A community-based nursing program delivered in collaboration with existing health care services is more effective in reducing the number of older people dying from chronic illnesses, such as cardiovascular disease and diabetes, than usual care according to a study by US researchers published in this week’s PLoS Medicine.
The authors led by Kenneth Coburn from Health Quality Partners in Pennsylvania in the US, randomized 1736 eligible patients (aged 65 years and over with heart failure, coronary heart disease, asthma, diabetes, hypertension, and/or hyperlipidemia who received traditional Medicare – a fee for service insurance scheme in which beneficiaries can choose to receive their care from any Medicare provider) to receive usual care or the nursing intervention in addition to usual services. The intervention included an individualized plan comprising education, symptom monitoring, medication counseling for adherence to treatment, help identifying, arranging, and monitoring community health and social service referrals in addition to group interventions such as weight loss maintenance and exercise classes.
The researchers found that 86 (9.9%) participants in the intervention group and 111 (12.9%) participants in the control group died during the study period, representing a 25% lower relative risk of death among the intervention group, a difference which became slightly larger when the authors considered other factors, such as sex, age, medical condition, and the number of medications taken.
The authors say: “The program of community-based care management tested in the current study appears to be a valuable addition to the primary care of appropriately selected chronically ill older adults.” They add: “Efforts to more broadly test the adaptability, scalability, and generalizability of this model seem warranted.”
In an accompanying Perspective, Arlene Bierman from the Faculty of Nursing at the University of Toronto, in Canada describes the health needs of the aging population as an impending storm. She argues that all adults at risk of chronic diseases should be considered in such programs: “Because complex interventions are most successful in high risk populations, there is the possibility that resources will be targeted primarily to these highest cost users of health services, perpetuating underinvestment in chronic disease prevention and management across risk strata. We need to learn how to efficiently tailor services and interventions across the continuum of risk.”
She continues: “Ultimately, the goal should be to reduce the population burden of chronic illness. This can only be accomplished by targeting the root causes of disease in the social determinants of health and an enhanced focus on prevention. Health system sustainability is dependent on improving the health of aging populations.”
Funding: This study was funded by Health Quality Partners, provided by the U.S. Centers for Medicare and Medicare Services (CMS) through a cooperative agreement with HQP to provide care coordination services as part of the conduct of the Medicare Coordinated Care Demonstration (MCCD). CMS and its contracted evaluator, Mathematica Policy Research, Inc. (MPR) had a significant role in the overall conduct and evaluation of the MCCD, but neither had any role in the data collection, analysis, decision to publish, or preparation associated with this manuscript.
Competing Interests: All authors are paid employees of Health Quality Partners, a nonprofit health care quality research and development organization.
Citation: Coburn KD, Marcantonio S, Lazansky R, Keller M, Davis N (2012) Effect of a Community-Based Nursing Intervention on Mortality in Chronically Ill Older Adults: A Randomized Controlled Trial. PLoS Med 9(7): e1001265. doi:10.1371/journal.pmed.1001265
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