Promotion of health in older people: a randomised controlled trial of health risk appraisal in British general practice. Nurse-led health promotion interventions improve quality of life in frail older home care clients: lessons learned from three randomized trials in Ontario, Canada. Feasibility of a men’s health promotion programme in Irish primary care Process Evaluation of an Integrated Health Promotion/Occupational Health Model in WellWorks-2 Promoting independence, health and well-being for older people: a feasibility study of computer-aided health and social risk appraisal system in primary care Effectiveness and cost-effectiveness of a multidisciplinary intervention programme to prevent new falls and functional decline among elderly persons at risk: design of a replicated randomised controlled trial [ISRCTN64716113] Challenges with cost-utility analyses of behavioural interventions among older adults at risk for dementia The ability of health promoters to deliver group diabetes education in South African primary care Health promotion for frail older home care clients. Health promotion for the oldest of old people. Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT. [Evaluation of the state intervention project to improve quality of life and reduce the complications associated with aging: "Add health to your years"]. Effects of a health promotion program on sustaining health behaviors in older adults. Improving the health behaviours of elderly people: randomised controlled trial of a general practice education programme Evaluation of a health promotion demonstration program for the rural elderly. A Web-Based Health Promotion Program for Older Workers: Randomized Controlled Trial Assessing Care of Vulnerable Elders: ACOVE Project Overview
BACKGROUND there is inadequate evidence to support currently formulated NHS strategies to achieve health promotion and preventative care in older people through broad-based screening and assessment in primary care . The most extensively evaluated delivery instrument for this purpose is Health Risk Appraisal ( HRA ) . This article describes a trial using HRA to evaluate the effect on health behaviour and preventative-care uptake in older people in NHS primary care . METHODS a r and omised controlled trial was undertaken in three London primary care group practice s. Functionally independent community-dwelling patients older than 65 years ( n = 2,503 ) received a self-administered Health Risk Appraisal for Older Persons ( HRA-O ) question naire leading to computer-generated individualised written feedback to participants and general practitioners ( GPs ) , integrated into practice information-technology ( IT ) systems . All primary care staff received training in preventative health in older people . The main outcome measures were self-reported health behaviour and preventative care uptake at 1-year follow-up . RESULTS of 2,503 individuals r and omised , 2,006 respondents ( 80.1 % ) ( intervention , n = 940 , control n = 1,066 ) were available for analysis . Intervention group respondents reported slightly higher pneumococcal vaccination uptake and equivocal improvement in physical activity levels compared with controls . No significant differences were observed for any other categories of health behaviour or preventative care measures at 1-year follow-up . CONCLUSIONS HRA-O implemented in this way result ed in minimal improvement of health behaviour or uptake of preventative care measures in older people . Supplementary reinforcement involving contact by health professionals with patients over and above routine clinical encounters may be a prerequisite to the effectiveness of IT-based delivery systems for health promotion in older people OBJECTIVE This paper explores the lessons learned from a series of three r and omized controlled trials that included 498 community-living frail older adults ( ≥65 years ) using home care services in Southern Ontario , Canada . Each study was design ed to evaluate the effectiveness of different multi-component nurse-led health promotion and disease prevention ( HPDP ) interventions . METHODS The nurse-led HPDP interventions were 6- or 12-month multi-component and evidence -based strategies targeting known risk factors for functional decline and frailty . Across the three studies , a common approach was used to measure the change in health-related quality of life ( HRQOL ) ( SF-36 ) and the costs of use of health services ( Health and Social Services Utilization Inventory ) from baseline to the end of the intervention . RESULTS The main lesson learned from the three studies is that nurse-led HPDP interventions for frail older home care clients provide greater improvements in HRQOL compared with usual home care . Such approaches are highly acceptable to this population and can be implemented using existing home care re sources . Nurse-led HPDP interventions should include multiple home visits , multidimensional screening and assessment , multi-component evidence -based HPDP strategies , intensive case management , inter-professional collaboration , providers with geriatric training and experience , referral to and coordination of community services , and theory use . CONCLUSION The results of the three trials underscore the need to reinvest in nurse-led HPDP interventions in home care to optimize HRQOL and promote ageing in place in the target population of frail older adults . More studies are needed to evaluate the effectiveness of additional nurse-led HPDP interventions in other context s and setting Background To assess the feasibility of offering health promotion and preventive medicine initiatives in primary care . Aims A pilot study aim ed at men in general practice to establish the uptake , acceptability and effectiveness of interventions in health initiatives . Methods One thous and men aged 18–65 were selected at r and om from five general practice s in the Western Health Board area . Practice s were r and omly allocated to one of four brief interventions : cardiovascular screening , cancer screening , stress management or general lifestyle advice . Results Fifty-five per cent of men responded , with 35.7 % actually attending . There were minor but significant short-term changes in health status and behaviours . Participants expressed high levels of satisfaction , but tended to prefer interventions with an explicit clinical component . Conclusion It is at least as feasible to offer health promotion for men in primary care as it is for other demographic groups , but adequate training and re sources are required Disparities in chronic disease risk by occupation call for newapproaches to health promotion . Well Works-2 was a r and omized , controlled study comparing the effectiveness of a health promotion/occupational health program ( HP/OHS ) with a st and ard intervention ( HP ) . Interventions in both studies were based on the same theoretical foundations . Results from process evaluation revealed that a similar number of activities were offered in both conditions and that in the HP/OHS condition there were higher levels of worker participation using three measures : mean participation per activity ( HP : 14.2 % vs. HP/OHS : 21.2 % ) , mean minutes of worker exposure to the intervention/site ( HP : 14.9 vs. HP/OHS : 33.3 ) , and overall mean participation per site ( HP : 34.4 % vs. HP/ OHS : 45.8 % ) . There were a greater number of contacts with management ( HP : 8.8 vs. HP/OHS : 24.9 ) in the HP/ OHS condition . Addressing occupational health may have contributed to higher levels of worker and management participation and smoking cessation among blue-collar workers Background With population ageing , research is needed into new low-cost , scalable methods of effective promotion of health and wellbeing for older people . We aim ed to assess feasibility , reach and costs of implementing a new tailored computer-aided health and social risk appraisal system in primary care . Methods Design : Feasibility study . Setting : Five General Practice s in London ( Ealing ) and Hertfordshire , United Kingdom ( UK ) Participants : R and om sample of patients aged 65 + years . Intervention : The Multi-dimensional Risk Appraisal for Older people ( MRA-O ) system includes : 1 ) Postal question naire including health , lifestyle , social and environmental domains ; 2 ) Software system generating a personalised feedback report with advice on health and wellbeing ; 3 ) Follow-up of people with new concerning or complex needs by GPs or practice nurses . Evaluation : Feasibility of implementation ; participant wellbeing , functional ability and quality of life ; social needs , health risks , potential lifestyle changes ; and costs of implementation . Results Response rates to initial postal invitations were low ( 526/1550 , 34 % ) . Of these , 454/526 ( 86 % ) completed MRA-O assessment s. Compared to local UK Census data on older people , participants were younger , more were owner-occupiers and fewer were from ethnic minority groups than expected . A range of problems was identified by participants , including pain in last week ( 269/438 , 61.4 % ) , low physical activity ( 173/453 , 38.2 % ) , sedentary lifestyle ( 174/447 , 38.3 % ) , falls ( 117/439 , 26.7 % ) , incontinence ( 111/441 25.2 % ) , impaired vision 116/451 ( 25.7 % ) , impaired hearing ( 145/431 , 33.6 % ) , depressed mood ( 71/451 , 15.7 % ) , impaired memory ( 44/444 9.9 % ) , social isolation ( 46/449 , 10.2 % ) and loneliness ( 31/442 , 7.0 % ) . Self-rated health was good/excellent in 312/437 ( 71.4 % ) , and quality of life and well-being were slightly above age-specific population norms . Implementation costs were low . Practice s review ed medical records of 143/454 ( 31.5 % ) of participants as a consequence of their responses , and actively followed up 110/454 ( 24.2 % ) of their patients . Conclusions A computer-aided risk appraisal system was feasible for General Practice s to implement , yields useful information about health and social problems , and identifies individual needs . Participation rates were however low , particularly for the oldest old , the poorest , and ethnic minority groups , and this type of intervention may increase inequalities in access . Widespread implementation of this approach would require work to address potential inequalities Background Falls are common among community-dwelling elderly people and can have a considerable impact on quality of life and healthcare costs .  People who have sustained a fall are at greater risk of falling again . We replicated a British r and omised controlled trial which demonstrated the effectiveness of a multidisciplinary intervention programme to prevent falls . The objective is to describe the design of a replication study evaluating a multidisciplinary intervention programme on recurrent falls and functional decline among elderly persons at risk . The study consists of an effect evaluation , an economic evaluation and a process evaluation . Methods / design The programme is aim ed at community-dwelling elderly people aged 65 years or over who have visited an accident and emergency department ( A&E department ) or a general practitioners ' cooperative ( GP cooperative ) because of a fall . The design involves a two-group r and omised controlled trial . Participants are followed for twelve months after baseline . The intervention programme consists of a detailed medical and occupational therapy assessment with referral to relevant services if indicated . People in the  control  group receive usual care . The main outcome measures of the effect evaluation are number of falls and daily functioning . The economic evaluation will be performed from a societal perspective . A process evaluation will be carried out to evaluate the feasibility of the intervention programme Background Cognitive decline is one of the most prominent healthcare issues of the 21st century . Within the context of combating cognitive decline through behavioural interventions , physical activity is a promising approach . There is a dearth of health economic data in the area of behavioural interventions for dementia prevention . Yet , economic evaluations are essential for providing information to policy makers for re source allocation . It is essential we first address population and intervention-specific method ological challenges prior to building a larger evidence base . We use a cost-utility analysis conducted alongside the exercise for cognition and everyday living ( EXCEL ) study to illustrate method ological challenges specific to assessing the cost-effectiveness of behavioural interventions aim ed at older adults at risk of cognitive decline . Methods A cost-utility analysis conducted concurrently with a 6-month , three-arm r and omised controlled trial ( ie , the EXCEL study ) was used as an example to identify and discuss method ological challenges . Results Both the aerobic training and resistance training interventions were less costly than twice weekly balance and tone classes . In critically evaluating the economic evaluation of the EXCEL study we identified four category-specific challenges : ( 1 ) analysing costs ; ( 2 ) assessing quality -adjusted life-years ; ( 3 ) Incomplete data ; and ( 4 ) ‘ Intervention ’ activities of the control group . Conclusions Resistance training and aerobic training result ed in healthcare cost saving and were equally effective to balance and tone classes after only 6 months of intervention . To ensure this population is treated fairly in terms of cl aims on re sources , we first need to identify areas for method ological improvement Abstract Background Diabetes makes a significant contribution to the burden of disease in South Africa . This study assesses a group diabetes education programme using motivational interviewing in public sector health centres serving low socio-economic communities in Cape Town . The programme was delivered by mid-level health promotion officers ( HPOs ) . Objectives The aim of the study was to explore the experience of the HPOs and to observe their fidelity to the educational programme . Methods Three focus group interviews were held with the 14 HPOs who delivered the educational programme in 17 health centres . Thirty-three sessions were observed directly and the audio tapes were analysed using the motivational interviewing ( MI ) integrity code . Results The HPOs felt confident in their ability to deliver group education after receiving the training . They reported a significant shift in their communication style and skills . They felt the new approach was feasible and better than before . The re source material was found to be relevant , underst and able and useful . The HPOs struggled with poor patient attendance and a lack of suitable space at the facilities . They delivered the majority of the content and achieved beginning-level proficiency in the MI guiding style of communication and the use of open questions . The HPOs did not demonstrate proficiency in active listening and continued to offer some unsolicited advice . Conclusion The HPOs demonstrated their potential to deliver group diabetes education despite issues that should be addressed in future training and the district health services . The findings will help with the interpretation of results from a r and omised controlled trial evaluating the effectiveness of the education AIM This paper reports a study evaluating the comparative effects and costs of a proactive nursing health promotion intervention in addition to usual home care for older people compared with usual home care services alone . BACKGROUND An ageing population , budget constraints and technological advances in many countries have increased the pressure on home care re sources . The result is a shift in nursing services from health promotion to meet the more pressing need for postacute care . For frail older people with long-term needs , these changes combine to create a fragmented system of health service delivery , characterized by providing nursing on dem and rather than proactively . METHODS A two-armed , single-blind , r and omized controlled trial was carried out with older people > or = 75 years and eligible for personal support services through a home care programme in Ontario , Canada . Participants were r and omly allocated either to usual home care ( control ) or to a nursing ( experimental ) group . In addition to usual home care , the nursing group received a health assessment combined with regular home visits or telephone contacts , health education about management of illness , coordination of community services , and use of empowerment strategies to enhance independence . The data were collected in 2001 - 2002 . RESULTS Of the 288 older people who were r and omly allocated at baseline , 242 ( 84 % ) completed the study ( 120 nursing group ; 122  control group ) . Proactively providing older people with nursing health promotion , compared with providing nursing services on-dem and , result ed in better mental health functioning ( P = 0.009 ) , a reduction in depression ( P = 0.009 ) , and enhanced perceptions of social support ( P = 0.009 ) at no additional cost from a societal perspective . CONCLUSIONS Home based nursing health promotion , proactively provided to frail older people with chronic health needs , enhances quality of life while not increasing the overall costs of health care . The results underscore the need to re-invest in nursing services for health promotion for older clients receiving home care AIM The aim of this study was to explore the factors that contribute to health promotion in the oldest old and the barriers that prevent it . METHOD A non-r and om sample ( n = 52 ) of people aged 80 and older participated in a descriptive correlational study . Respondents completed a series of two Likert-type question naires . The  Health Promoting Lifestyle Profile II  ( Walker et al 1995 ) and  Barriers to Health Promoting Activities  for Disabled Persons Scale ( Becker et al 1991 ) were used to measure health behaviours . RESULTS Differences were noted between the age groups ( 80 - 90 and 91 - 101 ) for health responsibility , physical activity and nutrition . Impairment was the major barrier to health promotion . CONCLUSION To foster optimal living , the health , illness , function and motivation as well as age of older adults must be considered . They should be encouraged to pursue physical , social and intellectual activity , which can enable them to have active and fulfilling lives BACKGROUND Mild frailty or pre-frailty is common and yet is potentially reversible . Preventing progression to worsening frailty may benefit individuals and lower health/social care costs . However , we know little about effective approaches to preventing frailty progression . OBJECTIVES ( 1 ) To develop an evidence - and theory-based home-based health promotion intervention for older people with mild frailty . ( 2 ) To assess feasibility , costs and acceptability of ( i ) the intervention and ( ii ) a full-scale clinical effectiveness and cost-effectiveness r and omised controlled trial ( RCT ) . DESIGN Evidence review s , qualitative studies , intervention development and a feasibility RCT with process evaluation . INTERVENTION DEVELOPMENT Two systematic review s ( including systematic search es of 14 data bases and registries , 1990 - 2016 and 1980 - 2014 ) , a state-of-the-art review ( from inception to 2015 ) and policy review identified effective components for our intervention . We collected data on health priorities and potential intervention components from semistructured interviews and focus groups with older people ( aged 65 - 94 years ) ( n = 44 ) , carers ( n = 12 ) and health/social care professionals ( n = 27 ) . These data , and our evidence review s , fed into development of the ' HomeHealth ' intervention in collaboration with older people and multidisciplinary stakeholders . ' HomeHealth ' comprised 3 - 6 sessions with a support worker trained in behaviour change techniques , communication skills , exercise , nutrition and mood . Participants addressed self-directed independence and well-being goals , supported through education , skills training , enabling individuals to overcome barriers , providing feedback , maximising motivation and promoting habit formation . FEASIBILITY RCT Single-blind RCT , individually r and omised to ' HomeHealth ' or treatment as usual ( TAU ) . SETTING Community setting s in London and Hertfordshire , UK . PARTICIPANTS A total of 51 community-dwelling adults aged ≥ 65 years with mild frailty . MAIN OUTCOME MEASURES Feasibility - recruitment , retention , acceptability and intervention costs . Clinical and health economic outcome data at 6 months included functioning , frailty status , well-being , psychological distress , quality of life , capability and NHS and societal service utilisation/costs . RESULTS We successfully recruited to target , with good 6-month retention ( 94 % ) . Trial procedures were acceptable with minimal missing data . Individual r and omisation was feasible . The intervention was acceptable , with good fidelity and modest delivery costs ( £ 307 per patient ) . A total of 96 % of participants identified at least one goal , which were mostly exercise related ( 73 % ) . We found significantly better functioning ( Barthel Index + 1.68 ; p = 0.004 ) , better grip strength ( + 6.48 kg ; p = 0.02 ) , reduced psychological distress ( 12-item General Health Question naire -3.92 ; p = 0.01 ) and increased capability-adjusted life-years [ + 0.017 ; 95 % confidence interval ( CI ) 0.001 to 0.031 ] at 6 months in the intervention arm than the TAU arm , with no differences in other outcomes . NHS and carer support costs were variable but , overall , were lower in the intervention arm than the TAU arm . The main limitation was difficulty maintaining outcome assessor blinding . CONCLUSIONS Evidence is lacking to inform frailty prevention service design , with no large-scale trials of multidomain interventions . From stakeholder/public perspectives , new frailty prevention services should be personalised and encompass multiple domains , particularly socialising and mobility , and can be delivered by trained non-specialists . Our multicomponent health promotion intervention was acceptable and delivered at modest cost . Our small study shows promise for improving clinical outcomes , including functioning and independence . A full-scale individually RCT is feasible . FUTURE WORK A large , definitive RCT of the HomeHealth service is warranted . STUDY REGISTRATION This study is registered as PROSPERO CRD42014010370 and Current Controlled Trials IS RCT N11986672 . FUNDING This project was funded by the National Institute for Health Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 21 , No. 73 . See the NIHR Journals Library website for further project information OBJECTIVE This paper evaluates the effectiveness of a Public Health program for the elderly based on health promotion and pathologies prevention , in order to avoid complications associated with illnesses and improves the quality of life ( QOL ) in elderly adults ( EA ) . METHODS A 12 month intervention studies used 700 EA r and omized in 2 groups : intervention and control . Each group was su bmi tted to pre-post intervention measurements that included weight , height , blood pressure ( BP ) , cholesterol , lipids , glycaemia , cardiovascular ( infa rct , stroke ) and bone fractures events , hospitalization , and a QOL survey . Intervention consisted of periodic physical activity to fortify muscular groups , as well as recreational activities , nutritional and food manipulation training visits . A medical student was assigned to each participant from the intervention group to assure periodical contact and to share activities . The control group continued with their normal activities during observational period . RESULTS The intervention group showed a significant reduction in the BP , lipids and cholesterol values compared to control group . Reduction on cardiovascular events ( -31 % ) , hip fractures ( -18.2 % ) and number of hospital admittance ( -21.1 % ) were obtained for group A in relation to B. The QOL survey showed 28.7 % improvement for group A compared with 33.4 % improvement compared with control group . CONCLUSION The health program with exhaustive follow-up administration , significantly reduced risk factors and complications associated with aging BACKGROUND Controversy exists regarding the optimal way to provide health promotion education to the elderly . This prospect i ve r and omized study evaluated the effectiveness of individualized assessment and counseling coupled with the receipt of a written health plan on client adherence to health behavior recommendations . METHODS Two hundred thirty-seven ethnically diverse and predominantly low-income adults 60 and older , participating for the first time in an established statewide public health prevention program delivered in both rural and urban clinics , were recruited and r and omly assigned to treatment and control groups . All participants received a st and ardized assessment that included a health history , nutrition assessment , and limited physical exam from a public health nurse . The treatment group additionally received a written personal health plan and individualized counseling to support implementation of the plan . Both groups were interviewed after one year to determine their adherence to the original recommendations . RESULTS Seventeen preventive services and health behaviors were evaluated . There were no statistically significant differences between the groups on health care use and previous health behaviors at baseline . Using logistic regression and controlling for socioeconomic and demographic variables , we found that the treatment group that received a personal health plan and counseling completed significantly more preventive referrals and health behavior changes ( P < .001 ) . CONCLUSIONS A client-centered planning process with supportive counseling by public health nurses , combined with health plans provided to clients , can significantly increase the prevention measures taken by older adults Abstract Objectives : To establish the effect of an educational intervention for general practitioners on the health behaviours and wellbeing of elderly patients . Design : R and omised controlled trial with 1 year follow up . Setting : Metropolitan general practice s in Melbourne , Australia . Subjects : 42 general practitioners and 267 of their patients aged over 65 years . Intervention : Educational and clinical practice audit programme for general practitioners on health promotion for elderly people . Main outcome measures : Patients ' physical activity , functional status , self rated health , immunisation status , social contacts , psychological wellbeing , drug usage , and rate of influenza vaccination .  Primary efficacy variables were changes in outcome measures over 1 year period . Results : Patients in the intervention group had increased ( a ) walking by an average of 88 minutes per fortnight , ( b ) frequency of pleasurable activities , and ( c ) self rated health compared with the control group . No change was seen in drug usage , rate of influenza vaccination , functional status , or psychological wellbeing as a result of the intervention . Extrapolations of the known effect of these changes in behaviour suggest mortality could be reduced by 22 % if activity was sustained for 5 years . Conclusions : Education of the general practitioners had a positive effect on health outcomes of their elderly patients . General practitioners may have considerable public health impact in promotion of health for elderly patients . Key messages Few educational interventions for doctors have shown benefit to the health of patients Elderly people were identified in the UK health initiatives as in need of additional attention , and levels of health protective behaviours were low in community surveys A multifaceted educational intervention for general practitioners was effective in improving walking behaviour , self rated health status , and the frequency of social contacts in elderly patients General practitioners are effective in improving health and health behaviours in their elderly OBJECTIVE This article evaluates a demonstration program that extended coverage for disease prevention/health promotion services to Medicare beneficiaries . STUDY SETTING / DATA SOURCES Community-dwelling Medicare beneficiaries who lived in five rural counties in northwest Pennsylvania were recruited between May and December 1989 . The demonstration lasted 18 months and beneficiaries were followed for an additional 18 months . Data for the evaluation came from an initial health risk assessment , Medicare administrative records , follow-up surveys , and redeemed vouchers for the waivered services . The waivered services included health screenings , influenza immunization , nutritional counseling , smoking and alcohol cessation , and depression/dementia evaluations . STUDY DESIGN Medicare beneficiaries were r and omized to one of two experimental groups and a control group . One experimental group received the newly waived services from hospitals that received a capitated fee ; the other received services from providers who were paid fee-for-service . Eligibility for most waivered services was based on risk . Chi-square tests of association were used to determine if use of health promotion services and use of medical care services varied across groups . Logistic regressions were used to assess the factors associated with participation . Product-limit survival analysis was used to assess whether mortality rates varied across groups . PRINCIPAL FINDINGS Participation rates in the new programs varied by program and by experimental group , and ranged from 16.8 percent for smoking cessation programs to 58 percent for influenza immunization . The demonstration led to an increase in influenza immunization rates relative to the control group . There were no differences in the use of medical care services or health outcomes between the experimental and control groups . CONCLUSIONS Older rural Americans will modestly increase their use of disease prevention/ health promotion services if they are covered by Medicare . Use will be higher among those with more education . Further research is needed to assess long-term benefits of such programs Background Recent evidence supports the efficacy of programs that promote improvements in the health practice s of workers 50 years and older who are at higher risk for chronic diseases than younger workers are .  Internet-based programs that promote healthy practice s have also shown promise and , therefore , should be especially appropriate for workers aged 50 years and older . Objective The purpose of the research was to evaluate the effectiveness of  HealthyPast50 , a fully automated Web-based health promotion program based on social cognitive theory and aim ed specifically at workers 50 years and older . Methods The r and omized controlled trial was conducted across multiple US offices of a large global information technology company . The sample included 278 employees aged 50 to 68 who were recruited online and r and omly assigned to the  Web-based HealthyPast50 program or to a  wait-list control condition .  Self-report measures of diet , physical activity , stress , and tobacco use were collected online before and 3 months after the program group was given access to the program . Use data included number of log-ins and number of pages accessed . The primary analysis was multiple linear regression , following intent-to-treat principles with multiple imputation using the Markov chain Monte Carlo ( MCMC ) approach for nonmonotone missing data . Potential moderators from demographic characteristics and program dosage effects were assessed using multiple linear regression models . Additional analyses were conducted on complete ( nonimputed ) cases , excluding program participants who used the program for less than 30 minutes . Results Retention rates were good for both groups : 80.4 % ( 111/138 ) for the program group and 94.3 % ( 132/140 ) for the control group . Program group participants spent a mean of 102.26 minutes in the program ( SD 148.32 ) , logged in a mean of 4.33 times ( SD 4.28 ) , and viewed a mean of 11.04 pages ( SD 20.08 ) . In the analysis of the imputed data set , the program group performed significantly better than the control group on diet behavioral change self-efficacy ( estimated adjusted difference [Δ]=0.16 , P=.048 ) , planning healthy eating ( Δ=0.17 , P=.03 ) , and mild exercise ( Δ=1.03 , P=.01 ) . Moderator and dosage analyses of the data set found no significant program effects . Analyses of the nonimputed data set comparing program users with controls found additional significant program effects on eating practice s ( Δ=0.09 , P=.03 ) , exercise self-efficacy ( Δ=0.12 , P=.03 ) , exercise planning ( Δ=0.18 , P=.03 ) , and aging beliefs ( Δ=0.17 , P=.01 ) . Moderator analysis of this data set also found significant moderator effects of gender on multiple measures of exercise . Conclusions A Web-based health promotion program showed promise for making a significant contribution to the short-term dietary and exercise practice s of older working adults . Gender effects suggest that the program effects on exercise are due mainly to improvements among women Civilization and modern medicine now allow an unprecedented number of people to survive to old age . Not only has the definition of old evolved , but the aims of medical care for the elderly have progressed far beyond survival to maximizing functional and cognitive status , improving quality of life , and preserving productivity . Although many health problems in older age can be prevented or postponed by medical interventions , the quality of medical care for older persons remains largely unexamined . Previous work on quality -of-care measurement has focused on specific diseases or aspects of care , and in some cases targeted only a slice of the older population ( 16 ) . Such targeted approaches may not present a fair picture of overall quality and may lead to unintended incentives ( gaming the system ) ( 7 ) . Although broad systems of quality -of-care evaluation are less susceptible to gaming , they seldom include quality indicators focused on aspects of care important to older sick persons ( 8 , 9 ) . Substantial variation in preferences may make quality of care for older adults particularly difficult to measure . For example , older adults do not consistently prefer care that prolongs life , particularly if this care occurs at the expense of comfort . Furthermore , many ill , older adults can not advocate for themselves and may have no family members or friends to do so on their behalf . Thus , objective measures of the care they receive are particularly important . The Assessing Care of Vulnerable Elders ( ACOVE ) project endeavored to develop a comprehensive set of  quality - assessment tools for ill older persons . Because ill older persons constitute a heterogeneous cohort that is not easily delineated , we created a system to identify high-risk , community-dwelling individuals and targeted the most important clinical conditions affecting them . Specifically , our goals for this project were the following : 1 . Develop a definition of vulnerable elders that delineates a group of community-living persons 65 years of age and older who are at high risk for death or functional decline , and develop a system to identify them . 2 . Identify important medical conditions that affect vulnerable elders and for which effective methods of prevention or management exist . 3 . Develop a set of evidence -based , quality -of-care indicators that are relevant to vulnerable elders using systematic literature review s , expert opinion , and the guidance of expert groups and stakeholders . 4 . Design a chart abstract ion tool , interview instrument , and administrative data analytic methods to implement the quality -of-care indicator system . Project Structure : Advisory Boards To make the ACOVE tools as clinical ly useful as possible and to enhance their value to those who may use them , two advisory committees oversaw the project . The Clinical Committee directed the definition of the target population and identified the target conditions . It also review ed the full set of quality indicators assembled by the expert panels ( see the Methods paper ) . The Policy Advisory Committee directed the structure of the quality indicator system and the measurement approach . This committee review ed the sampling system , considered the value of a community surveybased sample versus a sample drawn from administrative data , advised the project on methods of data collection , and advocated the use of process measures rather than outcomes .Project Overview The Appendix lists the members and institutional affiliations of the Clinical Committee and the Policy Advisory Committee and ACOVE investigators and staff . Definition and Selection of the Patient Sample We termed our target sample vulnerable elders . With the assistance of the Clinical Committee , we defined vulnerable elders as persons 65 years of age and older who are at increased risk for death or functional decline . We considered several methods of identifying a community-based sample for measurement , including use of administrative data and survey sampling . The Policy Advisory Committee advised against using a sampling method based solely on administrative data because , by definition , using utilization data to define health status and disease burden disproportionately sample s persons with higher utilization of health services and may not identify persons who are undertreated or underdiagnosed . We selected a survey method that would identify vulnerable elders regardless of the amount of health care they used and that would be versatile for use across venues and health insurance systems . Using the Medicare Current Beneficiary Survey , we determined that functional status is a more important predictor of death and functional decline than are specific clinical conditions . A parsimonious set of factors that could be asked about in a brief interview , including age , self-rated health , and functional disabilities and limitations , predicted functional decline and death . Using these factors , we developed a scoring system that identified 32 % of a nationally representative sample as vulnerable : This group had more than four times the risk for death or functional decline over a 2-year period compared to the lower-scoring majority of the sample ( 10 ) . When we applied this definition to a r and om sample of persons 65 years of age and older enrolled in managed care plans , 21 % of elders were classified as vulnerable . Target Conditions for Assessing Quality of Care We selected the target conditions for quality -of-care assessment using literature review s and a formal group-judgment process . Target conditions were conceptualized as prevalent , important to health status and quality of life , having outcomes affected by medical care , feasible to measure , and geriatric . The Clinical Committee used these criteria to select 21 diseases , geriatric syndromes , physiologic impairments , and clinical situations ( see the Methods article for a list of these 21 conditions ) . The Policy Advisory Committee added a 22nd condition , continuity and coordination of care . According to national survey estimates , the prevalence of the selected conditions ranged from 10 % to 50 % among community-dwelling elders . These conditions accounted for at least 43 % of acute hospital admissions and 33 % of office visits for persons 65 years of age and older . The process of selecting the conditions is discussed in detail elsewhere ( 11 ) . Developing  Quality -of-Care Indicators  for Vulnerable Elders Clinical experts developed potential quality indicators for each target condition using existing guidelines and clinical opinion . Indicators covered the domains of prevention , diagnosis , treatment , and follow-up . Structured literature review s were then performed to assess the evidence supporting a link between the proposed processes of care and improved outcomes in older adults . We subsequently presented the proposed quality indicators and the literature syntheses to panels of experts in geriatric care and medical specialists . These expert panels considered the indicators ' validity and feasibility . On the basis of the panels ' ratings and a comprehensive review of the set by the Clinical Committee , we developed a set of 236  quality indicators  covering the 22 conditions . The Methods article describes this process in detail . This set of indicators was review ed and modified by the American College of PhysiciansAmerican Society of Internal Medicine ( ACPASIM ) Task Force on Aging . The full set of quality indicators with the literature substantiation for 11 of the conditions constitute the remainder of this supplement . A review of the accepted quality indicators reveals their decidedly geriatric nature . Many of them focus on the transfer of information between the health care provider and the patient or patient 's proxy . In addition to disease management , the indicators pay attention to detecting classically underidentified conditions , such as depression , dementia , and functional impairment . Consideration of proportionate care , informed consent , and end-of-life issues permeates the set . Implementing the Quality Indicators We developed instruments to implement the quality indicators using information collected from three sources : the medical record , a patient ( or , if necessary , proxy ) interview , and administrative data . Medical records include all inpatient and outpatient care over a 1-year period . The interview is design ed to be conducted by telephone with the patient to identify aspects of care that are not well captured in the medical record . The  quality indicators  presented here are currently undergoing feasibility testing in two managed care plans . Scoring the quality indicators accounts for clinical circumstances , patient preferences , and patient prognosis . The scoring of each quality indicator accounts for these factors at the following five levels : 1 . Any chart documentation indicating that a care process does not apply to the patient excludes application of this indicator to the patient . 2 . Any care process that is contraindicated because of comorbidity , allergy , or intolerance ( such as contraindications to medication ) excludes application of the indicator to the patient . 3 . If an indicator states that a care process should be offered to a patient , this indicator is satisfied if the care process occurs , if the medical record ( or patient interview ) indicates that the patient rejected the care process , or if the medical record ( or patient interview ) documents that the care process was offered to the patient . 4 . If the medical record contains documentation or if during an interview a patient states that he or she would not want , under any circumstances , to be hospitalized , then the 11 indicators that would require hospitalization do not apply . Similarly , a preference not to accept surgery would exclude from application to that patient the 9 indicators that prescribe surgery or procedures that would lead to surgery . 5 . If a patient has advanced dementia or a chart-documented poor prognosis ( expected survival < 6 months ) , then
In this area , there are examples of good and moderate quality studies which confirm the cost-effectiveness of diverse physical activity interventions in fall prevention .
Background Healthy ageing and health promotion ( HP ) actions for older people have become an important health sector priority .
At the same time , the application of economic evaluation methods in the field of health interventions in order to support allocative decision processes is of growing importance .
The aims of the review were to analyze what the existing evidence is on cost-effectiveness of HP and /or primary prevention ( PP ) programmes for older people whilst providing deeper insight into method ological aspects of such studies , their overall quality and issues related to practical implementation of results .