Effect of a community-based nursing intervention on mortality in chronically ill older adults: A randomized controlled trial

PLoS Medicine

Volumn 9, Issue 7, 2012, Pages

  Coburn, Kenneth D ^a   Marcantonio, Sherry ^a   Lazansky, Robert ^a   Keller, Maryellen ^a   Davis, Nancy ^a  

^a Health Quality Partners   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

AGED; ARTICLE; ASTHMA; CHRONIC DISEASE; COMMUNITY HEALTH NURSING; CONTROLLED STUDY; CORONARY ARTERY DISEASE; DIABETES MELLITUS; FEMALE; FOLLOW UP; GERIATRIC DEPRESSION SCALE; HEALTH ASSESSMENT QUESTIONNAIRE; HEALTH CARE MANAGEMENT; HEART FAILURE; HUMAN; HYPERLIPIDEMIA; HYPERTENSION; INTERVENTION STUDY; KATZ INDEX; MALE; MINI MENTAL STATE EXAMINATION; MORTALITY; PATIENT CARE; RANDOMIZED CONTROLLED TRIAL; RISK; RISK ASSESSMENT; SURVIVAL RATE;

ADULT; AGED; CHRONIC DISEASE; COMMUNITY HEALTH NURSING; FEMALE; HUMANS; KAPLAN-MEIER ESTIMATE; MALE; MEDICARE; OUTCOME ASSESSMENT (HEALTH CARE); QUALITY OF HEALTH CARE; UNITED STATES;

EID: 84864423110     PISSN: 15491277     EISSN: 15491676     Source Type: Journal    
DOI: 10.1371/journal.pmed.1001265     Document Type: Article

References (58)

1. Pham HH, Schrag D, O'Malley AS, Wu B, Bach PB, (2007) Care patterns in medicare and their implications for pay for performance. N Engl J Med 356: 1130-1139.
2. Pham HH, O'Malley AS, Bach PB, Saiontz-Martinez C, Schrag D, (2009) Primary care physicians' links to other physicians through medicare patients: the scope of care coordination. Ann Intern Med 150: 236-242.
3. Jencks SF, Williams MV, Coleman EA, (2009) Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 360: 1418-1428.
4. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, et al. (2003) The quality of health care delivered to adults in the United States. N Engl J Med 348: 2635-2645.
5. CBO (2005) High-cost medicare beneficiaries Washington (D.C.) US Congressional Budget Office Paper Available: http://www.cbo.gov/publication/16487. Accessed 06/06/2012.
6. MedPac (2007) Report to Congress: promoting greater efficiency in Medicare. MedPac Report to Congress June 2007. Chapter 1: 3-26. Available: http://www.medpac.gov/documents/Jun07_EntireReport.pdf. Accessed 06/06/2012.
7. Lopez A, Mathers C, Ezzati M, Jamison D, Murray C, (2006) Global burden of disease and risk factors New York The World Bank and Oxford University Press.
8. Alwan A, (2011) Global status report on noncommunicable diseases 2010 Geneva World Health Organization (QHO) Available: http://whqlibdoc.who.int/publications/2011/9789240686458_eng.pdf. Accessed 06/06/2012.
9. IOM (2003) Priority areas for national action: transforming health care quality Rockville (Maryland) Agency for Healthcare Research and Quality Available: http://www.ahrq.gov/qual/iompriorities.htm. Accessed 06/06/2012.
10. Schultz AM, McGinnis JM, Rapporteurs; Institute of Medicine (2009) Integrative medicine and the health of the public: a summary of the February 2009 Summit Washington (D.C.) National Academy Press.
11. Bodenheimer T, (2008) Coordinating care - a perilous journey through the health care system. N Engl J Med 358: 1064-1071.
12. Cant RP, Foster MM, (2011) Investing in big ideas: utilisation and cost of Medicare Allied Health services in Australia under the Chronic Disease Management initiative in primary care. Aust Health Rev 35: 468-474.
13. Wilson PM, Brooks F, Procter S, Kendall S, (2012) The nursing contribution to chronic disease management: a case of public expectation? Qualitative findings from a multiple case study design in England and Wales. Int J Nurs Stud 49: 2-14.
14. Douglas KA, Yen LE, Korda RJ, Kljakovic M, Glasgow NJ, (2011) Chronic disease management items in general practice: a population-based study of variation in claims by claimant characteristics. Med J Aust 195: 198-202.
15. May CR, Finch TL, Cornford J, Exley C, Gately C, et al. (2011) Integrating telecare for chronic disease management in the community: what needs to be done? BMC Health Serv Res 11: 131.
16. Griffiths P, Maben J, Murrells T, (2011) Organisational quality, nurse staffing and the quality of chronic disease management in primary care: observational study using routinely collected data. Int J Nurs Stud 48: 1199-1210.
17. Lupari M, Coates V, Adamson G, Crealey GE, (2011) 'We're just not getting it right'-how should we provide care to the older person with multi-morbid chronic conditions? J Clin Nurs 20: 1225-1235.
18. Candy B, Taylor SJC, Ramsay J, Esmond G, Griffiths CJ, et al. (2007) Service implications from a comparison of the evidence on the effectiveness and a survey of provision in England and Wales of COPD specialist nurse services in the community. Int J Nurs Stud 44: 601-610.
19. Cheah J, (2001) Chronic disease management: a Singapore perspective. BMJ 323: 990-993.
20. Bott DM, Kapp MC, Johnson LB, Magno LM, (2009) Disease management for chronically ill beneficiaries in traditional Medicare. Health Aff (Millwood) 28: 86-98.
21. Drabik A, Buscher G, Sawicki PT, Thomas K, Graf C, et al. (2012) Life prolonging of disease management programs in patients with type 2 diabetes is cost-effective. Diabetes Res Clin Pract 95: 194-200.
22. Lowery J, Hopp F, Subramanian U, Wiitala W, Welsh DE, et al. (2012) Evaluation of a nurse practitioner disease management model for chronic heart failure: a multi-site implementation study. Congest Heart Fail 18: 64-71.
23. Bischoff A, Ekoe T, Perone N, Slama S, Loutan L, (2009) Chronic disease management in Sub-Saharan Africa: whose business is it? Int J Environ Res Public Health 6: 2258-2270.
24. Lekoubou A, Awah P, Fezeu L, Sobngwi E, Kengne AP, (2010) Hypertension, diabetes mellitus and task shifting in their management in sub-Saharan Africa. Int J Environ Res Public Health 7: 353-363.
25. Centers for Medicare and Medicaid Services US (2011) Medicare Coordinated Care Demonstration information webpage. Available http://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/Medicare-Demonstrations-Items/CMS1198864.html. Accessed 06/06/2012.
26. Brown R, Peikes D, Chen A, Ng J, Schore J, et al. (2007) The evaluation of the Medicare coordinated care demonstration: findings for the first two years Princeton (New Jersey) Mathematica Policy Research, Inc Available: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/Downloads/Brown.pdf. Accessed 06/06/2012.
27. Peikes D, Chen A, Schore J, Brown R, (2009) Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA 301: 603-618.
28. Peikes D, Brown R, Chen A, Schore J, (2008) Third report to Congress on the evaluation of the Medicare Coordinated Care Demonstration Princeton (New Jersey) Mathematica Policy Research, Inc MPR reference number 8756-430. Available: http://www.mathematica-mpr.com/publications/PDFs/health/MCCD_rptcongress08.pdf. Accessed 06/06/2012.
29. Schore J, Peikes D, Peterson G, Gerolamo A, Brown R, (2011) Fourth report to Congress on the evaluation of the Medicare Coordinated Care Demonstration Princeton (New Jersey) Mathematica Policy Research, Inc Available: https://www.cms.gov/reports/downloads/Schore_Fourth_Eval_MCCD_March_2011.pdf. Accessed 06/06/2012.
30. Brown RS, Aliotta S, Archibald N, Chen A, Peikes D, et al. (2001) Research design for the evaluation of the Medicare Coordinated Care Demonstration. Available: http://www.mathematica-mpr.com/publications/PDFs/researchdesign.pdf. Accessed 06/06/2012.
31. Archibald N, Schore J, (2003) The early experience of the Health Quality Partners case management program Princeton (New Jersey) Mathematica Policy Research, Inc MPR reference number 8756-310. Available; http://www.mathematica-mpr.com/publications/PDFs/healthqualitypartnersearly.pdf. Accessed 06/06/2012.
32. Phillips-Harris C, (1996) The integration of primary care and case management in chronic disease. Qual Manag Health Care 5: 1-6.
33. Phillips-Harris C, (1998) Case management: high-intensity care for frail patients with complex needs. Geriatrics 53: 62-64, 67-68; quiz 69.
34. Fixsen DL, Blase KA, Naoom SF, Wallace F, (2009) Core implementation components. Res Social Work Prac 19: 531-540.
35. Vetter NJ, Jones DA, Victor CR, (1984) Effect of health visitors working with elderly patients in general practice: a randomised controlled trial. Br Med J (Clin Res Ed) 288: 369-372.
36. Hendriksen C, Lund E, Strømgård E, (1984) Consequences of assessment and intervention among elderly people: a three year randomised controlled trial. Br Med J (Clin Res Ed) 289: 1522-1524.
37. Pathy, Bayer A, Harding K, Dibble A, (1992) Randomised trial of case finding and surveillance of elderly people at home. Lancet 340: 890-893.
38. Vetter NJ, Lewis PA, Ford D, (1992) Can health visitors prevent fractures in elderly people? BMJ 304: 888-890.
39. Leff B, Reider L, Frick KD, Scharfstein DO, Boyd CM, et al. (2009) Guided care and the cost of complex healthcare: a preliminary report. Am J Manag Care 15: 555-559.
40. Boult C, Reider L, Frey K, Leff B, Boyd CM, et al. (2008) Multidimensional geriatric assessment: back to the future early effects of "guided care" on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial. J Gerontol A Biol Sci Med Sci 63: 321-327.
41. Boyd CM, Shadmi E, Conwell LJ, Griswold M, Leff B, et al. (2008) A pilot test of the effect of guided care on the quality of primary care experiences for multimorbid older adults. J Gen Intern Med 23: 536-542.
42. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW, (2009) Cost analysis of the geriatric resources for assessment and care of elders care management intervention. J Am Geriatr Soc 57: 1420-1426.
43. Counsell SR, Callahan CM, Clark DO, Tu W, Buttar AB, et al. (2007) Geriatric care management for low-income seniors: a randomized controlled trial. JAMA 298: 2623-2633.
44. Stock R, Mahoney ER, Reece D, Cesario L, (2008) Developing a senior healthcare practice using the chronic care model: effect on physical function and health-related quality of Life. J Am Geriatr Soc 56: 1342-1348.
45. Coleman K, Austin BT, Brach C, Wagner EH, (2009) Evidence on the chronic care model in the new millennium. Health Aff (Millwood) 28: 75-85.
46. Coleman K, Mattke S, Perrault PJ, Wagner EH, (2009) Untangling practice redesign from disease management: how do we best care for the chronically ill? Annu Rev Public Health 30: 385-408.
47. Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, et al. (1999) Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA 281: 613-620.
48. Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, et al. (2004) Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc 52: 675-684.
49. Coleman EA, Parry C, Chalmers S, Min SJ, (2006) The care transitions intervention: results of a randomized controlled trial. Arch Intern Med 166: 1822-1828.
50. Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, et al. (2004) Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc 52: 1817-1825.
51. Cohen HJ, Feussner JR, Weinberger M, Carnes M, Hamdy RC, et al. (2002) A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med 346: 905-912.
52. Boult C, Reider L, Leff B, Frick KD, Boyd CM, et al. (2011) The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Arch Intern Med 171: 460-466.
53. McCall N, Cromwell J, (2011) Results of the Medicare Health Support disease-management pilot program. N Engl J Med 365: 1704-1712.
54. Schraeder C, Shelton P, Sager M, (2001) The effects of a collaborative model of primary care on the mortality and hospital use of community-dwelling older adults. J Gerontol A Biol Sci Med Sci 56: M106-M112.
55. Dorr DA, Wilcox AB, Brunker CP, Burdon RE, Donnelly SM, (2008) The effect of technology-supported, multidisease care management on the mortality and hospitalization of seniors. J Am Geriatr Soc 56: 2195-2202.
56. Phillips LS, Branch WT, Cook CB, Doyle JP, El-Kebbi IM, et al. (2001) Clinical inertia. Ann Intern Med 135: 825-834.
57. Hing E, Burt CW, (2007) Characteristics of office-based physicians and their practices: United States, 2003-04. Vital Health Stat 13: 1-34.
58. Rittenhouse DR, Casalino LP, Shortell SM, McClellan SR, Gillies RR, et al. (2011) Small and medium-size physician practices use few patient-centered medical home processes. Health Aff (Millwood) 30: 1575-1584.