Practice redesign to improve care for falls and urinary incontinence: primary care intervention for older patients.

BACKGROUND: In primary care, medical care for age-associated conditions, such as falls and urinary incontinence (UI), is inadequate. In collaboration with the American College of Physicians, we augmented the Assessing Care of Vulnerable Elders practice redesign intervention to improve falls and UI care. METHODS: We performed a controlled trial in 5 nonrandomly selected primary care intervention (26 physicians across sites) and control (18 physicians) practices from diverse communities. Patients 75 years and older who screened positive for falls or fear of falling and UI were included in the study. We conducted a multicomponent intervention between October 30, 2006, and December 31, 2007, that included efficient collection of data, medical record prompts, patient education materials, and physician decision support. Main outcome measures were quality of care for falls and UI comparing intervention and control sites. RESULTS: Of 6051 patients screened, 2847 (47.1%) screened positive for falls or UI (46.1% in the intervention group and 48.8% in the control group). Across the 5 practices, 1211 patient medical records were evaluated after stratified random selection. Intervention patients received 60.0% of recommended care for falls vs 37.6% provided by control health care professionals (P < .001). Similarly, intervention health care professionals provided more recommended care for UI (47.2% vs 27.8%, P < .001). Intervention health care professionals more often performed a falls history, orthostatic blood pressure measurement, gait and balance examination, and UI history and tried UI behavioral treatments first. Knowledge about falls and UI increased more among intervention than control group health care professionals. CONCLUSIONS: Practice redesign can improve the care that community-based primary care physicians provide for older patients with falls and UI. Outcomes of such care improvements require further evaluation.

Prospective evaluation of an outpatient heart failure disease management program designed for primary care: the Oregon model.

BACKGROUND: Most heart failure care is provided by primary care providers. Although heart failure disease management programs improve outcomes, most have been hospital-based with little integration with primary care providers. To address this issue, a heart failure clinic disease management model was adapted for use in the primary care setting. METHODS AND RESULTS: A heart failure clinic staffed by 2 internists and their nurses was established in a large primary care practice. Medical care and pharmacotherapy were based on national guidelines. Nurses assisted with disease management. Primary outcomes included quality of life, functional class, and all-cause hospital and emergency room admissions 12 months before compared with 12 months after enrollment; a secondary endpoint was patient satisfaction. Of 165 patients sent to the heart failure clinic, 54 were referred back because of no active heart failure, and 18 had only 1 clinic visit. The 93 patients seen 2 or more times had a median age of 75 years. Anti-angiotensin II therapy was present in 84% and did not change over time, but doses of angiotensin-converting enzyme inhibitor increased by >50%. beta-blocker use increased from 40% at baseline to 63% at 6 months. Emergency room visits or all-cause hospitalizations were reduced (0.86 +/- 1.5 to 0.52 +/- 0.86, P < .001) or trended to be reduced (0.56 +/- 0.98 to 0.35 +/- 0.62, P = .07), respectively, by approximately 40%. Quality of life improved significantly at all time points, and patients were highly satisfied. CONCLUSION: This heart failure disease management model, designed for patients and providers in an primary care setting, was feasible and successful.