Availability and quality of assessment instruments on patient-centredness in older adults with multimorbidity: a systematic review.

OBJECTIVE: Patient-centredness (PC) is central to the health care of older adults with multimorbidity, but knowledge about the psychometric quality of instruments measuring it in this group is scarce. Based on an integrative model of PC, we aimed to identify assessment instruments of PC for this particular group and evaluate their psychometric properties. METHODS: We systematically searched six electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO, Web of Science and PSYNDEX), initially covering research published up to 2018 and updated later to include work up to July 2022. In evaluating the psychometric properties of identified instruments, we followed the COSMIN methodology. RESULTS: We identified 12 studies reporting on 10 instruments measuring PC in the health care of older adults with multimorbidity. For these instruments, structural validity and internal consistency were the psychometric properties reported most often. Based on the COSMIN criteria, eight instruments received favourable ratings for internal consistency with respect to methodological quality ('very good'), measurement property ('sufficient') and overall quality of evidence ('moderate'). Ratings of structural validity varied more largely, with three to seven instruments showing at least adequate methodological quality, sufficient structural validity or moderate quality of evidence. CONCLUSIONS: Similar to comparable previous reviews, evidence on the psychometric properties of instruments assessing PC in the health care of older adults with multimorbidity was rather limited. Informed by comprehensive models of PC, further research should aim at developing measures of PC that stand out on a broader range of psychometric properties.

Local, collaborative, stepped, and personalized care management for older people with chronic diseases - results from the randomized controlled LoChro-trial.

BACKGROUND: In the aging population of Western societies, an increasing number of older adults have multiple chronic diseases. As multifaceted health problems imply the involvement of several healthcare professionals, multimorbid older people frequently face a fragmentation of health care. Addressing these challenges, we developed a local, collaborative, stepped, and personalized care management approach (LoChro-Care) and evaluated its effectiveness. METHODS: A two-group, parallel randomized controlled trial was conducted comparing LoChro-Care recipients (IG) to participants with usual care (CG). Patients aged 65 + with chronic conditions were recruited at inpatient and outpatient departments of the Medical Center, University of Freiburg. Participants were allocated using block randomization (nIG = 261, nCG = 263). LoChro-Care comprised individualized care provided by chronic care managers with 7 to 13 contacts over 12 months. Questionnaires were given at 3 time points (T0: baseline, T1: after 12 months, T2: after 18 months). The primary outcome was the physical, psychological, and social health status represented by a composite score of functional health and depressive symptoms. Secondary outcomes were the participants' evaluation of their health care situation, health-related quality of life (HRQL), and life-satisfaction (LS). The data were analyzed using linear mixed modelling. RESULTS: We analyzed N = 491 participants (nIG = 244, nCG = 247), aged M = 76.78 years (SD = 6.35). For the composite endpoint, neither a significant difference between IG and CG (p = .88) nor a group-time interaction (p = .52; p = .88) could be observed. Participants in both groups showed a significant decline on the primary outcome between T0 and T2 (p < .001). Post hoc analyses revealed a decline in both functional health (p < .001) and depressive symptoms (p = .02). Both groups did not differ in their evaluation of their health care situation (p = .93), HRQL (p = .44) or LS (p = .32). Relevant confounding variables were female gender and multimorbidity. CONCLUSION: Supporting patients' self-management in coordinating their individual care network through LoChro-Care did not result in any significant effect on the primary and secondary outcomes. A decline of functional health and depressive symptoms was observed among all participants. Potential future intervention adaptations are discussed, such as a more active case management through direct referral to (in-)formal support, an earlier treatment initiation, and the consideration of specific sociodemographic factors in care management planning. TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00013904 (02.02.2018), https://drks.de/search/de/trial/DRKS00013904.

The economic impact of a local, collaborative, stepped, and personalized care management for older people with chronic diseases: results from the randomized comparative effectiveness LoChro-trial.

BACKGROUND: Within the ageing population of Western societies, an increasing number of older people have multiple chronic conditions. Because multiple health problems require the involvement of several health professionals, multimorbid older people often face a fragmented health care system. To address these challenges, in a two-group parallel randomized controlled trial, a newly developed care management approach (LoChro-Care) was compared with usual care. METHODS: LoChro-Care consists of individualized care provided by chronic care managers with 7 to 16 contacts over 12 months. Patients aged 65 + with chronic conditions were recruited from inpatient and outpatient departments. Healthcare utilization costs are calculated by using an adapted version of the generic, self-reporting FIMA©-questionnaire with the application of standardized unit costs. Questionnaires were given at 3 time points (T0 baseline, T1 after 12 months, T2 after 18 months). The primary outcome was overall 3-month costs of healthcare utilization at T1 and T2. The data were analyzed using generalized linear models with log-link and gamma distribution and adjustment for age, sex, level of care as well as the 3-month costs of care at T0. RESULTS: Three hundred thirty patients were analyzed. The results showed no significant difference in the costs of healthcare utilization between participants who received LoChro-Care and those who received usual care, regardless of whether the costs were evaluated 12 (adjusted mean difference € 130.99, 95%CI €-1477.73 to €1739.71, p = 0.873) or 18 (adjusted mean difference €192.99, 95%CI €-1894.66 to €2280.65, p = 0.856) months after the start of the intervention. CONCLUSION: This study revealed no differences in costs between older people receiving LoChro-Care or usual care. Before implementing the intervention, further studies with larger sample sizes are needed to provide robust evidence on the cost effects of LoChro-Care. TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00013904, https://drks.de/search/de/trial/DRKS00013904 ; date of first registration 02/02/2018.

Over- and under-prescribing, and their association with functional disability in older patients at risk of further decline in Germany - a cross-sectional survey conducted as part of a randomised comparative effectiveness trial.

BACKGROUND: Older patients at risk of functional decline are frequently affected by polypharmacy. This is associated with a further loss of independence. However, a relationship between functional disability and medications, such as 'Potentially Inappropriate Medications' (PIMs) and 'Potential Prescribing Omissions' (PPOs), as itemised for (de) prescribing in practice-orientated medication lists, has yet to be established. METHODS: As part of a randomised comparative effectiveness trial, LoChro, we conducted a cross-sectional analysis of the association between PIMs and PPOs measured using the 'Screening Tool of Older Persons' Prescription Criteria / Screening Tool To Alert to Right Treatment' (STOPP/START) Version 2, with functional disability assessed using the 'World Health Organization Disability Assessment Schedule 2.0' (WHODAS). Individuals aged 65 and older at risk of loss of independence were recruited from the inpatient and outpatient departments of the local university hospital. Multiple linear regression analysis was used to model the potential prediction of functional disability using the numbers of PIMs and PPOs, adjusted for confounders including multimorbidity. RESULTS: Out of 461 patients, both the number of PIMs and the number of PPOs were significantly associated with an increase in WHODAS-score (Regression coefficients B 2.7 [95% confidence interval: 1.5-3.8] and 1.5 [95% confidence interval: 0.2-2.7], respectively). In WHODAS-score prediction modelling the contribution of the number of PIMs exceeded the one of multimorbidity (standardised coefficients beta: PIM 0.20; multimorbidity 0.13; PPO 0.10), whereas no significant association between the WHODAS-score and the number of medications was seen. 73.5 % (339) of the participants presented with at least one PIM, and 95.2% (439) with at least one PPO. The most common PIMs were proton pump inhibitors and analgesic medication, with frequent PPOs being pneumococcal and influenza vaccinations, as well as osteoporosis prophylaxis. CONCLUSIONS: The results indicate a relationship between inappropriate prescribing, both PIMs and PPOs, and functional disability, in older patients at risk of further decline. Long-term analysis may help clarify whether these patients benefit from interventions to reduce PIMs and PPOs.

Reduction of care-relevant risks to older patients during and after acute hospital care (ReduRisk) - study protocol of a cluster randomized efficacy trial in a stepped wedge design.

BACKGROUND: Older patients are at an increased risk of hospitalization, negatively affecting their health and quality of life. Such patients also experience a lack of physical activity during their inpatient stay, as well as being at increased risk of delirium and inappropriate prescribing. These risk factors can accumulate, promoting a degree of morbidity and the development of cognitive impairment. METHODS: Through the ReduRisk-program, patients at risk of functional impairment, immobility, falls, delirium or re-hospitalization shortly after hospital discharge, will be identified via risk-screening. These patients will receive an individually tailored, multicomponent and risk-adjusted prevention program. The trial will compare the effectiveness of the ReduRisk-program against usual care in a stepped-wedge-design, with quarterly cluster randomization of six university hospital departments into intervention and control groups. 612 older adults aged 70 years or more are being recruited. Patients in the intervention cluster (n = 357) will receive the ReduRisk-program, comprising risk-adjusted delirium management, structured mobility training and digitally supported planning of post-inpatient care, including polypharmacy management. This study will evaluate the impact of the ReduRisk-program on the primary outcomes of activities of daily living and mobility, and the secondary outcomes of delirium, cognition, falls, grip strength, health-related quality of life, potentially inappropriate prescribing, health care costs and re-hospitalizations. Assessments will be conducted at inpatient admission (t0), at discharge (t1) and at six months post-discharge (t2). In the six-month period following discharge, a health-economic evaluation will be carried out based on routine health insurance data (t3). DISCUSSION: Despite the importance of multicomponent, risk-specific approaches to managing older patients, guidelines on their effectiveness are lacking. This trial will seek to provide evidence for the effectiveness of a multicomponent, risk-adjusted prevention program for older patients at risk of functional impairment, immobility, falls, delirium and re-hospitalization. Positive study results would support efforts to improve multicomponent prevention and the management of older patients. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00025594, date of registration: 09/08/2021.

Patient-centeredness in the multimorbid elderly: a focus group study.

BACKGROUND: Patient-centeredness (PC) aims to adapt health care to the individual needs and preferences of patients. An existing integrative model of PC comprises several dimensions of PC which have not yet been investigated from the patients' perspective. Older patients with multimorbidity represent a target group for patient-centered care, as their care needs are particularly complex and should be addressed individually. We aimed to assess the perspective that older patients with multimorbidity have of patient-centered care and to examine the transferability of the integrative model of PC to this specific population. METHOD: We performed 4 guided focus group interviews with a total of 20 older individuals with multimorbidity. The focus group interviews were audio-recorded and transcribed verbatim. Patients' statements were content-analyzed applying an a priori designed system of categories that included the dimensions of PC from the integrative model and the additional category 'prognosis and life expectancy', which had emerged from an initial literature search on aspects of PC specific to the multimorbid elderly. RESULTS: The new category 'prognosis and life expectancy' was confirmed and expanded to 'individual care needs related to aging and chronic disesase'. All dimensions of our integrative PC model were confirmed for older patients with multimorbidity. Among these, we found that eight dimensions (individual care needs related to aging and chronic disease, biopsychosocial perspective, clinician-patient communication, essential characteristics of the clinician, clinician-patient-relationship, involvement of family and friends, coordination and continuity of care, access to care) were complemented by aspects specific to this target population. CONCLUSIONS: The integrative PC model is applicable to the population of older patients with multimorbidity. For a population-specific adaptation, it might be complemented by the dimension 'individual care needs in aging and chronic disease', in conjunction with age-specific aspects within existing dimensions. Together with corresponding results from a Delphi survey, our adapted PC model will serve as the basis for a subsequent systematic review of instruments measuring PC in older patients with multimorbidity. TRIAL REGISTRATION: PROSPERO ( https://www.crd.york.ac.uk/prospero; CRD42018084057; 2018/02/01), German Clinical Trials Register ( www.drks.de ; DRKS00013309; 2018/01/23).

Evidence gap on antihyperglycemic pharmacotherapy in frail older adults : A systematic review.

BACKGROUND: Although antihyperglycemic pharmacotherapy in frail older adults with type 2 diabetes mellitus (T2DM) is challenging, recommendations from international guidelines are mainly based on indirect evidence from trials not including frail participants. OBJECTIVE: This systematic review investigated the effectiveness and safety of pharmacotherapy in frail older adults with T2DM. MATERIAL AND METHODS: Randomized (RCT) and non-randomized prospective clinical trials (non-RCT) were searched in three electronic databases (Medline, Embase, Central) up to October 2018. Trials in older adults with T2DM who were assessed as significantly or severely impaired by defined cut-off scores of assessment instruments on frailty, activities of daily living or physical functional impairment were included. RESULTS: Two reviewers independently screened 17,391 references for inclusion and assessed risk of bias with ROBINS­I. Five non-RCTs and no RCT were identified. Treatment of T2DM without insulin compared to insulin could be associated with increased improvement in cardiac functions in patients with cardiac resynchronization therapy and with decreased falls in frail older women. While better glycemic control with low variability and low HbA1c (hemoglobin A1c) values (<7%) was associated with better maintenance of physical function in community-dwelling older persons, higher HbA1c values (8-8.9%) were associated with a reduction in the composite outcome of death or functional decline in community-dwelling diabetic older adults with need for skilled assistance. Due to serious risk of bias in all studies, results should be considered with caution. CONCLUSION: Well-designed, large-scale RCTs including this important group of patients are required to assess the effectiveness and safety of pharmacotherapy and HbA1c targets.

[Integrated care management for older people with chronic diseases in domesticity: evidence from Cochrane reviews]. / Integriertes Versorgungsmanagement für chronisch erkrankte ältere Menschen in der eigenen Häuslichkeit: Evidenz aus Cochrane-Reviews.

BACKGROUND: The number of multiple chronically ill older people is increasing and multimorbidity is associated with high utilization of health services. Integrated care management is increasingly used to address this problem; however, there is a substantial lack of reliable data on its effectiveness in this target group. OBJECTIVE: To assess the effectiveness of components of integrated care management in adults of all ages and to estimate the transferability to older, multimorbid people in Germany. METHODS: A systematic search was carried out in the Cochrane Library for Cochrane reviews (CR) on (a) the 13 most frequent health problems in old age, which (b) evaluated components of integrated care management in (c) adults of all ages. Experts assessed the transferability of the included CR to multiple chronically ill older people in Germany. RESULTS: Out of 1412 hits 126 CR were included. Regarding independence and functional health outcomes, 25 CR showed clinically relevant results with at least a moderate level of evidence. The following intervention components were estimated to be transferable and could be adapted to be part of an effective integrated care management for multimorbid chronically ill older people, specified by indications and taking identified barriers into account: (1) physical activation, (2) multidisciplinary interventions (3) interventions that enhance self-management, (4) cognitive therapy modalities, (5) telemedical interventions and (6) disease management programs. CONCLUSION: The effectiveness of the identified components in frail older patients should be assessed in care-related and patient-related randomized controlled studies.

The Online Health Information Needs of Family Physicians: Systematic Review of Qualitative and Quantitative Studies.

BACKGROUND: Digitalization and the increasing availability of online information have changed the way in which information is searched for and retrieved by the public and by health professionals. The technical developments in the last two decades have transformed the methods of information retrieval. Although systematic evidence exists on the general information needs of specialists, and in particular, family physicians (FPs), there have been no recent systematic reviews to specifically address the needs of FPs and any barriers that may exist to accessing online health information. OBJECTIVE: This review aims to provide an up-to-date perspective on the needs of FPs in searching, retrieving, and using online information. METHODS: This systematic review of qualitative and quantitative studies searched a multitude of databases spanning the years 2000 to 2020 (search date January 2020). Studies that analyzed the online information needs of FPs, any barriers to the accessibility of information, and their information-seeking behaviors were included. Two researchers independently scrutinized titles and abstracts, analyzing full-text papers for their eligibility, the studies therein, and the data obtained from them. RESULTS: The initial search yielded 4541 studies for initial title and abstract screening. Of the 144 studies that were found to be eligible for full-text screening, 41 were finally included. A total of 20 themes were developed and summarized into 5 main categories: individual needs of FPs before the search; access needs, including factors that would facilitate or hinder information retrieval; quality needs of the information to hand; utilization needs of the information available; and implication needs for everyday practice. CONCLUSIONS: This review suggests that searching, accessing, and using online information, as well as any pre-existing needs, barriers, or demands, should not be perceived as separate entities but rather be regarded as a sequential process. Apart from accessing information and evaluating its quality, FPs expressed concerns regarding the applicability of this information to their everyday practice and its subsequent relevance to patient care. Future online information resources should cater to the needs of the primary care setting and seek to address the way in which such resources may be adapted to these specific requirements.

Local, collaborative, stepped and personalised care management for older people with chronic diseases (LoChro): study protocol of a randomised comparative effectiveness trial.

BACKGROUND: Multimorbid older adults suffering from a long-term health condition like depression, diabetes mellitus type 2, dementia or frailty are at high risk of losing their autonomy. Disability and multimorbidity in the older population are associated with social inequality and lead to soaring costs. Our local, collaborative, stepped and personalised care management for older people with chronic diseases (LoChro-Care) aims at improving outcomes for older multimorbid patients with chronic conditions whose social and medical care must be improved. METHODS: The study will evaluate the effects of LoChro-Care on functional health, depressive symptoms and satisfaction with care, resource utilisation as well as health costs in older persons with long-term conditions. The trial will compare the effectiveness of LoChro-Care and usual care in a cross-sectoral setting from hospital to community care. We will recruit 606 older adults (65+) admitted to local hospital inpatient or outpatient departments who are at risk of loss of independence. Half of them will be randomised to receive the LoChro-Care intervention, comprising seven to 16 contacts with chronic care managers (CCM) within 12 months. The hypothesis that LoChro-Care will result in better patient-centred outcomes will be tested through mixed-method process and outcome evaluation and valid measures completed at baseline and at 12 and 18 months. Cost-effectiveness analyses from the healthcare perspective will include incremental cost-effectiveness ratios. DISCUSSION: The trial will provide evidence about the effectiveness of local, collaborative, stepped and personalised care management for multimorbid patients with more than one functional impairment or chronic condition. Positive results will be a first step towards the implementation of a systematic cross-sectoral chronic care management to facilitate the appropriate use of available medical and nursing services and to enhance self-management of older people. TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00013904 ; Trial registration date: 02. February 2018.

Well informed physician-patient communication in consultations on back pain - study protocol of the cluster randomized GAP trial.

BACKGROUND: Back pain is one of the most frequent causes of health-related work absence. In Germany, more than 70% of adults suffer from at least one back pain episode per annum. It has strong impact on health care costs and patients' quality of life. Patients increasingly seek health information on the internet. However, judging its trustworthiness is difficult. In addition, physicians who are being confronted with this type of information often experience it to complicate the physician-patient interaction. The GAP trial aims to develop, implement and evaluate an evidence-based, easy-to-understand and trustworthy internet information portal on lower back pain to be used by general practitioners and patients during and after the consultation. Effectiveness of GAP portal use compared to routine consultation on improving communication and informedness of both physicians and patients will be assessed. In addition, effects on health care costs and patients' days of sick leave will be evaluated. METHODS: We will conduct a prospective multi-centre, cluster-randomized parallel group trial including 1500 patients and 150 recruiting general practitioners. The intervention group will have access to the GAP portal. The portal will contain brief guides for patients and physicians on how to improve the consultation as well as information on epidemiology, aetiology, symptoms, benefits and harms of treatment options for acute, sub-acute and chronic lower back pain. The GAP portal will be designed to be user-friendly and present information on back pain tailored for either patients or physicians in form of brief fact sheets, educative videos, info-graphics, animations and glossaries. Physicians and patients will assess their informedness and the physician-patient communication in consultations at baseline and at two time points after the consultations under investigation. Days of sick leave and health care costs related to back pain will be compared between control and intervention group using routine data of company health insurance funds. DISCUSSION: The GAP-trial intends to improve the communication between physicians and their patients and the informedness of both groups. If proven beneficial, the evidence-based and user-friendly portal will be made accessible for all patients and health professionals in back pain care. Inclusion of further indications might be implemented and evaluated in the long term. TRIAL REGISTRATION: German Clinical Trials Register DRKS00014279 (registered 27th of April 2018).

[Non-pharmacological treatment of dementia in geriatric psychiatry care units : Scoping review]. / Nichtmedikamentöse Behandlung von Demenz in gerontopsychiatrischen Einrichtungen : Systematischer Überblick.

BACKGROUND: The number of persons suffering from dementia will continuously increase in the coming years; therefore, evidence-based interventions are needed in geriatric psychiatric care. When evidence is poor scoping reviews may help to identify knowledge gaps and needs for research. AIM OF THE ARTICLE: To present an overview of clinical trials on non-pharmacological treatment for elderly with dementia in hospitals, wards and nursing homes, specializing in gerontopsychiatric care. MATERIAL AND METHODS: A systematic search was carried out by one of the authors for clinical trials (randomized controlled, controlled and single group pre-post design, English and German, 1998-2014) in PsycINFO, PubMED, PSYNDEX and the Cochrane Library as well as a manual search in two relevant German peer-reviewed journals. Two authors included studies according to a priori defined inclusion criteria. One author extracted data after consulting the second author in cases of ambiguity. The risk of bias of the studies was not assessed. RESULTS AND DISCUSSION: A total of 77 studies were identified, 29 studies on restructured treatment pathways or settings, 14 trials on environmental changes and 34 studies on therapeutic single or group interventions. Both the methodological quality of the studies and the evidence for the efficacy of non-pharmacological treatment were limited. There are clear indications for an advantage of specialized environments and treatment settings for the elderly with dementia in hospitals, wards and nursing homes. There are consistent indications for positive effects of psychosocial activation alone or in combination with cognitive or physical activation, partly with high-quality study designs. This is consistent with the German S3 guidelines for dementia. For single interventions, such as electroconvulsive therapy or horticultural activities, the level of evidence remains limited.

Association between continuity of care and inappropriate prescribing in outpatient care in Germany: a cross-sectional analysis conducted as part of the LoChro trial.

OBJECTIVES: Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are common in multimorbid patients. This study aims to describe PIMs and PPOs in an open-access outpatient setting and to investigate any association between continuity of care (CoC) and PIMs and PPOs in multimorbid older patients. DESIGN: Cross-sectional study using patient-confirmed outpatient medication plans to describe PIMs and PPOs using the 'Screening Tool of Older Person's Prescription/Screening Tool to Alert to Right Treatment' version 2. Four Poisson regressions modelled the number of PIMs and PPOs using context-adapted versions of the Usual Provider of Care (UPC) and the Modified Modified Continuity Index (MMCI) as measures for CoC. SETTING: Southern Germany, outpatient setting. PARTICIPANTS: 321 participants of the LoChro-trial at 12-month follow-up (both arms). The LoChro-trial compared healthcare involving an additional care manager with usual care. Inclusion criteria were age over 64, local residence and scoring over one in the Identification of Older patients at Risk Screening Tool. PRIMARY OUTCOMES: Numbers of PIMs and PPOs. RESULTS: The mean number of PIMs was 1.5 (SD 1.5), lower than the average number of PPOs at 2.9 (SD 1.7). CoC showed similar results for both indices with a mean of 0.548 (SD 0.279) for MMCI and 0.514 (SD 0.262) for UPC. Both models predicting PPOs indicated more PPOs with higher CoC; statistical significance was only demonstrated for MMCI (MMCI~PPO: Exp(B)=1.42, 95% CI (1.11; 1.81), p=0.004; UPC~PPO: Exp(B)=1.29, 95% CI (0.99; 1.67), p=0.056). No significant association between PIMs and CoC was found (MMCI~PIM: Exp(B)=0.72, 95% CI (0.50; 1.03), p=0.072; UPC~PIM: Exp(B)=0.83, 95% CI (0.57; 1.21), p=0.337). CONCLUSION: The results did not show a significant association between higher CoC and lesser PIMs. Remarkably, an association between increased CoC, represented through MMCI, and more PPOs was found. Consultation of different care providers in open-access healthcare systems could possibly ameliorate under-prescribing in multimorbid older patients. TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00013904.