Effectiveness of interventions that assist caregivers to support people with dementia living in the community: a systematic review.

Objectives  The objective of this review was to assess the effectiveness of interventions that assist caregivers to provide support for people living with dementia in the community. Inclusion criteria  Types of participants  Adult caregivers who provide support for people with dementia living in the community (non-institutional care). Types of interventions  Interventions designed to support caregivers in their role such as skills training, education to assist in caring for a person living with dementia and support groups/programs. Interventions of formal approaches to care designed to support caregivers in their role, care planning, case management and specially designated members of the healthcare team - for example dementia nurse specialist or volunteers trained in caring for someone with dementia. Types of studies  This review considered any meta-analyses, systematic reviews, randomised control trials, quasi-experimental studies, cohort studies, case control studies and observational studies without control groups that addressed the effectiveness of interventions that assist caregivers to provide support for people living with dementia in the community. Search strategy  The search sought to identify published studies from 2000 to 2005 through the use of electronic databases. Only studies in English were considered for inclusion. The initial search was conducted of the databases, CINAHL, MEDLINE and PsychINFO using search strategies adapted from the Cochrane Dementia and Cognitive Improvement Group. A second more extensive search was then conducted using the appropriate Medical Subject Headings (MeSH) and keywords for other available databases. Finally, hand searching of reference lists of articles retrieved and of core dementia, geriatric and psycho geriatric journals was undertaken. Assessment of quality  Methodological quality of each of the articles was assessed by two independent reviewers using appraisal checklist developed by the Joanna Briggs Institute and based on the work of the Cochrane Collaboration and Centre for Reviews and Dissemination. Data collection and analysis  Standardised mean differences or weighted mean differences and their 95% confidence intervals were calculated for each included study reported in the meta-analysis. Results from comparable groups of studies were pooled in statistical meta-analysis using Review Manager Software from the Cochrane Collaboration. Heterogeneity between combined studies was tested using standard chi-square test. Where statistical pooling was not appropriate or possible, the findings are summarised in narrative form. Results  A comprehensive search of relevant databases, hand searching and cross referencing found 685 articles that were assessed for relevance to the review. Eighty-five papers appeared to meet the inclusion criteria based on title and abstract, and the full paper was retrieved. Of the 85 full papers reviewed, 40 were accepted for inclusion, three were systematic reviews, three were meta-analysis, and the remaining 34 were randomised controlled trials. For the randomised controlled trials that were able to be included in a meta-analysis, standardised mean differences or weighted mean differences and their 95% confidence intervals were calculated for each. Results from comparable groups of studies were pooled in statistical meta-analysis using Review Manager Software and heterogeneity between combined studies was assessed by using the chi-square test. Where statistical pooling was not appropriate or possible, the findings are summarised in narrative form. The results are discussed in two main sections. Firstly it was possible to assess the effectiveness of different types of caregiver interventions on the outcome categories of depression, health, subjective well-being, self-efficacy and burden. Secondly, results are reported by main outcome category. For each of these sections, meta-analysis was conducted where it was possible; otherwise, a narrative summary describes the findings. Effectiveness of intervention type  Four categories of intervention were included in the review - psycho-educational, support, multi-component and other. Psycho-educational Thirteen studies used psycho-educational interventions, and all but one showed positive results across a range of outcomes. Eight studies were entered in a meta-analysis. No significant impact of psycho-educational interventions was found for the outcome categories of subjective well-being, self-efficacy or health. However, small but significant results were found for the categories of depression and burden. Support Seven studies discussed support only interventions and two of these showed significant results. These two studies were suitable for meta-analysis and demonstrated a small but significant improvement on caregiver burden. Multi-component Twelve of the studies report multi-component interventions and 10 of these report significant outcomes across a broad range of outcome measures including self-efficacy, depression, subjective well-being and burden. Unfortunately because of the heterogeneity of study designs and outcome measures, no meta-analysis was possible. Other interventions Other interventions included the use of exercise or nutrition which resulted in improvements in psychological distress and health benefits. Case management and a computer aided support intervention provided mixed results. One cognitive behavioural therapy study reported a reduction in anxiety and positive impacts on patient behaviour. Effectiveness of interventions using specific outcome categories  In addition to analysis by type of intervention it was possible to analyse results based on some outcome categories that were used across the studies. In particular the impact of interventions on caregiver depression was available for meta-analysis from eight studies. This indicated that multi-component and psycho-educational interventions showed a small but significant positive effect on caregiver depression. Five studies using the outcome category of caregiver burden were entered into a meta-analysis and findings indicated that there were no significant effects of any of interventions. No meta-analysis was possible for the outcome categories of health, self-efficacy or subjective well-being. Implications for practice  From this review there is evidence to support the use of well-designed psycho-educational or multi-component interventions for caregivers of people with dementia who live in the community. Factors that appear to positively contribute to effective interventions are those which: •  Provide opportunities within the intervention for the person with dementia as well as the caregiver to be involved •  Encourage active participation in educational interventions for caregivers •  Offer individualised programs rather than group sessions •  Provide information on an ongoing basis, with specific information about services and coaching regarding their new role •  Target the care recipient particularly by reduction in behaviours Factors which do not appear to have benefit in interventions are those which: •  Simply refer caregivers to support groups •  Only provide self help materials •  Only offer peer support.

Parker D ，Mills S ，Abbey J 《-》

Effectiveness of interventions that assist caregivers to support people with dementia living in the community: a systematic review.

Parker D ，Mills S ，Abbey J 《-》

How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect?

EXECUTIVE SUMMARY: Across the developed world, we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision. Integrated care pathways (ICPs) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration. ICPs map out a patient's journey, providing coordination of services for users. They aim to have: 'the right people, doing the right things, in the right order, at the right time, in the right place, with the right outcome'. The value for ICPs in supporting the delivery of care across organisational boundaries, providing greater consistency in practice, improving service continuity and increasing collaboration has been advocated by many. However, there is little evidence to support their use, and the need for systematic evaluations in order to measure their effectiveness has been widely identified. A recent Cochrane review assessed the effects of ICPs on functional outcome, process of care, quality of life and hospitalisation costs of inpatients with acute stroke, but did not specifically focus on service integration or its derivatives. To the best of our knowledge, no such systematic review of the literature exists. • To systematically review all high-quality studies which have evaluated the impact of care pathway technologies on 'service integration' and its derivatives in stroke care • To examine how elements of service integration are defined in such studies • To examine the type of evidence utilised to measure service integration • To analyse the weight of evidence used to support claims about the effectiveness of ICPs on improving service integration • To produce recommendations for ICP developers, users and evaluators. Types of participants The review focused on the care of adult patients who had suffered a stroke. It included the full spectrum of services - acute care, rehabilitation and long-term support - in hospital and community settings. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest, defined for the purpose of this review as 'a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and standardise the outcome orientated care' Here 'multidisciplinary' is taken to refer to the involvement of two or more disciplines. Types of outcomes 'Service integration' was the outcome of interest however, this was defined and measured in the selected studies. Types of studies This review was concerned with how 'service integration' was defined in evaluations of ICPs; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on 'service integration'. Studies that made an explicit link between ICPs and service integration were included in the review. Evidence generated from randomised controlled trials, quasi-experimental, qualitative and health economics research was sought. The search was limited to publications after 1980, coinciding with the emergence of ICPs in the healthcare context. Assessment for inclusion of foreign papers was based on the English-language abstract, where available. These were included only if an English translation was available. This review excluded studies that: • focused only on a single aspect of stroke care (e.g. dysphasia) • evaluated ICPs as part of a wider program of service development • did not make an explicit link between ICPs and service integration • did not meet the definition of ICP utilised for the purposes of the review • focused exclusively on the outcomes of variance analysis In order to avoid replication, the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Database and the Cochrane Library were searched to establish that no systematic reviews existed and none were in progress. A three-stage search strategy was then used to identify both published and unpublished studies (see Appendix III). Our search strategy located 2123 papers, of which 39 were retrieved for further evaluation. We critically appraised seven papers, representing five studies. These were all evaluation studies and, as is typical in this field, comprised a range of study designs and data collection methods. Owing to the diversity of the study types included in the review, we developed a single-appraisal checklist and data-extraction tool which could be applied to all research designs.(32) The tool drew on the Joanna Briggs Institute (JBI) appraisal checklists for experimental studies and interpretive and critical research, and also incorporated specific information and issues which were relevant for our purposes (see Appendix VI). This extends the thinking outlined in Lyne et al.(31) in which, drawing on Campbell and Stanley's classic paper, the case is made for developing an appraisal tool which is applicable to all types of evaluation, irrespective of study design. In assessing the quality of the papers, we were sympathetic to the methodological challenges of evaluating complex interventions such as ICPs. We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare contexts. In accordance with the aims of this particular review, we have included studies, which are methodologically weaker than is typical of many systematic reviews because, in our view, in the absence of stronger evidence, they yield useful information. Given the heterogeneity of the included studies, meta-analysis and/or qualitative synthesis was not possible. A narrative summary of the study findings is presented. 1 ICPs can be effective in ensuring that patients receive relevant clinical interventions and/or assessments in a timely manner, although these improvements may reflect better documentation rather than actual changes in practice. 2 ICPs can be effective in improving the documentation of rehabilitation goals, documentation of communication with patients, carers (diagnosis, prognosis and follow-up arrangements) and documentation of notification of primary care physicians of discharge. However, this can create additional burdens of work for staff. 3 Early studies of ICP-managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination, morbidity or mortality. These effects do not reach statistical significance, however, and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay. While later studies in the acute and rehabilitation contexts do not reveal any significant reduction in length of stay, they do report greater documented use of certain clinical interventions and assessments, suggesting that ICPs can be effective in mobilising hospital resources around the patient. 4 ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections, although we do not know whether this can be attributed to improved service integration. 5 ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher-level functioning and carer needs influencing perceptions of quality of life. 6 ICP management may assist in clarifying role boundaries and a shared understanding of the work, but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation. 7 There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement, but in situations in which multidisciplinary working is effective, their positive effects may be limited. Furthermore, it is far from clear what the active ingredients of ICPs actually are. Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.(20) 8 None of the studies assessed the balance of costs and benefits of ICP use. Therefore, we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits. Implications for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care. This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of resources around the patient without incurring additional increases in length of stay. ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable. Their value in the context of rehabilitation settings in which recovery pathways are more variable is less clear. There is some evidence that ICPs may be effective in bringing about behavioural changes in contexts where deficiencies in service provision have been identified. Their value in contexts where inter-professional working is well established is less clear. While earlier before and after studies show a reduction in length of stay in ICP-managed care, this may reflect wider healthcare trends, and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced. There is some evidence to suggest that ICPs bring about improvements in documentation, but we do not know how far documented practice reflects actual practice. It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use. (ABSTRACT TRUNCATED)

Allen D ，Rixson L 《-》

Association between pacifier use and breast-feeding, sudden infant death syndrome, infection and dental malocclusion.

Callaghan A ，Kendall G ，Lock C ，Mahony A ，Payne J ，Verrier L ... -  《-》

Promoting and supporting self-management for adults living in the community with physical chronic illness: A systematic review of the effectiveness and meaningfulness of the patient-practitioner encounter.

There has been a reported rise in the number of people with chronic illness (also referred to as long-term disease) in the Western world. One hundred million people in the United States have at least one chronic condition and in the United Kingdom (UK) as many as 17.5 million adults may be living with chronic disease. New models of care have been developed which recognise the complexities of managing care where there is overlap between the wider community, the health care system and provider organisations, for example, the Chronic Care Model and the Expert Patient Programme. These new models herald a shift away from the idea of chronically ill patients as passive recipients of care towards active engagement, in partnership with health professionals, in managing their own care.Partnership, ideally, involves collaborative care and self-management education. This may support self-care alongside medical, preventative and health maintenance interventions. In this context the nature of the patient-practitioner consultation in promoting self-care takes on a new importance. The overall objective of the review was to determine the best available evidence regarding the promotion and support of self-care management for adults living in the community with chronic illness during the patient-practitioner encounter. Specifically the review sought to determine: What is the effectiveness of the patient-practitioner encounter in promoting and supporting self-care management of people with chronic illness? What are the individual and organisational factors which help or hinder recognition, promotion and support of chronic disease self-care management strategies? What are the similarities and differences between how 'effectiveness' is defined in this context by patients and different practitioners? The review focussed on self-caring adults aged nineteen years and older living in the community, with a physical chronic illness, and not currently being treated as an in-patient. For example, people with diabetes, asthma, arthritis, coronary disease, lung disease, heart failure, epilepsy, kidney disease and inflammatory bowel disease. Since patients meet various professionals in a variety of community settings regarding their care, a practitioner in this review included doctors (physicians and General Practitioners), nurses, nurse specialists, dieticians, podiatrists and community health workers.A variety of outcomes measures was used to evaluate effective self-care management. These included physiological measurements such as: HbA1c, blood pressure, body weight, lipids; lifestyle measurements, for example physical activity; and self-care determinants such as knowledge, attitude; and self-care behaviours regarding, for example, diet and physical exercise, and medication. The outcome measures used to explore the meaningfulness of the patient-practitioner encounter, concerned patients', physicians' and nurses' views and perceptions of self-care management and support.The review considered all types of quantitative and qualitative evidence regarding the patient-practitioner encounter where self-care in chronic illness was the focus. The quantitative studies reviewed included systematic reviews, randomised controlled trials (RCTs), quasi-experimental studies, and survey studies.Qualitative studies reviewed included interview designs, vignette technique, qualitative evaluation, grounded theory, and exploratory descriptive design. The search sought to find both published and unpublished studies between 1990 and 2005. The year 1990 was deemed appropriate since it precedes the development of the Chronic Care Model in which self-management support for people living with chronic illness is heralded as an important part of care-management. An initial search of CINAHL and MEDLINE databases was undertaken to identify appropriate search terms regarding self-care and chronic illness. A search strategy was then developed using all identified MeSH headings and key words and the following databases were searched: - Ovid CINAHL; Ovid MEDLINE (R); Ovid EMBASE; Ovid EBM Reviews (CDSR, ACP Journal Club, DARE, CCTR); ASSIA; SIGLE; Digital Dissertations; and British Library's Zetoc Services. Thirty-two papers were considered applicable to the review topic from the title and abstract. Two reviewers used the appropriate critical appraisal instruments designed by the Joanna Briggs Institute (JBI) to assess methodological quality of papers retrieved for review, and agreed on the papers for inclusion. A total of 18 papers reporting 16 studies were included in the review (3 papers reported from the same study): 12 quantitative studies, 5 qualitative studies and 1 study using mixed methods. These papers were heterogeneous in nature, diverse in subject matter and considered a wide range of physiological, psychological, sociological and behavioural self-care outcome measures. Data were extracted by the two independent reviewers using a variety of data extraction instruments developed by JBI. The heterogeneous nature of the quantitative studies prevented meta-analysis and so these studies are presented in narrative summary. Meta-synthesis of the qualitative data was performed for the six qualitative pieces following the process of meta-synthesis set out in the JBI-QARI software package. The process of meta-synthesis embodied in this programme involves the aggregation or synthesis of findings. Seven syntheses were produced from fifty findings. For effective patient-centeredness to be established patients should be able to discuss their own ideas about self-care actions, including lifestyle management in an unhurried fashion and with a practitioner who has the time and who is willing to listen. Patient-centred interventions aimed at providers such as patient-centred training and patient-centred materials were shown to have a positive effect on the patient-centeredness of an encounter, but their effect on self-care outcomes was not clear. Interventions directed at enhancing patient participation in the encounter were shown to effect diabetes self-care and self-behaviour.Nurses were shown to have an effective role in educating patients and facilitating adherence to treatment. Patients found nurses approachable and some studies showed that when given the choice, patients were more likely to contact a nurse (than a doctor) regarding their care.Professional interventions such as education, and organisational interventions such as management of regular review and follow up, were shown to improve process outcomes in the management of a patient-practitioner encounter. When patient-orientated interventions were added to professional and organisational interventions, in which patient education and / or the role of the nurse was enhanced, patient health outcomes were improved.The different patient-orientated interventions reviewed highlighted some of the elements that can effectively support self-care management during a patient-practitioner encounter. These are information giving, including the use of a guidebook, the use of care plans, the structure of treatment using checklists, and education and support for staff in 'collaboratives'.Comprehensive, well-paced, user-friendly information is effective in supporting and promoting self-care management in a variety of ways. It informs and reassures patients and their families. It can be used during a doctor/patient consultation to assist communication between doctors and patients, and may help patients feel more involved in their care.For information to effect self-care management, it is important that it is given at diagnosis and from then onwards so that the implications of good self-care management in relation to long term health outcomes are established.Care plans and self-management plans can be useful in facilitating patients' discussion of self-care actions and lifestyle management.Organisational factors affect opportunities for professionals to support patient self-care management. These include time, resources, the existing configuration and expectations of a consultation, the opportunity for open access to appointments, the ability to see the same doctor and early referral to other professional groups.Correlational design studies indicated that individual psychological factors, such as attachment style and autonomy support given to a patient during a patient-practitioner encounter, have a relationship to self-care behaviours and outcomes.Correlational design studies indicated that both general communication and diabetic specific communication used during a patient-practitioner encounter have a positive effect on patient self-care management and outcomes for patients with diabetes.Consultations about self-care for patients with chronic illness tend to be medically focussed and do not always include discussion of patients' views of the routines and self-care actions. This can lead to tension and unresolved issues between the patient and professional.Studies in the context of diabetes self-management reveal that professionals can effectively support patients in a number of ways. These include assisting the orientation of patients towards skills and competencies needed for self-care; sharing knowledge and information; endorsing the patient's view that he or she is the most reliable and accurate source of information about his or her physiological function; trusting the patients' interpretations of their physiological function, and modifying advice in response to patients in accordance with their bodily cues and experiences. The nature of the patient-practitioner encounter is multifaceted involving patient, professional and organisational factors. Patient-orientated interventions are the most effective in effecting positive self-care behavioural and health outcomes. Patient participation in the patient-practitioner encounter is a key factor in influencing self-care outcomes. Patients' self-care management involves social as well as medical management. Professionals need to recognise and value patients' views and experiences in order to support their self-care management. Patients need information at diagnosis and from then onwards to enable good self-care management. It is important to enable patient participation during the patient-practitioner encounter.For patients' self-care needs to be addressed opportunities for patients to talk about their diet, routines and lifestyle management need to be incorporated into the encounter. Extra time in consultations may be required. Care plans can help to facilitate this discussion.To support patients with their self-care management, both sharing of medical and nursing knowledge, and recognition of the value of patient's knowledge and experiences are vital.Nurses relate well to patients who want to discuss self-care management.Professional interventions and organisational interventions can improve the management of a patient-practitioner encounter. Patient-orientated interventions in addition to good management of the encounter can improve health care outcomes. Patient focussed interventions have a positive effect on patient self-care outcomes. Further research regarding patients' self-care and health outcomes and behaviours is needed to establish which patient focussed interventions in particular are effective.Qualitative research has proved to be important in understanding the different ways that professionals and patients approach self-care management during an encounter. More qualitative research would assist an understanding of the processes that inspire effective partnership between patients and professionals to support the establishment of self-care management of chronic illness.

Rees S ，Williams A 《-》