Trajectories of Self-Rated Health in an Older General Population and Their Determinants: The Lifelines Cohort Study

OBJECTIVES: Poor self-rated health (SRH) is a strong predictor of premature mortality in older adults. Trajectories of poor SRH are associated with multimorbidity and unhealthy behaviours. Whether trajectories of SRH are associated with deviating physiological markers is unclear. This study identified trajectories of SRH and investigated the associations of trajectory membership with chronic diseases, health risk behaviours and physiological markers in community-dwelling older adults. STUDY DESIGN AND SETTING: Prospective general population cohort. PARTICIPANTS: Trajectories of SRH over 5 years were identified using data of 11 600 participants aged 65 years and older of the Lifelines Cohort Study. OUTCOME MEASURES: Trajectories of SRH were the main outcome. Covariates included demographics (age, gender, education), chronic diseases, health-risk behaviour (physical activity, smoking, drinking) and physiological markers (body mass index, cardiovascular function, lung function, glucose metabolism, haematological condition, endocrine function, renal function, liver function and cognitive function). RESULTS: Four stable trajectories were identified, including excellent (n=607, 6%), good (n=2111, 19%), moderate (n=7677, 65%) and poor SRH (n=1205, 10%). Being women (OR: 1.4; 95% CI: 1.0 to 1.9), low education (OR: 2.1; 95% CI: 1.5 to 3.0), one (OR: 10.4; 95% CI: 7.4 to 14.7) or multiple chronic diseases (OR: 37.8; 95% CI: 22.4 to 71.8), smoking (OR: 1.8; 95% CI: 1.0 to 3.2), physical inactivity (OR: 3.1; 95% CI: 1.8 to 5.2), alcohol abstinence (OR: 2.2; 95% CI: 1.4 to 3.2) and deviating physiological markers (OR: 1.5; 95% CI: 1.1 to 2.0) increase the odds for a higher probability of poor SRH trajectory membership compared with excellent SRH trajectory membership. CONCLUSION: SRH of community-dwelling older adults is stable over time with the majority (65%) having moderate SRH. Older adults with higher probabilities of poor SRH often have unfavourable health status

Investigating the Effectiveness of Care Delivery at an Acute Geriatric Community Hospital for Older Adults in the Netherlands:A Prospective Controlled Observational Study

ObjectivesHospital admission in older adults is associated with unwanted outcomes such as readmission, institutionalization, and functional decline. To reduce these outcomes, the Netherlands introduced an alternative to hospital-based care: the Acute Geriatric Community Hospital (AGCH). The AGCH is an acute care unit situated outside of a hospital focusing on early rehabilitation and comprehensive geriatric assessment. The objective of this study was to evaluate if AGCH care is associated with decreasing unplanned readmissions or death compared with hospital-based care.DesignProspective cohort study controlled with a historic cohort.Setting and ParticipantsA (sub)acute care unit (AGCH) and 6 hospitals in the Netherlands; participants were acutely ill older adults.MethodsWe used inverse propensity score weighting to account for baseline differences. The primary outcome was 90-day readmission or death. Secondary outcomes included 30-day readmission or death, time to death, admission to long-term residential care, occurrence of falls and functioning over time. Generalized logistic regression models and multilevel regression analyses were used to estimate effects.ResultsAGCH patients (n = 206) had lower 90-day readmission or death rates [odds ratio (OR) 0.39, 95% CI 0.23-0.67] compared to patients treated in hospital (n = 401). AGCH patients had a lower risk of 90-day readmission (OR 0.38, 95% CI 0.21-0.67) but did not differ on all-cause mortality (OR 0.89, 95% CI 0.44-1.79) compared with the hospital control group. AGCH patients had lower 30-day readmission or death rates. Secondary outcomes did not differ.Conclusions and ImplicationsAGCH patients had lower rates of readmission and/or death than patients treated in a hospital. Our results support further research on the implementation and cost-effectiveness of AGCH in the Netherlands and other countries seeking alternatives to hospital-based care

Performance Indicators for the Assessment of Aging-In-Place Reform Policies:A Scoping Review and Evidence Map

Objectives: Many countries have reformed their long-term care system to promote aging-in-place. Currently, there is no framework for evaluating these reforms. This review aimed to identify performance indicators used for aging-in-place reform evaluation. Design: A scoping review and evidence map of literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist. Setting and participants: Long-term care reforms aimed at aging-in-place. Methods: The databases Medline, Embase, and Academic Search Premier were searched. Three independent reviewers screened the articles. Pairs of data collectors extracted the data, with conflicts determined by agreement or by a third reviewer. Performance indicators were classified into the Donabedian framework as structure, process, or outcome. Results: We retained 58 articles. From the included articles, 28 discussed structure indicators, comprising of 71 indicators in the domains expenditures, care availability, and workforce; 36 articles included process indicators comprising 80 indicators about care utilization, service quality, and service satisfaction; and 20 articles reported on outcome indicators comprising 34 indicators about health status and informal caregiving. Conclusion and Implications: Most articles focused on the performance domains care expenditures and care utilization, whereas measuring effects on older adults and society was less common. A framework assessing system and services delivery indicators and the effects on those aging-in-place with actionable performance indicators is recommended.</p

Is It Time for a Change? A Cost-Effectiveness Analysis Comparing a Multidisciplinary Integrated Care Model for Residential Homes to Usual Care

OBJECTIVE: The objective of this study was to evaluate the cost-effectiveness of a Multidisciplinary Integrated Care (MIC) model compared to Usual Care (UC) in Dutch residential homes. METHODS: The economic evaluation was conducted from a societal perspective alongside a 6 month, clustered, randomized controlled trial involving 10 Dutch residential homes. Outcome measures included a quality of care weighted sum score, functional health (COOP WONCA) and Quality Adjusted Life-Years (QALY). Missing cost and effect data were imputed using multiple imputation. Bootstrapping was used to analyze differences in costs and cost-effectiveness. RESULTS: The quality of care sum score in MIC was significantly higher than in UC. The other primary outcomes showed no significant differences between the MIC and UC. The costs of providing MIC were approximately €225 per patient. Total costs were €2,061 in the MIC group and €1,656 for the UC group (mean difference €405, 95% -13; 826). The probability that the MIC was cost-effective in comparison with UC was 0.95 or more for ceiling ratios larger than €129 regarding patient related quality of care. Cost-effectiveness planes showed that the MIC model was not cost-effective compared to UC for the other outcomes. INTERPRETATION: Clinical effect differences between the groups were small but quality of care was significantly improved in the MIC group. Short term costs for MIC were higher. Future studies should focus on longer term economic and clinical effects. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN11076857

Eliciting preferences of persons with dementia and informal caregivers to support ageing in place in the Netherlands:a protocol for a discrete choice experiment

Introduction:Ageing in place (AIP) for persons with dementia is encouraged by European governments and societies. Healthcare packages may need reassessment to account for the preferences of care funders, patients and informal caregivers. By providing insight into people's preferences, discrete choice experiments (DCEs) can help develop consensus between stakeholders. This protocol paper outlines the development of a Dutch national study to cocreate a healthcare package design methodology built on DCEs that is person-centred and helps support informal caregivers and persons with dementia to AIP. A subpopulation analysis of persons with dementia with a migration background is planned due to their high risk for dementia and under-representation in research and care. Methods and analysis:The DCE is designed to understand how persons with dementia and informal caregivers choose between different healthcare packages. Qualitative methods are used to identify and prioritise important care components for persons with dementia to AIP. This will provide a list of care components that will be included in the DCE, to quantify the care needs and preferences of persons with dementia and informal caregivers. The DCE will identify individual and joint preferences to AIP. The relative importance of each attribute will be calculated. The DCE data will be analysed with the use of a random parameters logit model. Ethics and dissemination:Ethics approval was waived by the Amsterdam University Medical Center (W23_112 #23.137). A study summary will be available on the websites of Alzheimer Nederland, Pharos and Amsterdam Public Health institute. Results are expected to be presented at (inter)national conferences, peer-reviewed papers will be submitted, and a dissemination meeting will be held to bring stakeholders together. The study results will help improve healthcare package design for all stakeholders.</p

The Cardiac Care Bridge transitional care program for the management of older high-risk cardiac patients: An economic evaluation alongside a randomized controlled trial

Objective To evaluate the cost-effectiveness of the Cardiac Care Bridge (CCB) nurse-led transitional care program in older (≥70 years) cardiac patients compared to usual care. Methods The intervention group (n = 153) received the CCB program consisting of case management, disease management and home-based cardiac rehabilitation in the transition from hospital to home on top of usual care and was compared with the usual care group (n = 153). Outcomes included a composite measure of first all-cause unplanned hospital readmission or mortality, Quality Adjusted Life Years (QALYs) and societal costs within six months follow-up. Missing data were imputed using multiple imputation. Statistical uncertainty surrounding Incremental Cost-Effectiveness Ratios (ICERs) was estimated by using bootstrapped seemingly unrelated regression. Results No significant between group differences in the composite outcome of readmission or mortality nor in societal costs were observed. QALYs were statistically significantly lower in the intervention group, mean difference -0.03 (95% CI: -0.07; -0.02). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective was 0.31 at a Willingness To Pay (WTP) of €0,00 and 0.14 at a WTP of €50,000 per composite outcome prevented and 0.32 and 0.21, respectively per QALY gained. Conclusion The CCB program was on average more expensive and less effective compared to usual care, indicating that the CCB program is dominated by usual care. Therefore, the CCB program cannot be considered cost-effective compared to usual care

Measurement properties of the EQ-5D across four major geriatric conditions: Findings from TOPICS-MDS

Background: As populations age, chronic geriatric conditions linked to progressive organ failure jeopardize health-related quality of life (HRQoL). Thus, this research assessed the validity and applicability of the EQ-5D (a common HRQoL instrument) across four major chronic geriatric conditions: hearing issues, joint damage, urinary incontinence, or dizziness with falls. Methods: The study sample comprised 25,637 community-dwelling persons aged 65 years and older residing in the Netherlands (Data source: TOPICS-MDS, www.topics-mds.eu ). Floor and ceiling effects were examined. To assess convergent validity, random effects meta-correlations (Spearman's rho) were derived between individual EQ-5D domains and related survey items. To further examine construct validity, the association between sociodemographic characteristics and EQ-5D summary scores were assessed using linear mixed models. Outcomes were compared to the overall study population as well as a 'healthy' subgroup reporting no major chronic conditions. Results: Whereas ceiling effects were observed in the overall study population and the 'healthy' subgroup, such was not the case in the geriatric condition subgroups. The majority of hypotheses regarding correlations between survey items and sociodemographic associations were supported. EQ-5D summary scores were lower in respondents who were older, female, widowed/single, lower educated, and living alone. Increasing co-morbidity had a clear negative effect on EQ-5D scores. Conclusion: This study supported the construct validity of the EQ-5D across four major geriatric conditions. For older persons who are generally healthy, i.e. reporting few to no chronic conditions, the EQ-5D confers poor discriminative ability due to ceiling effects. Although the overall dataset initially suggested poor discriminative ability for the EQ-5D, such was not the case within subgroups presenting with major geriatric conditions

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

<p>Abstract</p> <p>Background</p> <p>Dementia 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.</p> <p>Design</p> <p>Mixed 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.</p> <p>Discussion</p> <p>This 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.</p

Comorbid conditions and emergency department treat and release utilization in multimorbid persons with cognitive impairment

Background: There is an increasing focus in the emergency department (ED) on addressing the needs of persons with cognitive impairment, most of whom have multiple chronic conditions. We investigated which common comorbidities among multimorbid persons with cognitive impairment conferred increased risk for ED treat and release utilization. Methods: We examined the association of 16 chronic conditions on use of ED treat and release visit utilization among 1006 adults with cognitive impairment and ≥ 2 comorbidities using the nationally-representative National Health and Aging Trends Study merged with Fee-For-Service Medicare claims data, 2011–2015. Results: At baseline, 28.5% had ≥6 conditions and 35.4% were ≥ 85 years old. After controlling for sex, age, race, education, urban-living, number of disabled activities of daily living, and sampling strata, we found significantly increased adjusted risk ratios (aRR) of ED treat and release visits for persons with depression (aRR 1.38 95% CI 1.15–1.65) representing 78/100 person-years, and osteoarthritis or rheumatoid arthritis (aRR 1.32 95% CI 1.12–1.57) representing 71/100 person-years. At baseline 93.9% had ≥1 informal caregiver and 69.7% had a caregiver that helped with medications or attended physician visits. Conclusion: These results show that multimorbid cognitively impaired older adults with depression or osteoarthritis or rheumatoid arthritis are at higher risk of ED treat and release visits. Future ED research with multimorbid cognitively impaired persons may explore behavioral aspects of depression and/or pain and flairs associated with osteoarthritis or rheumatoid arthritis, as well as the role of informal caregivers in the care of these conditions

Self-Reports and Caregivers’ Proxy Reports of Unmet Needs of Persons With Dementia: Implications for Both Partners’ Health-Related Quality of Life

Objective: This study examined in a large sample of dementia caregiving dyads the associations between both partners’ reports of unmet needs in persons with dementia (PwDs) and both partners’ health-related quality of life (HRQOL). Methods: This was a cross-sectional self-report survey of 521 community-dwelling dyads in a pragmatic trial in the Netherlands. The Camberwell Needs Assessment was used to measure PwDs’ unmet needs. Both partners’ self-reported their HRQOL using the EuroQol-5. Results: Controlling for covariates, PwDs’ self-reported greater unmet needs were significantly associated with PwDs’ and caregivers’ lower self-reported HRQOL (actor effect; b = −0.044, β = −0.226, z = −3.588, p <0.001 and partner effect; b = −0.021, β = −0.131, z = −2.154, p = 0.031). Caregivers’ proxy reports were greater than PwDs’ self-reported unmet needs (Δ=0.66,χ 2(1)=55.881,p<.0001). Conclusion: Clinicians should use caution in relying on caregiver proxy reports of PwDs’ needs and HQOL alone regarding healthcare decision making