Skyline of Hamilton, Ontario A study of “preventive primary care outreach” for older adults at risk of functional decline, conducted in Hamilton, Ontario was recently (April 16, 2010) published in the British Medical Journal [link here]. The study design, execution, and analysis appear to be carefully thought out and well done. Results show little impact of the intervention tested over a one year period in terms of quality of life, health care service utilization, cost, or mortality.
The intervention included home assessments by nurses at baseline, 6, and 12 months (mean 3.03 per patient per year) and additional telephone calls (mean 1.17 per patient per year). During the home visits, assessments were performed and patients referred to services as needed, patients and families given some educational support and encouraged to adopt more healthy behaviors.
Conceptually the Canadian intervention appears designed to link patients to already existing primary care services more proactively and is less geared to directly providing a new set of services to these patients to affect outcomes – for example, nurse-led seated exercise, gait and balance training, weight management classes, etc.. In fact, there appears to have been no group classes directly provided by nurse care managers in the Hamilton model.
The contrast between this program and the community-based nurse care management program designed by HQP is striking. The HQP model averages about 17 nurse contacts per person per year, with about half of those as some type of in-person contact – either one-to-one or as part of a group program. There is a strong emphasis on the direct provision of services and supports by the nurses that have no readily available equivalent in primary care offices or the community. And the average follow-up period for HQP enrollees is now about 4 years and counting. Bottom line is that the “duration”, “dose”, and “treatment” itself is vastly different from the Canadian model.
It is crucial that providers, researchers, and policy makers working in this field understand how crucial it is to define differences in program design, target population, implementation strategies, “dose”, and “duration” when evaluating program effectiveness. We know better than to conclude that an unsuccessful trial of one type, dose, frequency or route of a drug for one type of cancer indicates that all chemotherapy is useless for cancer treatment. Likewise, we must become more discerning about how we understand the potential of nurse care management and other services that can augment our existing primary care model. They too vary greatly in many characteristics that determine their impact on health outcomes.
Conceptually the Canadian intervention appears designed to link patients to already existing primary care services more proactively and is less geared to directly providing a new set of services to these patients to affect outcomes – for example, nurse-led seated exercise, gait and balance training, weight management classes, etc.. In fact, there appears to have been no group classes directly provided by nurse care managers in the Hamilton model.
The contrast between this program and the community-based nurse care management program designed by HQP is striking. The HQP model averages about 17 nurse contacts per person per year, with about half of those as some type of in-person contact – either one-to-one or as part of a group program. There is a strong emphasis on the direct provision of services and supports by the nurses that have no readily available equivalent in primary care offices or the community. And the average follow-up period for HQP enrollees is now about 4 years and counting. Bottom line is that the “duration”, “dose”, and “treatment” itself is vastly different from the Canadian model.
It is crucial that providers, researchers, and policy makers working in this field understand how crucial it is to define differences in program design, target population, implementation strategies, “dose”, and “duration” when evaluating program effectiveness. We know better than to conclude that an unsuccessful trial of one type, dose, frequency or route of a drug for one type of cancer indicates that all chemotherapy is useless for cancer treatment. Likewise, we must become more discerning about how we understand the potential of nurse care management and other services that can augment our existing primary care model. They too vary greatly in many characteristics that determine their impact on health outcomes.