The Assessment of Services Promoting Independence and Recovery in Elders Trial (ASPIRE): a pre-planned meta-analysis of three independent randomised controlled trial evaluations of ageing in place initiatives in New Zealand.

INTRODUCTION: intermediate care has been developed to support older people to remain living in their own homes, combining a higher level of support with a rehabilitation focus. Evidence around their effectiveness remains mixed and there is ambiguity around the components. AIMS: to establish the impact of intermediate care on institutional free survival in frail older people referred for needs assessment in New Zealand (NZ). METHODS: pre-planned meta-analysis of three randomised controlled trials with follow-up at 3, 6, 12, 18 and 24 months. A total of 567 older people at risk of permanent institutionalisation as well as their primary informal carer (n = 234) were randomised to either intermediate or usual care. Interventions had common key features of care management, though varied in the use of ongoing care provision. RESULTS: the adjusted hazard ratio for the combined primary outcome of death or residential entry was 31% lower with a 95% confidence interval of (9%, 47%) for the intermediate care initiatives compared with usual care. CONCLUSION: intermediate care utilising a care management approach reduces a frail older person's risk of mortality and permanent institutionalisation.

Should care managers for older adults be located in primary care? A randomized controlled trial.

OBJECTIVES: To determine the effect of a primary care-based care management initiative on residential care placement and death in a population of frail older adults referred for needs assessment in New Zealand. DESIGN: Randomized controlled trial with follow-up at 3, 6, 12, 18, and 24 months for residential care placement and mortality. SETTING: Fifty-five family physician practices in New Zealand that established a care management initiative for older adults assessed as being at high risk of residential care placement in 2004 to 2006. PARTICIPANTS: Three hundred fifty-one individuals (243 female, 108 male) aged 65 and older (mean 81) who were assessed as being at risk of permanent residential care placement. INTERVENTIONS: The care management program (Coordinator of Services for Elderly) consisted of a nominated health professional care manager geographically aligned to family physicians housed with the family physician or located nearby. MEASUREMENTS: Rates of permanent residential care placement and mortality. RESULTS: The risk of permanent residential care placement or death was 0.36 for usual care (control group) and 0.26 for the care management initiative, a 10.2% absolute risk reduction, with the majority of the risk reduction seen in residential care placement (control group 0.25, intervention group 0.16). CONCLUSION: A family physician-aligned community care management approach reduces frail older adults' risk of mortality and permanent residential care placement.

Elevated total cholesterol: its prevalence and population attributable fraction for mortality from coronary heart disease and ischaemic stroke in the Asia-Pacific region.

BACKGROUND: About half of the world's cases of cardiovascular disease occur in the Asia-Pacific region. The contribution of serum total cholesterol (TC) to this burden is poorly quantified. DESIGN: The most recent nationally representative data on TC distributions for countries in the region were sought. Individual participant data from 380,483 adults in the Asia Pacific Cohort Studies Collaboration were used to estimate associations between TC and cardiovascular disease. METHODS: High TC was defined as > or =6.2 mmol/l, and nonoptimal TC as > or =3.8 mmol/l. Hazard ratios for fatal coronary heart disease (CHD) and ischaemic stroke (IS) were found from Cox models. Sex-specific population attributable fractions for high TC and nonoptimal TC were estimated for each country. The former used conventional methods, based on single measures of TC and a fixed dichotomy of risk strata; the latter took account of the continuous positive association between TC and both CHD and IS and regression dilution. RESULTS: Data were available from 16 countries. Where reported, the prevalence of high TC ranged from 4 to 27%. The fraction of fatal CHD and IS attributable to high TC ranged from 0 to 14% and 0 to 15%, respectively. Although leaving the relative ranking of countries much the same, the fractions estimated for nonoptimal TC were typically at least twice as big, ranging from 0 to 47% and 0 to 35%, respectively. CONCLUSION: Conventional methods for estimating disease burden severely underestimate the effect of TC. Cholesterol-lowering strategies could have a tremendous effect in reducing cardiovascular deaths in this populous region.