Primary care physicians (PCPs) are often the ones who manage these patient groups, but the care provided in these settings may not always be adequate. A variety of interventions have been utilized to improve care for falls and urinary incontinence (UI) in older patients. While some of these interventions have demonstrated improvements in patient care and outcomes, they’ve often been difficult to implement in current practice environments. They also aren’t always disseminated into small- and medium-sized primary care practices, where many older patients receive their care. In these locations, redesigning internal workflow and healthcare provision processes may be more effective in improving care for these patients.
Analyzing Practice Redesign
In the October 25, 2010 Archives of Internal Medicine, my colleagues and I had a study published in which we performed a controlled trial in five non-randomly selected primary care intervention and control practices from diverse communities. In collaboration with the American College of Physicians, we augmented the Assessing Care of Vulnerable Elders (ACOVE) intervention to conduct the “ACOVE Practice Redesign for Improved Medical Care for Elders” (ACOVEprime) project to improve falls and UI care. Patients aged 75 and older who screened positive for falls or fear of falling and UI were included in the study. We compared quality of care for falls and UI at intervention sites and compared them with care at control sites.
“Practice redesign appeared to improve the care that community-based PCPs provided for older patients with falls and UI.”
In our analysis, practice redesign appeared to improve the care that community-based PCPs provided for older patients with falls and UI. Of the 6,051 patients screened in the study, nearly half (47.1%) screened positive for falls or UI. Recommended care for falls was received by 60.0% of intervention patients, compared with 37.6% of control patients. In addition, recommended care for UI was received by 47.2% of intervention patients, compared with 27.8% of patients from the control group. When compared with healthcare professionals at the control practices, those at the intervention practices more often performed a falls history, orthostatic blood pressure measurement, gait and balance examination, and UI history. These intervention practices were also more likely to try behavioral treatments for UI first. Knowledge about falls and UI also increased more among intervention than control group healthcare professionals.
While our investigation suggests that practice redesign using the ACOVEprime intervention can improve care that community-based PCPs provide for older patients with falls and UI, it should be noted that outcomes of such care improvements require further evaluation. Our study was limited in that physician practice participants were voluntary and were specifically interested in improving geriatric care, as well as other factors.
Regardless of the limitations of our study, it seems clear that interventions to improve care of older patients such as ACOVEprime can be implemented across small- and medium-sized medical practices that do not have a research infrastructure. This intervention has the potential to be applied more broadly in order to change the way falls and UI are treated in large groups of older patients. Furthermore, it may be applicable to other geriatric conditions. Hopefully, as we gain more insights with future research, we’ll be able to further implement practice redesign interventions to improve care for falls and UI in more primary care practices and other healthcare settings, perhaps even emergency departments and other high-traffic departments within hospitals.
Wenger NS, Roth CP, Hall WJ, et al. Practice redesign to improve care for falls and urinary incontinence: primary care intervention for older patients. Arch Intern Med. 2010;170:1765-1772. Available at:http://archinte.ama-assn.org/cgi/content/full/170/19/1765#AUTHINFO.
Wenger NS, Solomon DH, Roth CP, et al. The quality of medical care provided to vulnerable community-dwelling older patients. Ann Intern Med. 2003;139:740-747.
Gates S, Fisher JD, Cooke MW, Carter YH, Lamb SE. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. BMJ. 2008;336(7636):130-133.
Wenger NS, Solomon DH, Amin A, et al, ACOVE-3 Clinical Committee. Application of assessing care of vulnerable elders—3 quality indicators to patients with advanced dementia and poor prognosis. J Am Geriatr Soc. 2007;55(suppl 2):S457-S463.