Challenges with cost-utility analyses of behavioural interventions among older adults at risk for dementia Health promotion for frail older home care clients. Promotion of health in older people: a randomised controlled trial of health risk appraisal in British general practice. Health promotion for the oldest of old people. Promoting independence, health and well-being for older people: a feasibility study of computer-aided health and social risk appraisal system in primary care Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT. Feasibility of a men’s health promotion programme in Irish primary care Population-based multidimensional assessment of older people in UK general practice: a cluster-randomised factorial trial Assessing Care of Vulnerable Elders: ACOVE Project Overview Derivation and Pilot Assessment of a Health Promotion Program for Mandarin-Speaking Chinese Older Adults Evaluation of a health promotion demonstration program for the rural elderly. An interprofessional nurse-led mental health promotion intervention for older home care clients with depressive symptoms Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in general practice for older people. A cluster randomised controlled trial: Integrated Systematic Care for older People—the ISCOPE study Health-promoting interventions for persons aged 80 and older are successful in the short term--results from the randomized and three-armed Elderly Persons in the Risk Zone study. Effects of a health promotion program on sustaining health behaviors in older adults. A Cost Analysis of Self-Management Programs for People with Chronic Illness Methods for analysing recurrent events in health care data. Examples from admissions in Ebeltoft Health Promotion Project.
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 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 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 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 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 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 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 BACKGROUND The benefit of multidimensional assessment and management of older people remains controversial . Most trials have been too small to produce adequate evidence to inform policy . We aim ed to measure the effects of different approaches to assessment and management of older people . METHODS We undertook a cluster-r and omised factorial trial in 106 general practice s ( 43219 eligible patients aged 75 years and older , 78 % participation ) , comparing ( 1 ) universal versus targeted assessment and ( 2 ) subsequent management by hospital outpatient geriatric team versus the primary -care team .  All participants received a brief multidimensional assessment followed by a nurse-led in-depth assessment in the universal group , whereas in the targeted group the in-depth assessment was offered only to those with problems established at the brief assessment . Referrals to the r and omised team ( geriatric management or primary care ) , other medical or social services , health-care workers , or agencies , and emergency referrals to the general practitioner were based on a st and ard protocol at the in-depth assessment . The primary endpoints were mortality , admissions to hospital and institution , and quality of life . Analysis was by intention to treat and per protocol . This trial has been assigned the International St and ardised R and omised Controlled Trial Number IS RCT N23494848 . FINDINGS Mortality and hospital or institutional admissions did not differ between groups . During 3 years ' follow-up , significant improvements in quality of life result ed from universal versus targeted assessment in terms of homecare , and from management by geriatric team versus primary -care team , in terms of mobility , social interaction , and morale . However , only the result for social interaction was consistent with a small but important effect . INTERPRETATION The different forms of multidimensional assessment offered almost no differences in patient outcome 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 As the percentage of older adults of diverse ethnicities increases in the United States , the call for culturally sensitive health care service strategies that target the special needs of older people grows . The present report describes methods used to adapt a health care program so that it would better meet the needs of a group of well , older M and arin-speaking Chinese residents of Los Angeles . The specific qualitative research procedures that we used to adapt the treatment program are described , along with the particular adaptations that emerged . Additionally , outcomes from a r and omized pilot experiment are presented that are consistent with the notion that the adapted program was effective in reducing health-related declines among older M and arin-speaking men and women . The overall outcome of this project is in agreement with other reports in the health care literature that address the importance of providing culturally sensitive health care service for elders 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  Depressive symptoms in older home care clients are common but poorly recognized and treated , result ing in adverse health outcomes , premature institutionalization , and costly use of health services . The objectives of this study were to examine the feasibility and acceptability of a new six-month interprofessional ( IP ) nurse-led mental health promotion intervention , and to explore its effects on reducing depressive symptoms in older home care clients ( ≥ 70 years ) using personal support services . Methods A prospect i ve one-group pre-test/post-test study design was used . The intervention was a six-month evidence -based depression care management strategy led by a registered nurse that used an IP approach . Of 142 eligible consenting participants , 98 ( 69 % ) completed the six-month and 87 ( 61 % ) completed the one-year follow-up . Outcomes included depressive symptoms , anxiety , health-related quality of life ( HRQoL ) , and the costs of use of all types of health services at baseline and six-month and one-year follow-up . An interpretive descriptive design was used to explore clients ’ , nurses ’ , and personal support workers ’ perceptions about the intervention ’s appropriateness , benefits , and barriers and facilitators to implementation . Results Of the 142 participants , 56 % had clinical ly significant depressive symptoms , with 38 % having moderate to severe symptoms . The intervention was feasible and acceptable to older home care clients with depressive symptoms . It was effective in reducing depressive symptoms and improving HRQoL at six-month follow-up , with small additional improvements six months after the intervention . The intervention also reduced anxiety at one year follow-up . Significant reductions were observed in the use of hospitalization , ambulance services , and emergency room visits over the study period . Conclusions Our findings provide initial evidence for the feasibility , acceptability , and sustained effects of the nurse-led mental health promotion intervention in improving client outcomes , reducing use of expensive health services , and improving clinical practice behaviours of home care providers . Future research should evaluate its efficacy using a r and omized clinical trial design , in different setting s , with an adequate sample of older home care recipients with depressive symptoms . Trial registration Clinical trials.gov identifier : NCT01407926 Background : older people often experience complex problems . Because of multiple problems , care for older people in general practice needs to shift from a ‘ problem-based , disease-oriented ’ care aim ing at improvement of outcomes per disease to a ‘ goal -oriented care ’ , aim ing at improvement of functioning and personal quality of life , integrating all healthcare providers . Feasibility and cost-effectiveness of this proactive and integrated way of working are not yet established . Design : cluster r and omised trial . Participants : all persons aged ≥75 in 59 general practice s ( 30 intervention , 29 control ) , with a combination of problems , as identified with a structured postal question naire with 21 questions on four health domains . Intervention : for participants with problems on ≥3 domains , general practitioners ( GPs ) made an integrated care plan using a functional geriatric approach . Control practice s : care as usual . Outcome measures : ( i ) quality of life ( QoL ) , ( ii ) activities of daily living , ( iii ) satisfaction with delivered health care and ( iv ) cost-effectiveness of the intervention at 1-year follow-up . Trial registration : Netherl and s trial register , NTR1946 . Results : of the 11,476 registered eligible older persons , 7,285 ( 63 % ) participated in the screening . One thous and nine hundred and twenty-one ( 26 % ) had problems on ≥3 health domains . For 225 r and omly chosen persons , a care plan was made . No beneficial effects were found on QoL , patients ' functioning or healthcare use/costs . GPs experienced better overview of the care and stability , e.g. less unexpected dem and s , in the care . Conclusions : GPs prefer proactive integrated care . ‘ Horizontal ’ care using care plans for older people with complex problems can be a valuable tool in general practice . However , no direct beneficial effect was found for older persons OBJECTIVES To examine the outcomes of the Elderly Persons in the Risk Zone study , which was design ed to evaluate whether it is possible to delay deterioration if a health-promoting intervention is made when an older adult ( ≥80 ) is at risk of becoming frail and whether a multiprofessional group intervention is more effective in delaying deterioration than a single preventive home visit with regard to frailty , self-rated health , and activities of daily living ( ADLs ) at 3-month follow-up . DESIGN R and omized , three-armed , single-blind , controlled trial performed between November 2007 and May 2011 . SETTING Two urban districts of Gothenburg , Sweden . PARTICIPANTS Four hundred fifty-nine community-living adults aged 80 and older not dependent on the municipal home help service . INTERVENTION A preventive home visit or four weekly multiprofessional senior group meetings with one follow-up home visit .  MEASUREMENTS Change in frailty , self-rated health , and ADLs between baseline and 3-month follow-up . RESULTS Both interventions delayed deterioration of self-rated health ( odds ratio ( OR ) = 1.99 , 95 % confidence interval ( CI ) = 1.12 - 3.54 ) . Senior meetings were the most beneficial intervention for postponing dependence in ADLs ( OR = 1.95 , 95 % CI = 1.14 - 3.33 ) . No effect on frailty could be demonstrated . CONCLUSION Health-promoting interventions made when older adults are at risk of becoming frail can delay deterioration in self-rated health and ADLs in the short term . A multiprofessional group intervention such as the senior meetings described seems to have a greater effect on delaying deterioration in ADLs than a single preventive home visit . Further research is needed to examine the outcome in the long term and in different context 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 The soaring cost of health care is a national problem that needs response at multiple levels , including that of the community . Reducing or limiting health care costs through interventions that emphasize the self-management of health may promote broader health care coverage , better quality of health care , and a sense of control over one 's health . Therefore , it behooves community psychologists to perform cost analyses when testing interventions for people in a community . The present study investigated the effects of social support and education interventions on psychosocial variables , health status , and health care costs in older people with osteoarthritis . Participants were 363 members of a health maintenance organization ( HMO ) , 60 years of age and older , with osteoarthritis . Participants were r and omly assigned to one of three intervention groups ( social support , education , or a combination of both ) or to a control group . The results indicated that feelings of helplessness decreased in the intervention groups but not in the control group . All groups showed increases in self-efficacy and overall health status . In addition , health care costs increased less in the intervention groups than in the control group . Cost analysis was used to demonstrate that the monetary savings of the intervention greatly outweighed the cost of conducting the intervention . It appears that interventions can limit health care costs while improving health and increasing feelings of control for older people with osteoarthritis . Further , this paper demonstrates how a cost-benefit focus can benefit community studies BACKGROUND Evaluation of health care contacts from first events alone often misses large amounts of potentially important data and may produce different results than evaluation of all data including recurrent events . OBJECTIVE We aim to bring the different method ological approaches for analysing longitudinal health care data to the attention of research ers in primary care . METHODS We used  hospital admission data from the Ebeltoft Health Promotion Project , a r and omized trial in primary care examining the effect of preventive health checks .  Comparisons included three r and omized groups : an intervention group receiving health checks , a group where intervention consisted of a health check followed by a health discussion with the GP and one control group .  RESULTS Both intervention groups had approximately 20 % fewer hospital admissions than the control group over a 6 year period . If dependence among recurrent events is excluded , such a reduction amounts to a highly significant effect . Use of the st and ard Poisson distribution for analysing recurrent events and exclusion of their dependent structure causes data interpretation to be incorrect , because the model does not account for the extra variability between persons ; the result ing 95 % CIs would therefore be too small . CONCLUSION Analysis of health care contacts should embrace both first and recurrent events and it should use a model appropriate to these data . An individual rate model that includes a parameter of an unspecified individual event distribution frailty may be a natural choice when analysing longitudinal data of contacts to the health care system in broad terms
Disregarding these method ological obstacles could implicitly lead to discrimination against the elderly in terms of health promotion and disease prevention and , hence , an age-based rationing of public health care
Background In the light of demographic developments health promotion interventions for older people are gaining importance .
In addition to method ological challenges arising from the economic evaluation of health promotion interventions in general , there are specific method ological problems for the particular target group of older people .
There are especially four main method ological challenges that are discussed in the literature .
They concern measurement and valuation of informal caregiving , accounting for productivity costs , effects of unrelated cost in added life years and the inclusion of ‘ beyond-health ’ benefits .
This paper focuses on the question whether and to what extent specific method ological requirements are actually met in applied health economic evaluations .