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Journal ArticleDOI

Impact of PRISMA, a Coordination-Type Integrated Service Delivery System for Frail Older People in Quebec (Canada): A Quasi-experimental Study

TL;DR: The PRISMA model improves the efficacy of the health care system for frail older people with a lower number of visits to emergency rooms and hospitalizations than expected was observed in the experimental cohort.
Abstract: Objectives . To evaluate the impact of a coordination-type integrated service delivery (ISD) model on health, satisfaction, empowerment, and services utilization of frail older people. Methods . Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA) is a populationbased, quasi-experimental study with three experimental and three comparison areas. From a random selection of people 75 years or older, 1,501 persons identifi ed at risk of functional decline were recruited (728 experimental and 773 comparison). Participants were measured over 4 years for disabilities (Functional Autonomy Measurement System), unmet needs, satisfaction with services, and empowerment. Information on utilization of health and social services was collected by bimonthly telephone questionnaires. Results . Over the last 2 years (when the implementation rate was over 70%), there were 62 fewer cases of functional decline per 1,000 individuals in the experimental group. In the fourth year of the study, the annual incidence of functional decline was lower by 137 cases per 1,000 in the experimental group, whereas the prevalence of unmet needs in the comparison region was nearly double the prevalence observed in the experimental region. Satisfaction and empowerment were signifi cantly higher in the experimental group. For health services utilization, a lower number of visits to emergency rooms and hospitalizations than expected was observed in the experimental cohort. Conclusion . The PRISMA model improves the effi cacy of the health care system for frail older people.
Citations
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Journal ArticleDOI
TL;DR: Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear.
Abstract: Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context. The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence. One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users. Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand. Prospero registration number: 42016037725 .

300 citations

Journal ArticleDOI
TL;DR: Slow gait speed, PRISMA 7 and the timed get-up-and-go test have high sensitivity for identifying frailty, but limited specificity implies many false-positive results which means that these instruments cannot be used as accurate single tests to identify frailty.
Abstract: Background: frailty is a state of vulnerability to adverse outcomes. Routine identification of frailty is recommended in international guidance. This systematic review investigates the diagnostic test accuracy (DTA) of simple instruments for identifying frailty in community-dwelling older people. Methods: the review methodology followed Cochrane procedures. Databases were searched from January 1990 to October 2013. Prospective studies assessing the DTA of simple instruments for identifying frailty in community-dwelling older people (aged ≥65 years) as index tests against a reference standard phenotype model, cumulative deficit frailty index or comprehensive geriatric assessment were eligible for inclusion. Sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratios were calculated for index tests. Risk of bias was assessed using the QUADAS-2 checklist. Results: three studies involving 3,261 participants were included. Median frailty prevalence was 10.5%. Seven index tests were assessed: gait speed, timed-up-and-go test, PRISMA 7 questionnaire, self-reported health, general practitioner clinical assessment, polypharmacy and Groningen Frailty Index. For a gait speed of <0.8 m/s, the sensitivity = 0.99 and specificity = 0.64. For the PRISMA 7, the sensitivity = 0.83 and specificity = 0.83. For the timed get-up-and-go test of 10 s, the sensitivity = 0.93 and specificity = 0.62. DTAwas notably lower for all other index tests. All three studies were judged at unclear risk of bias. Discussion: slow gait speed, PRISMA 7 and the timed get-up-and-go test have high sensitivity for identifying frailty. However, limited specificity implies many false-positive results which means that these instruments cannot be used as accurate single tests to identify frailty.

285 citations

04 Sep 2013
TL;DR: Citing this paper Please note that where the full-text provided on King's Research Portal is the Author Accepted Manuscript or Post-Print version this may differ from the final Published version.
Abstract: Citing this paper Please note that where the full-text provided on King's Research Portal is the Author Accepted Manuscript or Post-Print version this may differ from the final Published version. If citing, it is advised that you check and use the publisher's definitive version for pagination, volume/issue, and date of publication details. And where the final published version is provided on the Research Portal, if citing you are again advised to check the publisher's website for any subsequent corrections.

232 citations

Journal ArticleDOI
TL;DR: It is difficult to show which tool today is the best for screening for frailty in the elderly in primary care settings, but two instruments are potentially suitable – the Tilburg Frailty Indicator and the SHARE Frailty Index.
Abstract: Frailty is the loss of resources in several domains leading to the inability to respond to physical or psychological stress. The evaluation of frailty is generally carried out using the Comprehensive Geriatric Assessment. For this evolving and potentially reversible syndrome, screening and early intervention are a priority in primary health care, and general practitioners require a simple screening tool. The aim of the present work was to review the literature for validated screening instruments for frailty in primary health care setting. A search was carried out on PubMed and Cochrane Central in June 2011. A total of 10 instruments screening for frailty in primary health care were listed, analysed and compared. It is difficult to show which tool today is the best for screening for frailty in the elderly in primary care settings. Two instruments are potentially suitable – the Tilburg Frailty Indicator and the SHARE Frailty Index. In addition, these instruments require validation in larger studies in primary health care settings and with more quality criteria. Geriatr Gerontol Int 2012; 12: 189–197.

217 citations

Journal ArticleDOI
TL;DR: Gaps in the evidence base were apparent in the quality domains of timeliness, equity, efficiencies for community providers, effectiveness/symptom management, and domains of person and family centred care.
Abstract: Background: Provision of high quality transitional care is a challenge for health care providers in many western countries. This systematic review was conducted to (1) identify and synthesise research, using randomised control trial designs, on the quality of transitional care interventions compared with standard hospital discharge for older people with chronic illnesses, and (2) make recommendations for research and practice. Methods: Eight databases were searched; CINAHL, Psychinfo, Medline, Proquest, Academic Search Complete, Masterfile Premier, SocIndex, Humanities and Social Sciences Collection, in addition to the Cochrane Collaboration, Joanna Briggs Institute and Google Scholar. Results were screened to identify peer reviewed journal articles reporting analysis of quality indicator outcomes in relation to a transitional care intervention involving discharge care in hospital and follow-up support in the home. Studies were limited to those published between January 1990 and May 2013. Study participants included people 60 years of age or older living in their own homes who were undergoing care transitions from hospital to home. Data relating to study characteristics and research findings were extracted from the included articles. Two reviewers independently assessed studies for risk of bias. Results: Twelve articles met the inclusion criteria. Transitional care interventions reported in most studies reduced re-hospitalizations, with the exception of general practitioner and primary care nurse models. All 12 studies included outcome measures of re-hospitalization and length of stay indicating a quality focus on effectiveness, efficiency, and safety/risk. Patient satisfaction was assessed in six of the 12 studies and was mostly found to be high. Other outcomes reflecting person and family centred care were limited including those pertaining to the patient and carer experience, carer burden and support, and emotional support for older people and their carers. Limited outcome measures were reported reflecting timeliness, equity, efficiencies for community providers, and symptom management. Conclusions: Gaps in the evidence base were apparent in the quality domains of timeliness, equity, efficiencies for community providers, effectiveness/symptom management, and domains of person and family centred care. Further research that involves the person and their family/caregiver in transitional care interventions is needed.

157 citations

References
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Journal ArticleDOI
TL;DR: A simplified, scored form of the cognitive mental status examination, the “Mini-Mental State” (MMS) which includes eleven questions, requires only 5-10 min to administer, and is therefore practical to use serially and routinely.

76,181 citations

01 Jan 2002
TL;DR: The Mini-Mental State (MMS) as mentioned in this paper is a simplified version of the standard WAIS with eleven questions and requires only 5-10 min to administer, and is therefore practical to use serially and routinely.
Abstract: EXAMINATION of the mental state is essential in evaluating psychiatric patients.1 Many investigators have added quantitative assessment of cognitive performance to the standard examination, and have documented reliability and validity of the several “clinical tests of the sensorium”.2*3 The available batteries are lengthy. For example, WITHERS and HINTON’S test includes 33 questions and requires about 30 min to administer and score. The standard WAIS requires even more time. However, elderly patients, particularly those with delirium or dementia syndromes, cooperate well only for short periods.4 Therefore, we devised a simplified, scored form of the cognitive mental status examination, the “Mini-Mental State” (MMS) which includes eleven questions, requires only 5-10 min to administer, and is therefore practical to use serially and routinely. It is “mini” because it concentrates only on the cognitive aspects of mental functions, and excludes questions concerning mood, abnormal mental experiences and the form of thinking. But within the cognitive realm it is thorough. We have documented the validity and reliability of the MMS when given to 206 patients with dementia syndromes, affective disorder, affective disorder with cognitive impairment “pseudodementia”5T6), mania, schizophrenia, personality disorders, and in 63 normal subjects.

70,887 citations

Journal ArticleDOI
TL;DR: In this article, an extension of generalized linear models to the analysis of longitudinal data is proposed, which gives consistent estimates of the regression parameters and of their variance under mild assumptions about the time dependence.
Abstract: SUMMARY This paper proposes an extension of generalized linear models to the analysis of longitudinal data. We introduce a class of estimating equations that give consistent estimates of the regression parameters and of their variance under mild assumptions about the time dependence. The estimating equations are derived without specifying the joint distribution of a subject's observations yet they reduce to the score equations for multivariate Gaussian outcomes. Asymptotic theory is presented for the general class of estimators. Specific cases in which we assume independence, m-dependence and exchangeable correlation structures from each subject are discussed. Efficiency of the proposed estimators in two simple situations is considered. The approach is closely related to quasi-likelih ood. Some key ironh: Estimating equation; Generalized linear model; Longitudinal data; Quasi-likelihood; Repeated measures.

17,111 citations


"Impact of PRISMA, a Coordination-Ty..." refers methods in this paper

  • ...For dichotomous outcome variables (e.g., being hospitalized), generalized estimating equation ( Liang & Zeger, 1986 ) models were used....

    [...]

Book
01 Jan 2003
TL;DR: In this paper, a framework for investigating change over time is presented, where the multilevel model for change is introduced and a framework is presented for investigating event occurrence over time.
Abstract: PART I 1. A framework for investigating change over time 2. Exploring Longitudinal Data on Change 3. Introducing the multilevel model for change 4. Doing data analysis with the multilevel mode for change 5. Treating TIME more flexibly 6. Modelling discontinuous and nonlinear change 7. Examining the multilevel model's error covariance structure 8. Modelling change using covariance structure analysis PART II 9. A Framework for Investigating Event Occurrence 10. Describing discrete-time event occurrence data 11. Fitting basic Discrete-Time Hazard Models 12. Extending the Discrete-Time Hazard Model 13. Describing Continuous-Time Event Occurrence Data 14. Fitting Cox Regression Models 15. Extending the Cox Regression Model

8,435 citations


"Impact of PRISMA, a Coordination-Ty..." refers methods in this paper

  • ...The evolution of continuous outcome variables over time was studied using growth modeling, which takes into account participants with incomplete follow-up ( Singer & Willett, 2003 )....

    [...]

Journal ArticleDOI
Walter Leutz1
TL;DR: Five "laws of integration" are presented that identify three levels of integration, point to alternative roles for physicians, outline resource requirements, highlight friction from differing medical and social paradigms, and urge policy makers and administrators to consider carefully who would be most appropriately selected to design, oversee, and administer integration initiatives.
Abstract: Because persons with disabilities (PWDs) use health and social services extensively, both the United States and the United Kingdom have begun to integrate care across systems. Initiatives in these two countries are examined within the context of the reality that personal needs and use of systems differ by age and by type and severity of disability. The lessons derived from this scrutiny are presented in the form of five “laws” of integration. These laws identify three levels of integration, point to alternative roles for physicians, outline resource requirements, highlight friction from differing medical and social paradigms, and urge policy makers and administrators to consider carefully who would be most appropriately selected to design, oversee, and administer integration initiatives. Both users and caregivers must be involved in planning to ensure that all three levels of integration are attended to and that the borders between medical and other systems are clarified.

707 citations


"Impact of PRISMA, a Coordination-Ty..." refers background in this paper

  • ...According to W. N. Leutz (1999) , there are three types of integration in health care: (a) linkage, (b) coordination, and (c) full integration....

    [...]