Real-world evidence: new opportunities for osteoporosis research. Recommendations from a Working Group from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO).

This narrative review summarises the recommendations of a Working Group of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) for the conduct and reporting of real-world evidence studies with a focus on osteoporosis research. PURPOSE: Vast amounts of data are routinely generated at every healthcare contact and activity, and there is increasing recognition that these real-world data can be analysed to generate scientific evidence. Real-world evidence (RWE) is increasingly used to delineate the natural history of disease, assess real-life drug effectiveness, understand adverse events and in health economic analysis. The aim of this work was to understand the benefits and limitations of this type of data and outline approaches to ensure that transparent and high-quality evidence is generated. METHODS: A ESCEO Working Group was convened in December 2022 to discuss the applicability of RWE to osteoporosis research and approaches to best practice. RESULTS: This narrative review summarises the agreed recommendations for the conduct and reporting of RWE studies with a focus on osteoporosis research. CONCLUSIONS: It is imperative that research using real-world data is conducted to the highest standards with close attention to limitations and biases of these data, and with transparency at all stages of study design, data acquisition and curation, analysis and reporting to increase the trustworthiness of RWE study findings.

Organizing integrated health-care services to meet older people's needs.

In most countries, a fundamental shift in the focus of clinical care for older people is needed. Instead of trying to manage numerous diseases and symptoms in a disjointed fashion, the emphasis should be on interventions that optimize older people's physical and mental capacities over their life course and that enable them to do the things they value. This, in turn, requires a change in the way services are organized: there should be more integration within the health system and between health and social services. Existing organizational structures do not have to merge; rather, a wide array of service providers must work together in a more coordinated fashion. The evidence suggests that integrated health and social care for older people contributes to better health outcomes at a cost equivalent to usual care, thereby giving a better return on investment than more familiar ways of working. Moreover, older people can participate in, and contribute to, society for longer. Integration at the level of clinical care is especially important: older people should undergo comprehensive assessments with the goal of optimizing functional ability and care plans should be shared among all providers. At the health system level, integrated care requires: (i) supportive policy, plans and regulatory frameworks; (ii) workforce development; (iii) investment in information and communication technologies; and (iv) the use of pooled budgets, bundled payments and contractual incentives. However, action can be taken at all levels of health care from front-line providers through to senior leaders - everyone has a role to play.

Dans la plupart des pays, un changement fondamental de priorité dans l'organisation des soins cliniques destinés aux personnes âgées est nécessaire. Plutôt que d'essayer de gérer la variété des maladies et symptômes de manière individuelle, l'accent devrait être mis sur les interventions qui optimisent les capacités physiques et mentales des personnes âgées sur tout leur parcours de vie et qui leur permettent de continuer de réaliser les activités qui comptent pour elles. Mais cela suppose de modifier le mode d'organisation des prestations, avec une meilleure intégration à l'intérieur du système de santé et entre les services de santé et d'aide sociale. Cela ne signifie pas que les structures existantes doivent fusionner, mais plutôt qu'une grande diversité de prestataires doit travailler ensemble de manière plus coordonnée. Des données factuelles montrent que des prestations de santé et d'aide sociale intégrées entraînent de meilleurs résultats sur la santé des personnes âgées que les prestations de soins habituelles, pour un coût équivalent; d'où l'obtention d'une meilleure rentabilité des investissements comparativement aux modes de travail classiques. Elles permettent aussi aux personnes âgées de s'impliquer socialement et d'apporter leurs contributions à la société pendant plus longtemps. Une telle intégration est particulièrement importante au niveau des soins cliniques: des évaluations exhaustives devraient être réalisées chez les personnes âgées dans une optique d'optimisation de leurs capacités fonctionnelles, et les plans de soins devraient être communs à tous les prestataires. Au niveau du système de santé, l'intégration des prestations nécessite: (i) l'adoption de politiques, programmes et cadres réglementaires favorables; (ii) le développement du personnel de santé; (iii) un investissement dans les technologies de l'information et de la communication; et (iv) la mise en place de budgets communs, de paiements regroupés et de mesures contractuelles incitatives. Toutefois, des actions peuvent être entreprises à tous les niveaux d'organisation des soins de santé, depuis les prestataires de première ligne jusqu'aux hauts responsables ­ tout le monde a un rôle à jouer.

En la mayoría de países se necesita un cambio fundamental en el enfoque de la atención clínica que reciben las personas mayores. En lugar de intentar gestionar numerosas enfermedades y síntomas por separado, debería ponerse énfasis en las intervenciones que optimizan las capacidades físicas y mentales de las personas mayores durante su vida y que les permitan hacer lo que ellos valoran. Esto, a su vez, requiere un cambio en la forma en la que se organizan los servicios: debería haber más integración dentro del sistema sanitario y entre los servicios sanitarios y sociales. Las estructuras organizativas existentes no deben fusionarse, sino que el amplio conjunto de proveedores de servicios debe trabajar conjuntamente de una forma más coordinada. Las pruebas indican que la atención sanitaria y social integrada para las personas mayores contribuye a unos mejores resultados sanitarios a un coste equivalente a la atención habitual. De esta forma, se obtiene una mayor rentabilidad de la inversión que la obtenida con formas de trabajar más familiares. Además, las personas mayores pueden participar y contribuir en la sociedad durante más tiempo. La integración a nivel de la atención clínica es especialmente importante: las personas mayores deberían someterse a asesoramiento integral con el objetivo de optimizar la capacidad funcional, y deberían compartirse los planes de atención entre todos los proveedores. A nivel del sistema sanitario, la atención integrada requiere: (i) política, planes y marcos normativos de apoyo; (ii) desarrollo del personal sanitario; (iii) inversión en tecnologías de la información y comunicación; y (iv) el uso de presupuestos y pagos combinados e incentivos contractuales. No obstante, esto puede realizarse en todos los niveles de la atención sanitaria, desde los proveedores de primera línea hasta el personal directivo; todos juegan un papel.

Social support network typologies and health outcomes of older people in low and middle income countries--a 10/66 Dementia Research Group population-based study.

This study aims to assess the construct validity of the Wenger social support network typology in low and middle income countries. We hypothesize that, in comparison with the integrated network type, the non-integrated network type is associated with loneliness, depression, poor quality of life (less happiness), poor self-reported health, increased disability and higher care needs. Cross-sectional one-phase surveys were conducted of all residents aged 65 and over in catchment areas in eight low and middle income countries (India, China, Cuba, Dominican Republic, Venezuela, Mexico, Peru and Puerto Rico). Wenger's Practitioner Assessment of Network Type (PANT) was used to measure social network type. Family dependent, local self-contained, wider community-focused and private restricted network types were considered non-integrated, in comparison to the locally integrated network type. Overall, 17,031 participants were interviewed. Family dependent and locally integrated network types were the most prevalent. Adjusted pooled estimates across sites showed that loneliness, depression, less happiness, poor health, disability, and need for care were significantly associated with non-integrated network type. The findings of this study support the construct validity of Wenger's network typology in low and middle income countries. However, further research is required to test the criterion validity of Wenger typology using longitudinal data. Identifying older people who are vulnerable could inform the development of social care interventions to support older people and their families in the context of deteriorating health.

A Recommended Package of Long-Term Care Services to Promote Healthy Ageing Based on a WHO Global Expert Consensus Study.

OBJECTIVES: To reach consensus on a minimum list of long-term care (LTC) interventions to be included in a service package delivered through universal health coverage (UHC). DESIGN: A multistep expert consensus process. SETTING AND PARTICIPANTS: Multinational and multidisciplinary experts in LTC and ageing. METHODS: The consensus process was composed of 3 stages: (1) a preconsultation round that built on an initial list of LTC interventions generated by a previous scoping review; (2) 2-round surveys to reach consensus on important, acceptable, and feasible interventions for LTC; (3) a panel meeting to finalize the consensus. RESULTS: The preconsultation round generated an initial list of 117 interventions. In round 1, 194 experts were contacted and 92 (47%) completed the survey. In round 2, the same experts contacted for round 1 were invited, and 115 (59%) completed the survey. Of the 115 respondents in round 2, 80 participated in round 1. Experts representing various disciplines (eg, geriatricians, family doctors, nurses, mental health, and rehabilitation professionals) participated in round 2, representing 42 countries. In round 1, 81 interventions achieved the predetermined threshold for importance, and in round 2, 41 interventions achieved the predetermined threshold for acceptability and feasibility. Nine conflicting interventions between rounds 1 and 2 were discussed in the panel meeting. The recommended list composed of 50 interventions were from 6 domains: unpaid and paid carers' support and training, person-centered assessment and care planning, prevention and management of intrinsic capacity decline, optimization of functional ability, interventions needing focused attention, and palliative care. CONCLUSIONS AND IMPLICATIONS: An international discussion and consensus process generated a minimum list of LTC interventions to be included in a service package for UHC. This package will enable actions toward a more robust framework for integrated services for older people in need of LTC across the continuum of care.

Elements of integrated care approaches for older people: a review of reviews.

OBJECTIVE: The World Health Organization (WHO) recently proposed an Integrated Care for Older People approach to guide health systems and services in better supporting functional ability of older people. A knowledge gap remains in the key elements of integrated care approaches used in health and social care delivery systems for older populations. The objective of this review was to identify and describe the key elements of integrated care models for elderly people reported in the literature. DESIGN: Review of reviews using a systematic search method. METHODS: A systematic search was performed in MEDLINE and the Cochrane database in June 2017. Reviews of interventions aimed at care integration at the clinical (micro), organisational/service (meso) or health system (macro) levels for people aged ≥60 years were included. Non-Cochrane reviews published before 2015 were excluded. Reviews were assessed for quality using the Assessment of Multiple Systematic Reviews (AMSTAR) 1 tool. RESULTS: Fifteen reviews (11 systematic reviews, of which six were Cochrane reviews) were included, representing 219 primary studies. Three reviews (20%) included only randomised controlled trials (RCT), while 10 reviews (65%) included both RCTs and non-RCTs. The region where the largest number of primary studies originated was North America (n=89, 47.6%), followed by Europe (n=60, 32.1%) and Oceania (n=31, 16.6%). Eleven (73%) reviews focused on clinical 'micro' and organisational 'meso' care integration strategies. The most commonly reported elements of integrated care models were multidisciplinary teams, comprehensive assessment and case management. Nurses, physiotherapists, general practitioners and social workers were the most commonly reported service providers. Methodological quality was variable (AMSTAR scores: 1-11). Seven (47%) reviews were scored as high quality (AMSTAR score ≥8). CONCLUSION: Evidence of elements of integrated care for older people focuses particularly on micro clinical care integration processes, while there is a relative lack of information regarding the meso organisational and macro system-level care integration strategies.

Social network typologies and mortality risk among older people in China, India, and Latin America: A 10/66 Dementia Research Group population-based cohort study.

BACKGROUND: Restricted social networks have been associated with higher mortality in several developed countries but there are no studies on this topic from developing countries. This gap exists despite potentially greater dependence on social networks for support and survival due to various barriers to health care and social protection schemes in this setting. Thus, this study aims to examine how social network type at baseline predicts all-cause mortality among older adults in six Latin American countries, China, and India. METHODS: Population-based surveys were conducted of all individuals aged 65+ years in eight countries (Cuba, Dominican Republic, Peru, Venezuela, Mexico, Puerto Rico, China, and India). Data on mortality were obtained at follow-up (mean 3.8 years after cohort inception). Follow-up data for 13,891 individuals were analysed. Social network types were assessed using Wenger's Practitioner Assessment of Network Type (PANT). Cox proportional hazard models were constructed to estimate the impact of social network type on mortality risk in each country, adjusting for socio-demographics, receipt of pension, disability, medical conditions, and depression. Meta-analysis was performed to obtain pooled estimates. RESULTS: The prevalence of private network type was 64.4% in urban China and 1.6% in rural China, while the prevalence of locally integrated type was 6.6% in urban China and 86.8% in rural China. The adjusted pooled estimates across (a) all countries and (b) Latin America showed that, compared to the locally integrated social network type, the locally self-contained [(b) HR = 1.24, 95% CI 1.01-1.51], family dependent [(a) HR = 1.13, 95% CI 1.01-1.26; (b) HR = 1.13, 95% CI 1.001-1.28], and private [(a) HR = 1.36, 95% CI 1.06-1.73; (b) HR = 1.45, 95% CI 1.20-1.75] social network types were significantly associated with higher mortality risk. CONCLUSION: Survival time is significantly reduced in individuals embedded in restricted social networks (i.e. locally self-contained, family dependent, and private network types). Social care interventions may be enhanced by addressing the needs of those most at risk of neglect and deteriorating health. Health policy makers in developing countries may use this information to plan efficient use of limited resources by targeting those embedded in restricted social networks.