Interventions for improving older patients' involvement in primary care episodes

 

Abstract

Background

There is a growing expectation among patients that they should be involved in the delivery of medical care. Accumulating evidence from empirical studies shows that patients of average age who are encouraged to participate more actively in treatment decisions have more favourable health outcomes, in terms of both physiological and functional status, than those who do not. Interventions to encourage more active participation may be focused on different stages, including: the use of health care; preparation for contact with a care provider; contact with the care provider; or feedback about care. However, it is unclear whether the benefits of these interventions apply to the elderly as well.

Objectives

To assess the effects of interventions in primary medical care that improve the involvement of older patients (>=65 years) in their health care.

Search methods

We searched: the Cochrane Consumers and Communication Review Group Specialised Register (May 2003); the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library issue 1, 2004; MEDLINE (Ovid) (1966 to June 2004); EMBASE (1988 to June 2004); PsycINFO (1872 to June 2004); DARE, The Cochrane Library issue 1, 2004; ERIC (1966 to June 2004); CINAHL (1982 to June 2004); Sociological Abstracts (1963 to June 2004); Dissertation Abstracts International (1861 to June 2004); and reference lists of articles.

Selection criteria

Randomised controlled trials or quasi-randomised trials of interventions to improve the involvement of older patients (>= 65 years) in single consultations or episodes of primary medical care.

Data collection and analysis

Two review authors independently assessed trial quality and extracted data. Results are presented narratively as meta-analysis was not possible.

Main results

We identified three studies involving 433 patients. Overall, the quality of studies was not high, and there was moderate to high risk of bias. Interventions of a pre-visit booklet and a pre-visit session (either combined or pre-visit session alone) led to more questioning behaviour and more self-reported active behaviour in the intervention group (3 studies). One study (booklet and pre-visit session) showed no difference in consultation length and time engaged in talk between the intervention and control groups. The booklet and pre-visit session in one study was associated with more satisfaction with interpersonal aspects of care for the intervention group although no difference in overall satisfaction between intervention and control. There was no long-term follow up to see if effects were sustained. No studies measured outcomes relating to the use of health care, health status and wellbeing, or health behaviour.

Authors' conclusions

Overall this review shows some positive effects of specific methods to improve the involvement of older people in primary care episodes. Because the evidence is limited, however, we can not recommend the use of the reviewed interventions in daily practice. There should be a balance between respecting patients' autonomy and stimulating their active participation in health care. Face-to-face coaching sessions, whether or not complemented with written materials, may be the way forward. As this is impractical for the whole population, it could be worthwhile to identify a subgroup of older patients who might benefit the most from enhanced involvement, ie. those who want to be involved, but lack the necessary skills. This group could be coached either individually or, more practically, in group sessions.

 

Plain language summary

Ways of improving older patients' involvement in their primary care

Stimulating the involvement of older patients in their primary care may enhance their health. Therefore we reviewed studies of interventions to improve older people's involvement in their care. There has been little research in this area involving older people as the main target of the research. Only three trials were identified. These evaluated the effects of written or face-to-face preparation for consultations with doctors. Interventions of a pre-visit booklet and a pre-visit session (either combined or pre-visit session alone) led to more questioning behaviour by older people and more self-reported active behaviour. Overall, there is sparse evidence about the effects of interventions for improving older patients' involvement in their primary care.

 

摘要

背景

改善老年病人參與基層照護診療的介入

病人們愈來愈期待他們可以參與醫療照顧的進行。從經驗研究的累積證據發現，就一般年齡層者而言，有被鼓勵積極參與治療決策者比沒有被鼓勵參與者有較好的生理及功能之健康狀態。鼓勵更主動參與的介入分為幾個不同的階段，其包含：健康照顧的使用，與健康照護提供者聯絡的準備，與照護提供者的聯絡，或對於照護的回饋。但關於這些介入對於老年人是否有好處則未知。

目標

評估老年病人 (> = 65歲) 在基層醫療照護上，改善他們對健康照護參與的介入成效。

搜尋策略

我們搜尋了Cochrane Consumers 及Communication Review Group Specialised Register (2003年5月); the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library, 2004年第1期; MEDLINE (Ovid) (1966年到2004年6月); EMBASE (1988年到2004年6月); PsycINFO (1872年到2004年6月); DARE, The Cochrane Library 2004年第1期; ERIC (1966年到2004年6月); CINAHL (1982年2004年6月); Sociological Abstracts (1963年2004年6月); Dissertation Abstracts International (1861年到2004年6月) 及列出文獻的參考資料。

選擇標準

使用改善老年病人 (> = 65歲) 在單一次諮詢或基層醫療照護參與之隨機對照試驗或準隨機試驗的介入研究。

資料收集與分析

兩位審查者獨立評估研究試驗的品質並擷取資料。當無法作統合分析時，則以敘述性分析來呈現其結果。

主要結論

我們發現了3個研究，共納入433個病人。整體而言，這些研究的品質並不高，而且有中至高風險的偏差。3個研究顯示看診前小冊子或會議 (合併一起使用或單獨看診前會議) 的介入，會導致在介入組有較多的詢問行為或自我報告的主動行為。1個研究 (小冊子及看診前會議) 顯示介入組及對照組在諮詢長度及參與談話時間，並沒有差異。另1個研究顯示小冊子及看診前會議的介入，介入組及對照組在整體滿意度並無差異，但介入組在照顧層面有較高人際間滿意度，目前並無長期的追蹤可以看出其效果可否持續，也沒有研究用以評估健康照護使用、健康狀況及安寧美好的感覺，或健康行為等層面的結果。

作者結論

此回顧發現，用以改善老年人對於基層照顧參與的特定方法有一些正向的效果。因為證據有限，我們無法建議使用回顧所提到的介入方式於日常的執業之中，因此應在尊重病人自主性及刺激他們主動參與的健康照護中取得平衡。不管有無使用講義之面對面的指導會議，其可能是未來的可行方法，雖然此方式對於所有族群並不實際可行，但仍值得找出某些特定的老年族群可能最受惠於深入的參與，這一群人就是有心想要參與，但又缺少必要技巧的老年人，這群人可以以個別指導、或更實用的團體會議來作指導。

翻譯人

本摘要由成功大學附設醫院賴麗容翻譯。

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

少有證據顯示改善老年病人參與基層健康照護的介入效果。鼓勵老年病人參與基層照顧可能可以增進他們的健康。因此，我們回顧了增進老年人參與他們照顧的介入研究。在這方面的研究很少把老年人當作主要的研究族群，只發現3篇相關的研究，這些研究評估文字手冊或面對面對於與醫師諮詢前準備的效果，結果顯示看診前小冊子和會議 (合併或單純看診前會議) 的介入，可增加老年人有較多的詢問行為及自我報告的主動行為。