Organizational interventions to improve health outcomes of older persons

BACKGROUND: With the reorganization of the financing of health care and creation of systems of care, it is possible to design and implement organizational interventions to improve the care of older persons beyond the services that can be provided by an individual provider. OBJECTIVES: To review the effectiveness of organizational interventions for older persons, describe barriers to dissemination of success models into practice settings, and identify future directions for such interventions. METHODS: Selective review of organizational interventions that have been aimed primarily at the geriatric population and have been formally evaluated using conventional research designs, usually randomized clinical trials. RESULTS: Organizational interventions can be classified into two groups: component models and systems changes. The former can be superimposed upon an intact system but do not fundamentally change the system of care whereas the latter modify the basic structure of primary care. A variety of organizational interventions have been implemented in diverse settings, but the evidence supporting the effectiveness of these interventions is inconsistent. Even when such interventions have been effective in research settings, these interventions rarely reduce health care costs. Moreover, there have been formidable barriers to implementation of successful interventions into practice. CONCLUSIONS: Organizational interventions are potentially powerful methods to influence health care and maintain health status of older persons. Nevertheless, gaps between knowledge and practice and unanswered questions about the effectiveness of organizational interventions currently limit the potential value of this approach to improving health care of older persons.     

Lifestyle interventions

Lifestyle intervention for the self-management of diabetes is complex and will constantly evolve as the patient's life changes and the diabetes progresses. Although the patient ultimately makes the most important decisions with regard to self-management, the primary care provider plays a critical role as expert consultant to the patient in this effort. Involving a multidisciplinary team in the care and education of the patient with diabetes is an effective approach that capitalizes on each profession's expertise. The team must work collaboratively to ensure that patients are provided the educational underpinnings and taught the behavior change skills that will empower them to effectively master their diabetes.     

Effectiveness of knowledge translation interventions to improve cancer pain management

ContextCancer pain is prevalent, yet patients do not receive best care despite widely available evidence. Although national cancer control policies call for education, effectiveness of such programs is unclear and best practices are not well defined.ObjectivesTo examine existing evidence on whether knowledge translation (KT) interventions targeting health care providers, patients, and caregivers improve cancer pain outcomes.MethodsA systematic review and meta-analysis were undertaken to evaluate primary studies that examined effects of KT interventions on providers and patients.ResultsTwenty-six studies met the inclusion criteria. Five studies reported interventions targeting health care providers, four focused on patients or their families, one study examined patients and their significant others, and 16 studies examined patients only. Seven quantitative comparisons measured the statistical effects of interventions. A significant difference favoring the treatment group in least pain intensity (95% confidence interval [CI]: 0.44, 1.42) and in usual pain/average pain (95% CI: 0.13, 0.74) was observed. No other statistical differences were observed. However, most studies were assessed as having high risk of bias and failed to report sufficient information about the intervention dose, quality of educational material, fidelity, and other key factors required to evaluate effectiveness of intervention design.ConclusionTrials that used a higher dose of KT intervention (characterized by extensive follow-up, comprehensive educational program, and higher resource allocation) were significantly more likely to have positive results than trials that did not use this approach. Further attention to methodological issues to improve educational interventions and research to clarify factors that lead to better pain control are urgently needed.     

New ways to reduce unnecessary variation and improve outcomes in the intensive care unit

The care of critically ill patients and the advent of the modern day intensive care unit (ICU) present a large person power and cost burden to society. The high cost of critical care is attributed to high overhead expenses (eg, experienced staff and equipment), high resource utilization (eg, pharmaceutical resources, lab testing, imaging procedures), and high demand for services. Pathways to standardize numerous facets of patient care have been shown to improve the efficiency of delivery of care and to reduce resource utilization, and are becoming the most sought-after means of improving patient outcomes and reducing overall ICU expenditures. A number of large, randomized, prospective trials have demonstrated that protocol-based strategies can not only reduce variation and cost of ICU medicine but also improve morbidity and mortality of critically ill patients requiring ICU support. In this article, we discuss examples of these trials investigating four major areas of modern ICU medicine: ventilator management, ventilator weaning, sedation and analgesia, and blood transfusions.     

Systematic review of interventions to improve appropriate use and outcomes associated with do-not-attempt-cardiopulmonary-resuscitation decisions

Background

The treatment for a cardiac arrest, cardiopulmonary resuscitation (CPR), may be lifesaving following an acute, potentially reversible illness. Yet this treatment is unlikely to be effective if cardiac arrest occurs as part of the dying process towards the end of a person's natural life. Do not attempt CPR (DNACPR) decisions allow resuscitation to be withheld when it has little chance of success, or where the patient, or those close to the patient, indicate the burdens of CPR outweigh the benefits. This review sought to identify evidence for systems that improve the appropriate use of DNACPR decisions.

Methods

Electronic databases were searched (Medline, CINAHL and Embase) for English language articles from 2001 to 2014.

Results

4090 citations were identified of which 37 studies were relevant. The overall quality of evidence was moderate to poor. Thematic synthesis identified key interventions which may improve DNACPR decision making. The most promising interventions involved structured discussion at the time of acute admission to hospital and review by specialist teams at the point of an acute deterioration. Linking DNACPR decisions to discussions about overall treatment plans provided greater clarity about goals of care, aided communication between clinicians and reduced harms. Standardised documentation proved helpful for improving the frequency and quality of recording DNACPR decisions. Patient and clinician education in isolation were associated with limited or no effects.

Conclusion

Relatively simple process changes may enhance the appropriate use of and outcomes associated with DNACPR decisions.Systematic review registration number: PROSPERO2012:CRD42012002669.     

Readiness to change and brief educational interventions: successful strategies to reduce stroke risk.

Despite recent advances in stroke treatment and prevention, identifying effective educational interventions for "at-risk" groups that will help reduce their stroke risk and improve the speed of seeking treatment remains of paramount importance. The purpose of this pilot study was to determine whether a brief educational intervention, tailored to the patient's stage of readiness to change, could affect the initiation and achievement of stroke risk-reducing behaviors for this at-risk population. The study also explored potential demographic and medical confounders that could influence behavioral and knowledge goal achievement. Three groups of 20 participants, each with multiple risk factors for stroke, from a family practice clinic were randomly assigned to a control, simple-advice, or brief intervention group. The majority of the participants were African American with a mean age of 68 years. Selected findings showed (a) significant differences in the number of newly initiated stroke-risk-reduction behaviors and stroke knowledge among the three groups and (b) significant positive correlations between the action stage of readiness to change and the initiation and achievement of the new stroke-risk-reduction behaviors. Although results supported the usefulness of the brief intervention model to reduce modifiable stroke-risk factors and increase stroke knowledge, the necessity of additional longitudinal research that refines the targeting of interventions for diverse racial, cultural, and age groups was acknowledged.     

Targeting autophagy during cancer therapy to improve clinical outcomes

Autophagy is a catabolic process that turns over long-lived proteins and organelles and contributes to cell and organism survival in times of stress. Current cancer therapies including chemotherapy and radiation are known to induce autophagy within tumor cells. This is therefore an attractive process to target during cancer therapy as there are safe, clinically available drugs known to both inhibit and stimulate autophagy. However, there are conflicting positive and negative effects of autophagy and no current consensus on how to manipulate autophagy to improve clinical outcomes. Careful and rigorous evaluation of autophagy with a focus on how to translate laboratory findings into relevant clinical therapies remains an important aspect of improving clinical outcomes in patients with malignant disease.     

Evidence for interventions to improve psychological outcomes in people with head and neck cancer: a systematic review of the literature

Purpose  

In addition to cancer-related distress, people with head and neck cancer (HNC) endure facial disfigurement and difficulties with eating and communication. High rates of alcohol use and socio-economic disadvantage raise concerns that patients with HNC may be less likely than others to participate in and adhere to psychological interventions. This article aims to inform future practice and research by reviewing the evidence in support of psychological interventions for this patient group.     

"Low-tech" personal emergency response systems reduce costs and improve outcomes

A relatively inexpensive low-technology solution can be used by managed care organizations (MCOs) to improve outcomes and significantly reduce health care costs among community-residing elderly patients. Clinical studies indicate that usage of monitored Personal Emergency Response Systems (PERS) reduce mortality rates by nearly four times, reduce hospital utilization by 59 percent, and yield a positive benefit-to-cost ratio of over seven to one (every dollar spent on PERS results in $7.19 in health care cost savings).     

Research and interventions to reduce domestic violence revictimization

Despite decades of research on domestic violence, considerable challenges must be addressed to develop sound, theoretically and empirically based interventions for reducing domestic violence revictimization. Many basic and applied research issues remain unaddressed by existing studies, and evaluations frequently do not sufficiently highlight their limitations or program or policy implications. Nonetheless, progress has been made, and practitioners and policy makers increasingly have a wide range of promising interventions from which to select. This article reviews research on domestic violence and focuses particular attention on interventions aimed at reducing revictimization among individuals known to have been abused. It also provides a conceptual framework for practitioners and policy makers to situate existing evaluation research and highlights the need for better data to understand and assess efforts to reduce domestic violence revictimization. The author concludes by discussing directions for future research and recommendations for practice and policy.