To guide the planning of a multifacetted hypertension control program in Edgecombe County, North Carolina, a baseline survey of a stratified (by township) random sample of 1,000 households was conducted. All adults (greater than or equal to 18 years) were interviewed and had their blood pressures (BP) measured. Five hundred thirty-nine individuals, 27 per cent of the survey population, had diastolic BP greater than or equal to 90 mm Hg or were receiving anti-hypertensive drug therapy. The 539 hypertensives were divided into seven subgroups reflecting successive stages in the control of hypertension based on the awareness, treatment, and control of their hypertension. Unaware hypertensives were further subdivided into three groups according to the recency of their last BP check, and those aware but untreated were subdivided by whether they had previously received treatment. The seven subgroups of hypertensives were compared, separately for women and men, with respect to sociodemographic characteristics, health behaviors, and health status. In general, the progression from undetected hypertension to treatment and control appeared to be associated with being older, female, and White. This progression was further associated with greater educational levels and higher family incomes among women and increasing self-reported morbidity among men. The implications for intervention of these and other described associations are discussed.
With its emphasis on addressing symptoms and acute problems, primary care is not currently designed to provide comprehensive geriatric care (Bodenheimer, Wagner, and Grumbach, 2002). This situation is likely to lead to over-treatment (Wennberg et al., 2005), undertreatment (Wenger et al., 2003), or incorrect treatment planning with older adults who have multiple interacting chronic medical conditions (Tsilimingras, Rosen, and Berlowitz, 2003). A collaborative approach to treatment planning may help address this challenge. Collaborative treatment is defined as care mat strengthens and supports self-care in chronic illness while ensuring that effective medical, preventive, and health maintenance interventions take place (Von Korff et al., 1997). Collaborative treatment has been shown to decrease acutecare utilization, improve function, increase the ability to live independently, and increase the use of hospice in geriatric rehabilitation and end-of-life care (Tinetti et al., 2002; Casarett et al., 2005). A practical model of implementation, however, has not yet been suggested in the geriatric literature. Although collaborative treatment has been held up as the ideal in primary care, no established method to meet this ideal has been defined (Saba et al., 2006). This paper describes a method, employed in the context of a research study, to facilitate collaborative treatment planning for older patients in primary care. BALANCING LENGTH OF LIFE AND QUALITY OF LIFE Medical interventions are generally life-extending or life-enhancing. The balance between treatments that extend life and treatments that enhance quality of life shifts with increasing age and worsening health status. Planning care for patients at the extremes of this age and health status continuum is fairly straightforward. However, many older adults have a mix of life-extending and life-enhancing concerns that makes care planning more complicated. Achieving the optimal balance for a given individual may be facilitated through collaborative treatment planning and use of our priority-setting approach. THE PROCESS OF GENERATING CLINICAL PRIORITIES In a randomized controlled trial testing an intervention to improve the care of older adults in primary care, we integrated a geriatric team-consisting of a geriatrician, a gerontologie nurse practitioner, and a geropharmacist-into several primary care practices. The team had consultative and comanagement functions with primary care providers and developed care plans for frail older adults with multiple coexisting conditions. Such patients typically have a long list of medical problems (commonly referred to among Healthcare providers as the list). Developing a treatment plan that took the lengthy problem list into account was a central challenge that the geriatric team faced with these patients. We refer to the approach adopted by the team to meet this challenge as priority-setting. How was clinical priority-setting accomplished? The team established clinical priorities with a patient over two visits. At the first visit, the nurse practitioner conducted a standardized assessment that included a review of chronic medical problems, medications, functional status, physical and social activity levels, along with screening for pain, depression, dementia, urinary incontinence, balance problems and falls, completion of advance directives, substance use, and goals and preferences for care. The nurse asked the patient to consider which of the identified problems were most important to him or her. The patient was then scheduled for a follow-up visit in two weeks. At the second visit, the geriatrician met with the nurse and the patient to review findings from the first visit, and classify each identified problem into one of these three categories: 1. Threats to quality of life and safety (e.g., shortness of breath, pain, dementia, depression, falls). 2. …
EnhanceWellness (EW) is a community-based health promotion program that helps prevent disabilities and improves health and functioning in older adults. A previous randomized controlled trial demonstrated a decrease in inpatient use for EW participants but did not evaluate health care costs. We assessed the effect of EW participation on health care costs.We performed a retrospective cohort study in King County, Washington. Enrollees in Group Health Cooperative (GHC), a mixed-model health maintenance organization, who were aged 65 years or older and who participated in EW from 1998 through 2005 were matched 1:3 by age and sex to GHC enrollees who did not participate in EW. We matched 218 EW participants by age and sex to 654 nonparticipants. Participants were evaluated for 1 year after the date they began the program. The primary outcome was total health care costs; secondary outcomes were inpatient costs, primary care costs, percentage of hospitalizations, and number of hospital days. We compared postintervention outcomes between EW participants and nonparticipants by using linear regression. Results were adjusted for prior year costs (or health care use), comorbidity, and preventive health care-seeking behaviors.Mean age of participants and nonparticipants was 79 years, and 72% of participants and nonparticipants were female. Adjusted total costs in the year following the index date were $582 lower among EW participants than nonparticipants, but this difference was not significant.Although EW participation demonstrated health benefits, participation does not appear to result in significant health care cost savings among people receiving health care through a health maintenance organization.
To identify the most appropriate generic instrument to measure experience and/or satisfaction of people receiving integrated chronic care.Health care is becoming more user-centred and, as a result, the experience of users of care and evaluation of their experience and/or satisfaction is taken more seriously. It is unclear to what extent existing instruments are appropriate in measuring the experience and/or satisfaction of people using integrated chronic care.Instruments were identified by means of a systematic literature review. Appropriateness of instruments was analysed on seven criteria. The two most promising instruments were translated into Dutch, if necessary, and administered to a convenience sample of 109 people with a chronic illness. Data derived from respondents were analysed statistically. Focus-group interviews were conducted to assess the semantic and technical equivalence as well as opinions of people about the applicability and relevance of the translated instruments.From 37 instruments identified, the Patients' Assessment of Care for chronIc Conditions (PACIC) and the short form of the Patient Satisfaction Questionnaire III (PSQ-18) were selected as most promising instruments. Both instruments produced similar median scores across people with different chronic conditions. The overall PACIC and its subscales and the overall PSQ-18 were highly internally consistent, but not the PSQ-18 subscales. Overall, the PACIC demonstrated better psychometric characteristics. PACIC and PSQ-18 scores were found to be moderately correlated. Whereas more respondents preferred the PSQ-18, focus-group participants regarded the PACIC to be more applicable and relevant. The technical and semantic equivalence of both instruments were sufficient.Because of its psychometric characteristics, perceived applicability and relevance, the PACIC is the most appropriate instrument to measure the experience of people receiving integrated chronic care.
Purpose: To clarify the concept of fragmentation of chronic care and contribute to the international debate on how to reform systems to better address the needs of people with a chronic disorder.
The entire student enrollment (n = 624) in a public junior high school in Raleigh, North Carolina were visited in their homes between October 1978 and February 1979. Eleven (2.9%) of 384 students completing the Center for Epidemiologic Studies self-report depression scale reported symptom patterns consistent with the Research Diagnostic Criteria for major depressive disorder. These 11 subjects were concentrated in the top l2% of the distribution of symptom scores and had symptom prevalences exceeding those in the overall study population by a factor of three or more. Black males trom low income households predominated. A self-report questionnaire may be usable to detect a depressive "syndrome" in young adolescents. The prevalence of such a syndrome is similar to prevalence estimates for adults and young adolescents, but considerably lower than estimates derived from total scale scores and cutoff points. A syndrome-oriented analytic approach for symptom scales should be explored as an alternative to the use of cutoff scores for epidemiologic studies of psychiatric disorders.
