Preventive interventions to improve older people's health outcomes: systematic review and meta-analysis.

BACKGROUND: Systematic reviews of preventive, non-disease-specific primary care trials for older people often report effects according to what is thought to be the intervention's active ingredient. AIM: To examine the effectiveness of preventive primary care interventions for older people and to identify common components that contribute to intervention success. DESIGN AND SETTING: A systematic review and meta-analysis of 18 randomised controlled trials (RCTs) published in 22 publications from 2009 to 2019. METHOD: A search was conducted in PubMed, MEDLINE, Embase, Web of Science, CENTRAL, CINAHL, and the Cochrane Library. Inclusion criteria were: sample mainly aged ≥65 years; delivered in primary care; and non-disease-specific interventions. Exclusion criteria were: non-RCTs; primarily pharmacological or psychological interventions; and where outcomes of interest were not reported. Risk of bias was assessed using the original Cochrane tool. Outcomes examined were healthcare use including admissions to hospital and aged residential care (ARC), and patient-reported outcomes including activities of daily living (ADLs) and self-rated health (SRH). RESULTS: Many studies had a mix of patient-, provider-, and practice-focused intervention components (13 of 18 studies). Studies included in the review had low-to-moderate risk of bias. Interventions had no overall benefit to healthcare use (including admissions to hospital and ARC) but higher basic ADL scores were observed (standardised mean difference [SMD] 0.21, 95% confidence interval [CI] = 0.01 to 0.40) and higher odds of reporting positive SRH (odds ratio [OR] 1.17, 95% CI = 1.01 to 1.37). When intervention effects were examined by components, better patient-reported outcomes were observed in studies that changed the care setting (SMD for basic ADLs 0.21, 95% CI = 0.01 to 0.40; OR for positive SRH 1.17, 95% CI = 1.01 to 1.37), included educational components for health professionals (SMD for basic ADLs 0.21, 95% CI = 0.01 to 0.40; OR for positive SRH 1.27, 95% CI = 1.05 to 1.55), and provided patient education (SMD for basic ADLs 0.28, 95% CI = 0.09 to 0.48). Additionally, admissions to hospital in intervention participants were fewer by 23% in studies that changed the care setting (incidence rate ratio [IRR] 0.77, 95% CI = 0.63 to 0.95) and by 26% in studies that provided patient education (IRR 0.74, 95% CI = 0.56 to 0.97). CONCLUSION: Preventive primary care interventions are beneficial to older people's functional ability and SRH but not other outcomes. To improve primary care for older people, future programmes should consider delivering care in alternative settings, for example, home visits and phone contacts, and providing education to patients and health professionals as these may contribute to positive outcomes.

Investigating the health status of primary school children in Tonga: Lessons learnt and reflections on field work in the Pacific Islands.

Globally, the child health focus has been on reducing under-5-year mortality, with large populations in low-resource regions prioritised. Children in older age groups, particularly in less populated regions such as the Pacific, have received limited attention. Child health research in the Pacific region has been lacking, and research approaches for the region have historically been from Western biomedical paradigms. We completed the study of primary school children's health over a period of 5 years. Firstly, we conducted a literature review, then we completed an audit of hospital admissions of primary school children, then we completed a two-round Delphi process and finally, we piloted the survey in three primary schools. Our results found there were high levels of oral health problems, ear health, obesity and exposure to violence and poverty impacting on the quality of health of primary school-age children. Identifying these indicators was made possible by the partnerships and trust established by the study team and provides specific and measurable targets for future work to improve the quality of child health outcomes. This paper describes key field work lessons learnt for research in the Pacific region. It must: (i) be on the platform of relationship, cultural safety and local ownership; (ii) include consideration of holistic Pacific paradigms of health; (iii) be adaptive to the context and environment; and (iv) be committed to long-term partnership and work.

The Practice and Feasibility of Screening, Treatment, and Referral for Gaming Problems in Gambling, Alcohol and Other Drugs, and Youth Services.

Screening, brief intervention, and referral to treatment (SBIRT) is a comprehensive approach to identifying people at risk of addiction, but its feasibility for gaming disorder is unknown. This study surveyed 88 clinicians from gambling, alcohol and other drugs, and youth services in New Zealand. Results indicated that the most frequent GD screening method was an unstructured interview (61%), but 74% stated they would use a standardized tool if available. Responsivity to the detection of GD was an immediate intervention (84%), and rates of referral were low (28%). Around 50% of clinicians indicated high confidence in administering motivational approaches and relapse prevention. There was strong support for screening training (85%), treatment guidelines (88%), self-help materials (92%), and access to internet-delivered CBT that could be used in conjunction with other treatment (84%). Clinicians appear motivated and willing to implement SBIRT for GD but report lacking necessary training and resources, including access to screening tools and treatment guidelines.

Content and Effectiveness of Web-Based Treatments for Online Behavioral Addictions: Systematic Review.

BACKGROUND: Very few people seek in-person treatment for online behavioral addictions including gaming and gambling or problems associated with shopping, pornography use, or social media use. Web-based treatments have the potential to address low rates of help seeking due to their convenience, accessibility, and capacity to address barriers to health care access (eg, shame, stigma, cost, and access to expert care). However, web-based treatments for online behavioral addictions have not been systematically evaluated. OBJECTIVE: This review aimed to systematically describe the content of web-based treatments for online behavioral addictions and describe their therapeutic effectiveness on symptom severity and consumption behavior. METHODS: A database search of MEDLINE, Embase, PsycInfo, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar was conducted in June 2022. Studies were eligible if the study design was a randomized controlled trial or a pre-post study with at least 1 web-based intervention arm for an online behavioral addiction and if the study included the use of a validated measure of problem severity, frequency, or duration of online behavior. Data on change techniques were collected to analyze intervention content, using the Gambling Intervention System of CharacTerization. Quality assessment was conducted using the Effective Public Health Practice Project Quality Assessment Tool. RESULTS: The review included 12 studies with 15 intervention arms, comprising 7 randomized controlled trials and 5 pre-post studies. The primary focus of interventions was gaming (n=4), followed by internet use inclusive of screen time and smartphone use (n=3), gambling (n=3), and pornography (n=2). A range of different technologies were used to deliver content, including websites (n=6), email (n=2), computer software (n=2), social media messaging (n=1), smartphone app (n=1), virtual reality (n=1), and videoconferencing (n=1). Interventions contained 15 different change techniques with an average of 4 per study. The techniques most frequently administered (>30% of intervention arms) were cognitive restructuring, relapse prevention, motivational enhancement, goal setting, and social support. Assessment of study quality indicated that 7 studies met the criteria for moderate or strong global ratings, but only 8 out of 12 studies evaluated change immediately following the treatment. Across included studies, two-thirds of participants completed after-treatment evaluation, and one-quarter completed follow-up evaluation. After-intervention evaluation indicated reduced severity (5/9, 56%), frequency (2/3, 67%), and duration (3/7, 43%). Follow-up evaluation indicated that 3 pre-post studies for gaming, gambling, and internet use demonstrated reduced severity, frequency, and duration of consumption. At 3-month evaluation, just 1 pre-post study indicated significant change to mental health symptoms. CONCLUSIONS: Web-based treatments for online behavioral addictions use an array of mechanisms to deliver cognitive and behavioral change techniques. Web-based treatments demonstrate promise for short-term reduction in symptoms, duration, or frequency of online addictive behaviors. However, there is limited evidence on the effectiveness of web-based treatments over the longer term due to the absence of controlled trials.

The impact of COVID-19 on addiction treatment in New Zealand.

COVID-19 public health measures, including lockdowns, have disrupted psychological service delivery for substance use and behavioural addictions. This study aimed to examine how addictions treatment had been affected by COVID-19 related factors from the perspective of addiction and mental health service providers. Participants (n = 93) were experienced service managers and clinicians in New Zealand who completed an online survey. Clinicians reported increased presentations for problems related to internet gambling (n = 57, 61%), gaming (n = 53, 57%), social media use (n = 52, 56%), and pornography (n = 28, 30%). A qualitative analysis of responses generated six themes. Themes included service management and increased administrative burden, and service delivery reconfiguration. Access improved for some clients because of convenience and reduced structural barriers. However, online service delivery was problematic for those with unstable or no internet access and devices that could not support video conferencing and/or lack of safe, confidential or private spaces at home. Increased client complexity and restricted in-person care prompted changes to focus, and content of clinical interventions, and some respondents offered more frequent but shorter appointments. Clinicians who provided services by phone or email, rather than video conferencing, reported treatment was less effective, with reduced rapport and engagement a contributing factor. The New Zealand addictions sector has responded to COVID-19 by increasing treatment access through distance-based options. Maintaining multifaceted models of care that are agile to rapidly changing environments presents unique challenges but is critical to addressing the needs of people impacted by addiction.

Surviving versus thriving: The wellbeing of primary school aged children in Tonga.

AIM: To enable improvements in global child health, the focus must move beyond child survival to child wellbeing. In the Pacific Islands, the wellbeing of children has received little attention. This study aimed to investigate the wellbeing of children from three primary schools in Tonga. METHODS: A cross-sectional survey was completed in three primary schools in Nuku'alofa with children aged 5-15 years. The study participants (256 children, 143 caregivers) completed the Child Health and Illness Profile - Child Edition, CHIP-CE (Version 1.0). RESULTS: On average, >70% of children and caregivers described home and school environments as positive. From the children's reports, boys had significantly lower scores for risk avoidance than girls (3.40 vs. 3.73, P < 0.001). Children aged 5-7 versus 8-15 years had significantly lower scores for satisfaction (3.63 vs. 3.92, P = 0.002), resilience (3.34 vs. 3.56, P = 0.016) and achievement (3.25 vs. 3.62, P = 0.002). From the caregivers' report, girls had significantly lower scores for academic performance than boys (3.60 vs. 3.81, P = 0.04). Boys had significantly lower scores for individual risk association compared to girls (3.93 vs. 4.29, P = 0.01). Overall CHIP-CE scores were lower than those of comparable populations in the West, while at the same time protective factors were documented. CONCLUSIONS: Understanding child wellbeing in the Pacific is critical for strengthening protective factors known to mitigate poor child health outcomes. Continuing to base global child health success on child survival alone misses opportunities for improving the wellbeing of nations.

Primary Care Variation in Rates of Unplanned Hospitalizations, Functional Ability, and Quality of Life of Older People.

PURPOSE: To investigate variability in older people's outcomes according to general practitioner (GP) and practice characteristics in New Zealand and the Netherlands. METHODS: We used data from 2 primary care-based, cluster-randomized, controlled trials to separately fit mixed models of unplanned admission rates, functional ability, and quality of life (QOL) and examine variation according to GP- and practice-level characteristics after adjusting for participant-level characteristics. For the New Zealand sample (n = 3,755 aged 75+ years in 60 practices), we modeled 36-month unplanned admission rates, Nottingham Extended Activities of Daily Living (NEADL) scale, and QOL domain ratings from the brief version of the World Health Organization Quality of Life assessment tool. For the Netherlands sample (n = 3,141 aged 75+ years in 59 practices), we modeled 12-month unplanned admission rates, Groningen Activity Restriction Scale scores, and EuroQOL 5 dimensions (EQ-5D) summary index. RESULTS: None of the GP or practice characteristics were significantly associated with rates of unplanned admissions in the New Zealand sample, but we found greater rates of admission in larger practices (incidence rate ratio [IRR], 1.45; 95% CI, 1.15-1.81) and practices staffed with a practice nurse (IRR, 1.74; 95% CI, 1.20-2.52) in the Netherlands sample. In both samples, differences were consistently small where there were significant associations with function (range, -0.26 to 0.19 NEADL points in the New Zealand sample; no associations in the Netherlands sample) and QOL (range, -1.64 to 0.97 QOL points in New Zealand; -0.01 EQ-5D points in the Netherlands). CONCLUSIONS: In the absence of substantial differences in older people's function and QOL, it remains unclear whether intriguing GP- or practice-related variations in admission rates represent low- or high-quality practice.

Person-centred interventions for problem gaming: a stepped care approach.

BACKGROUND: Problem gaming is reported by approximately 1-3% of the population and is associated with decreased health and wellbeing. Research on optimal health responses to problem gaming remains limited. This study aimed to identify and describe the key components of a person-centred approach to interventions for problem gaming for individuals who voluntary seek assistance. METHODS: Online interviews were conducted with 20 adults (90% male; Mage = 23y) currently seeking help for problem gaming. The interview protocol was guided by a health care access framework which investigated participants' experiences and needs related to accessing professional support. Transcripts were analysed in NVivo using qualitative content analysis to systematically classify participant data into the themes informed by this framework. RESULTS: Participants had mixed views on how the negative consequences of problem gaming could be best addressed. Some indicated problems could be addressed through self-help resources whereas others suggested in-person treatment with a health professional who had expertise in gaming. Participants described the essential components of an effective health service for problem gaming as including: valid and reliable screening tools; practitioners with specialist knowledge of gaming; and access to a multimodal system of intervention, including self-help, internet and in-person options that allow gamers to easily transition between types and intensity of support. CONCLUSION: A comprehensive health care approach for interventions for problem gaming is in its infancy, with numerous service access and delivery issues still to be resolved. This study highlights the importance of involving individuals with gaming-related problems in developing solutions that are fit for purpose and address the spectrum of individual preferences and needs. These findings recommend a stepped healthcare system that adheres to evidence-based practice tailored to each individual and the implementation of standard assessment and routine outcome monitoring.

GP- and practice-related variation in ambulatory sensitive hospitalisations of older primary care patients.

BACKGROUND: Reducing ambulatory sensitive hospitalisations (ASHs) is a strategy to control spending on hospital care and to improve quality of primary health care. This research investigated whether ASH rates in older people varied by GP and practice characteristics. METHODS: We identified ASHs from the national dataset of hospital events for 3755 community-dwelling participants aged 75+ enrolled in a cluster randomised controlled trial involving 60 randomly selected general practices in three regions in New Zealand. Poisson mixed models of 36-month ASH rates were fitted for the entire sample, for complex participants, and non-complex participants. We examined variation in ASH rates according to GP- and practice-level characteristics after adjusting for patient-level predictors of ASH. RESULTS: Lower rates of ASHs were observed in female GPs (IRR 0.83, CI 0.71 to 0.98). In non-complex participants, but not complex participants, practices in more deprived areas had lower ASH rates (4% lower per deprivation decile higher, IRR 0.96, CI 0.92 to 1.00), whereas main urban centre practices had higher rates (IRR 1.84, CI 1.15 to 2.96). Variance explained by these significant factors was small (0.4% of total variance for GP sex, 0.2% for deprivation, and 0.5% for area type). None of the modifiable practice-level characteristics such as home visiting and systematically contacting patients were significantly associated with ASH rates. CONCLUSIONS: Only a few GP and non-modifiable practice characteristics were associated with variation in ASH rates in 60 New Zealand practices interested in a trial about care of older people. Where there were significant associations, the contribution to overall variance was minimal. It also remains unclear whether lower ASH rates in older people represents underservicing or less overuse of hospital services, particularly for the relatively well patient attending practices in less central, more disadvantaged communities. Thus, reducing ASHs through primary care redesign for older people should be approached carefully. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Register ACTRN12609000648224 .

Taking the pulse of the health services research community: a cross-sectional survey of research impact, barriers and support.

Objective This study reports on the characteristics of individuals conducting health service research (HSR) in Australia and New Zealand, the perceived accessibility of resources for HSR, the self-reported impact of HSR projects and perceived barriers to conducting HSR. Methods A sampling frame was compiled from funding announcements, trial registers and HSR organisation membership. Listed researchers were invited to complete online surveys. Close-ended survey items were analysed using basic descriptive statistics. Goodness of fit tests determined potential associations between researcher affiliation and access to resources for HSR. Open-ended survey items were analysed using thematic analysis. Results In all, 424 researchers participated in the study (22% response rate). Respondents held roles as health service researchers (76%), educators (34%) and health professionals (19%). Most were employed by a university (64%), and 57% held a permanent contract. Although 63% reported network support for HSR, smaller proportions reported executive (48%) or financial (26%) support. The least accessible resources were economists (52%), consumers (49%) and practice change experts (34%); researchers affiliated with health services were less likely to report access to statisticians (P<0.001), economists (P<0.001), librarians (P=0.02) and practice change experts (P=0.02) than university-affiliated researchers. Common impacts included conference presentations (94%), publication of peer-reviewed articles (87%) and health professional benefits (77%). Qualitative data emphasised barriers such as embedding research culture within services and engaging with policy makers. Conclusions The data highlight opportunities to sustain the HSR community through dedicated funding, improved access to methodological expertise and greater engagement with end-users. What is known about the topic? HSR faces several challenges, such as inequitable funding allocation and difficulties in quantifying the effects of HSR on changing health policy or practice. What does this paper add? Despite a vibrant and experienced HSR community, this study highlights some key barriers to realising a greater effect on the health and well-being of Australian and New Zealand communities through HSR. These barriers include limited financial resources, methodological expertise, organisational support and opportunities to engage with potential collaborators. What are the implications for practitioners? Funding is required to develop HSR infrastructure, support collaboration between health services and universities and combine knowledge of the system with research experience and expertise. Formal training programs for health service staff and researchers, from short courses to PhD programs, will support broader interest and involvement in HSR.

Living Life After Traumatic Brain Injury: Phase 1 of a Longitudinal Qualitative Study.

OBJECTIVE: To explore what helps and hinders recovery and adaptation after disabling traumatic brain injury (TBI) and make recommendations for improving service responsiveness. DESIGN: A longitudinal qualitative descriptive study across all TBI severities. SETTING: Community. PARTICIPANTS: Forty people with TBI, and 22 significant others, 6 to 9 months following a TBI. MAIN MEASURES: Semistructured interviews, analyzed using qualitative description, focused on (a) key areas of importance or concern and (b) strategies or actions that people found helpful or that hindered recovery. RESULTS: Traumatic brain injury produced a complex set of challenges in keeping up with life, and understanding what having a TBI means for, and to, me. This period encompassed a tangled fit and misfit in life as brain injury did not occur in isolation. People had to actively change some aspects of life and yet allow other changes to happen. Valued supports from others included being looked out for and having someone to help drive the process. CONCLUSION: Improved services delivery and better outcomes may result if we respond to the person within his or her context; listen, believe, and acknowledge the person's story through our actions; and avoid assumptions about aspects of life that mean most to people and who/what may help best.

Children's perceptions of a 'self-explaining road' intervention to improve neighbourhood safety.

AIM: Safe neighbourhood environments can provide important spaces for child activity and well-being. Self-explaining roads (SERs), which reduce vehicle speeds by changing neighbourhood street design, are an intervention with known safety benefits. However, little is known about children's experiences of SERs. METHODS: We engaged schoolchildren in developing a project to articulate children's perspectives of SERs. Students actively researched the experiences of other children at their school, and then participated in a researcher-led focus group. RESULTS: Children emphasised safer spaces for play as an important benefit of SERs. As well as using new designated play spaces adjoining footpaths, children also felt the roadway became safer, and more fun for cycling. In contrast, children reported that parents held mainly negative views of SERs, considering them annoying and inconvenient. CONCLUSION: From children's perspective, SERs can provide safe spaces for neighbourhood play, despite limited parental support. Potential benefits for children as well as established safety benefits should inform future implementation of SERs.

Usual primary care of older people in New Zealand: association between practice characteristics and practice activities.

INTRODUCTION Information on the processes used by primary care practices to help identify older patients in need of assistance are limited in New Zealand. AIM To describe the processes used to promote early problem detection in older patients in primary care and the practice characteristics associated with the use of these proactive processes. METHODS Sixty practices were randomly selected from all primary care practices in three regions (52% response rate) and surveyed in 2010 to identify characteristics of practices performing the following activities: using assessment tools; auditing the practice; conducting specific clinics; providing home visits; and providing active patient follow-up. Practice level variables were examined. RESULTS Only 4 (7%) of 57 practices did not perform any of the activities. We found the following associations in the many comparisons done: no activities and greater level of deprivation of practice address (p = 0.048); more activities in main urban centres (p = 0.034); more main urban centre practices doing home visits (p = 0.001); less Canterbury practices conducting specific clinics for frail older patients (p = 0.010); and more Capital and Coast practices following-up patients who do not renew their prescriptions (p = 0.019). DISCUSSION There are proactive processes in place in most New Zealand practices interested in a trial about care of older people. Future research should determine whether different types of practices or the activities that they undertake make a difference to older primary care patients' outcomes.

Exploring the experience of sleep and fatigue in male and female adults over the 2 years following traumatic brain injury: a qualitative descriptive study.

OBJECTIVES: To explore the experience of fatigue and sleep difficulties over the first 2 years after traumatic brain injury (TBI). DESIGN: Longitudinal qualitative descriptive analysis of interviews completed as part of a larger longitudinal study of recovery following TBI. Data relating to the experience of fatigue and/or sleep were extracted and coded by two independent researchers. SETTING: Community-based study in the Hamilton and Auckland regions of New Zealand. PARTICIPANTS: 30 adult participants who had experienced mild, moderate or severe brain injury within the past 6 months (>16 years of age). 15 participants also nominated significant others to take part. Interviews were completed at 6, 12 and 24 months postinjury. RESULTS: Participants described feeling unprepared for the intensity, impact and persistent nature of fatigue and sleep difficulties after injury. They struggled to learn how to manage their difficulties by themselves and to adapt strategies in response to changing circumstances over time. Four themes were identified: (1) Making sense of fatigue and sleep after TBI; (2) accepting the need for rest; (3) learning how to rest and; (4) need for rest impacts on ability to engage in life. CONCLUSIONS: Targeted support to understand, accept and manage the sleep and fatigue difficulties experienced may be crucial to improve recovery and facilitate engagement in everyday life. Advice needs to be timely and revised for relevance over the course of recovery.

Approaches to capturing the financial cost of family care-giving within a palliative care context: a systematic review.

The economic burden faced by family caregivers of people at the end of life is well recognised. Financial burden has a significant impact on the provision of family care-giving in the community setting, but has seen limited research attention. A systematic review with realist review synthesis and thematic analysis was undertaken to identify literature relating to the financial costs and impact of family care-giving at the end of life. This paper reports findings relating to previously developed approaches which capture the financial costs and implications of caring for family members receiving palliative/end-of-life care. Seven electronic databases were searched from inception to April 2012, for original research studies relating to the financial impact of care-giving at the end of life. Studies were independently screened to identify those which met the study inclusion criteria, and the methodological quality of included studies was appraised using realist review criteria of relevance and rigour. A descriptive thematic approach was used to synthesise data. Twelve articles met the inclusion criteria for the review. Various approaches to capturing data on the financial costs of care-giving at the end of life were noted; however, no single tool was identified with the sole purpose of exploring these costs. The majority of approaches used structured questionnaires and were administered by personal interview, with most studies using longitudinal designs. Calculation of costs was most often based on recall by patients and family caregivers, in some studies combined with objective measures of resource use. While the studies in this review provide useful data on approaches to capturing costs of care-giving, more work is needed to develop methods which accurately and sensitively capture the financial costs of caring at the end of life. Methodological considerations include study design and method of administration, contextual and cultural relevance, and accuracy of cost estimates.

The cluster-randomized BRIGHT trial: Proactive case finding for community-dwelling older adults.

PURPOSE: People are now living longer, but disability may affect the quality of those additional years of life. We undertook a trial to assess whether case finding reduces disability among older primary care patients. METHODS: We conducted a cluster-randomized trial of the Brief Risk Identification Geriatric Health Tool (BRIGHT) among 60 primary care practices in New Zealand, assigning them to an intervention or control group. Intervention practices sent a BRIGHT screening tool to older adults every birthday; those with a score of 3 or higher were referred to regional geriatric services for assessment and, if needed, service provision. Control practices provided usual care. Main outcomes, assessed in blinded fashion, were residential care placement and hospitalization, and secondary outcomes were disability, assessed with Nottingham Extended Activities of Daily Living Scale (NEADL), and quality of life, assessed with the World Health Organization Quality of Life scale, abbreviated version (WHOQOL-BREF). RESULTS: All 8,308 community-dwelling patients aged 75 years and older were approached; 3,893 (47%) participated, of whom 3,010 (77%) completed the trial. Their mean age was 80.3 (SD 4.5) years, and 55% were women. Overall, 88% of the intervention group returned a BRIGHT tool; 549 patients were referred. After 36 months, patients in the intervention group were more likely than those in the control group to have been placed in residential care: 8.4% vs 6.2% (hazard ratio = 1.32; 95% CI, 1.04-1.68; P = .02). Intervention patients had smaller declines in mean scores for physical health-related quality of life (1.6 vs 2.9 points, P = .007) and psychological health-related quality of life (1.1 vs 2.4 points, P = .005). Hospitalization, disability, and use of services did not differ between groups, however. CONCLUSIONS: Our case-finding strategy was effective in increasing identification of older adults with disability, but there was little evidence of improved outcomes. Further research could trial stronger primary care integration strategies.

Met and unmet need for personal assistance among community-dwelling New Zealanders 75 years and over.

Ageing in place initiatives that aim to keep older people out of hospitals and rest homes and in their own homes for longer have been at the forefront of aged care policy since the early 1990s. The success of these policies depends largely on the availability of a suitable home environment, a supportive social network and regular assessment to detect changes in the older person's health status and needs for support. The BRIGHT Trial was a randomised control trial investigating the effectiveness of introducing case finding in primary care settings to detect unmet need and risk of disability among older people. We used baseline questionnaire data collected in 2008-2009 from 3753 community-dwelling older people to estimate and describe use and need for additional personal assistance. Logistic regression was used to identify the most important predictors of reporting some need for support and unmet need. Eighty-one per cent of participants required support with at least one instrumental activity of daily living. Sixty-six per cent were meeting their needs with the support they were currently receiving. Unmet need was most frequently reported for heavy housework (65%) and light housework (53%). While spouses, family members and friends were the main providers of support for light housework, meal preparation, shopping, finances and transportation, paid staff most frequently provided personal care and heavy housework assistance. Reporting mobility difficulty (OR = 3.5), identifying as a care provider (OR = 1.7) and being female (OR = 1.9) were all significant predictors of some need for assistance as well as unmet need for assistance (OR = 2.5, 1.7 and 1.7 respectively). The findings highlight the importance of regular needs assessment for older people living in the community particularly, given the reliance on spousal support for the majority of activities.

Exploring the financial impact of caring for family members receiving palliative and end-of-life care: a systematic review of the literature.

BACKGROUND: Research regarding the economic dimensions of palliative care is relatively limited. The economic implications of providing informal care are well recognised; however, within the context of palliative care, little is known about the costs and implications of providing care for a loved one at the end of life. AIM: To explore the financial costs and the financial impact of caring for family members receiving palliative/end-of-life care. DESIGN: A systematic literature review of empirical research following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. DATA SOURCES: Seven electronic databases were searched from inception to April 2012. Inclusion criteria were as follows: articles relating to the financial costs or implications of family caregiving at the end-of-life care, English language articles, empirical research or systematic reviews and articles relating to adults. RESULTS: The review identified 21 relevant articles; however, evidence relating to the costs and implications of caregiving was relatively limited. The results indicate that the financial costs of caring for someone at the end of life are substantial. Financial costs can result in significant and multidimensional caregiver burden. Various factors were found to mediate the extent of financial burden. CONCLUSIONS: This review identified a significant gap in the evidence base regarding the economic implications of providing care to a family member within a palliative care context. Economic costs and implications are likely to be significant, and research to address this gap is urgently needed, particularly given policy initiatives in a number of developed countries to move the provision of palliative and end-of-life care from hospital to community settings.

Estimating the additional cost of disability: beyond budget standards.

Disabled people have long advocated for sufficient resources to live a life with the same rights and responsibilities as non-disabled people. Identifying the unique resource needs of disabled people relative to the population as a whole and understanding the source of these needs is critical for determining adequate levels of income support and for prioritising service provision. Previous attempts to identify the resources and costs associated with disability have tended to rely on surveys of current resource use. These approaches have been criticised as being inadequate for identifying the resources that would be required to achieve a similar standard of living to non-disabled people and for not using methods that are acceptable to and appropriate for the disabled community. The challenge is therefore to develop a methodology that accurately identifies these unique resource needs, uses an approach that is acceptable to the disabled community, enables all disabled people to participate, and distinguishes 'needs' from 'wants.' This paper describes and presents the rationale for a mixed methodology for identifying and prioritising the resource needs of disabled people. The project is a partnership effort between disabled researchers, a disability support organisation and academic researchers in New Zealand. The method integrates a social model of disability framework and an economic cost model using a budget standards approach to identify additional support, equipment, travel and time required to live an 'ordinary life' in the community. A survey is then used to validate the findings and identify information gaps and resource priorities of the community. Both the theoretical basis of the approach and the practical challenges of designing and implementing a methodology that is acceptable to the disabled community, service providers and funding agencies are discussed.

Cost of prescribed and delivered health services resulting from a comprehensive geriatric assessment tool in New Zealand.

The objective of this study was to estimate the health service use and costs resulting from the introduction of the interRAI Minimum Data Set-Home Care (MDS-HC) assessment compared with usual assessment.A randomised controlled trial of elderly people in New Zealand measured the use and cost of prescribed and delivered (4 months post-assessment) health services of 153 participants assessed using the standard [Needs Assessment and Service Co-ordination (NASC)] tool,and 158 participants assessed using the MDS-HC. The results suggest that the MDS-HC resulted in more prescribed personal health and community services, and less disability support services than with NASC. The cost of prescribed services was significantly greater for the MDS-HC (NZ$1840) than the NASC (NZ$1522, P < 0.001). The cost of delivered services was significantly greater for the MDS-HC (NZ$4809)than the NASC (NZ$2727, P < 0.001), including higher costs of hospitalizations (NZ$2523 vs. NZ$1112, P= 0.257). There were pronounced differences among 'low-need' compared with 'high-need'elderly people. These results suggest that the interRai assessment tool resulted in greater cost of prescribed preventive services and less prescribed disability services than the NASC. However, differences in delivered services were driven primarily by differences in hospitalizations. The results highlight the importance of integrating the assessment procedure with the delivery of health services, but suggest that further study is warranted. The results have implications for purchasers of health services for elderly people.