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A Practice-Based Intervention to Improve Primary Care for Falls, Urinary Incontinence and Dementia

A Practice-Based Intervention to Improve Primary Care for Falls, Urinary Incontinence and Dementia

Critique date: Fri, 05/01/2009 - 10:26am
Institution: 
Mount Sinai School of Medicine
   
Article Citation
Citation: 
Wenger NS et al. A Practice-Based Intervention to Improve Primary Care for Falls, Urinary Incontinence and Dementia. JAGS 2009; 57(3): 547-555.
   
Clinical Bottom Lines
  1. Robust study using ACOVE-2 quality indicators to determine quality of care for older adults for falls/urinary incontinence/cognitive impairment; good process outcomes with reliable and repeatable assessments. 
  2. Educational intervention directed at physicians with a large practice change effort resulted in higher rates of incorporation of process quality indicators in the subsequent care of patients.
  3. Multifaceted intervention incorporates patient, staff, and physician in attempt to achieve control over those syndromes. 
   
Methods
Type of Study: 
Therapy / Prevention
Study Design: 
Cohort study
Follow-up Period: 
Period of intervention lasted 13 months.
Patient Population: 
Physician Participants: Two large medical groups participated, each with two distinct clinical sites; each group, therefore, had a control site and an intervention site. Medical Group 1: 30 physicians; Medical Group 2: 100 physicians. However, only 20 physicians’ patients studied in control group and in intervention group. Mean age 48/44. Baseline characteristics: mostly internal medicine; 10% intervention group had geri training c/w 5% in control group; intervention group had higher percentage of patient population identified as >75. 

Patient Participants: 644 participants; 357 intervention, 287 control.  Mean age 81. Baseline characteristics affecting generalization: 95% white; lower to middle incomes predominate; general health rating fair to good (2.9)
 
Inclusions: All patients 75 years old and older with appointments scheduled with their physicians; Eligible if they spoke English; capable of consenting or had proxy capable of consenting; screened positive for one of the areas of interest: falls/fear of falling; bothersome urinary incontinence; cognitive impairment. 
Significant Exclusions: 
As intimated above. Excluded if did not speak English, could not consent even through proxy, or did not screen positive for the areas of interest.
Intervention/Exposure: 
Study Design: cohort trial (two groups of physicians “exposed” to the intervention and two groups not; outcomes measured for patients in all groups)

Intervention/Exposure:
1) Individual Case Finding: Identification of patients with one of three study conditions (falls/fear of falling, urinary incontinence, cognitive impairment) by telephone screening. This consisted of three screening questions to identify falls – fear of falling – bothersome urinary incontinence, and a three item recall after 60 seconds or question to proxy, if patient was unable to answer. 
For ALL screened patients – both the control and the intervention group – a note was placed on the chart. 
In the intervention group, a structured visit note generating a condition specific intervention was placed on the medical record in addition to the positive screen. This allowed collection of condition specific data with automatic orders. Also prompted “essential care processes”. Patient education materials and physician decision support materials provided.
2) Physician Education: Three hour educational program teaching an efficient approach to each of these conditions. Decision support information provided. This mirrored the content of the notes/condition specific interventions.
3) Practice-Change Effort: Condition specific patient information was generated, including a list of local community-based resources. Available in the clinicians’ rooms. Practices and individual clinicians altered the structure to suit their practice. Group sessions with physicians reviewed charts and discussed experience of restructuring care for these patients. 
Outcome Measures: 
Primary Outcome:
Medical record abstractions performed on all medical contacts that the identified patients received during a 13 month intervention period and for the 19 months preceding the intervention period. This abstraction determined eligibility for process of care quality indicators for falls, incontinence, and dementia. These are historical, physical exam, or lab/study that reflects quality of care for each of these areas. QI scores were generated in percentage format individually for falls, urinary incontinence, and cognitive impairment. Control and intervention groups were compared.
 
Secondary Outcomes:
Physician before-and-after questionnaires asking 21 questions about knowledge regarding care for targeted conditions, their relevance to the practice, their confidence in caring for each condition, and level of frustration with each condition.
Participant Follow-up: 
82% of the intervention group and 83% of the control group completed screening, received care, and agreed to participate after the screening. Patient charts were analyzed in the group they were assigned from the beginning.
   
Conclusion
Results: 
Analysis:
t-tests conducted to test difference between groups
 
Results:
  Intervention Control P value
Overall 41% 25% <0.001
Falls 44% 23% <0.001
Incontinence 37% 22% <0.001
Cognitive Impairment 44% 41% 0.67
Percentage of Quality Indicator (QI) care provided
Concerns Regarding Methodology, Applicability to Older Adults, etc.: 
  • screening questions generate note on chart with list of what to do; interesting how resistant doctors are to “checklist” medicine – such that the algorithm cannot generate more than 40-50% of completion of QIs.
  • Also, does this intervention test more for utility of the use of structured notes than truly testing for practice change on the basis of valuation and understanding of the issues at hand?
  • QIs are process, not outcome measures. (but are among the most validated process measures).
  • Multifactorial intervention – may be difficult to reproduce.
Funding Source and Role: 
Contract from Pfizer to RAND (RAND is Research ANd Development – nonprofit global think tank for public policy research, especially). No role stated.
Created By: 
Kate Callahan MD, Geriatrics Fellow, Mount Sinai School of Medicine
This is a review of the validity of a single study; the ‘bottom lines’ do not reflect comparison with the rest of the literature on this subject.