of recommended preventive care interventions, but also improves survival. The intervention tested in our study may serve as a model of how to implement a relatively low-cost but effective programme of disease prevention and health promotion in older individuals.Trial RegistrationInternational Standard Randomized Controlled Trial Number: ISRCTN 28458424

Highlights

An increasing number of older individuals are affected by multiple risks and morbidities, leading to functional impairment, nursing home admissions, or premature death, with enormous social and economic costs to society [1]
The main limitations of the study include the single-site study design, the use of a brief self-administered questionnaire for 2-y outcome data collection, the unavailability of other long-term outcome data, and the availability of long-term follow-up data on mortality for analysis only in 2014. This is the first trial to our knowledge demonstrating that a collaborative care model of Health risk assessment (HRA) in community-dwelling older people results in better health behaviours and increased use of recommended preventive care interventions, and improves survival
The intervention tested in our study may serve as a model of how to implement a relatively low-cost but effective programme of disease prevention and health promotion in older individuals

Summary

Introduction

An increasing number of older individuals are affected by multiple risks and morbidities, leading to functional impairment, nursing home admissions, or premature death, with enormous social and economic costs to society [1]. These adverse outcomes might at least in part be avoidable. Systematic analyses of multimodal preventive care home visit programmes found no consistent effects on mortality and other outcomes, some studies found that these programmes significantly reduced or delayed nursing home admissions in older individuals [6]. In part, these adverse outcomes are linked to avoidable risk factors, unhealthy lifestyles and failure to engage in preventative care. Older people commonly are physically inactive, smoke, drink too much alcohol, or do not have regular blood pressure checks or annual influenza vaccinations

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