Interventions for improving older patients' involvement in primary care episodes.
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.


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


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.


METHODS
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.


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


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.


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.
Wetzels
R
R
Radboud University Nijmegen Medical Centre, Centre for Quality of Care Research (WOK), (117 KWAZO), PO Box 9101, Nijmegen, Netherlands, 6500 HB. r.wetzels@kwazo.umcn.nl
Harmsen
M
M
Van Weel
C
C
Grol
R
R
Wensing
M
M
D000368:Aged; D006801:Humans; D010358:Patient Participation; D011320:Primary Health Care; D012648:Self Care; D016896:Treatment Outcome