Design and methods of the Hospital Elder Life Program (HELP), a multicomponent targeted intervention to prevent delirium in hospitalized older patients: efficacy and cost-effectiveness in Dutch health care

BMC Geriatrics

Marieke J Schuurmans²  Sharon K Inouye⁴  Roos C van der Mast¹  Bas Steunenberg³  Marije J Strijbos² 

[1] Department of Psychiatry, Leiden University Medical Center, Postbus 9600, Leiden 2300 RC, The Netherlands;Department of Rehabilitation, Nursing Science and Sports Medicine, University Medical Center Utrecht, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands;Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, Utrecht 3584 CG, The Netherlands;Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, and the Institute for Aging Research, Hebrew Senior Life, 1200 Center Street, Boston, MA 02131, USA

关键词: Hospital elder life program;    The Netherlands;    Older people;    Hospital care organization;    Design and methods;    Prevention;    Delirium;   

Others  :  857513
DOI  :  10.1186/1471-2318-13-78

 received in 2013-06-06, accepted in 2013-07-18,  发布年份 2013

【 摘 要 】

Background

The Hospital Elder Life Program (HELP) has been shown to be highly efficient and (cost-)effective in reducing delirium incidence in the USA. HELP provides multicomponent protocols targeted at specific risk factors for delirium and introduces a different view on care organization, with trained volunteers playing a pivotal role. The primary aim of this study is the quantification of the (cost-)effectiveness of HELP in the Dutch health care system. The second aim is to investigate the experiences of patients, families, professionals and trained volunteers participating in HELP.

Methods/Design

A multiple baseline approach (also known as a stepped-wedge design) will be used to evaluate the (cost-) effectiveness of HELP in a cluster randomized controlled study. All patients aged 70 years and older who are at risk for delirium and are admitted to cardiology, internal medicine, geriatrics, orthopedics and surgery at two participating community hospitals will be included. These eight units are implementing the intervention in a successive order that will be determined at random. The incidence of delirium, the primary outcome, will be measured with the Confusion Assessment Method (CAM). Secondary outcomes include the duration and severity of delirium, quality of life, length of stay and the use of care services up to three months after hospital discharge. The experiences of patients, families, professionals and volunteers will be investigated using a qualitative design based on the grounded theory approach. Professionals and volunteers will be invited to participate in focus group interviews. Additionally, a random sample of ten patients and their families from each hospital unit will be interviewed at home after discharge.

Discussion

We hypothesize that HELP will reduce delirium incidence during hospital admission and decrease the duration and severity of delirium and length of hospital stays among these older patients, which will lead to reduced health care costs. The results of this study may fundamentally change our views on care organization for older patients at risk for delirium. The stepped-wedge design was chosen for ethical, practical and statistical reasons. The study results will be generalizable to the Dutch hospital care system, and the proven cost-effectiveness of HELP will encourage the spread and implementation of this program.

Trial Registration

Netherlands Trial register: NTR3842

【 授权许可】

   
2013 Strijbos et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Statistics Netherland: CBS Bevolkingstrends. Den Haag/Heerlen: Centraal Bureau voor de Statistiek; 2009.
• [2]Central Agency for Statistics (CBS): Gezondheid en zorg in cijfers. Den Haag: Centraal Bureau voor de Statistiek; 2012.
• [3]The Health Care Inspectorate (IGZ): De oudere patiënt met een delirium in het ziekenhuis: verwardheid nog onvoldoende onderkend. Den Haag, The Netherlands: Inspectie voor de Gezondheidszorg; 2005.
• [4]American Psychiatric Association: Diagnostic and statistical manual of mental disorders. 4th edition. Washington: American Psychiatric Association; 2000.
• [5]Mast RC, Huyse FJ, Drooglever HA, Heeren TJ, Izaks GJ, Kalisvaart CJ, Klijn FAM, Leentjes AFG, Sno HN, Schuurmans MJ, Wilterdink J: Richtlijn Delirium. Amsterdam: Uitgeverij Boom; 2004.
• [6]Puts MT, Shekary N, Widdershoven G, Heldens J, Lips P, Deeg DJ: What does quality of life mean to older frail and non-frail community-dwelling adults in the Netherlands? Qual Life Res 2007, 16(2):263-277.
• [7]Hoogerduijn JG, Schuurmans MJ, Duijnstee MS, De Rooij SE, Grypdonck MF: A systematic review of predictors and screening instruments to identify older hospitalized patients at risk for functional decline. J Clin Nurs 2007, 16(1):46-57.
• [8]Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P: Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med 1998, 13(4):234-242.
• [9]Teslyar P, Stock VM, Wilk CM, Camsari U, Ehrenreich MJ, Himelhoch S: Prophylaxis with antipsychotic medication reduces the risk of post-operative delirium in elderly patients: a meta-analysis. Psychosomatics 2013, 54(2):124-133.
• [10]Tabet N, Howard R: Pharmacological treatment for the prevention of delirium: review of current evidence. Int J Geriatr Psychiatry 2009, 24(10):1037-1044.
• [11]Kalisvaart CJ, Vreeswijk R, de Jonghe JF, Milisen K: A systematic review of multifactorial interventions for primary prevention of delirium in the elderly. Tijdschr Gerontol Geriatr 2005, 36(6):224-231.
• [12]Siddiqi N, Stockdale R, Britton AM, Holmes J: Interventions for preventing delirium in hospitalised patients. Cochrane Database Syst Rev 2007, 18(2):CD005563.
• [13]Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM Jr: A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999, 340(9):669-676.
• [14]Milisen K, Lemiengre J, Braes T, Foreman MD: Multicomponent intervention strategies for managing delirium in hospitalized older people: systematic review. J Adv Nurs 2005, 52(1):79-90.
• [15]NICE clinical guidelines: Delirium: diagnosis, prevention and management. NICE; 2010.
• [16]Inouye SK, Baker DI, Fugal P, Bradley EH: Dissemination of the Hospital Elder Life Program implementation, adaptation, and successes. J Am Geriatr Soc 2006, 54(10):1492-1499.
• [17]Rubin FH, Williams JT, Lescisin DA, Mook WJ, Hassan S, Inouye SK: Replicating the Hospital Elder Life Program in a community hospital and demonstrating effectiveness using quality improvement methodology. J Am Geriatr 2006, 54(6):969-974.
• [18]Rizzo JA, Bogardus ST, Leo-Summers L, Williams CS, Acampora D, Inouye SK: Multicomponent targeted intervention to prevent delirium in hospitalizes older patients: what is the economic value? Medical Care 2001, 39(7):740-752.
• [19]Leslie DL, Zhang Y, Bogardus ST, Holford TR, Leo-Summers LS, Inouye SK: Consequences of preventing delirium in hospitalized older adults on nursing home costs. J Am Geriatr Soc 2005, 53:405-409.
• [20]Caplan GA, Harper EL: Recruitment of volunteers to improve vitality in the elderly: the REVIVE study. Intern Med J 2007, 37:95-100.
• [21]Chen CCH, Lin MT, Tien YWm Yen CJ, Huang GH, Inouye SK: Modified Hospital Elder Life Program: effects on abdominal surgery patients. J Am Coll Surg 2011, 213:245-252.
• [22]Vidán MT, Sánchez E, Alonso M, Montero B, Ortiz J, Serra JA: An intervention integrated into daily clinical practice reduces the incidence of delirium during hospitalization in elderly patients. J Am Geriatr Soc 2009, 57(11):2029-2036.
• [23]Hawkins NG, Sanson-Fisher RW, Shakeshaft A, D'Este C, Green LW: The multiple baseline design for evaluating population-based research. Am J Prev Med 2007, 33(2):162-168.
• [24]Glaser BG, Strauss AL: The discovery of the grounded theory: strategies for grounded qualitative research. Chicago, IL: Aldine; 1967.
• [25]Strauss A, Corbin J: Basics of qualitative research: grounded theory procedures and techniques. London: Sage; 1990.
• [26]Safety Management Program (VMS: Vulnerable older people. VMS; 2009.
• [27]Inouye SK, Van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI: Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990, 113(12):941-948.
• [28]Inouye SK, Ferrucci L: Elucidating the pathophysiology of delirium and the interrelationship of delirium and dementia. J Gerontol A Biol Sci Med Sci 2006, 61(12):1277-1280.
• [29]Inouye SK, Zhang Y, Jones RN, Shi P, Cupples LA, Calderon HN, Marcantonio ER: Risk factors for hospitalization among community-dwelling primary care older patients: development and validation of a predictive model. Med Care 2008, 46(7):726-731.
• [30]Schuurmans MJ: Early recognition of delirium. PhdThesis University of Utrecht: Academia Press; 2001.
• [31]The HELP Programhttp://www.hospitalelderlifeprogram.org webcite
• [32]Pfeiffer E: A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 1975, 23(10):433-441.
• [33]Tuijl JP, Scholte EM, de Craen AJM, van der Mast RC: Screening for cognitive impairment in older general hospital patients: comparison of the Six-item Cognitive Impairment Test with the Mini-Mental State Examination. Int J Geriatr Psychiatry 2012, 27(7):755-762.
• [34]Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, Jimerson N: Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium. J Neuropsychiatry Clin Neurosci 2001, 13(2):229-242.
• [35]Schuurmans MJ, Shortridge-Baggett LM, Duursma SA: The Delirium Observation Screening Scale: a screening instrument for delirium. Res Theory Nurs Pract 2003, 17(1):31-50.
• [36]Wei LA, Fearing MA, Sternberg EJ, Inouye SK: The Confusion Assessment Method: a systematic review of current usage. J Am Geriatr Soc 2008, 56(5):823-830.
• [37]Wong CL, Holroyd-Leduc J, Simel DL, Straus SE: Does this patient have delirium? Value of bedside instruments. JAMA 2010, 304(7):779-786.
• [38]van Gemert LA, Schuurmans MJ: The Neecham Confusion Scale and the Delirium Observation Screening Scale: capacity to discriminate and ease of use in clinical practice. BMC Nurs 2007, 6:3. BioMed Central Full Text
• [39]Brooks B: EQ-5D, the current state of play. Health Pol 1996, 37(9):53-72.
• [40]What is R?http://www.r-project.org webcite
• [41]Hussey MA, Hughes JP: Design and analysis of stepped-wedge cluster randomized trials. Contemp Clin Trials 2007, 28(2):182-191.
• [42]Brown CA, Lilford RJ: The stepped-wedge trial design: a systematic review. BMC Med Res Methodol 2006, 8(6):54.
• [43]Ridda I, MacIntyre CR, Lindley RI, Tan TC: Difficulties in recruiting older people in clinical trials: an examination of barriers and solutions. Vaccine 2010, 28(4):901-906.