A Practice-Based Intervention to Improve Primary Care for Falls, Urinary Incontinence, and Dementia

(See editorial comments by C. Seth Landefeld, pp 000–000)

Authors

  • Neil S. Wenger MD, MPH,

    1. From *RAND, Santa Monica, CaliforniaDepartment of Medicine, University of California at Los Angeles, Los Angeles, CaliforniaGreater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California§RAND, Washington, District of ColumbiaZynx Health, Los Angeles, California#National Cancer Center, Tokyo, Japan**Programs for Clinical Excellence, WellPoint, Inc., Woodland Hills, California††Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, California‡‡Desert Medical Group, Palm Springs, California.
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  • Carol P. Roth RN, MPH,

    1. From *RAND, Santa Monica, CaliforniaDepartment of Medicine, University of California at Los Angeles, Los Angeles, CaliforniaGreater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California§RAND, Washington, District of ColumbiaZynx Health, Los Angeles, California#National Cancer Center, Tokyo, Japan**Programs for Clinical Excellence, WellPoint, Inc., Woodland Hills, California††Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, California‡‡Desert Medical Group, Palm Springs, California.
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  • Paul G. Shekelle MD, PhD,

    1. From *RAND, Santa Monica, CaliforniaDepartment of Medicine, University of California at Los Angeles, Los Angeles, CaliforniaGreater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California§RAND, Washington, District of ColumbiaZynx Health, Los Angeles, California#National Cancer Center, Tokyo, Japan**Programs for Clinical Excellence, WellPoint, Inc., Woodland Hills, California††Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, California‡‡Desert Medical Group, Palm Springs, California.
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  • Roy T. Young MD,

    1. From *RAND, Santa Monica, CaliforniaDepartment of Medicine, University of California at Los Angeles, Los Angeles, CaliforniaGreater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California§RAND, Washington, District of ColumbiaZynx Health, Los Angeles, California#National Cancer Center, Tokyo, Japan**Programs for Clinical Excellence, WellPoint, Inc., Woodland Hills, California††Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, California‡‡Desert Medical Group, Palm Springs, California.
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  • David H. Solomon MD,

    1. From *RAND, Santa Monica, CaliforniaDepartment of Medicine, University of California at Los Angeles, Los Angeles, CaliforniaGreater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California§RAND, Washington, District of ColumbiaZynx Health, Los Angeles, California#National Cancer Center, Tokyo, Japan**Programs for Clinical Excellence, WellPoint, Inc., Woodland Hills, California††Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, California‡‡Desert Medical Group, Palm Springs, California.
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  • Caren J. Kamberg MSPH,

    1. From *RAND, Santa Monica, CaliforniaDepartment of Medicine, University of California at Los Angeles, Los Angeles, CaliforniaGreater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California§RAND, Washington, District of ColumbiaZynx Health, Los Angeles, California#National Cancer Center, Tokyo, Japan**Programs for Clinical Excellence, WellPoint, Inc., Woodland Hills, California††Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, California‡‡Desert Medical Group, Palm Springs, California.
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  • John T. Chang MD, MPH,

    1. From *RAND, Santa Monica, CaliforniaDepartment of Medicine, University of California at Los Angeles, Los Angeles, CaliforniaGreater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California§RAND, Washington, District of ColumbiaZynx Health, Los Angeles, California#National Cancer Center, Tokyo, Japan**Programs for Clinical Excellence, WellPoint, Inc., Woodland Hills, California††Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, California‡‡Desert Medical Group, Palm Springs, California.
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  • Rachel Louie MS,

    1. From *RAND, Santa Monica, CaliforniaDepartment of Medicine, University of California at Los Angeles, Los Angeles, CaliforniaGreater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California§RAND, Washington, District of ColumbiaZynx Health, Los Angeles, California#National Cancer Center, Tokyo, Japan**Programs for Clinical Excellence, WellPoint, Inc., Woodland Hills, California††Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, California‡‡Desert Medical Group, Palm Springs, California.
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  • Takahiro Higashi MD, PhD,

    1. From *RAND, Santa Monica, CaliforniaDepartment of Medicine, University of California at Los Angeles, Los Angeles, CaliforniaGreater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California§RAND, Washington, District of ColumbiaZynx Health, Los Angeles, California#National Cancer Center, Tokyo, Japan**Programs for Clinical Excellence, WellPoint, Inc., Woodland Hills, California††Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, California‡‡Desert Medical Group, Palm Springs, California.
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  • Catherine H. MacLean MD, PhD,

    1. From *RAND, Santa Monica, CaliforniaDepartment of Medicine, University of California at Los Angeles, Los Angeles, CaliforniaGreater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California§RAND, Washington, District of ColumbiaZynx Health, Los Angeles, California#National Cancer Center, Tokyo, Japan**Programs for Clinical Excellence, WellPoint, Inc., Woodland Hills, California††Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, California‡‡Desert Medical Group, Palm Springs, California.
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  • John Adams PhD,

    1. From *RAND, Santa Monica, CaliforniaDepartment of Medicine, University of California at Los Angeles, Los Angeles, CaliforniaGreater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California§RAND, Washington, District of ColumbiaZynx Health, Los Angeles, California#National Cancer Center, Tokyo, Japan**Programs for Clinical Excellence, WellPoint, Inc., Woodland Hills, California††Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, California‡‡Desert Medical Group, Palm Springs, California.
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  • Lillian C. Min MD,

    1. From *RAND, Santa Monica, CaliforniaDepartment of Medicine, University of California at Los Angeles, Los Angeles, CaliforniaGreater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California§RAND, Washington, District of ColumbiaZynx Health, Los Angeles, California#National Cancer Center, Tokyo, Japan**Programs for Clinical Excellence, WellPoint, Inc., Woodland Hills, California††Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, California‡‡Desert Medical Group, Palm Springs, California.
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  • Kurt Ransohoff MD,

    1. From *RAND, Santa Monica, CaliforniaDepartment of Medicine, University of California at Los Angeles, Los Angeles, CaliforniaGreater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California§RAND, Washington, District of ColumbiaZynx Health, Los Angeles, California#National Cancer Center, Tokyo, Japan**Programs for Clinical Excellence, WellPoint, Inc., Woodland Hills, California††Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, California‡‡Desert Medical Group, Palm Springs, California.
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  • Marc Hoffing MD,

    1. From *RAND, Santa Monica, CaliforniaDepartment of Medicine, University of California at Los Angeles, Los Angeles, CaliforniaGreater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California§RAND, Washington, District of ColumbiaZynx Health, Los Angeles, California#National Cancer Center, Tokyo, Japan**Programs for Clinical Excellence, WellPoint, Inc., Woodland Hills, California††Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, California‡‡Desert Medical Group, Palm Springs, California.
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  • David B. Reuben MD

    1. From *RAND, Santa Monica, CaliforniaDepartment of Medicine, University of California at Los Angeles, Los Angeles, CaliforniaGreater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California§RAND, Washington, District of ColumbiaZynx Health, Los Angeles, California#National Cancer Center, Tokyo, Japan**Programs for Clinical Excellence, WellPoint, Inc., Woodland Hills, California††Sansum-Santa Barbara Medical Foundation Clinic, Santa Barbara, California‡‡Desert Medical Group, Palm Springs, California.
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Address correspondence to Neil S. Wenger, Department of Medicine, 911 Broxton Plaza, Los Angeles, CA 90095. E-mail: nwenger@mednet.ucla.edu

Abstract

OBJECTIVES: To determine whether a practice-based intervention can improve care for falls, urinary incontinence, and cognitive impairment.

DESIGN: Controlled trial.

SETTING: Two community medical groups.

PARTICIPANTS: Community-dwelling patients (357 at intervention sites and 287 at control sites) aged 75 and older identified as having difficulty with falls, incontinence, or cognitive impairment.

INTERVENTION: Intervention and control practices received condition case-finding, but only intervention practices received a multicomponent practice-change intervention.

MEASUREMENTS: Percentage of quality indicators satisfied measured using a 13-month medical record abstraction.

RESULTS: Before the intervention, the quality of care was the same in intervention and control groups. Screening tripled the number of patients identified as needing care for falls, incontinence, or cognitive impairment. During the intervention, overall care for the three conditions was better in the intervention than the control group (41%, 95% confidence interval (CI)=35–46% vs 25%, 95% CI=20–30%, P<.001). Intervention group patients received better care for falls (44% vs 23%, P<.001) and incontinence (37% vs 22%, P<.001) but not for cognitive impairment (44% vs 41%, P=.67) than control group patients. The intervention was more effective for conditions identified by screening than for conditions identified through usual care.

CONCLUSION: A practice-based intervention integrated into usual clinical care can improve primary care for falls and urinary incontinence, although even with the intervention, less than half of the recommended care for these conditions was provided. More-intensive interventions, such as embedding intervention components into an electronic medical record, will be needed to adequately improve care for falls and incontinence.

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