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Original Investigation
Health Care Reform
October 25, 2010

Practice Redesign to Improve Care for Falls and Urinary Incontinence: Primary Care Intervention for Older Patients

Author Affiliations

Author Affiliations: Divisions of General Internal Medicine and Health Services Research (Dr Wenger) and Geriatrics (Drs Ganz and Reuben), David Geffen School of Medicine at University of California, Los Angeles; RAND Health, Santa Monica, California (Drs Wenger and Adams and Mss Roth, Beckman, and Rosen); Department of Medicine, University of Rochester, Rochester, New York (Dr Hall); Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California (Dr Ganz); American College of Physicians, Philadelphia, Pennsylvania (Dr Snow and Ms Snooks); Salem Clinic, Salem, Oregon (Dr Byrkit); Physicians Health Alliance, Scranton, Pennsylvania (Dr Dzielak); Mayo Clinic, Scottsdale, Arizona (Dr Gullen); Franciscan Skemp Healthcare, Mayo Health System, La Crosse, Wisconsin (Dr Loepfe); and Canandaigua Medical Group, Canandaigua, New York (Dr Sahler).

Arch Intern Med. 2010;170(19):1765-1772. doi:10.1001/archinternmed.2010.387
Abstract

Background  In primary care, medical care for age-associated conditions, such as falls and urinary incontinence (UI), is inadequate. In collaboration with the American College of Physicians, we augmented the Assessing Care of Vulnerable Elders practice redesign intervention to improve falls and UI care.

Methods  We performed a controlled trial in 5 nonrandomly selected primary care intervention (26 physicians across sites) and control (18 physicians) practices from diverse communities. Patients 75 years and older who screened positive for falls or fear of falling and UI were included in the study. We conducted a multicomponent intervention between October 30, 2006, and December 31, 2007, that included efficient collection of data, medical record prompts, patient education materials, and physician decision support. Main outcome measures were quality of care for falls and UI comparing intervention and control sites.

Results  Of 6051 patients screened, 2847 (47.1%) screened positive for falls or UI (46.1% in the intervention group and 48.8% in the control group). Across the 5 practices, 1211 patient medical records were evaluated after stratified random selection. Intervention patients received 60.0% of recommended care for falls vs 37.6% provided by control health care professionals (P < .001). Similarly, intervention health care professionals provided more recommended care for UI (47.2% vs 27.8%, P < .001). Intervention health care professionals more often performed a falls history, orthostatic blood pressure measurement, gait and balance examination, and UI history and tried UI behavioral treatments first. Knowledge about falls and UI increased more among intervention than control group health care professionals.

Conclusions  Practice redesign can improve the care that community-based primary care physicians provide for older patients with falls and UI. Outcomes of such care improvements require further evaluation.

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