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Biomedical subjects

C Boult

Publications and source records attributed to C Boult.

At least 19 recordsLinked to original sources
PubMed2001

A randomized clinical trial of outpatient geriatric evaluation and management.

OBJECTIVES: To measure the effects of outpatient geriatric evaluation and management (GEM) on high-risk older persons' functional ability and use of health services. DESIGN: Randomized clinical trial. SETTING: Ambulatory clinic in a community hospital. PARTICIPANTS: A population-based sample of community-dwelling Medicare beneficiaries age 70 and older who were at high risk for hospital admission in the future (N = 568). INTERVENTION: Comprehensive assessment followed by interdisciplinary primary care. MEASUREMENTS: Functional ability, restricted activity days, bed disability days, depressive symptoms, mortality, Medicare payments, and use of health services. Interviewers were blinded to participants' group status. RESULTS: Intention-to-treat analysis showed that the experimental participants were significantly less likely than the controls to lose functional ability (adjusted odds ratio (aOR) = 0.67, 95% confidence interval (CI) = 0.47-0.99), to experience increased health-related restrictions in their daily activities (aOR = 0.60, 95% CI = 0.37-0.96), to have possible depression (aOR = 0.44, 95% CI = 0.20-0.94), or to use home healthcare services (aOR = 0.60, 95% CI = 0.37-0.92) during the 12 to 18 months after randomization. Mortality, use of most health services, and total Medicare payments did not differ significantly between the two groups. The intervention cost $1,350 per person. CONCLUSION: Targeted outpatient GEM slows functional decline.

Aged↗
PubMed2000

The effects of outpatient geriatric evaluation and management on caregiver burden.

This study investigated the effects of outpatient geriatric evaluation and management (GEM) on informal caregivers' sense of burden. We randomized 568 high-risk, community-dwelling older adults to receive either GEM or usual care for 6 months. At baseline and one year later, we assessed the burden experienced by their informal caregivers (N = 88). Compared with caregivers of participants in the usual care group, caregivers of participants in the GEM group were less than half as likely to report increased burden during the one-year follow-up period (16.7% vs 38.5%, p = .034). The findings suggest that GEM helps protect the informal caregivers of high-risk older people from the increases in burden that often accompany advancing age.

Adult↗
PubMed2000

The effect of case management on the costs of health care for enrollees in Medicare Plus Choice plans: a randomized trial.

OBJECTIVE: To measure the effects of case management on an older population's costs of health care. DESIGN: A 1-year randomized controlled trial. SETTING: Multiple sites of care in San Francisco, California. PARTICIPANTS: Patients aged 65 or older of primary care physicians in a large provider organization bearing financial risk for their care (n = 6409). INTERVENTION: Screening for high risk and provision of social work-based case management. OUTCOME MEASURES: Volume and cost of hospital, physician, case management, and other health-related services. RESULTS: The experimental group used more case management services than the control group (0.09 vs. 0.02 months per person, P<.001). The experimental group's average total payments for health care were slightly lower ($3148 vs $3277, P = .40). CONCLUSIONS: This study provides no statistically significant evidence that social work-oriented case management reduces the use or the cost of health care for high-risk older people. Other potentially favorable effects of this type of case management need to be evaluated, as do the effects of other types of case management.

Aged↗
PubMed1999

The validity of nutritional status as a marker for future disability and depressive symptoms among high-risk older adults.

OBJECTIVE: To measure the validity of the DETERMINE Checklist as a marker for future functional disability, depressive symptoms, and mortality among high-risk older adults. DESIGN: A Cohort study. SETTING: An Urban-suburban Midwestern community. PARTICIPANTS: Community-dwelling Medicare beneficiaries at high risk for hospital admission who received geriatric evaluation and management (GEM) (n = 251). MEASUREMENTS: Demographic, health-related, functional, psychosocial, survival, and nutritional data were collected through telephone and in-home interviews. RESULTS: GEM recipients with baseline Checklist scores of four or higher were found to be significantly more likely than those with lower scores to have functional disability or high levels of depressive symptoms a year later. Checklist scores did not predict mortality. CONCLUSIONS: The 10-item Checklist could be used as a secondary screen to identify older persons who, without treatment, are at especially high-risk to have disability or depression a year later.

Activities of Daily Living↗
PubMed1999

Integrating healthcare for older populations.

The complex array of needs posed by older adults has frequently produced fragmentation of care in traditional fee-for-service systems. Integration of care components in newer health systems will maximize patient benefits and organizational efficiency. This article outlines the major issues involved in integration of care for older populations. A health system must integrate its care of older adults in many ways: among providers, both in primary care and specialty services; with community-based sources of care; and across sites of care (clinic, hospital, emergency department, and nursing home). Integrating reimbursement structures for various services will serve to create a client-oriented system, as opposed to a finance-centered system, thereby enhancing coordination of care. The extent to which two experimental comprehensive systems, PACE (Program of All-inclusive Care of the Elderly) and SHMO II (Social Health Maintenance Organization), have achieved clinical and financial integration are discussed in detail. Healthcare organizations are encouraged to create integrated models of care and to study the effects of integration on patient outcomes.

Aged↗
PubMed1999

Innovative healthcare for chronically ill older persons: results of a national survey.

OBJECTIVE: To describe the origin, scope, operations, funding, and outcomes of innovative healthcare programs for chronically ill older persons. STUDY DESIGN: Cross-sectional survey. METHODS: A national expert panel nominated chronic illness programs they believed to be innovative and field tested. The directors of the 31 eligible programs provided descriptive information in 60-minute semistructured telephone interviews. RESULTS: The innovative programs we surveyed tended to target their services to high-risk patients, use teams of providers to deliver care, designate providers to coordinate multiple components of complex care plans, and shift care from higher- to lower-cost environments and/or redesign the delivery of primary care. CONCLUSIONS: Recent innovations in healthcare programs hold considerable promise for improving the outcomes of chronic care, but most have yet to be rigorously evaluated.

Aged↗
PubMed1998

Soliciting defined populations to recruit samples of high-risk older adults.

BACKGROUND: Generalizable research on high-risk older persons requires samples that are both large enough for adequate statistical power and similar enough to community populations that its results can be generalized to them. We tested the effectiveness and efficiency of mixed-mode (mail-telephone) solicitation of a defined population as a method for recruiting a large, representative sample for a randomized trial of outpatient geriatric evaluation and management (GEM). METHODS: Fee-for-service, community-dwelling older Medicare beneficiaries were mailed a short self-administered screening questionnaire. Eligible respondents were called to assess eligibility and willingness to give consent; consenters were called again for baseline data. Information about nonrespondents, ineligibles, and refusers was obtained from the Health Care Financing Administration. RESULTS: The response rate to the screening questionnaire was 61.1%. Of the respondents, 13.2% were eligible for the study and, of those, 34.4% agreed to participate. Response rates appeared to be influenced by small financial incentives and by subjects' age, race, sex, location of residence, and use of hospitals in the previous year. Consent rates were influenced by age and sex. The final sample (N = 522) was representative of community high-risk respondents in racial composition, previous use of hospitals, and probability of repeated admission (Pre) in the future, but it was slightly younger and contained a higher percentage of men. Recruitment costs averaged $286.92 per consenting person. CONCLUSIONS: Mixed-mode solicitation of defined populations can produce, at reasonable cost, large samples whose representativeness of community high-risk populations can be determined. Procedures that may enhance the success of this approach include: advance communication with members of the target population and their families and physicians; provision of medical and small financial incentives; continuous monitoring of recruitment results; and attention to subjects' needs for convenience, time, transportation, and reassurance.

Aged↗
PubMed1998

Satisfaction with outpatient geriatric evaluation and management (GEM).

The purpose of this study was to evaluate high-risk older adults' satisfaction with outpatient geriatric evaluation and management (GEM). Community-dwelling Medicare beneficiaries (n = 522) age 70 years and older who had a high probability of repeated admission to hospitals (Pra > .40) were randomly assigned to receive either usual care or GEM for six months. Despite the stresses imposed by outpatient GEM (e.g., new relationships with providers, frequent office visits and changes in treatments), the mean satisfaction scores of the recipients of GEM were 9% higher than those of the recipients of usual care (4.31 vs 3.96, p < .001). The primary physicians of GEM recipients were also highly satisfied with GEM care.

Aged↗
PubMed1998

Outpatient geriatric evaluation and management.

OBJECTIVE: To describe the development and operation of a practical model of outpatient geriatric evaluation and management (GEM) for high-risk, community-dwelling older adults. PARTICIPANTS: Community-dwelling Medicare beneficiaries age 70 years and older who were medically stable but had a high probability of repeated admission to hospitals (P(ra) > .40) in the future (n = 248). INTERVENTION: Outpatient GEM. MEASUREMENTS: Demographic, clinical, and use-of-hospital characteristics of patients; nature and quantity of GEM services; satisfaction of patients and their established primary physicians. RESULTS: At enrollment, the average patient was 78.7 years old, took 5.0 long-term prescription medications and was unable to perform 0.5 (of six) activities of daily living (ADL) and 1.4 (of seven) instrumental ADL. Many patients (71.3%) reported hospital days during the previous year. Each of three interdisciplinary teams (geriatrician, gerontological nurse practitioner, nurse and social worker) performed comprehensive assessments and then provided primary care and case management to a case load of 45 to 52 patients. On average, GEM required 6 months, during which patients visited the GEM clinic 7.4 times, had 10.4 active problems addressed, spoke to GEM staff members weekly by telephone, and were referred to two other providers. Most patients (94.4%) completed the GEM program; 66.7% completed advance directives. Satisfaction with GEM was high among the patients and their established primary physicians. The cost of the GEM personnel averaged about $1540 per patient treated. CONCLUSIONS: This model of outpatient GEM provided 6 months of targeted intensive care at a reasonable cost. The satisfaction ratings of patients and their primary physicians were high.

Activities of Daily Living↗
PubMed1998

Identification and assessment of high-risk seniors. HMO Workgroup on Care Management.

CONTEXT: Many older adults with chronic illnesses and multidimensional needs are at high risk of adverse health outcomes, poor quality of life, and heavy use of health-related services. Modern proactive care of older populations includes identification of such high-risk individuals, assessment of their health-related needs, and interventions designed both to meet those needs and to prevent undesirable outcomes. OBJECTIVE: This paper outlines an approach to the tasks of identifying and assessing high-risk seniors. Intervention identification of high-risk seniors (also called case finding) is accomplished through a combination of periodic screening, recognition of high-risk seniors by clinicians, and analysis of administrative databases. Once identified, potentially high-risk individuals undergo on initial assessment in eight domains: cognition, medical conditions, medications, access to care, functional status, social situation, nutrition, and emotional status. The initial assessment is accomplished in a 30- to 45-minute interview conducted by a skilled professional--usually one with a background in nursing. The data are used to link some high-risk persons with appropriate services and to identify others who require more detailed assessments. Detailed assessment is often performed by interdisciplinary teams of various compositions and methods of operation, depending on local circumstances. CONCLUSION: The rapid growth in Medicare managed care is presenting many opportunities for developing more effective strategies for the proactive care for older populations. Identification and assessment of high-risk individuals are important initial steps in this process, paving the way for testing of interventions designed to reduce adverse health consequences and to improve the quality of life.

Activities of Daily Living↗
PubMed1998

Managed primary care of nursing home residents.

OBJECTIVE: To measure the rates of hospital use and mortality of nursing homes residents who received their primary care from nurse practitioner-physician teams. DESIGN: A cohort study. SETTING: Thirty nursing homes in Southern California. PATIENTS: Older, long-term residents of nursing homes enrolled in a Medicare HMO (n = 307). INTERVENTION: Primary care by an accessible interdisciplinary team supported by clinical guidelines, continuous quality improvement techniques, and increased availability of clinical services at the nursing homes. RESULTS: The residents (mean age 83.5 years, 69.0% women) had a high prevalence of dementia (83.5%) and functional disability (87.2% were dependent in two or more activities of daily living). About half (50.8%) expressed a preference for "no hospitalization and no resuscitation." Compared with other nursing homes populations, this cohort experienced a lower annual rate of hospital use (518 days/1000 residents) and a similar rate of mortality (23.8%). CONCLUSIONS: Integration of the efforts of physicians, nurse practitioners, and nursing home staff can lead to low rates of hospital use by nursing home residents. The effects on residents' quality of life and mortality require further study.

Activities of Daily Living↗
PubMed1997

Predictive validity of the Pra instrument among older recipients of managed care.

OBJECTIVE: To determine the validity of the Pra instrument in predicting the use of health-related services by older enrollees in a managed care plan. DESIGN: Cohort study. At baseline, a survey was administered by mail. Responses were entered into the Pra formula to estimate each person's probability of using health-related services heavily in the future. The subjects' use of services during the following year was monitored through claims submitted to their managed care organization. SETTING: Urban and suburban areas of Southern California. PARTICIPANTS: Persons aged 65 years and older enrolled in a Medicare risk health plan (n = 6802). MEASUREMENTS: Baseline data included demographic, health-related, social, functional, and previous-use-of-service characteristics. Follow-up data included the use of and claims for payment for inpatient hospital care, emergency room services, nursing home services, home care, ambulance services, outpatient surgery, and durable medical equipment. RESULTS: High-risk subjects (highest quartile of Pra values) incurred hospital admissions and claims that were 2.5 and 2.7 times greater than those of low-risk subjects (lower three quartiles). CONCLUSIONS: The Pra formula is recommended for screening older adults enrolled in managed care organizations (as well as for screening those in the fee-for-service environment). It identifies older people who may benefit from interventions designed to avert health crises and the need for expensive care.

Aged↗
PubMed1996

Factors affecting sample selection in a randomized trial of balance enhancement: the FICSIT Study.

OBJECTIVE: To determine demographic, functional, and health-related factors that may have influenced the selection of older adults for a randomized trial of balance enhancement. DESIGN: Comparison of participants with nonparticipants at various stages of the recruiting process. SETTING: Northeastern suburban community. PARTICIPANTS: Registered voters aged 75 and older (n = 7191). MEASUREMENTS: Demographic, health-related, functional, balance, gait, and falling characteristics. RESULTS: The overall participation rate in the randomized trial was 1.5%. Compared with nonparticipants, participants were significantly more likely to be male, married, living with others, living in a house, highly educated, healthy, and physically active. CONCLUSION: Recruiting older subjects by mail to studies of rigorous interventions can produce significant selection biases that may limit the population to which results can be generalized.

Accidental Falls↗