Effect of preventive home visits by a nurse on the outcomes of frail elderly people in the community: a randomized controlled trial.

BACKGROUND: Timely recognition and prevention of health problems among elderly people have been shown to improve their health. In this randomized controlled trial the authors examined the impact of preventive home visits by a nurse compared with usual care on the outcomes of frail elderly people living in the community. METHODS: A screening questionnaire identified eligible participants (those aged 70 years or more at risk of sudden deterioration in health). Those randomly assigned to the visiting nurse group were assessed and followed up in their homes for 14 months. The primary outcome measure was the combined rate of deaths and admissions to an institution, and the secondary outcome measure the rate of health services utilization, during the 14 months; these rates were determined through a medical chart audit by a research nurse who was blind to group allocation. RESULTS: The questionnaire was mailed to 415 elderly people, of whom 369 (88.9%) responded. Of these, 198 (53.7%) were eligible, and 142 consented to participate and were randomly assigned to either the visiting nurse group (73) or the usual care group (69). The combined rate of deaths and admissions to an institution was 10.0% in the visiting nurse group and 5.8% in the usual care group (p = 0.52). The rate of health services utilization did not differ significantly between the 2 groups. Influenza and pneumonia vaccination rates were significantly higher in the visiting nurse group (90.1% and 81.9%) than in the usual care group (53.0% and 0%) (p < 0.001). INTERPRETATION: The trial failed to show any effect of a visiting nurse other than vastly improved vaccination coverage.

Screening seniors for risk of functional decline: results of a survey in family practice.

OBJECTIVE: To measure functional status, determine risk of functional decline and assess consistency between responses and standardized instruments. DESIGN: A mailed survey which measured functional impairment, recent hospitalization and bereavement. A positive response on at least one of these factors indicated that the individual was "at risk" for functional decline. A random sample (n = 73) of "at risk" subjects (specifically, family practice patients aged 70 and older) were assessed by a nurse. RESULTS: The response rate was 89% (369/415), 59% of seniors were female and the mean age was 77.1 (SD = 5.5) years. Self-reported risk, based on activities of daily living (ADLs), was associated with impairment in at least one basic ADL (p < 0.0005) using a standardized instrument. The positive predictive value of the survey for ADL impairment was 65%. CONCLUSION: Response to a mailed survey was high and self-reported ADL risks were consistent with findings from standardized assessment tools.

Effect of the framing of questionnaire items regarding satisfaction with training on residents' responses.

PURPOSE: To determine whether framing questions positively or negatively influences residents' apparent satisfaction with their training. METHOD: In 1993-94, 276 residents at five Canadian internal medicine residency programs responded to 53 Likert-scale items designed to determine sources of the residents' satisfaction and stress. Two versions of the questionnaire were randomly distributed: one in which half the items were stated positively and the other half negatively, the other version in which the items were stated in the opposite way. RESULTS: The residents scored 43 of the 53 items higher when stated positively and scored ten higher when stated negatively (p < .0001). When analyzed using an analysis-of-variance model, the effect of positive versus negative framing was highly significant (F = 129.81, p < .0001). While the interaction between item and framing was also significant, the effect was much less strong (F = 5.56, p < .0001). On a scale where 1 represented the lowest possible level of satisfaction and 7 the highest, the mean score of the positively stated items was 4.1 and that of the negatively stated items, 3.8, an effect of 0.3. CONCLUSIONS: These results suggest a significant "response acquiescence bias." To minimize this bias, questionnaires assessing attitudes toward educational programs should include a mix of positively and negatively stated items.

Prospective care of elderly patients in family practice. Is screening effective?

OBJECTIVE: To evaluate cost and benefits of screening for and treating health and lifestyle risks among community-dwelling elderly. DESIGN: Randomized controlled trial. SETTING: Primary care. PARTICIPANTS: An opportunistic and prompted sample of 619 rostered elderly patients presenting for treatment who screened positive. INTERVENTIONS: One third (209) of experimental subjects had screening questionnaires placed in their charts with concerns highlighted for referrals. Two control groups received usual care. MAIN OUTCOME MEASURES: Yearly assessments of health service use and multidimensional functional capacity. RESULTS: Overall, screening and treatment of functionally active, elderly, middle-class people had no significant beneficial effect. Almost half of the experimental sample was ineligible because of treatment noncompliance. Generally ineligible subjects were older and more severely impaired. Subjects 75 years and older with risk factors showed improvement in daily living activities, and those living alone were found to have improved mental health and social functions (11% and 22%, respectively). CONCLUSIONS: Screening and treatment was ineffective in improving total functional capacity of all seniors 65 years and older. Elderly people 75 years and older, however, who were living alone or lonely did benefit from screening and treatment showing an improvement in daily activities, mental health scores, and social functions. This finding has implications for selective preventive health care spending for the elderly. A 2-year follow-up period could be too brief to detect long-term effects of early intervention with younger, middle-class seniors, especially those who are already functionally active.