Effects on leisure activities and social participation of a case management intervention for frail older people living at home : A randomised controlled trial

Frailty causes disability and restrictions on older people's ability to engage in leisure activities and for social participation. The objective of this study was to evaluate the effects of a 1-year case management intervention for frail older people living at home in Sweden in terms of social participation and leisure activities. The study was a randomised controlled trial with repeated follow-ups. The sample (n = 153) was consecutively and randomly assigned to intervention (n = 80) or control groups (n = 73). The intervention group received monthly home visits over the course of a year by nurses and physiotherapists working as case managers, using a multifactorial preventive approach. Data collections on social participation, leisure activities and rating of important leisure activities were performed at baseline, 3, 6, 9 and 12 months, with recruitment between October 2006 and April 2011. The results did not show any differences in favour of the intervention on social participation. However, the intervention group performed leisure activities in general, and important physical leisure activities, to a greater extent than the control group at the 3-month follow-up (median 13 vs. 11, P = 0.034 and median 3 vs. 3, P = 0.031 respectively). A statistically significantly greater proportion of participants from the intervention group had an increased or unchanged number of important social leisure activities that they performed for the periods from baseline to 3 months (93.2% vs. 75.4%, OR = 4.48, 95% CI: 1.37-14.58). Even though statistically significant findings in favour of the intervention were found, more research on activity-focused case management interventions is needed to achieve clear effects on social participation and leisure activities

Cost-utility analysis of case management for frail older people: effects of a randomised controlled trial

Background To evaluate the effects of a case management intervention for frail older people (aged 65+ years) by cost and utility. Materials and methods One hundred and fifty-three frail older people living at home were randomly assigned to either an intervention (n = 80) or a control group (n = 73). The 1-year intervention was carried out by nurses and physiotherapists working as case managers, who undertook home visits at least once a month. Differences in costs and quality-adjusted life years (QALYs) based on the health-related quality-of-life instruments EQ-5D and EQ-VAS, and also the incremental cost-effectiveness ratio were investigated. All analyses used the intention-to-treat principle. Results There were no significant differences between the intervention group and control group for total cost, EQ-5D-based QALY or EQ-VAS-based QALY for the 1-year study. Incremental cost-effectiveness ratio was not conducted because no significant differences were found for either EQ-5D- or EQ-VAS-based QALY, or costs. However, the intervention group had significantly lower levels of informal care and help with instrumental activities of daily living both as costs (€3,927 vs. €6,550, p = 0.037) and provided hours (200 vs. 333 hours per year, p = 0.037). Conclusions The intervention was cost neutral and does not seem to have affected health-related quality of life for the 1-year study, which may be because the follow-up period was too short. The intervention seems to have reduced hours and cost of informal care and help required with instrumental activities of daily living. This suggests that the intervention provides relief to informal caregivers

Prevalence and predictors of healthcare utilization among older people (60+): Focusing on ADL dependency and risk of depression.

The aim of this study was to investigate healthcare utilization patterns over a six-year period among older people (60+), classified as dependent/independent in Activities of Daily Living (ADL) and/or at/not at risk of depression and to identify healthcare utilization predictors. A sample (n=1402) comprising ten age cohorts aged between 60 and 96 years was drawn from the Swedish National study on Aging and Care (SNAC). Baseline data were collected between 2001 and 2003. Number and length of hospital stays were collected for six years after baseline year. Group differences and mean changes over time were investigated. Healthcare utilization predictors were explored using multiple linear regression analysis. The results revealed that 21-24% had at least one hospital stay in the six years after baseline, 29-37% among ADL dependent subjects and 24-33% among those at risk of depression. There was a significant increase of hospital stays in all groups over time. ADL-dependent subjects and those at risk of depression had significant more hospital stays, except for those at/not at risk of depression in years 2, 4 and 5. The healthcare utilization predictors 5-6 years after baseline were mainly age, previous healthcare utilization and various symptoms and, in 1-2 and 3-4 years after baseline, age, various diagnostic groups and various physical variables. Thus healthcare utilization patterns seem to be similar for the different groups, but it is difficult to find universal predictors. This suggests that different variables should be considered, including both ADL and psychosocial variables, when trying to identify future healthcare users

Coupling an aerosol box model with one-dimensional flow : a tool for understanding observations of new particle formation events

Field observations of new particle formation and the subsequent particle growth are typically only possible at a fixed measurement location, and hence do not follow the temporal evolution of an air parcel in a Lagrangian sense. Standard analysis for determining formation and growth rates requires that the time-dependent formation rate and growth rate of the particles are spatially invariant; air parcel advection means that the observed temporal evolution of the particle size distribution at a fixed measurement location may not represent the true evolution if there are spatial variations in the formation and growth rates. Here we present a zero-dimensional aerosol box model coupled with one-dimensional atmospheric flow to describe the impact of advection on the evolution of simulated new particle formation events. Wind speed, particle formation rates and growth rates are input parameters that can vary as a function of time and location, using wind speed to connect location to time. The output simulates measurements at a fixed location; formation and growth rates of the particle mode can then be calculated from the simulated observations at a stationary point for different scenarios and be compared with the 'true' input parameters. Hence, we can investigate how spatial variations in the formation and growth rates of new particles would appear in observations of particle number size distributions at a fixed measurement site. We show that the particle size distribution and growth rate at a fixed location is dependent on the formation and growth parameters upwind, even if local conditions do not vary. We also show that different input parameters used may result in very similar simulated measurements. Erroneous interpretation of observations in terms of particle formation and growth rates, and the time span and areal extent of new particle formation, is possible if the spatial effects are not accounted for.Peer reviewe

Healthcare consumption, experiences of care and test of and intervention in frail old people. Implications for case management

The overall aim of thesis was to explore frail older people’s experiences of receiving healthcare and/or social services and to investigate healthcare consumption and costs in both men and women and in different age groups in the two years prior to the introduction of long-term municipal care. A second aim was to explore a preventive intervention in a pilot study using case managers to older people with functional dependency and repeated healthcare contacts. Study I was qualitative and comprised 14 people (mean age 81) who were interviewed about their experiences of the healthcare and social services delivered to them. The results were analysed using content analysis. A cross-sectional, comparative design was used in studies II and III, which comprised 362 people who received a decision about the provision of municipal care or/and services during 2002-2003 and the participants were drawn from the Swedish National Study of Aging and Care (SNAC) and the county council register of healthcare consumption and costs. Study IV was a pilot trial with an experimental design and comprised 35 people who were consecutively and randomly assigned to either an intervention (n=19) or a control (n=16) group. Two nurses worked as case managers and carried out the intervention, which had four dimensions. Data were collected at baseline and after the intervention had been in place for about three months. Study I showed that the experience of receiving healthcare and/or social services in old age could be interpreted according to the overall theme “Having power or being powerless”, divided into three main categories: Autonomous or without control in relation to the healthcare and/or social service system; Confirmed or violated in relation to caregivers and Paradoxes in healthcare and social services. The results from Study II showed that about 50% of the acute hospital stays occurred within the five months prior to receiving municipal care. The men (n= 115, mean age 80.8) had significantly more bed days in hospital, more diagnoses and contacts with other staff groups besides physicians in outpatient care compared to the women (n=247, mean age 83.8). The results from study III showed that 13% of the sample had overall higher healthcare costs throughout the two years of observation. A majority (58% for the women and 54% for the men) of the costs for acute inpatient care occurred within five months prior to municipal care. The results from Study IV showed no differences between groups at baseline. Those included reported low life satisfaction, low perceived health and were also at risk of suffering from depression. The Life Satisfaction Index, Geriatric Depression Scale-20 and the ADL staircase had satisfactory internal consistency. Healthcare staff must be aware of the risk that older people loose control over their life situation when receiving healthcare and/or social services from various agencies. Preventive interventions and a more empowering approach are seemingly needed. This requires continuity and accessibility on an individual and organisational level. Early detection through a systematic clinical assessment, a more proactive and integrated care and applying preventive interventions to people in a transitional stage of becoming increasingly dependent on continuous care and services seems urgent to prevent escalating acute hospital admissions and thereby costs. The intervention had a feasible design. The sampling procedure led to similar groups and the measures were reliable to use. Both groups had a low life satisfaction, a low self reported health and were at risk of having a depression and could benefit from preventive interventions. No effects were found on self perceived health and depressed mood after three months. This might be due to the follow up time being too short. Further investigations about the content of the interventions are needed in the future