Bi-monthly Telephone Research Articles

Male Caregivers Report Problems in Caring at Home After Spouses Survive Stroke.

STROKE is sudden and often traumatic with results that affect both the patient and family members who provide care. Approximately 40% of individuals caring for family members/friends are male. Transitioning from the noncaregiver role to caregiver can be unsettling. Guided by Friedemann's framework of systemic organization, this secondary data analysis examined problems reported by men caring for spouses in the first year after stroke. Using a mixed methods design, 73 caregivers (CGs) participated in bimonthly telephone interviews for 1 year. For this analysis, only the males caring for spouses (n = 12 married and n = 1 unmarried partner) were examined. These data were analyzed using Colaizzi's rigorous method of content analysis. Five problem themes emerged: 1) adjusting to multitasking in everyday living (Friedemann's system maintenance and individuation), 2) recognizing physical and mental disabilities (coherence), 3) dealing with outside forces and limited resources (individuation), 4) struggling to return to normal (system maintenance), and 5) feeling physically, mentally, and emotionally exhausted (system maintenance). These problem themes demonstrated incongruence as the men sought to maintain their prior lives.Theory-based themes of male stroke CGs' problems were uncovered that can be used to target interventions to help them achieve balance between incongruence and congruence in their lives.

Abstract NS8: Male Caregivers Report Problems and Successes Caring for Wives/Partners

Background: Stroke is sudden/often traumatic; its results affect both the person with stroke and family members providing care. Transitioning from the non-caregiver role to caregiver for a spouse who recently had a stroke may be unsettling, particular for men. Purpose: Guided by Friedemann’s framework of systemic organization, t his secondary data analysis examined problems and successes reported by males caring for partners (wife or long-time friend) in the first year after stroke. According to this framework, these men are driven by the desire for success, resulting in health/ well-being or congruence in caring. Whereas incongruence or poor health can result from problems experienced in caring. Method: Using a descriptive design with IRB approval, caregivers (n=73) participated in bimonthly telephone interviews for one year. These caregivers were asked open-ended questions about problems and successes experienced in caring in the past two weeks. For this analysis, only the males caring for a partner (n=12 wives; n=1 friend) were examined. These data were analyzed using Colaizzi’s rigorous method of content analysis. Results: The caregivers were white men with an average age of 62 years. Most were high school graduates, employed full-time, rated their health as very good/excellent, and spent 2-16 hours caring each day. There were 275 problems and 393 successes in caring reported. Five problem themes emerged: 1) adjusting to multi-tasking in everyday living, 2) recognizing physical and mental disabilities, 3) dealing with outside forces and limited resources, 4) struggling to return to normal, and 5) feeling physically, mentally and emotionally exhausted. These problem themes demonstrated incongruence as the men sought to maintain their prior lives. Three success themes appeared: 1) gaining confidence through functional improvement, 2) fostering success through mutually positive attitudes, and 3) resuming normal roles. The success themes demonstrated how these men were able to find a level of well-being/congruence in caring. Conclusions: Theory-based themes of male stroke caregivers’ problems and successes were uncovered that can be used to target interventions to help them achieve balance between incongruence and congruence in their lives.

Integrated care for geriatric frailty and sarcopenia: a randomized control trial.

BackgroundExercise, nutrition, and psychological interventions may all have positive impacts on frailty and sarcopenia. However, it is not known whether an integrated care programme with all three components can be beneficial and the intensity of such programme is also not certain. In this study, we aim to determine the effectiveness of two levels of integrated care on frailty and sarcopenia.MethodsA randomized control trial was conducted at two community hospitals in Taiwan. Older adults (65–79 years of age, N = 289) who scored ≥1 on the Cardiovascular Health Study Phenotypic Classification of Frailty (CHS_PCF) were enrolled in the trial. Low‐level care (LLC) participants received a 2 h education course on frailty, sarcopenia, coping strategy, nutrition, and demonstration of study exercise programme. Educational multimedia material was distributed as reference for home practice with bi‐monthly telephone follow‐ups on adherences. High‐level care (HLC) participants, in addition to LLC instructions, received six sessions of on‐site problem solving therapy and 48 exercise sessions within 6 months. Brief nutrition consultation was also provided during the exercise sessions. Primary outcome was improvement of the CHS_PCF by at least one category (from pre‐frail to robust, or from frail to pre‐frail or robust) from baseline. Secondary outcomes included changes of individual frailty, and sarcopenia indicators. Assessments were done at 3, 6, and 12 months by trained research assistants blinded to randomization status. Intention‐to‐treat analysis was applied.ResultsMean age was 71.6 ± 4.3 years, with 53% females. For the entire cohort, improvement of primary outcome was 35% at 3 months, increased to 40% at 6 months, and remained stable at 39% at 12 months. Improvement rates were similar in both groups. Compared with the LLC group, HLC participants had greater improvements in the following indices: energy expenditure of walking, 5 m walking time, dominant hand grip strength, timed‐up‐and‐go‐test, and one‐leg‐stand time — mainly at 6 and 12 month assessments.ConclusionsThe 6 month integrated care improved frailty and sarcopenia status among community‐dwelling elders, with high‐intensity training yielding greater improvements. Low‐level care could be promoted as a basic intervention, while HLC could be reserved for those at high risk and with high motivation.

GOLD severity stratification and risk of hospitalisation for COPD exacerbations

The Italian Costs for Exacerbations in COPD ("ICE") study, following a pharmacoeconomic assessment of costs due to COPD exacerbations (primary endpoint), aimed also at evaluating (secondary endpoint) which clinical factors, among those considered for cost-analysis, may, at follow up, present a risk of new exacerbations and re-admission to hospital. A prospective, multicentre study was carried out on COPD patients admitted to 25 Hospital Centres as a result of an exacerbation from October-December 2002. Following discharge, a 6-month follow-up was performed in each patient via three bi-monthly telephone interviews with a questionnaire administered by an investigator clinician. 570 patients were eligible for data processing, mean age 70.6 years (+/- 9.5 standard deviation, SD), males 69.2%. According to GOLD, severity stratification was as follows: moderate 36.4%; severe 31.3%; very severe 32.3%. 282 patients experienced at least one exacerbation at follow up, 42% of exacerbations requiring hospitalisation. No significant association was seen between exacerbations and GOLD stage or co-morbidities or treatments except LTOT. Conversely, COPD functional severity influenced hospitalisations very significantly, with relative risks 2.6 (95% Confidence Interval, CI 1.8-3.8) and 2.0 (CI 1.3-2.8) (GOLD very severe versus moderate and severe, respectively), and 1.3 (CI 0.85-2.1) (GOLD severe versus moderate). Hospitalisations were also significantly associated with treatments denoting more severe conditions (oral corticosteroids, oral theophylline, and LTOT). Severity stratification of COPD patients according to respiratory function classes as outlined in GOLD guidelines and need for LTOT are confirmed as important predictors of hospitalisation for an exacerbation.

The Agewell trial: a pilot randomised controlled trial of a behaviour change intervention to promote healthy ageing and reduce risk of dementia in later life.

BackgroundLifestyle factors represent prime targets for behaviour change interventions to promote healthy ageing and reduce dementia risk. We evaluated a goal-setting intervention aimed at promoting increased cognitive and physical activity and improving mental and physical fitness, diet and health.MethodsThis was a pilot randomised controlled trial designed to guide planning for a larger-scale investigation, provide preliminary evidence regarding efficacy, and explore feasibility and acceptability. Primary outcomes were engagement in physical and cognitive activity. Participants aged over 50 living independently in the community were recruited through a community Agewell Centre. Following baseline assessment participants were randomly allocated to one of three conditions: control (IC) had an interview in which information about activities and health was discussed; goal-setting (GS n = 24) had an interview in which they set behaviour change goals relating to physical, cognitive and social activity, health and nutrition; and goal-setting with mentoring (GM, n = 24) had the goal-setting interview followed by bi-monthly telephone mentoring. Participants and researchers were blinded to group assignment. Participants were reassessed after 12 months.ResultsSeventy-five participants were randomised (IC n = 27, GS n = 24, GM n = 24). At 12-month follow-up, the two goal-setting groups, taken together (GS n = 21, GM n = 22), increased their level of physical (effect size 0.37) and cognitive (effect size 0.15) activity relative to controls (IC n = 27). In secondary outcomes, the two goal-setting groups taken together achieved additional benefits compared to control (effect sizes ≥ 0.2) in memory, executive function, cholesterol level, aerobic capacity, flexibility, balance, grip strength, and agility. Adding follow-up mentoring produced further benefits compared to goal-setting alone (effect sizes ≥ 0.2) in physical activity, body composition, global cognition and memory, but not in other domains. Implementation of the recruitment procedure, assessment and intervention was found to be feasible and the approach taken was acceptable to participants, with no adverse effects.ConclusionsA brief, low-cost goal-setting intervention is feasible and acceptable, and has the potential to achieve increased activity engagement.Trial registrationCurrent Controlled Trials ISRCTN30080637

Abstract NS15: Adult Daughters’ Problems in Caring for Parents

Background: Women provide most of the unpaid care to family members. Transitioning from the role of adult daughter to caregiver can be very stressful and unsettling. Purpose: Guided by Friedemann’s framework of systemic organization , the purpose of this descriptive secondary data analysis was to examine problems reported by adult daughters in the first year of caring for a parent with a stroke. Problems in caring can lead to poor health/ incongruence . Method: An IRB approved randomized controlled trial conducted with 73 adult caregivers in Ohio and Michigan examined the experience of caring for someone with stroke. Open-ended questions were included in bimonthly telephone interviews asking caregivers to recall their problems in caring over the past two weeks. For this secondary data analysis, problems reported by only the adult daughters (n=13) were analyzed during two time periods (0-6 and 7-12 months) using Colaizzi’s rigorous method of content analysis. Results: The first theme of witnessing a parent’s condition centered on the adult daughter recognizing changes in their parents’ health condition and behavior (Friedemann’s process dimension of system maintenance ). This theme was consistently apparent throughout 12-months of caring. The second theme, balancing the challenges of the caregiver role , dealt with the struggles and adaption necessary for her new lifestyle of a caregiver ( system maintenance and individuation ).This theme was noticeable throughout the entire year, but more evident in the second 6-months. The final theme, feeling physically, emotionally, and mentally drained, involved problems associated with the overall exhaustion experienced by adult daughters ( system maintenance ). This theme was seen throughout the 1-year period, but more visible in the first 6-months of caring. Conclusions: The findings provide specific, theory-based themes of the adult daughters’ problems during that year of caring that could lead to incongruence in their lives. The information gleaned may offer nurses and other healthcare providers a clearer picture of the problems these daughters experience, leading to more targeted interventions, increased support, and ultimately improved overall health/ congruence for daughters.

The use of global positional satellite location in dementia: a feasibility study for a randomised controlled trial.

BackgroundGetting lost outside is stressful for people with dementia and their caregivers and a leading cause of long-term institutionalisation. Although Global Positional Satellite (GPS) location has been promoted to facilitate safe walking, reduce caregivers’ anxiety and enable people with dementia to remain at home, there is little high quality evidence about its acceptability, effectiveness or cost-effectiveness. This observational study explored the feasibility of recruiting and retaining participants, and the acceptability of outcome measures, to inform decisions about the feasibility of a randomised controlled trial (RCT).MethodsPeople with dementia who had been provided with GPS devices by local social-care services and their caregivers were invited to participate in this study. We undertook interviews with people with dementia, caregivers and professionals to explore the perceived utility and challenges of GPS location, and assessed quality of life (QoL) and mental health. We piloted three methods of calculating resource use: caregiver diary; bi-monthly telephone questionnaires; and interrogation of health and social care records. We asked caregivers to estimate the time spent searching if participants became lost before and whilst using GPS.ResultsTwenty people were offered GPS locations services by social-care services during the 8-month recruitment period. Of these, 14 agreed to be referred to the research team, 12 of these participated and provided data. Eight people with dementia and 12 caregivers were interviewed. Most participants and professionals were very positive about using GPS. Only one person completed a diary. Resource use, anxiety and depression and QoL questionnaires were considered difficult and were therefore declined by some on follow-up. Social care records were time consuming to search and contained many omissions. Caregivers estimated that GPS reduced searching time although the accuracy of this was not objectively verified.ConclusionsOur data suggest that a RCT will face challenges not least that widespread enthusiasm for GPS among social-care staff may challenge recruitment and its ready availability may risk contamination of controls. Potential primary outcomes of a RCT should not rely on caregivers’ recall or questionnaire completion. Time spent searching (if this could be accurately captured) and days until long-term admission are potentially suitable outcomes.

Decreasing Glycosylated Hemoglobin with Nutrition, Exercise and Bi-Monthly Telephone Calls in Patients withType 2 Diabetes Mellitus

Background: Decreasing glycosylated hemoglobin (HbgA1c) is a primary diabetes treatment goal. Despite the simplicity of the HbgA1c goal, failure to achieve this goal is a major healthcare concern. Healthcare providers fail to adequately educate patients on how to implement behavioral modifications needed for successful goal achievement. Narrowed focused patient encounters, reliance on patient self-education, denial, and delayed follow-up appointments limit a patient’s ability to implement required behavioral changes. Aim: This study was a quality improvement intervention designed to determine whether a personalized nutrition and exercise plan in conjunction with bi-monthly telephone reinforcement calls improved the HbgA1c of patients with type 2 diabetes mellitus. Setting: The study was conducted at a community clinic located in the southeastern U.S. that provides care predominantly to the working poor and uninsured patients. Sample: Type 2 diabetic patients (n = 40) with a baseline HbgA1c > 7%. Intervention: A nurse practitioner; certified diabetic educator and an exercise physiologist developed an individualized action plan with each participant. Baseline HbgA1c values were documented and participants were scheduled for three education sessions as well as telephone calls twice monthly for three months followed by a repeat HbgA1c. Results: Pretest and posttest HbgA1c data were analyzed using the Wilcoxon T-test statistic to determine if a personalized nutrition and exercise action plan in addition to bi-monthly telephone calls to the participants contributed to a decrease in the HbgA1c. Level of significance was set at an alpha value of less 0.05. The observed value of the test statistics t = 2.2714, with df = 62, p-value = 0.01292 rejects the null hypothesis. The p-value (0.012) demonstrated a significant improvement. Conclusion: Individualized attention and frequent reinforcement facilitated patients’ need to develop and integrate self-management behaviors, thereby, reducing the HbgA1c level and helping them to reach the desired goal.

A non-pharmacologic approach to address challenging behaviors of Veterans with dementia: description of the tailored activity program-VA randomized trial

BackgroundBehavioral symptoms accompanying dementia are associated with increased health care costs, reduced quality of life and daily functioning, heightened family caregiver burden, and nursing home placement. Standard care typically involves pharmacologic agents, but these are, at best, modestly effective, carry serious risks, including mortality, and do not address behavioral symptoms families consider most distressful and which may prompt nursing home placement. Given dementia’s devastating effects and the absence of an imminent cure, the Veterans Administration has supported the development and testing of new approaches to manage challenging behaviors at home.Methods/DesignThe Tailored Activity Program – Veterans Administration is a Phase III efficacy trial designed to reduce behavioral symptoms in Veterans with dementia living with their caregivers in the community. The study uses a randomized two-group parallel design with 160 diverse Veterans and caregivers. The experimental group receives a transformative patient-centric intervention designed to reduce the burden of behavioral symptoms in Veterans with dementia. An occupational therapist conducts an assessment to identify a Veteran’s preserved capabilities, deficit areas, previous roles, habits, and interests to develop activities tailored to the Veteran. Family caregivers are then trained to incorporate activities into daily care. The attention-control group receives bi-monthly telephone contact where education on topics relevant to dementia is provided to caregivers. Key outcomes include reduced frequency and severity of behavioral symptoms using the 12-item Neuropsychiatric Inventory (primary endpoint), reduced caregiver burden, enhanced skill acquisition, efficacy using activities, and time spent providing care at 4 months; and long-term effects (8 months) on the Veteran’s quality of life and frequency and severity of behavioral symptoms, and caregiver use of activities. The programs’ impact of Veterans Administration cost is also examined. Study precision will be increased through face-to-face research team trainings with procedural manuals and review of audio-taped interviews and intervention sessions.DiscussionThe Tailored Activity Program – Veterans Administration is designed to improve the quality of life of Veterans with dementia and lessen the burden of care on caregivers. Activities are tailored to reflect the Veteran’s preserved capabilities and interests to enhance active engagement, while not taxing areas of cognition that are most impaired.Trial registrationClinicalTrials.gov, NCT01357564

A Home-Based Exercise Program to Improve Function, Fatigue, and Sleep Quality in Patients With Stage IV Lung and Colorectal Cancer: A Randomized Controlled Trial

ContextExercise benefits patients with cancer, but studies of home-based approaches, particularly among those with Stage IV disease, remain small and exploratory. ObjectivesTo conduct an adequately powered trial of a home-based exercise intervention that can be facilely integrated into established delivery and reimbursement structures. MethodsSixty-six adults with Stage IV lung or colorectal cancer were randomized, in an eight-week trial, to usual care or incremental walking and home-based strength training. The exercising participants were instructed during a single physiotherapy visit and subsequently exercised four days or more per week; training and step-count goals were advanced during bimonthly telephone calls. The primary outcome measure was mobility assessed with the Ambulatory Post Acute Care Basic Mobility Short Form. Secondary outcomes included ratings of pain and sleep quality as well as the ability to perform daily activities (Ambulatory Post Acute Care Daily Activities Short Form), quality of life (Functional Assessment of Cancer Therapy-General), and fatigue (Functional Assessment of Cancer Therapy-Fatigue). ResultsThree participants dropped out and seven died (five in the intervention and two in the control group, P=0.28). At Week 8, the intervention group reported improved mobility (P=0.01), fatigue (P=0.02), and sleep quality (P=0.05) compared with the usual care group, but did not differ on the other measures. ConclusionA home-based exercise program seems capable of improving the mobility, fatigue, and sleep quality of patients with Stage IV lung and colorectal cancer.

The AgeWell study of behavior change to promote health and wellbeing in later life: study protocol for a randomized controlled trial

BackgroundLifestyle factors playing a role in the development of late-life disability may be modifiable. There is a need for robust evidence about the potential for prevention of disability through behavior change interventions.Methods/designThis feasibility study involves the development, implementation and initial testing of a behavior change intervention in a naturalistic setting. A small-scale randomized controlled trial (RCT) will investigate the implementation of a goal-setting intervention aimed at promoting behavior change in the domains of physical and cognitive activity in the context of a community resource center for over-50s. Healthy older participants attending the center (n = 75) will be randomized to one of three conditions: control (an interview involving a general discussion about the center); goal-setting (an interview involving identification of up to five personal goals in the domains of physical activity, cognitive activity, diet and health, and social engagement); or goal-setting with mentoring (the goal-setting interview followed by bi-monthly telephone mentoring). All participants will be reassessed after 12 months. Primary outcomes are levels of physical and cognitive activity. Secondary outcomes address psychosocial (self-efficacy, mood, quality of life), cognitive (memory and executive function), and physical fitness (functional and metabolic) domains. Cost-effectiveness will also be examined.DiscussionThis study will provide information about the feasibility of a community-based lifestyle intervention model for over-50s and of the implementation of a goal-setting intervention for behavior change, together with initial evidence about the short-term effects of goal-setting on behavior.Trial RegistrationCurrent Controlled Trials ISRCTN30080637 (http://www.controlled-trials.com)

Abstract 2249: Stroke Intervention Website: Design and Usage Evaluation

Background and Purpose: Web-based interventions have the potential to increase accessibility and efficiency of healthcare services, such as education and support for family caregivers. The major aim of this project was to evaluate the design and usage, of a stroke intervention website, which was guided by Friedemann’s framework of systemic organization, for new caregiving families residing in home settings. Methods: Thirty-six caregivers had access to this intervention of education and support used in a one-year randomized controlled trial (RCT) in Ohio and Michigan. The average participant was 54 years of age, white, female, and the spouse of the care recipient. Four questions related to the website were asked of the participants as part of a bi-monthly telephone interview. Additionally a 33-item telephone Survey at the conclusion of the RCT evaluated the website design and usage of its components. Number of visits to the website was also counted. Descriptive statistics and content analysis were used with these data. At the end of the RCT, the intervention was opened to everyone on the Internet, and website visits were counted for a 15-month period. Results: On average, the RCT participants accessed the website one to two hours per week, although participants’ usage declined after several months. There were a total of 7,121 visits over the one-year period. The participants found the training to be adequate and positively rated the website’s appearance and usability. They also agreed or strongly agreed that they learned a lot from the intervention’s components. In the 15-month period following the RCT, there were 19,431 total visits to the website. Conclusions: The family caregivers in the RCT, as well as subsequent website visitors, used the intervention for education information and social support in dealing with stroke and its outcomes. Healthcare providers can suggest this website to stroke caregiving families and website developers can replicate the design of this intervention website for other health conditions.

A randomized controlled trial of positive-affect induction to promote physical activity after percutaneous coronary intervention.

Within 1 year after percutaneous coronary intervention, more than 20% of patients experience new adverse events. Physical activity confers a 25% reduction in mortality; however, physical activity is widely underused. Thus, there is a need for more powerful behavioral interventions to promote physical activity. Our objective was to motivate patients to achieve an increase in expenditure of 336 kcal/wk or more at 12 months as assessed by the Paffenbarger Physical Activity and Exercise Index. Two hundred forty-two patients were recruited immediately after percutaneous coronary intervention between October 2004 and October 2006. Patients were randomized to 1 of 2 groups. The patient education (PE) control group (n = 118) (1) received an educational workbook, (2) received a pedometer, and (3) set a behavioral contract for a physical activity goal. The positive-affect/self-affirmation (PA) intervention group (n = 124) received the 3 PE control components plus (1) a PA workbook chapter, (2) bimonthly induction of PA by telephone, and (3) small mailed gifts. All patients were contacted with standardized bimonthly telephone follow-up for 12 months. Attrition was 4.5%, and 2.1% of patients died. Significantly more patients in the PA intervention group increased expenditure by 336 kcal/wk or more at 12 months, our main outcome, compared with the PE control group (54.9% vs 37.4%, P = .007). The PA intervention patients were 1.7 times more likely to reach the goal of a 336-kcal/wk or more increase by 12 months, controlling for demographic and psychosocial measures. In multivariate analysis, the PA intervention patients had nearly double the improvement in kilocalories per week at 12 months compared with the PE control patients (602 vs 328, P = .03). Patients who receive PA intervention after percutaneous coronary intervention are able to achieve a sustained and clinically significant increase in physical activity by 12 months. Trial Registration clinicaltrials.gov Identifier: NCT00248846.

Implications of a needs assessment intervention for people with progressive cancer: Impact on clinical assessment, response and service utilisation

To assess the impact of the systematic use of the Palliative Care Needs Assessment Guidelines and Needs Assessment Tool: Progressive Disease-Cancer (NAT: PD-C) on clinical assessment, response and service utilisation. Three major oncology treatment centres in NSW, Australia. Between March 2007 and December 2009, 219 people with advanced cancer were recruited to complete bi-monthly telephone interviews. The intervention, introduced after at least two baseline interviews, involved training health professionals to complete the NAT: PD-C with patients approximately monthly. Rates of service use and referrals were compared pre- and post-introduction of the NAT: PD-C. Rates of completion of the tool; its impact on consultation length; and the types of needs and follow-up care to address these were also assessed. The NAT: PD-C had a high rate of completion; identified needs consistent with those self-reported by patients in interviews; and did not alter consultation length. No changes in the number of health professionals seen by patients were found pre- and post-intervention. The NAT: PD-C is an efficient and acceptable strategy for supporting needs-based cancer care that can potentially be incorporated into standard routine care without increasing the burden on care providers.

Facilitating needs based cancer care for people with a chronic disease: Evaluation of an intervention using a multi-centre interrupted time series design

BackgroundPalliative care should be provided according to the individual needs of the patient, caregiver and family, so that the type and level of care provided, as well as the setting in which it is delivered, are dependent on the complexity and severity of individual needs, rather than prognosis or diagnosis [1]. This paper presents a study designed to assess the feasibility and efficacy of an intervention to assist in the allocation of palliative care resources according to need, within the context of a population of people with advanced cancer.Methods/designPeople with advanced cancer and their caregivers completed bi-monthly telephone interviews over a period of up to 18 months to assess unmet needs, anxiety and depression, quality of life, satisfaction with care and service utilisation. The intervention, introduced after at least two baseline phone interviews, involved a) training medical, nursing and allied health professionals at each recruitment site on the use of the Palliative Care Needs Assessment Guidelines and the Needs Assessment Tool: Progressive Disease - Cancer (NAT: PD-C); b) health professionals completing the NAT: PD-C with participating patients approximately monthly for the rest of the study period. Changes in outcomes will be compared pre-and post-intervention.DiscussionThe study will determine whether the routine, systematic and regular use of the Guidelines and NAT: PD-C in a range of clinical settings is a feasible and effective strategy for facilitating the timely provision of needs based care.Trials registrationISRCTN21699701

Impact of PRISMA, a Coordination-Type Integrated Service Delivery System for Frail Older People in Quebec (Canada): A Quasi-experimental Study

To evaluate the impact of a coordination-type integrated service delivery (ISD) model on health, satisfaction, empowerment, and services utilization of frail older people. Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) is a population-based, quasi-experimental study with three experimental and three comparison areas. From a random selection of people 75 years or older, 1,501 persons identified at risk of functional decline were recruited (728 experimental and 773 comparison). Participants were measured over 4 years for disabilities (Functional Autonomy Measurement System), unmet needs, satisfaction with services, and empowerment. Information on utilization of health and social services was collected by bimonthly telephone questionnaires. Over the last 2 years (when the implementation rate was over 70%), there were 62 fewer cases of functional decline per 1,000 individuals in the experimental group. In the fourth year of the study, the annual incidence of functional decline was lower by 137 cases per 1,000 in the experimental group, whereas the prevalence of unmet needs in the comparison region was nearly double the prevalence observed in the experimental region. Satisfaction and empowerment were significantly higher in the experimental group. For health services utilization, a lower number of visits to emergency rooms and hospitalizations than expected was observed in the experimental cohort. The PRISMA model improves the efficacy of the health care system for frail older people.

The effect of a Web-based stroke intervention on carers' well-being and survivors' use of healthcare services

Purpose. We hypothesised that carers of stroke survivors who participate in the Web-based intervention, Caring∼Web©, would have higher well-being than non-Web users. We also postulated that those survivors whose carers participated in Caring∼Web would use fewer healthcare services.Method. A randomised, two-group, repeated measures design was used. Subjects were recruited from four rehabilitation centres from which first-time stroke survivors were discharged to home in two Midwestern states. Of 144 carers screened, 103 carers of these survivors who were novice Internet users were assigned to a Web or non-Web user group. Seventy-three subjects completed the study.Intervention. Caring∼Web was a Web-based intervention of education and support provided to the Web user group for 1 year. A bi-monthly telephone survey collected data on all carers well-being (perceived depression, life satisfaction) and survivors healthcare service use (self-reported provider and emergency department visits, hospital re-admissions, nursing home placement).Results. No statistical differences were found between the groups in carers well-being or in the number of provider visits for survivors. There were significant differences in emergency department visits (p = 0.001) and hospital re-admissions (p = 0.0005) related to the health of survivors.Conclusions. This Web-based intervention helped new carers make informed decisions about healthcare needs of stroke survivors, thus reducing service use.

Risk factors for falls among elderly persons living in the community.

To study risk factors for falling, we conducted a one-year prospective investigation, using a sample of 336 persons at least 75 years of age who were living in the community. All subjects underwent detailed clinical evaluation, including standardized measures of mental status, strength, reflexes, balance, and gait; in addition, we inspected their homes for environmental hazards. Falls and their circumstances were identified during bimonthly telephone calls. During one year of follow-up, 108 subjects (32 percent) fell at least once; 24 percent of those who fell had serious injuries and 6 percent had fractures. Predisposing factors for falls were identified in linear-logistic models. The adjusted odds ratio for sedative use was 28.3; for cognitive impairment, 5.0; for disability of the lower extremities, 3.8; for palmomental reflex, 3.0; for abnormalities of balance and gait, 1.9; and for foot problems, 1.8; the lower bounds of the 95 percent confidence intervals were 1 or more for all variables. The risk of falling increased linearly with the number of risk factors, from 8 percent with none to 78 percent with four or more risk factors (P less than 0.0001). About 10 percent of the falls occurred during acute illness, 5 percent during hazardous activity, and 44 percent in the presence of environmental hazards. We conclude that falls among older persons living in the community are common and that a simple clinical assessment can identify the elderly persons who are at the greatest risk of falling.

Milk Feeding Patterns in the United States During the First 12 Months of Life

From 1955 to 1980, mail questionnaires were administered to a nationally representative sample of mothers to determine the use of various milks for feeding infants during the first 6 months of life. Data from these surveys have demonstrated the resurgence of breast-feeding both in incidence and duration, and this increase has occurred across all income and educational levels. Statistical analysis indicated that the trends were significant (P less than .01) for all demographic categories surveyed. In January 1980, a bi-monthly telephone survey of mothers of infants 8, 10, and 12 months of age was initiated to determine milk use during later infancy. A combination of data from the mail and telephone surveys for 1980 provided information on milk feeding patterns for the first 12 months of life.

Incidence of Illness in Early Group and Family Day-Care

The frequency of reported illness in children enrolled in a day-care center was compared to frequency in home-reared children and in children in family day-care homes. Children ranged from 6 to 42 months of age (mean, 21 months). Data on seven categories of illness were collected by bimonthly telephone interviews with parents during two consecutive winters. In the first year of the study gastrointestinal and total illnesses were reported significantly more frequently in children enrolled in the day-care center, though major illnesses were not. In the second year of the study illnesses were significantly more frequently reported in center children though mainly at the younger ages, that is, prior to 2 years of age. The mean numbers of illnesses and symptoms reported per call over the 2 years of the study were 2.56, 1.36, and 1.35 for center, home-reared and family day-care children respectively. Though it has been shown elsewhere that psychological health may be unaffected by early group care, the present findings imply that physical health may be somewhat reduced. It is unknown whether these children will be more resistant to infection at a later age.