Distress experienced by lung cancer patients and their family caregivers in the first year of their cancer journey.

OBJECTIVES: Diagnosis of cancer is emotionally threatening not only for patients but also for their family caregivers (FC) who witness and share much of the illness experience. This study compares distress experienced by lung cancer patients and their FC during the year following the diagnosis. METHODS: A prospective cohort study of 206 patients recently diagnosed with inoperable lung cancer (participation rate 79.5%) and 131 FC (participation rate 63.6%) was conducted in an ambulatory oncology clinic in Quebec City (Canada). They completed validated questionnaires regarding their personal and psychological characteristics (Hospital and Anxiety Depression Scale-HADS), in the first months after the diagnosis of lung cancer and after 6 and 12 months. Univariate, bivariate, and linear mixed models were conducted to compare patient and FC distress. RESULTS: At baseline, 7.8% of patients reported distress (HADS total score >15) and their mean distress score was 7.0 ± 4.9 (range 0-42). In contrast, 33.6% of FC presented significant distress and their mean distress score was 12.0 ± 7.2 (P < 0.0001). Proportions of patients and FC with distress remained relatively stable at 6 and 12 months, and at every time point, FC reported higher levels of distress compared to their relative with cancer (P < 0.0001). Comparable trends were found when looking at the mean scores of distress, anxiety, and depression throughout the study. SIGNIFICANCE OF RESULTS: Being diagnosed with lung cancer and going through its different phases seems to affect more FC than patients. The psychological impact of such diagnosis appears early after the diagnosis and does not significantly change over time. These findings reinforce the importance for oncology teams, to include FC in their systematic distress screening program, in order to help them cope with their own feelings and be able to play their role in patient support and care throughout the cancer journey.

Health Impacts and Characteristics of Deprescribing Interventions in Older Adults: Protocol for a Systematic Review and Meta-analysis.

BACKGROUND: Deprescribing, a relatively recent concept, has been proposed as a promising solution to the growing issues of polypharmacy and use of medications of questionable benefit among older adults. However, little is known about the health outcomes of deprescribing interventions. OBJECTIVE: This paper presents the protocol of a study that aims to contribute to the knowledge on deprescribing by addressing two specific objectives: (1) describe the impact of deprescribing in adults ≥60 years on health outcomes or quality of life; and (2) determine the characteristics of effective interventions in deprescribing. METHODS: Primary studies targeting three concepts (older adults, deprescribing, and health or quality of life outcomes) will be included in the review. The search will be performed using key international databases (MEDLINE, EMBASE, CINAHL, Ageline, PsycInfo), and a special effort will be made to identify gray literature. Two reviewers will independently screen the articles, extract the information, and evaluate the quality of the selected studies. If methodologically feasible, meta-analyses will be performed for groups of intervention studies reporting on deprescribing interventions for similar medications, used for similar or identical indications, and reporting on similar outcomes (eg, benzodiazepines used against insomnia and studies reporting on quality of sleep or quality of life). Alternatively, the results will be presented in bottom-line statements (objective 1) and a matrix outlining effective interventions (objective 2). RESULTS: The knowledge synthesis may be limited by the availability of high-quality clinical trials on deprescribing and their outcomes in older adults. Additionally, analyses will likely be affected by studies on the deprescribing of different types of molecules within the same indication (eg, different pharmacological classes and medications to treat hypertension) and different measures of health and quality of life outcomes for the same indication. Nevertheless, we expect the review to identify which deprescribing interventions lead to improved health outcomes among seniors and which of their characteristics contribute to these outcomes. CONCLUSIONS: This systematic review will contribute to a better understanding of the health outcomes of deprescribing interventions among seniors. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42015020866; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42015020866. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/25200.

Discontinuation of bisphosphonates in seniors: a systematic review on health outcomes.

PURPOSE: Bisphosphonates are used to treat osteoporosis. Despite their benefits on bone mineral density (BMD) and fractures, they have shown adverse effects, sometimes severe, during chronic use. Taken for several years, they achieve long-term bone retention, making deprescribing feasible. This review aimed to synthesize evidence on the success and health outcomes of deprescribing of bisphosphonates in seniors, aged over 60 years. METHODS: The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including articles in English, French, or German published before July 2020. Eligible studies included seniors having discontinued bisphosphonates and reported on health outcomes; some allowed meta-analyses on fracture risk. RESULTS: The review included 9 RCTs and 9 cohort studies of moderate quality. Bisphosphonates were discontinued after 2 to 7 years of use, and BMD or fractures were assessed during follow-up of 0.5 to 5 years. A significant reduction in BMD after discontinuation was observed in 9 of 10 studies. Results on fracture risk after discontinuation are mitigated: 6 RCT extensions showed no increase in the risk of any osteoporotic fractures after discontinuation. Meta-analyses including 4 RCTs showed an increased odds ratio of vertebral fractures of 2.04 (95% CI, 1.39-2.99) among discontinuers. Results from 2 large cohort studies showed no increased risks of any osteoporotic or vertebral fractures, while 2 studies found increased fracture risks. CONCLUSION: Bisphosphonates have successfully been discontinued low overall fracture risk after at least 3 years of use, but a risk for decreased BMD and increased vertebral fractures remained.

Continuity of Cancer Care and Collaboration Between Family Physicians and Oncologists: Results of a Randomized Clinical Trial.

PURPOSE: Collaboration between family physicians (FPs) and oncologists can be challenging. We present the results of a randomized clinical trial of an intervention designed to improve continuity of care and interprofessional collaboration, as perceived by patients with lung cancer and their FPs. METHODS: The intervention included (1) supplying FPs with standardized summaries related to each patient, (2) recommending that patients see their FP after receiving the cancer diagnosis, (3) supplying the oncology team with patient information resulting from FP visits, and (4) providing patients with priority access to FPs as needed. A total of 206 patients with newly diagnosed lung cancer were randomly assigned to the intervention (n = 104) or control group (n = 102), and 86.4% of involved FPs participated. Perceptions of continuity of care and interprofessional collaboration were assessed every 3 months for patients and at baseline and at the end of the study for FPs. Patient distress and health service utilization were also assessed. RESULTS: Patients and FPs in the intervention group perceived better interprofessional collaboration (patients: P <.0001; FPs: P = .0006) than those in the control group. Patients reported better informational continuity (P = .001) and management continuity (P = .05) compared to the control group, but no differences were found for FPs (information: P = .22; management: P = .13). No effect was found with regard to patient distress or health service utilization. CONCLUSIONS: This intervention improved patient and FP perception of interprofessional collaboration, but its effectiveness on continuity of care was less clear for FPs than for patients. Additional strategies should be considered to sustainably improve continuity of care and interprofessional collaboration.

Impact of the COVID-19 Pandemic on Older Adults: Rapid Review.

BACKGROUND: The COVID-19 pandemic has drastically changed the lives of countless members of the general population. Older adults are known to experience loneliness, age discrimination, and excessive worry. It is therefore reasonable to anticipate that they would experience greater negative outcomes related to the COVID-19 pandemic given their increased isolation and risk for complications than younger adults. OBJECTIVE: This study aims to synthesize the existing research on the impact of the COVID-19 pandemic, and associated isolation and protective measures, on older adults. The secondary objective is to investigate the impact of the COVID-19 pandemic, and associated isolation and protective measures, on older adults with Alzheimer disease and related dementias. METHODS: A rapid review of the published literature was conducted on October 6, 2020, through a search of 6 online databases to synthesize results from published original studies regarding the impact of the COVID-19 pandemic on older adults. The Human Development Model conceptual framework-Disability Creation Process was used to describe and understand interactions between personal factors, environmental factors, and life habits. Methods and results are reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement. RESULTS: A total of 135 records were included from the initial search strategy of 13,452 individual studies. Of these, 113 (83.7%) studies were determined to be of level 4 according to the levels of evidence classification by the Centre for Evidence-Based Medicine. The presence of psychological symptoms, exacerbation of ageism, and physical deterioration of aged populations were reported in the included studies. Decreased social life and fewer in-person social interactions reported during the COVID-19 pandemic were occasionally associated with reduced quality of life and increased depression. Difficulties accessing services, sleep disturbances, and a reduction of physical activity were also noted. CONCLUSIONS: Our results highlight the need for adequate isolation and protective measures. Older adults represent a heterogeneous group, which could explain the contradictory results found in the literature. Individual, organizational, and institutional strategies should be established to ensure that older adults are able to maintain social contacts, preserve family ties, and maintain the ability to give or receive help during the current pandemic. Future studies should focus on specific consequences and needs of more at-risk older adults to ensure their inclusion, both in public health recommendations and considerations made by policy makers.

Quality of Diabetic Foot Ulcer Care: Evaluation of an Interdisciplinary Wound Care Clinic Using an Extended Donabedian Model Based on a Retrospective Cohort Study.

OBJECTIVES: Diabetic foot ulcer (DFU), a serious complication of diabetes, is associated with increased morbidity and mortality and presents a substantial socioeconomic burden. However, DFU quality of care has been insufficiently studied. Therefore, the aim of this study was to evaluate the quality of DFU care at an interdisciplinary wound care clinic in Canada, based on an extended Donabedian model: structure, process and outcome quality indicators combined with patient characteristics. METHODS: This was a retrospective cohort study of 140 adult patients with diabetes who were treated between 2012 and 2018 at a wound care clinic in a university-affiliated hospital in the Québec City area of Canada. Twenty-two internationally recognized quality-of-care indicators were identified from the literature. Data were collected from medical files, and the results were used to document the selected quality-of-care indicators. RESULTS: The principal indicators regarding structure and process were met, and outcome indicators were influenced by study population characteristics, particularly peripheral artery disease and critical limb ischemia. Moreover, this study highlights that quality-of-care indicators are essential when evaluating DFU outcomes, as structure and process indicators can also affect wound healing outcomes. CONCLUSIONS: This study suggests that DFU care at a Canadian wound care clinic, with an interdisciplinary approach, meets most quality-of-care indicators. The socioeconomic burden of DFUs for patients, health-care organizations and policymakers, and the paucity of quality and performance evaluations, call for more studies evaluating DFU care.

Outcomes and prognosis of diabetic foot ulcers treated by an interdisciplinary team in Canada.

The aim of this study was to determine the wound healing outcomes of patients with a plantar diabetic foot ulcer (DFU) treated with an interdisciplinary team approach, and to identify associated variables. A retrospective observational cohort study of 140 adult patients, with a plantar DFU, treated between 2012 and 2018 at a wound care clinic of a University affiliated hospital was conducted. Predictive and explicative analyses were conducted with logistic multivariate methods and with a Receiver Operating Characteristics curve. The best predictor of wound healing at 3 months was a 41.8% wound size reduction at 4 weeks (AUC: 0.86; sensitivity: 83.1%; specificity: 67.2%, positive predictive value: 72.8%; negative predictive value: 78.9%; positive and negative likelihood ratios: 2.53 and 0.25, respectively). Main baseline variables independently associated with this predictor were: a monophasic Doppler waveform (OR 7.52, 95% CI [2.64-21.39]), cigarette smoking (OR 4.7, 95% CI [1.44-15.29]), and male gender (OR 3.58, 95% CI [1.30-9.87]). The health care provider should be cautious and intensify its management of DFUs particularly with patients of male gender; smoking, having a monophasic waveform with a hand-held Doppler, and not achieving a minimal 41.8% wound area reduction at 4 weeks of treatment.

Vitamin D status, cognitive decline and incident dementia: the Canadian Study of Health and Aging.

OBJECTIVE: Vitamin D could prevent cognitive decline because of its neuroprotective, anti-inflammatory and antioxidant properties. This study aimed to evaluate the associations of plasma 25-hydroxyvitamin D (25(OH)D) concentrations with global cognitive function and incident dementia, including Alzheimer's disease (AD). METHODS: The Canadian Study of Health and Aging is a 10-year cohort study of a representative sample of individuals aged 65 years or older. A total of 661 subjects initially without dementia with frozen blood samples and follow-up data were included. Global cognitive function was measured using the validated Modified Mini-Mental State (3MS) examination. A consensus diagnosis of all-cause dementia and AD was made between the physician and the neuropsychologist according to published criteria. Cognitive decline for a 5-year increase in age at specific 25(OH)D concentrations was obtained using linear mixed models with repeated measures. Hazard ratios of incident dementia and AD were obtained using semi-parametric proportional hazards models with age as time scale. RESULTS: Over a mean follow-up of 5.4 years, 141 subjects developed dementia of which 100 were AD. Overall, no significant association was found between 25(OH)D and cognitive decline, dementia or AD. Higher 25(OH)D concentrations were associated with an increased risk of dementia and AD in women, but not in men. CONCLUSION: This study does not support a protective effect of vitamin D status on cognitive function. Further research is needed to clarify the relation by sex.

Effect of personalised citizen assistance for social participation (APIC) on older adults' health and social participation: study protocol for a pragmatic multicentre randomised controlled trial (RCT).

INTRODUCTION: The challenges of global ageing and the growing burden of chronic diseases require innovative interventions acting on health determinants like social participation. Many older adults do not have equitable opportunities to achieve full social participation, and interventions might underempower their personal and environmental resources and only reach a minority. To optimise current practices, the Accompagnement-citoyen Personnalisé d'Intégration Communautaire (APIC), an intervention demonstrated as being feasible and having positive impacts, needs further evaluation. METHODS AND ANALYSIS: A pragmatic multicentre, prospective, two-armed, randomised controlled trial will evaluate: (1) the short-term and long-term effects of the APIC on older adults' health, social participation, life satisfaction and healthcare services utilisation and (2) its cost-effectiveness. A total of 376 participants restricted in at least one instrumental activity of daily living and living in three large cities in the province of Quebec, Canada, will be randomly assigned to the experimental or control group using a centralised computer-generated random number sequence procedure. The experimental group will receive weekly 3-hour personalised stimulation sessions given by a trained volunteer over the first 12 months. Sessions will encourage empowerment, gradual mobilisation of personal and environmental resources and community integration. The control group will receive the publicly funded universal healthcare services available to all Quebecers. Over 2 years (baseline and 12, 18 and 24 months later), self-administered questionnaires will assess physical and mental health (primary outcome; version 2 of the 36-item Short-Form Health Survey, converted to SF-6D utility scores for quality-adjusted life years), social participation (Social Participation Scale) and life satisfaction (Life Satisfaction Index-Z). Healthcare services utilisation will be recorded and costs of each intervention calculated. ETHICS AND DISSEMINATION: The Research Ethics Committee of the CIUSSS Estrie - CHUS has approved the study (MP-31-2018-2424). An informed consent form will be read and signed by all study participants. Findings will be published and presented at conferences. TRIAL REGISTRATION NUMBER: NCT03161860; Pre-results.

Mobilizing Local Authorities Around Public Health Priorities.

Large Analysis and Review of European Housing and Health Status (LARES) was conducted in Europe in 2002 to 2003 to study the relationship between citizens' health and built environments. One of its objectives was to put public health priorities on the agenda of local decision-makers to implement solutions for the community. We adapted the LARES protocol as a pilot project in a small French-Canadian town in Quebec Province in 2012. The distinguishing feature of this project was the collaborative approach taken with local actors, especially the municipality, which was committed a priori to using survey data from an urban planning perspective. The project produced interesting results that were used to motivate actions concerning people living in bad sanitary conditions; to draft the urban plan including the development of parks, green spaces, and bicycle paths; and to allow the municipality to meet eligibility criteria for access to renovation programs. If a partnership with the local actors and their commitment to promote and realize the project were obtained at the beginning, then the survey could be replicated in other communities.

Personalized citizen assistance for social participation (APIC): A promising intervention for increasing mobility, accomplishment of social activities and frequency of leisure activities in older adults having disabilities.

BACKGROUND: Social participation, a determinant of health in older adults, requires innovative interventions. The personalised citizen assistance for social participation (APIC) involves weekly three-hour personalised stimulation sessions targeting significant social and leisure activities difficult to accomplish. Recently adapted for older adults, the APIC's impact on this population is unknown. OBJECTIVE: This study explored the impact of APIC on older adults with disabilities. METHODS: A mixed-method design including a pre-experimental component was used with 16 participants (11 women) aged 66-91 (79.4±8.7) with disabilities, living at home. They completed functional autonomy, social participation, leisure and quality of life questionnaires, and semi-structured interviews. RESULTS: APIC increased older adults' functional autonomy (p=0.02), accomplishment (p<0.01) and satisfaction (p=0.02) with social participation, and frequency of leisure practice (p<0.01). Post-intervention, participants wished to modify the practice (p<0.01) and frequency (p<0.01) of leisure activities, and difficulties in their social environment diminished (p=0.03). Their attitude toward leisure (p=0.04) as well as their health (p<0.01) and psychological (p=0.03) quality of life improved. Older adults thought APIC helped them resume, maintain, explore and experiment with significant social activities. It also increased their psychological and physical well-being, feeling of control, connectedness, self-esteem and motivation to accomplish activities. Finally, APIC can compensate for an unavailable and crumbling social network. CONCLUSION: APIC is a promising intervention that leads to new opportunities for older adults to increase community integration and enhance the social component of their lives. It can also optimise how the needs of older adults are met, including utilisation of personal and environmental resources.

Preventive Home Visits for Older People: A Systematic Review.

RÉSUMÉ L'augmentation du nombre de personnes âgées présentant des incapacités et ayant des maladies chroniques entraîne une hausse des besoins en services de santé à domicile. Le nombre d'études et de revues systématiques traitant des approches préventives pour cette clientèle a proliféré, générant un besoin de synthèse des connaissances. Nous avons mené une revue systématique de revues systématiques évaluant l'effet des programmes de visite préventive pour les personnes âgées. Des 5 973 citations identifiées dans plus de 30 bases de données de littérature grise et scientifique, 10 articles répondaient à tous les critères d'inclusion. Les revues systématiques étaient retenues si elles comprenaient des essais randomisés contrôlés comparant des interventions de soins à domicile offerts par un professionnel de la santé et ceux sans professionnels. Les interventions sont souvent des évaluations gériatriques globales et s'accompagnent de visites de suivi. Il ressort que les visites préventives multidimensionnelles à domicile ont le potentiel de diminuer la mortalité, en particulier chez les personnes âgées plus jeunes, et offrent aussi un potentiel d'amélioration de l'autonomie fonctionnelle. Toutefois, ces résultats doivent être interprétés avec prudence vue la diversité des interventions analysées.

Development of integrated care pathways: toward a care management system to meet the needs of frail and disabled community-dwelling older people.

INTRODUCTION: The home care and services provided to older adults with the same needs are often inadequate and highly varied. Integrated care pathways (ICPs) can resolve these issues. The aim of this study was to develop the content of ICPs to follow-up frail and disabled community-dwelling older people. THEORY AND METHOD: A RIGOROUS PROCESS WAS APPLIED ACCORDING TO A SERIES OF STEPS: identification of desirable characteristics and a theoretical framework; review of evidence-based practices and current practices; and determination of ICPs by an interdisciplinary task team. RESULTS: ICPs are intended to prevent specific problems, maximize independence, and promote successful aging. They are organized according to a dynamic process: (1) needs assessment and assessment of risk/protection factors; (2) data-collection summary and goals identification; (3) planning of interventions from a client-centered view; (4) coordination, delivery, and follow-up; and (5) identification of variances, as well as review and adjustment of plans. CONCLUSION: Once computerized, these ICPs will facilitate the exchange of information as well as the clinical decision-making process with a perspective to adequately matching the needs of an individual person with resources that delay or slow the progression of frailty and disability. Once aggregated, the data will also support managers in organizing teamwork and follow-up for clients.

Variations in patients' assessment of chronic illness care across organizational models of primary health care: a multilevel cohort analysis.

PURPOSE: To measure patients' assessment of chronic illness care and its variation across primary healthcare (PHC) models. METHODS: We recruited 776 patients with diabetes, heart failure, arthritis or chronic obstructive pulmonary disease from 33 PHC clinics. Face-to-face interviews, followed by a telephone interview at 12 months, were conducted using the Patient Assessment of Chronic Illness Care (PACIC). Multilevel regression was used in the analysis. RESULTS: The mean PACIC score was low at 2.5 on a scale of 1 to 5. PACIC scores were highest among patients affiliated with family medicine groups (mean, 2.78) and lowest for contact models (mean, 2.35). Patients with arthritis and older persons generally reported a lower assessment of chronic care. CONCLUSION: Family medicine groups represent an integrated model of PHC associated with higher levels of achievement in chronic care. Variations across PHC organizations suggest that some models are more appropriate for improving management of chronic illness.

Primary Healthcare Organization and Quality-of-Life Outcomes for Persons with Chronic Disease.

PURPOSE: To explore the association between primary healthcare (PHC) organizational model and health-related quality of life (HRQoL) in persons with chronic disease. METHODS: We recruited 776 patients with a primary diagnosis of one of four chronic diseases from 33 PHC clinics. Patients were interviewed at baseline, 6, 12 and 18 months. We categorized PHC model by administrative type and by a taxonomy according to organizational attributes. HRQoL was measured by disease-specific questionnaires. RESULTS: Mean age was 67 years and 55.3% were female. PHC models differed with respect to case mix: community models served older patients with higher co-morbidity and lower health status. Multilevel logistic regression revealed that none of the PHC organizational models was associated with HRQoL. Having fewer co-morbidities, higher self-rated health and not using home care services were associated with higher HRQoL. CONCLUSION: Despite their having patients with more complex health problems, HRQoL in patients of community practices was equivalent to that of patients in other types of PHC organizations.

OBJET : Explorer les liens entre le modèle d'organisation des soins de santé primaires (SSP) et la qualité de vie liée à la santé (QVS) chez les personnes atteintes d'une maladie chronique. MÉTHODE : Nous avons interrogé 776 patients qui ont obtenu un diagnostic primaire pour une parmi quatre maladies chroniques dans 33 cliniques de SSP. Les patients ont été interrogés au début de l'étude, puis à 6, 12 et 18 mois. Nous avons classé les modèles de SSP selon le type d'établissement et selon une taxonomie des caractéristiques organisationnelles. Des questionnaires axés sur les maladies spécifiques ont servi à mesurer la QVS. RÉSULTATS : L'âge moyen des répondants était 67 ans et 55,3 % d'entre eux étaient des femmes. Les modèles de SSP différaient selon la composition des cas : les modèles communautaires offraient des services à une clientèle plus âgée présentant une plus grande comorbidité et un état de santé moindre. L'analyse de régression logistique multiniveau révèle qu'aucun des modèles d'organisation des SSP avait un lien avec la QVS. Une plus faible comorbidité, un plus haut taux d'autoévaluation en matière de santé et le non-usage des services de soins à domicile sont associés à une meilleure QVS. CONCLUSION : Malgré la présence de patients qui ont des problèmes de santé plus complexes, la QVS chez les patients des établissements communautaires est équivalente à celle des patients des autres types d'organisations de SSP.

Patients' perceptions of the quality of care after primary care reform: Family medicine groups in Quebec.

OBJECTIVE: To evaluate how a primary care reform, which aimed to promote interprofessional and interorganizational collaborative practices, affected patients' experiences of the core dimensions of primary care. DESIGN: Before-and-after comparison of patients' perceptions of care at the beginning of family medicine group (FMG) implementation (15 to 20 months after accreditation) and 18 months later. SETTING: Five FMGs in the province of Quebec from various settings and types of practice. PARTICIPANTS: A random sample of patients was selected in each FMG; a total of 1046 participants completed both the baseline and follow-up questionnaires. MAIN OUTCOME MEASURES: Patients' perceptions of relational and informational continuity, organizational and first-contact accessibility, attitude and efficiency of the clinic's personnel and waiting times (service responsiveness), physician-nurse and primary care physician-specialist coordination, and intra-FMG collaboration were assessed over the telephone, mostly using a modified version of the Primary Care Assessment Tool. Additional items covered patients' opinions about consulting nurses, patients' use of emergency services, and patients' recall of health promotion and preventive care received. RESULTS: A total of 1275 patients were interviewed at the study baseline, and 82% also completed the follow-up interviews after 18 months (n = 1046). Overall, perceptions of relational and informational continuity increased significantly (P < .05), whereas organizational and first-contact accessibility and service responsiveness did not change significantly. Perception of physician-nurse coordination remained unchanged, but perception of primary care physician-specialist coordination decreased significantly (P < .05). The proportion of participants reporting visits with nurses and reporting use of FMGs' emergency services increased significantly from baseline to follow-up (P < .05). CONCLUSION: This reorganization of primary care services resulted in considerable changes in care practices, which led to improvements in patients' experiences of the continuity of care but not to improvements in their experiences of the accessibility of care.

Selecting process quality indicators for the integrated care of vulnerable older adults affected by cognitive impairment or dementia.

BACKGROUND: This study aimed at evaluating face and content validity, feasibility and reliability of process quality indicators developed previously in the United States or other countries. The indicators can be used to evaluate care and services for vulnerable older adults affected by cognitive impairment or dementia within an integrated service system in Quebec, Canada. METHODS: A total of 33 clinical experts from three major urban centres in Quebec formed a panel representing two medical specialties (family medicine, geriatrics) and seven health or social services specialties (nursing, occupational therapy, psychology, neuropsychology, pharmacy, nutrition, social work), from primary or secondary levels of care, including long-term care. A modified version of the RAND(R)/University of California at Los Angeles (UCLA) appropriateness method, a two-round Delphi panel, was used to assess face and content validity of process quality indicators. The appropriateness of indicators was evaluated according to a) agreement of the panel with three criteria, defined as a median rating of 7-9 on a nine-point rating scale, and b) agreement among panellists, judged by the statistical measure of the interpercentile range adjusted for symmetry. Feasibility of quality assessment and reliability of appropriate indicators were then evaluated within a pilot study on 29 patients affected by cognitive impairment or dementia. For measurable indicators the inter-observer reliability was calculated with the Kappa statistic. RESULTS: Initially, 82 indicators for care of vulnerable older adults with cognitive impairment or dementia were submitted to the panellists. Of those, 72 (88%) were accepted after two rounds. Among 29 patients for whom medical files of the preceding two years were evaluated, 63 (88%) of these indicators were considered applicable at least once, for at least one patient. Only 22 indicators were considered applicable at least once for ten or more out of 29 patients. Four indicators could be measured with the help of a validated questionnaire on patient satisfaction. Inter-observer reliability was moderate (Kappa = 0.57). CONCLUSION: A multidisciplinary panel of experts judged a large majority of the initial indicators valid for use in integrated care systems for vulnerable older adults in Quebec, Canada. Most of these indicators can be measured using patient files or patient or caregiver interviews and reliability of assessment from patient-files is moderate.

Seniors' views on the use of electronic health records.

In the Mauricie and Centre-du-Québec region of the province of Quebec, Canada, an integrated services network has been implemented for frail seniors. It combines three of the best practices in the field of integrated services, namely: single-entry point, case management and personalized care plan. A shared interdisciplinary electronic health record (EHR) system was set up in 1998. A consensus on the relevance of using EHRs is growing in Quebec, in Canada and around the world. However, technology has out-paced interest in the notions of confidentiality, informed consent and the impact perceived by the clientele. This study specifically examines how frail seniors perceive these issues related to an EHR. The conceptual framework is inspired by the DeLone and McLean model whose main attributes are: system quality, information quality, utilisation modes and the impact on organisations and individuals. This last attribute is the focus of this study, which is a descriptive with quantitative and qualitative component. Thirty seniors were surveyed. Positive information they provided falls under three headings: (i) being better informed; (ii) trust and consideration for professionals; and (iii) appreciation of innovation. The opinions of the seniors are generally favourable regarding the use of computers and the EHR in their presence. Improvements in EHR systems for seniors can be encouraged.

Quasi-experimental study of the effectiveness of an integrated service delivery network for the frail elderly.

The aim of this study was to examine the effectiveness of a new, integrated service delivery (ISD) network of health and social services for frail elderly living in a semi-urban community. A quasi-experimental study was conducted from 1997 to 2000, with measures taken before implementation (T0) and every 12 months after implementation for a 3-year period (T1, T2, T3); 482 people aged 75 years or older from 2 communities, 272 in the experimental and 210 in the control group, were followed. Analyses were conducted using parametric and non-parametric statistics, a generalized linear model, and Cox regression for survival analysis. A declining trend in institutionalization was observed and the desire to be institutionalized was lower in the study group. When absence of deterioration on follow-up was analysed in terms of the level of autonomy, the ISD network produced positive effects on the frailer clientele at T1, effects that tended to be maintained at T2. In regard to caregivers' burden, the ISD network seemed to have been effective, with caregivers' burden being less at T1 and T2. The ISD network did not have a marked effect on the utilization of services. The ISD network did, in fact, produce some effects that should be seen as important for the elderly population.