FIRE (facilitating implementation of research evidence): a study protocol (Cost)effectiveness of life review for Older Adults: Design of a randomized controlled trial Next steps for falls and fracture reduction. A factorial-design cluster randomised controlled trial investigating the cost-effectiveness of a nutrition supplement and an exercise programme on pneumonia incidence, walking capacity and body mass index in older people living in Santiago, Chile: the CENEX study protocol Organisation of a proposed Cochrane Diet and Nutrition Field Multifactorial day hospital intervention to reduce falls in high risk older people in primary care: a multi-centre randomised controlled trial [ISRCTN46584556] Lifting the lid of the "black intervention box" - the systematic development of an action competence programme for people with screen-detected dysglycaemia Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT. Evaluation of community-based oral health promotion and oral disease prevention--WHO recommendations for improved evidence in public health practice. Can the concept of Health Promoting Schools help to improve students' health knowledge and practices to combat the challenge of communicable diseases: Case study in Hong Kong? More Informative Abstracts of Articles Describing Clinical Practice Guidelines Case management and self-management support for frequent users with chronic disease in primary care: a pragmatic randomized controlled trial Community pharmacy interventions for public health priorities: protocol for a systematic review of community pharmacy-delivered smoking, alcohol and weight management interventions From Outcomes Research to Disease Management: A Guide for the Perplexed Information provision for people with multiple sclerosis. Assessing Care of Vulnerable Elders: ACOVE Project Overview The prevention access and risk taking in young people (PARTY) project protocol: A cluster randomised controlled trial of health risk screening and motivational interviewing for young people presenting to general practice The role of evidence, context, and facilitation in an implementation trial: implications for the development of the PARIHS framework Breaking bones, breaking budgets: a clinical and economic evaluation of a prospective, randomized, practice controlled, intervention study in the prevention of accidents in primary care. Economic evaluation of a community based exercise programme to prevent falls Cost-effectiveness of a day hospital falls prevention programme for screened community-dwelling older people at high risk of falls Falls prevention for the elderly The Seattle-King County healthy homes project: implementation of a comprehensive approach to improving indoor environmental quality for low-income children with asthma.
Background Research evidence underpins best practice , but is not always used in healthcare . The Promoting Action on Research Implementation in Health Services ( PARIHS ) framework suggests that the nature of evidence , the context in which it is used , and whether those trying to use evidence are helped ( or facilitated ) affect the use of evidence . Urinary incontinence has a major effect on quality of life of older people , has a high prevalence , and is a key priority within European health and social care policy . Improving continence care has the potential to improve the quality of life for older people and reduce the costs associated with providing incontinence aids . Objectives This study aims to advance underst and ing about the contribution facilitation can make to implementing research findings into practice via : extending current knowledge of facilitation as a process for translating research evidence into practice ; evaluating the feasibility , effectiveness , and cost-effectiveness of two different models of facilitation in promoting the uptake of research evidence on continence management ; assessing the impact of context ual factors on the processes and outcomes of implementation ; and implementing a pro-active knowledge transfer and dissemination strategy to diffuse study findings to a wide policy and practice community . Setting and sample Four European countries , each with six long-term nursing care sites ( total 24 sites ) for people aged 60 years and over with documented urinary incontinence Methods and design Pragmatic r and omised controlled trial with three arms ( st and ard dissemination and two different programmes of facilitation ) , with embedded process and economic evaluation . The primary outcome is compliance with the continence recommendations . Secondary outcomes include proportion of residents with incontinence , incidence of incontinence-related dermatitis , urinary tract infections , and quality of life . Outcomes are assessed at baseline , then at 6 , 12 , 18 , and 24 months after the start of the facilitation interventions . Detailed context ual and process data are collected throughout , using interviews with staff , residents and next of kin , observations , assessment of context using the Alberta Context Tool , and documentary evidence . A realistic evaluation framework is used to develop explanatory theory about what works for whom in what circumstances . Trial registration Current Controlled Trials IS RCT N11598502 Background  Depression in older adults is a serious health problem with a poor prognosis . There is a need for indicated preventive psychological interventions for older adults , that show to be promising in preventing depressive disorders . Methods / design This manuscript describes the design of a study evaluating ' Looking for Meaning ' , a newly developed prevention course for older adults with depressive symptoms , based on life- review . Both clinical and economic effectiveness are evaluated in a pragmatic r and omized controlled trial . The control condition of this 12-session preventive intervention is a 20-minute video movie . The primary outcome is symptoms of depression at post-treatment and follow-up ( 6 months after post-treatment ) . Secondary outcomes are symptoms of anxiety , satisfaction with life , mastery , reminiscence styles , quality of life , and health care costs . An additional result of this study is the insight into the working elements of the course , provided by the qualitative study . The qualitative data , mainly based on 20 open-ended interviews with participants , are to be analyzed with an emphasis on newly emerging insight . Discussion This study will add to the existing scientific knowledge in several ways , especially by also including an economic evaluation and a qualitative study to gain insight into the working mechanisms of the course , both rather new in the field of life review . Positive results of this study will make an evidence -based intervention to improve public health among older people available . Trial registration Current Controlled Trials Ltd , IS RCT In July the Department of Health ( DH ) in Engl and published a toolkit of re sources to promote more effective services to reduce the burden of  falls and fractures in older people . Unfortunately , there is plenty of evidence that the present provision of falls services is suboptimal . The toolkit is part of a ‘ Prevention Package ’ aim ed primarily at commissioners of care , in an attempt to achieve a more consistent and integrated approach to a range of prevention issues in older people [ 1 ] . Falls are a major international public health challenge because of the myriad effects on older individuals : direct physical and psychological injury ; fear of falling and activity limitation ; reduced social participation and quality of life ; increased dependence [ 2–5 ] ; and because of the economic impact on health and social care providers [ 6 , 7 ] . Studies from various countries have shown that about one third of people aged above 65 years fall each year . In UK primary care population s , the rate rises with age to over 60 % of nonagenarians , and is generally higher in women [ 8 ] and in socio-economically deprived population s [ 9 ] . Fragility fractures are the commonest significant injury , 300,000 annually in the UK including upwards of 70,000 hip fractures . Many falls go unreported , but nevertheless they account for 40 % of UK ambulance call-outs , with the variable proportion being conveyed to hospital accounting for one in ten Emergency Department ( ED ) attendances of the over 75s [ 6 ] , a third of whom are admitted , thus comprising about 14 % of emergency admissions . Identifying all falls related activity is challenging but recent estimates suggest that it accounts for between 10 % and 25 % of all local health and social care spending on older people [ 10 ] . Care of fragility fractures is particularly expensive , total health and social care costs in the UK being around £ 2 billion , most of which relates to hip fractures [ 11 ] . Current population and incidence projections suggest that by 2020 , this figure will rise by 50 % . Early in the development of geriatric medicine , falls were identified as a ‘ geriatric giant’—adverse in their own right but also a non-specific indicator of functional decompensation . Building on clarification of falls risk factors [ 12 ] , r and omised controlled trials demonstrated the effectiveness of risk factor based multi-factorial interventions [ 13 , 14 ] . This led to the notion of ‘ falls prevention services ’ . Based on international consensus about what constituted best clinical practice [ 15 ] , broadly similar policies have been developed by the responsible government departments of the four UK nations , and in Irel and [ 16 ] . The National Service Framework for Older People in Engl and ( NSF , 2001 ) [ 17 ] required health services and their local council partners to develop integrated services by April 2005 , incorporating case finding , assessment and referral systems and specialist falls and fragility fracture services . The NSF was launched without earmarked implementation funding , but there was plenty of activity , some enabled and directed by various government initiatives , encouraging community engagement . An independent postal question naire survey to health and social care agencies about their falls services in 2004 [ 18 ] reported most having made plans for an integrated service but implementation was patchy and focused on widely differing priorities . Only 30 % included systems for identifying high risk individuals and only 13 % of falls prevention programmes included exercise classes , the most effective prevention strategy [ 19 ] whilst interventions with little or no evidence base were promoted [ 20 ] . Implementation of these policies across Engl and , Wales and Northern Irel and has been monitored in a series of government funded national audits run by the Royal College of Physicians of London ( RCP ) . The first of these confirmed major gaps at the organisational level , particularly in case finding and referrals for secondary prevention [ 21 ] . A subsequent patient level clinical care audit of fragility fracture patients showed that most returning home from the Emergency Department were not offered a falls risk assessment and only one third were on appropriate treatment for osteoporosis 3 months later [ 22 ] . Despite intense interest among clinicians in the UK and appointment of many geriatricians with a focus on falls , syncope and orthogeriatrics , a repeat organisational audit showed that by 2008 there had been little improvement in service structure , capacity or processes [ 23 ] . Meanwhile the picture was clouded by the negative results of a DH funded systematic review with meta-analyses [ 24 ] . This suggested that the variable outcomes of clinical trials might be associated with the way that the multifactorial approach was organised . There are now several negative outcome trials employing the strategy of nurse led case finding linked to interventions intended to be provided by a range of unconnected professions acting on referral [ 25 ] . In clinical practice , it is likely that there is even more differential effectiveness depending on case finding and referral practice s and context ual differences in service delivery . Research evidence is still lacking on how to achieve much that the NSF aspired to , but there is sufficient evidence and examples of successful implementation to do much better than most are currently doing . So how will the latest government action help ? A key step is to clarify priorities and to put available re sources into the activities likely to make Background Chile is currently undergoing a period of rapid demographic transition which has led to an increase in the proportion of older people in the population ; the proportion aged 60 years and over , for example , increased from 8 % of the population in 1980 to 12 % in 2005 . In an effort to promote healthy ageing and preserve function , the government of Chile has formulated a package of actions into the Programme of Complementary Feeding for the Older Population ( PACAM ) which has been providing a nutritional supplement to older people since 1998 . PACAM distributes micronutrient fortified foods to individuals aged 70 years and over registered at Primary Health Centres and enrolled in the programme . The recommended serving size ( 50 g/day ) of these supplements provides 50 % of daily micronutrient requirements and 20 % of daily energy requirements of older people . No information is currently available on the cost-effectiveness of the supplementation programme . Aim The aim of the CENEX cluster r and omised controlled trial is to evaluate the cost-effectiveness of an ongoing nutrition supplementation programme , and a specially design ed physical exercise intervention for older people of low to medium socio-economic status living in Santiago , Chile . Methods The study has been conceptualised as a public health programme effectiveness study and has been design ed as a 24-month factorial cluster-r and omised controlled trial conducted among 2800 individuals aged 65.0–67.9 years at baseline attending 28 health centres in Santiago . The main outcomes are incidence of pneumonia , walking capacity and change in body mass index over 24 months of intervention . Costing data ( user and provider ) , collected at all levels , will enable the determination of the cost-effectiveness of the two interventions individually and in combination . The study is supported by the Ministry of Health in Chile , which is keen to exp and and improve its national programme of nutrition for older people based on sound science-base and evidence for cost-effectiveness . Trial registration IS RCT The Cochrane Collaboration helps people make well-informed decisions about health care by preparing , maintaining and promoting the accessibility of systematic review s of the effects of healthcare interventions . In all , 51 Cochrane Review Groups are responsible for preparing and maintaining the review s. Most of these Review Groups are problem-based . However , there are a number of areas or dimensions of health care , such as the setting of care ( eg primary care ) or the type of patient/consumer ( eg older persons ) , that can not be usefully conceptualised as ‘ health problems ’ . In order to reflect the interests of these dimensions , or ‘ fields ’ , of health care more effectively , the Cochrane Collaboration created another type of entity : Cochrane Fields or Networks . The core functions of these Fields are described . It is proposed that a new Cochrane Subfield for Diet and Nutrition should be set up to attract a cadre of new review ers in order to ensure the proper representation of diet and nutrition expertise in the relevant Collaborative Review Groups . The method ological pitfalls of the use of nonr and omised studies will be a key issue for the new Subfield , since the focus of the Cochrane Collaboration 's programme of search ing data bases , journals and conference proceedings has been on the identification of reports of r and omised controlled trials ( RCTs ) . Some of these sources will be need to be search ed again for non- RCT studies . The financial considerations of establishing of a Cochrane Subfield for Diet and Nutrition are discussed Falls in older people are a major public health concern in terms of morbidity , mortality and cost . Previous studies suggest that multifactorial interventions can reduce falls , and many geriatric day hospitals are now offering falls intervention programmes . However , no studies have investigated whether these programmes , based in the day hospital are effective , nor whether they can be successfully applied to high-risk older people screened in primary care . The hypothesis is that a multidisciplinary falls assessment and intervention at Day hospitals can reduce the incidence of falls in older people identified within primary care as being at high risk of falling . This will be tested by a pragmatic parallel-group r and omised controlled trial in which the participants , identified as at high risk of falling , will be r and omised into either the intervention Day hospital arm or to a control ( current practice ) arm . Those participants preferring not to enter the full r and omised study will be offered the opportunity to complete brief diaries only at monthly intervals . This data will be used to vali date the screening question naire . Three day hospitals ( 2 Nottingham , 1 Derby ) will provide the interventions , and the University of Nottingham 's Departments of Primary Care , the Division of Rehabilitation and Ageing Unit , and the Trent Institute for Health Service Research will provide the method ological and statistical expertise . Four hundred subjects will be r and omised into the two arms . The primary outcome measure will be the rate of falls over one year . Secondary outcome measures will include the proportion of people experiencing at least one fall , the proportion of people experiencing recurrent falls ( > 1 ) , injuries , fear of falling , quality of life , institutionalisation rates , and use of health services . Cost-effectiveness analyses will be performed to inform health commissioners about re source allocation issues . The importance of this trial is that the results may be applicable to any UK day hospital setting .SitesGeneral practice s across Nottinghamshire and Derbyshire . Day hospitals : Derbyshire Royal Infirmary ( Southern Derbyshire Acute Hospitals NHS Trust)Sherwood Day Service ( Nottingham City Hospital Trust)Leengate Day Hospital ( Queen 's Medical Centre Nottingham University Hospital NHS Trust Background The evidence gained from effective self-management interventions is often criticised for the ambiguity of its active components , and consequently the obstruction of their implementation into daily practice .Our aim is to report how an intervention development model aids the careful selection of active components in an intervention for people with dysglycaemia . Methods The first three phases of the UK Medical Research Council 's model for developing complex interventions in primary care were used to develop a self-management intervention targeting people with screen-detected dysglycaemia . In the pre clinical phase , the expected needs of the target group were assessed by review of empirical literature and theories . In phase I , a preliminary intervention was modelled and in phase II , the preliminary intervention was pilot tested . Results In the pre clinical phase the achievement of health-related action competence was defined as the overall intervention goal and four learning objectives were identified : motivation , informed decision-making , action experience and social involvement . In Phase I , the educational activities were defined and the pedagogical tools tested . In phase II , the intervention was tested in two different primary healthcare setting s and adjusted accordingly . The 18-hour intervention " Ready to Act " ran for 3 months and consisted of two motivational one-to-one sessions conducted by nurses and eight group meetings conducted by multidisciplinary teams . Conclusions An intervention aim ed at health-related action competence was successfully developed for people with screen-detected dysglycaemia . The systematic and transparent developmental process is expected to facilitate future clinical research . The MRC model provides the necessary steps to inform intervention development but should be prioritised according to existing evidence in order to save time BACKGROUND Mild frailty or pre-frailty is common and yet is potentially reversible . Preventing progression to worsening frailty may benefit individuals and lower health/social care costs . However , we know little about effective approaches to preventing frailty progression . OBJECTIVES ( 1 ) To develop an evidence - and theory-based home-based health promotion intervention for older people with mild frailty . ( 2 ) To assess feasibility , costs and acceptability of ( i ) the intervention and ( ii ) a full-scale clinical effectiveness and cost-effectiveness r and omised controlled trial ( RCT ) . DESIGN Evidence review s , qualitative studies , intervention development and a feasibility RCT with process evaluation . INTERVENTION DEVELOPMENT Two systematic review s ( including systematic search es of 14 data bases and registries , 1990 - 2016 and 1980 - 2014 ) , a state-of-the-art review ( from inception to 2015 ) and policy review identified effective components for our intervention . We collected data on health priorities and potential intervention components from semistructured interviews and focus groups with older people ( aged 65 - 94 years ) ( n = 44 ) , carers ( n = 12 ) and health/social care professionals ( n = 27 ) . These data , and our evidence review s , fed into development of the ' HomeHealth ' intervention in collaboration with older people and multidisciplinary stakeholders . ' HomeHealth ' comprised 3 - 6 sessions with a support worker trained in behaviour change techniques , communication skills , exercise , nutrition and mood . Participants addressed self-directed independence and well-being goals , supported through education , skills training , enabling individuals to overcome barriers , providing feedback , maximising motivation and promoting habit formation . FEASIBILITY RCT Single-blind RCT , individually r and omised to ' HomeHealth ' or treatment as usual ( TAU ) . SETTING Community setting s in London and Hertfordshire , UK . PARTICIPANTS A total of 51 community-dwelling adults aged ≥ 65 years with mild frailty . MAIN OUTCOME MEASURES Feasibility - recruitment , retention , acceptability and intervention costs . Clinical and health economic outcome data at 6 months included functioning , frailty status , well-being , psychological distress , quality of life , capability and NHS and societal service utilisation/costs . RESULTS We successfully recruited to target , with good 6-month retention ( 94 % ) . Trial procedures were acceptable with minimal missing data . Individual r and omisation was feasible . The intervention was acceptable , with good fidelity and modest delivery costs ( £ 307 per patient ) . A total of 96 % of participants identified at least one goal , which were mostly exercise related ( 73 % ) . We found significantly better functioning ( Barthel Index + 1.68 ; p = 0.004 ) , better grip strength ( + 6.48 kg ; p = 0.02 ) , reduced psychological distress ( 12-item General Health Question naire -3.92 ; p = 0.01 ) and increased capability-adjusted life-years [ + 0.017 ; 95 % confidence interval ( CI ) 0.001 to 0.031 ] at 6 months in the intervention arm than the TAU arm , with no differences in other outcomes . NHS and carer support costs were variable but , overall , were lower in the intervention arm than the TAU arm . The main limitation was difficulty maintaining outcome assessor blinding . CONCLUSIONS Evidence is lacking to inform frailty prevention service design , with no large-scale trials of multidomain interventions . From stakeholder/public perspectives , new frailty prevention services should be personalised and encompass multiple domains , particularly socialising and mobility , and can be delivered by trained non-specialists . Our multicomponent health promotion intervention was acceptable and delivered at modest cost . Our small study shows promise for improving clinical outcomes , including functioning and independence . A full-scale individually RCT is feasible . FUTURE WORK A large , definitive RCT of the HomeHealth service is warranted . STUDY REGISTRATION This study is registered as PROSPERO CRD42014010370 and Current Controlled Trials IS RCT N11986672 . FUNDING This project was funded by the National Institute for Health Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 21 , No. 73 . See the NIHR Journals Library website for further project information Systematic evaluation is an integral part of the organisation and delivery of community oral health care programmes , ensuring the effectiveness of these community-based interventions . As for general health promotion programmes the common problems from effectiveness review s of oral health interventions relate to the quality and validity of programme evaluations . Problems identified mostly refer to the quality of outcome measures , short-term timescales to assess change , inadequate evaluation method ologies and inappropriate evaluation of programme implementation and processes . It remains a challenge to oral health professionals to integrate community oral health programmes into a wider health agenda . Public health research focusing on the development of evaluation method ologies has identified a variety of issues including the importance of using pluralistic evaluation approaches ( quantitative and /or qualitative ) , limitations of the r and omised controlled trial ( RCT ) design for evaluation of public health interventions , the need to match evaluation methods with the nature of intervention , development of outcome measures appropriate for the nature of intervention , importance of developing workforce capacity in evaluation techniques , and the need for development of partnerships between health practitioners and academics in conducting evaluations . In June 2003 , the WHO Oral Health Programme at Headquarters organised a two-day workshop to take forward the development and documentation of the evaluation of oral health promotion and oral disease prevention programmes . The aims of the workshop were to : ( 1 ) identify common problems and challenges in evaluating community-based  oral health interventions ; ( 2 ) explore developments in the evaluation approaches in public health ; ( 3 ) share experiences in evaluating oral health intervention programmes implemented at national or community levels in developing and developed countries and ( 4 ) develop guidelines for quality evaluation of national and community oral health programmes . Twenty-two invitees from 15 countries attended in addition to WHO staff . The first day was devoted to presentations of oral health promotion and oral disease prevention programmes from around the world . During the second day , WHO staff at Headquarters in Geneva discussed aspects of evaluation of public health programmes . Two working groups were formed to discuss agreed topics , and the reports from their deliberations , together with the general discussion , result ed in the presentation of emerging key issues and recommendations . In summary , it was agreed that evaluation of oral health promotion and disease prevention programmes should integrate , whenever possible , with general health programmes . While the design and advantages of RCTs in clinical evaluations are well documented , the relevance of this design in evaluation of community oral disease preventive programmes and oral health promotion programmes are much less clearly defined . Subsequently , the conduct of such programmes may be inappropriately evaluated in systematic review s. There is a need for more research into appropriate immediate , interim and ultimate outcome measures , as well as process evaluation , an assessment that is poorly understood and practised less often than outcome evaluation . Guidance on potential design , conduct , and especially the evaluation , of community oral disease prevention programmes and oral health promotion programmes should be developed and up date d regularly . WHO Collaborating Centres could have a role in promoting good practice , training and collaboration between teams throughout the world . Centres undertaking systematic review s should consider the guidelines given in the proposed WHO document when defining their evaluation criteria Background The growing epidemics of emerging infectious diseases has raised the importance of a setting approach and include the Health Promoting School ( HPS ) framework to promote better health and hygiene . Built on the concept of ' the ' HPS framework , the Hong Kong Healthy Schools Award scheme includes " Personal Health Skills " as one of its key aspects to improve student hygiene knowledge and practice s. This study examines the differences in student perceptions , knowledge and health behaviours between those schools that have adopted the HPS framework and those that have not adopted . Methods A cross-sectional study using multi-stage r and om sampling was conducted among schools with awards ( HSA ) and those schools not involved in the award scheme nor adopting the concept of HPS ( non-HPS ) .  For HSA group , 5 primary schools and 7 secondary schools entered the study with 510 students and 789 students sample d respectively . For the ' Non-HPS ' group , 8 primary schools and 7 secondary schools entered the study with 676 students and 725 students sample d respectively . A self-administered question naire was used as the measuring instrument . Results Students in the HSA category were found to be better with statistical significance in personal hygiene practice , knowledge on health and hygiene , as well as access to health information . HSA schools were reported to have better school health policy , higher degrees of community participation , and better hygienic environment . ConclusionS tudents in schools that had adopted the HPS framework had a more positive health behaviour profile than those in non-HPS schools . Although a causal relationship is yet to be established , the HPS appears to be a viable approach for addressing communicable diseases Patients hope that their doctors will correctly identify health problems , clearly articulate sensible options for managing each problem , wisely interpret the best available evidence about probable outcomes associated with each option , sensitively solicit patient preferences for each outcome , and thereby implement practice s that are likely to achieve the results patients care about . Groups of patients hope that doctors will work to prevent , detect , and treat health problems in a way that maximizes the public good achieved with available health care re sources . To meet these dual expectations , doctors face forbidding tasks of clinical decision making . Improved methods for preparing , appraising , and abstract ing overviews of available evidence about a clinical topic can bring a broader range of high- quality information within the busy practitioner 's grasp [ 1 - 4 ] . However , even well- design ed overviews often do not synthesize information about benefits , harms , and costs of medical practice s in a way that facilitates clinical decision making . Clinical practice guidelines have been defined as systematic ally developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances [ 5 ] . Guidelines that are based on sound scientific evidence , and a trustworthy process for judging the value of alternative practice s , could help physicians deal with the information overload they face . Existing practice guidelines , however , vary widely in their quality , and clinicians should carefully consider the validity and applicability of each guideline they read . We propose a structured format for abstract s of articles describing practice guidelines that is based on emerging principles of guideline development and evaluation [ 6 - 13 ] . The proposal is design ed to help readers obtain the key information needed to assess the applicability , importance , and validity of any guideline . The proposed structure for more informative abstract s of articles describing clinical practice guidelines has been review ed and pilot-tested by guideline developers , evaluators , and implementors and by groups of practicing clinicians . Early versions of the proposal were sent to consultants at the National Library of Medicine , the Institute of Medicine , the American College of Physicians ( ACP ) , and the Agency for Health Care Policy and Research . Subsequent versions of the proposal were pilot tested on various published guidelines and were assessed by selected health care organizations for applicability to guidelines under development . An improved proposal was sent to 82 persons active in guideline development , evaluation , and implementation . The Internal Medicine Center to Advance Research and Education circulated the proposal to volunteer practitioners , and the authors solicited feedback from physician and health administrator participants at three national workshops about practice guidelines . The proposal that follows represents an integration of the collective wisdom of our external review ers . ( A glossary of terms used in articles on clinical practice guidelines is supplied in the Appendix . ) Proposed Structure and Content for Abstract s of Articles Describing Clinical Practice Guidelines The proposed structure for abstract s of papers describing clinical practice guidelines is summarized in Table 1 . Key elements of the guideline development process are captured with statements about the principal objective and target of the guideline , the main practice options and outcomes that were considered , the nature of the evidence and values that were analyzed , the main benefits and harms expected from guideline implementation , the key recommendations , and a statement of whether the recommendations have been tested and by whom they have been endorsed . If details about guideline development methods or supporting evidence are published separately , then the abstract should indicate the existence of supporting documents and the most relevant parts of those should be summarized in the abstract . To be included in their entirety in the online bibliographic data bases of the National Library of Medicine , structured abstract s of clinical practice guidelines should not exceed 4096 characters ( approximately 500 words ) in length . Individual journals may have different requirements . Table 1 . Proposed Format for Structured Abstract s of Clinical Practice Guidelines Objective The abstract should state the objective of the guideline by identifying the targeted health problem , the targeted patients and physicians , and the main reason or reasons for developing new recommendations concerning this problem for this population . For guidelines primarily concerned with the management of health conditions , the stage of illness and intent to prevent , diagnose , treat , or palliate the disorder should be specified . For guidelines primarily concerned with health procedures , an intervention and its role in patient management should be defined . Targeted providers , setting s , and patients should be specified so that readers can tell who should do what , where it should be done , and to whom . A statement of objective also may specify why a new guideline is needed and how it should be used . Practice guidelines may be written to clarify or resolve clinical controversies , to communicate important new findings from clinical studies , or to promote more effective , efficient , or consistent physician practice s at less cost or risk to patients . Guidelines may be used concurrently to help physicians and patients make choices ( for example , clinical algorithms ) , retrospectively to compare physician choices to pre-established criteria ( for example , utilization review ) , or prospect ively to set limits on physician choices ( for example , preprocedure approval ) . Options Clinical practice guidelines pertain to clinical decisions . The nature of those decisions should be made explicit by disclosing the main management options considered . The abstract should list principal alternative preventive , diagnostic , or therapeutic strategies available to targeted clinicians and patients . Outcomes The abstract also should specify which health outcomes , such as death , morbidity , quality of life , economic costs , or changes in the process of health care were considered . Evidence To estimate the probable effect of a health intervention on an outcome , relevant data must be defined , gathered , and appraised . Readers need to know what kind of evidence was considered and what methods were used to select and combine evidence from different sources . Potential sources of evidence about clinical outcomes include the results of clinical studies ( published or unpublished ) , expert opinion , information contained in public or private health data bases , and direct input from patients or providers . Potential sources of evidence about economic outcomes include the results of cost-effectiveness studies , various fee schedules , and information contained in public or private health cl aims data bases . Potential methods of gathering evidence include computerized search es for articles that satisfy predetermined criteria , review s of bibliographies of relevant articles , and surveys of relevant persons or organizations [ 1 ] . The abstract should state whether explicit methods were used to combine results from scientific studies ( for example , meta- analysis ) or opinions of experts ( for example , Delphi technique ) [ 14 , 15 ] . The abstract may also indicate whether specific criteria were used to gauge the quality of information from different sources [ 16 , 17 ] . Scientific evidence regarding the likelihood of certain outcomes is often missing or conflicting . It is desirable for the strength of evidence supporting a guideline to be gauged in some way [ 16 ] . If gaps in the evidence were bridged formally ( for example , through use of decision- analysis models ) or informally ( for example , best guess of clinical experts ) , then major assumptions or areas of uncertainty should be acknowledged [ 11 ] . Because of the extraordinary time required to properly assemble and review evidence and then to achieve consensus about practice recommendations , the abstract of a practice guideline should specify the publication date s of the most recent evidence considered . If a sensitivity analysis was performed , then any major vulnerability of the guideline to weaknesses in the evidence should be acknowledged . These considerations may be summarized by qualifying a guideline as provisional by specifying date s for expiration or review , by listing studies in progress that could affect the guideline , or by identifying key research priorities . Values The declaration of a recommended practice presumes an implicit or explicit process for judging the relative desirability of the health , economic , and process outcomes associated with alternative practice s. These are matters of opinion and value . For example , in developing guidelines for breast cancer screening , it is necessary to weigh the value of preventing a death from breast cancer against the value of avoiding unnecessary harm or anxiety in women who do not have breast cancer . A high value placed on maximizing detection of asymptomatic malignancy may motivate an organization to recommend teaching self-examination of breasts to young women [ 18 ] . A relatively greater value placed on avoiding false-positive results may motivate others to not promote such programs [ 19 ] . Consequently , the principal sources of such values and the method by which judgments were made should be reported in guideline abstract s. At a minimum , the abstract should identify the major groups that participated in the process of assigning values to outcomes ( for example , generalist or specialist physicians , other health care providers , insurers , representatives of health organizations , and special-interest groups ) and whether patient preferences were represented . The abstract may also indicate the method used to synthesize opinions from Background Chronic diseases represent a major challenge for health care and social services . A number of people with chronic diseases require more services due to characteristics that increase their vulnerability . Given the burden of increasingly vulnerable patients on primary care , a pragmatic intervention in four Family Medicine Groups ( primary care practice s in Quebec , Canada ) has been proposed for individuals with chronic diseases ( diabetes , cardiovascular diseases , respiratory diseases , musculoskeletal diseases and /or chronic pain ) who are frequent users of hospital services . The intervention combines case management by a nurse with group support meetings encouraging self-management based on the Stanford Chronic Disease Self-Management Program . The goals of this study are to : ( 1 ) analyze the implementation of the intervention in the participating practice s in order to determine how the various context s have influenced the implementation and the observed effects ; ( 2 ) evaluate the proximal ( self-efficacy , self-management , health habits , activation and psychological distress ) and intermediate ( empowerment , quality of life and health care use ) effects of the intervention on patients ; ( 3 ) conduct an economic analysis of the efficiency and cost-effectiveness of the intervention . Methods / Design The analysis of the implementation will be conducted using realistic evaluation and participatory approaches within four categories of stakeholders ( Family Medicine Group and health centre management , Family Medicine Group practitioners , patients and their families , health centre or community partners ) . The data will be obtained through individual and group interviews , project documentation review s and by documenting the intervention . Evaluation of the effects on patients will be based on a pragmatic r and omized before-after experimental design with a delayed intervention control group ( six months ) . Economic analysis will include cost-effectiveness and cost-benefit analysis . Discussion The integration of a case management intervention delivered by nurses and self-management group support into primary care practice s has the potential to positively impact patient empowerment and quality of life and hopefully reduce the burden on health care . Decision-makers , managers and health care professionals will be aware of the factors to consider in promoting the implementation of this intervention into other primary care practice s in the region and elsewhere . Trial Registration Background Community pharmacists can deliver health care advice at an opportunistic level , related to prescription or non-prescription medicines and as part of focused services design ed to reduce specific risks to health . Obesity , smoking and excessive alcohol intake are three of the most significant modifiable risk factors for morbidity and mortality in the UK , and interventions led by community pharmacists , aim ed at these three risk factors , have been identified by the government as public health priorities . In 2008 , the Department of Health for Engl and stated that ‘ a sound evidence base that demonstrates how pharmacy delivers effective , high quality and value for money services is needed ’ ; this systematic review aims to respond to this requirement . Methods / design We will search the data bases MEDLINE , Embase , CINAHL , PsycINFO , Social Sciences Citation Index , ASSIA , IBSS , Sociological Abstract s , Scopus and NHS Economic Evaluation Data base for studies that have evaluated interventions based on community pharmacies that aim to target weight management , smoking cessation and alcohol misuse . We will include all r and omised controlled trials ( RCTs ) , non-r and omised controlled trials ( N RCTs ) , controlled before-after studies ( CBAs ) and interrupted time series ( ITS ) and repeated measures studies . Data from included studies will be extracted by two independent review ers and will include study details methods , results , intervention implementation/costs and method ological quality . Meta- analysis will be conducted if appropriate ; if not , the synthesis will be restricted to a narrative overview of individual studies looking at the same question . Discussion The review aims to summarise the evidence base on the effectiveness of community pharmacy interventions on health and health behaviours in relation to weight management , smoking cessation and alcohol misuse . It will also explore if , and how , socio-economic status , gender , ethnicity and age moderate the effect of the interventions and will describe how the interventions included in the review have been organised , implemented and delivered , since context is an important factor governing the success of public health interventions . The findings from this review will have an impact on the commissioning of public health services aim ing to promote healthy weight , smoking cessation and prevent excessive alcohol consumption . Systematic review registration The review has been registered with PROSPERO ( registration no. CRD42013005943 ) . Available at : http://www.crd.york.ac.uk/ prospero /display_record.asp?ID = CRD42013005943 The well-being of the soul can be obtained only after that of the body has been secured , said M aim onides in his classical treatise [ 1 ] . This early comment pre date s the current appreciation of the effect of physical health on quality of life . Outcomes research has exp and ed dramatically in recent years [ 2 - 5 ] through multidisciplinary efforts involving health services research ers , epidemiologists , economists , sociologists , statisticians , and ethicists . Driving this interest are concerns about rapidly increasing health care costs , growing consumer involvement in medical decision making , and incorporation of information systems into clinical medicine . The health care industry has also increased its focus on efficiency and productivity , with particular emphasis on outcomes . The latest concept in this field , disease management , refers to the use of an explicit systematic population -based approach to identify persons at risk , intervene with specific programs of care , and measure clinical and other outcomes . Disease management is not new ; for centuries , clinicians have been identifying and treating patients using information gleaned from their training , the medical literature , and personal experience . What is new about the current model of disease management is that it does much more than evaluate known practice s and suggest guidelines . It is a systematic information-driven approach in which clinical encounters are computerized , summarized , and shared ; opportunities for intervention are not always detected solely at the bedside , but sometimes from a central data -base ; practice guidelines may be implemented by computer screens in the practice setting ; and initiatives are measured and compared in terms of health outcomes . At the core of disease management are principles described as outcomes research , an evolving and somewhat embryonic field . Confusion has arisen over terminology and the application of principles to the management of patients . We identify core concepts and highlight some issues that become apparent as outcomes principles are applied to practice . Measurement of Outcomes An important aspect of disease management is the ability to measure and report health outcomes . The movement to collect this information has recently escalated , stimulated by federal initiatives to compare mortality among hospitals [ 6 , 7 ] , by comparative outcomes studies [ 8 ] , and by payers seeking to improve quality and reduce costs [ 9 ] . Donabedian [ 10 - 12 ] described quality health care as an optimal triad of structure , process , and outcomes . And erson and colleagues [ 13 ] extended this model by suggesting that relations among these factors should guide decision making . The outcome measures have evolved from simple dichotomous ones such as survival or occurrence of a clinical event to patient-oriented measures such as satisfaction , quality of life , and functional status . The term outcomes has been linked to different measures , ranging from physiologic values to quality of life assessment s. One approach to taxonomy is shown in Table 1 . The reporting of outcomes may need to differ , depending on the priorities of those examining the data . A clinician is likely to be primarily interested in clinical or humanistic outcomes , whereas a health plan administrator may be interested in economic ones . Patients are interested in humanistic outcomes and have trouble interpreting clinical outcomes . As clinicians ' financial risk increases , they are also developing greater interest in economic outcomes . Current disease management programs include mixtures of all measures . Table 1 . Types of Outcome Measures and Selected Examples Several points should be emphasized as these measures gain broader application . Selection of specific measures is currently a somewhat arbitrary process . For asthma , for example , several disease-specific measures of quality of life are available [ 14 - 17 ] . One way to distinguish among these measures is to examine the evidence behind the development of each measure : Has each one been vali date d ? This is now a st and ardized process of item generation , item reduction , reproducibility , responsiveness , and validation [ 18 , 19 ] ; however , multiple question naires can meet these criteria and still leave the clinician confused . Many outcomes measures were developed for use in population surveys or clinical trials and not for use in monitoring individual patients . The within-person variability can be great , but it is often offset with aggregate data ; thus , in the context of disease management , some measures must be used with care . Even when measures are aggregated , statistical power may be insufficient to detect a significant improvement in outcomes . For example , in a modestly sized health plan with 25 000 members , one might estimate that 150 persons have diabetes and use insulin . Even if all 150 participated in a program that reduced the number of diabetes-related complications by 50 % through improved diet , exercise , and appropriate use of insulin , the statistical power would be too low to document the program value compared with complication rates with a previous program . Thus , not all outcomes can be collected on all population s ; if outcomes are measured , statistical issues need sufficient attention . Finally , the interpretation of the change in outcomes is not yet clear for all measures . For example , what is the meaning of a 4-point change on a 100-point quality -of-life scale ? Is a $ 0.50 increase in the per-member per-month charge enough to warrant a disease management program ? Research ers attempting to define clinical significance are beginning to address these issues by anchoring degree of change to other events [ 20 - 24 ] . For example , Brook and colleagues [ 25 ] noted that a three-point difference on a st and ardized mental health scale was analogous to being laid off from a job . Considerable additional research into the meaning and application of outcomes is needed . Effectiveness Studies The distinction between effectiveness and efficacy is critical to disease management ; treatments with proven efficacy do not always perform as well under conditions of typical clinical practice ( effectiveness ) . In most efficacy studies , highly specialized practitioners treat selected patients on tight protocol s in a setting in which both patients and practitioners have economic incentives to comply . In effectiveness studies , on the other h and , treatments can be viewed as they would be in usual setting s ( Table 2 ) [ 26 - 28 ] . Table 2 . Effectiveness Studies Compared with Efficacy Studies * Most therapies require evaluation of efficacy before being implemented . This evaluation generally requires a priori hypotheses , r and omization ( to eliminate selection bias and confounding ) , homogeneous patients at high risk for the outcome , experienced investigators who follow a protocol , a comparative measure such as placebo ( if ethical ) , and intensive follow-up to ensure compliance . Under these circumstances , if a treatment proves to be better than placebo ( or a comparative measure ) , one can be reassured that the treatment can work . However , questions may remain about the ability of the treatment to work adequately in a broader range of patients and in usual practice setting s in which both patients and providers face natural barriers to care . These issues are of central importance in assessing relative cost-effectiveness in the community . To address these questions , most effectiveness studies have been done as observational studies , wherein observed groups are not r and omly assigned to therapy and neither patients nor providers generally know that they are being studied ( usually retrospective studies ) . This eliminates issues related to inclusion of special patients and providers and allows the treatment to be observed as it is typically used . Selection bias , which occurs when patients are not r and omly assigned to alternative treatments , becomes potentially problematic , and adjustment for case mix and severity of illness becomes important . In response to this problem , prospect i ve effectiveness trials are beginning to emerge [ 29 - 31 ] . As in typical clinical trials , these trials include the development of a protocol with a priori hypotheses , recruitment of participants with informed consent , r and omization to eliminate selection bias , and routine collection of data at prespecified time periods . Prospect i ve effectiveness trials differ from typical clinical trials in that they enroll heterogeneous participants , use providers more similar to those who treat the disease , impose few protocol -driven interventions , and incorporate outcome measures relevant to the disease and delivery system . Such trials attempt to provide unbiased information in relation to selection factors while still addressing outcomes and effectiveness . In disease management , clinical trials are not always possible . When a health plan has developed a new clinical program , members may not feel comfortable having an intervention withheld , and employers may be unwilling to conduct a trial before disseminating the program . However , if the program is implemented without a concurrent comparison group , what remains is a before- and -after comparison ; within a rapidly changing health care environment , the aging of the population and other factors can confound results . This issue is an especially important method ologic challenge of program evaluation . Health Economic Evaluation The types of studies that are considered to be economic evaluations are shown in Table 3 . Of these , cost-effectiveness and costutility analyses overlap with outcomes research because economic measures are frequently related to outcomes such as mortality , quality of life , or value assigned to years of life saved ( or quality -adjusted life-years ) . Table 3 . Health Economic Evaluations Suppose the intervention is design ed for middle-aged persons with a disease that leads to death and only requires treatment for 3 years . If the therapy costs $ 3/d , the total cost of BACKGROUND People with multiple sclerosis ( MS ) are confronted with a number of important uncertainties concerning many aspects of the disease . These include diagnosis , prognosis , disease course , disease-modifying therapies , symptomatic therapies , and non-pharmacological interventions , among others . While people with MS dem and adequate information to be able to actively participate in medical decision making and to self manage their disease , it has been shown that patients ' disease-related knowledge is poor , therefore guidelines recommend clear and concise high- quality information at all stages of the disease . Several studies have outlined communication and information deficits in the care of people with MS . However , only a few information and decision support programmes have been published . OBJECTIVES The primary objectives of this up date d review was to evaluate the effectiveness of information provision interventions  for people with MS that aim to promote informed choice and improve patient-relevant outcomes , Further objectives were to evaluate the components and the developmental processes of the complex interventions used , to highlight the quantity and the certainty of the research evidence available , and to set an agenda for future research . SEARCH METHODS For this up date , we search ed the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register , which contains trials from CENTRAL ( the Cochrane Library 2017 , Issue 11 ) , MEDLINE , Embase , CINAHL , LILACS , PEDro , and clinical trials registries ( 29 November 2017 ) as well as other sources . We also search ed reference lists of identified articles and contacted trialists . SELECTION CRITERIA R and omised controlled trials ( RCTs ) , cluster-r and omised controlled trials , and quasi-r and omised trials comparing information provision for people with MS or suspected MS ( intervention groups ) with usual care or other types of information provision ( control groups ) were eligible . DATA COLLECTION AND ANALYSIS Two review authors independently assessed the retrieved articles for relevance and method ological quality and extracted data . Critical appraisal of studies addressed the risk of selection bias , performance bias , attrition bias , and detection bias . We contacted authors of relevant studies for additional information . MAIN RESULTS We identified one new RCT ( 73 participants ) , which when added to the 10 previously included RCTs result ed in a total of 11 RCTs that met the inclusion criteria and were analysed ( 1387 participants overall ; mean age , range : 31 to 51 ; percentage women , range : 63 % to 100 % ; percentage relapsing-remitting MS course , range : 45 % to 100 % ) . The interventions addressed a variety of topics using different approaches for information provision in different setting s. Topics included disease-modifying therapy , relapse management , self care strategies , fatigue management , family planning , and general health promotion . The active intervention components included decision aids , decision coaching , educational programmes , self care programmes , and personal interviews with physicians . All studies used one or more components , but the number and extent differed markedly between studies . The studies had a variable risk of bias . We did not perform meta-analyses due to marked clinical heterogeneity . All five studies assessing MS-related knowledge ( 505 participants ; moderate-certainty evidence ) detected significant differences between groups as a result of the interventions , indicating that information provision may successfully increase participants ' knowledge . There were mixed results on decision making ( five studies , 793 participants ; low-certainty evidence ) and quality of life ( six studies , 671 participants ; low-certainty evidence ) . No adverse events were detected in the seven studies reporting this outcome . AUTHORS ' CONCLUSIONS Information provision for people with MS seems to increase disease-related knowledge , with less clear results on decision making and quality of life . The included studies in this review reported no negative side effects of providing disease-related information to people with MS . Interpretation of study results remains challenging due to the marked heterogeneity of interventions and outcome measures Civilization and modern medicine now allow an unprecedented number of people to survive to old age . Not only has the definition of old evolved , but the aims of medical care for the elderly have progressed far beyond survival to maximizing functional and cognitive status , improving quality of life , and preserving productivity . Although many health problems in older age can be prevented or postponed by medical interventions , the quality of medical care for older persons remains largely unexamined . Previous work on quality -of-care measurement has focused on specific diseases or aspects of care , and in some cases targeted only a slice of the older population ( 16 ) . Such targeted approaches may not present a fair picture of overall quality and may lead to unintended incentives ( gaming the system ) ( 7 ) . Although broad systems of quality -of-care evaluation are less susceptible to gaming , they seldom include quality indicators focused on aspects of care important to older sick persons ( 8 , 9 ) . Substantial variation in preferences may make quality of care for older adults particularly difficult to measure . For example , older adults do not consistently prefer care that prolongs life , particularly if this care occurs at the expense of comfort . Furthermore , many ill , older adults can not advocate for themselves and may have no family members or friends to do so on their behalf . Thus , objective measures of the care they receive are particularly important . The Assessing Care of Vulnerable Elders ( ACOVE ) project endeavored to develop a comprehensive set of  quality - assessment tools for ill older persons . Because ill older persons constitute a heterogeneous cohort that is not easily delineated , we created a system to identify high-risk , community-dwelling individuals and targeted the most important clinical conditions affecting them . Specifically , our goals for this project were the following : 1 . Develop a definition of vulnerable elders that delineates a group of community-living persons 65 years of age and older who are at high risk for death or functional decline , and develop a system to identify them . 2 . Identify important medical conditions that affect vulnerable elders and for which effective methods of prevention or management exist . 3 . Develop a set of evidence -based , quality -of-care indicators that are relevant to vulnerable elders using systematic literature review s , expert opinion , and the guidance of expert groups and stakeholders . 4 . Design a chart abstract ion tool , interview instrument , and administrative data analytic methods to implement the quality -of-care indicator system . Project Structure : Advisory Boards To make the ACOVE tools as clinical ly useful as possible and to enhance their value to those who may use them , two advisory committees oversaw the project . The Clinical Committee directed the definition of the target population and identified the target conditions . It also review ed the full set of quality indicators assembled by the expert panels ( see the Methods paper ) . The Policy Advisory Committee directed the structure of the quality indicator system and the measurement approach . This committee review ed the sampling system , considered the value of a community surveybased sample versus a sample drawn from administrative data , advised the project on methods of data collection , and advocated the use of process measures rather than outcomes .Project Overview The Appendix lists the members and institutional affiliations of the Clinical Committee and the Policy Advisory Committee and ACOVE investigators and staff . Definition and Selection of the Patient Sample We termed our target sample vulnerable elders . With the assistance of the Clinical Committee , we defined vulnerable elders as persons 65 years of age and older who are at increased risk for death or functional decline . We considered several methods of identifying a community-based sample for measurement , including use of administrative data and survey sampling . The Policy Advisory Committee advised against using a sampling method based solely on administrative data because , by definition , using utilization data to define health status and disease burden disproportionately sample s persons with higher utilization of health services and may not identify persons who are undertreated or underdiagnosed . We selected a survey method that would identify vulnerable elders regardless of the amount of health care they used and that would be versatile for use across venues and health insurance systems . Using the Medicare Current Beneficiary Survey , we determined that functional status is a more important predictor of death and functional decline than are specific clinical conditions . A parsimonious set of factors that could be asked about in a brief interview , including age , self-rated health , and functional disabilities and limitations , predicted functional decline and death . Using these factors , we developed a scoring system that identified 32 % of a nationally representative sample as vulnerable : This group had more than four times the risk for death or functional decline over a 2-year period compared to the lower-scoring majority of the sample ( 10 ) . When we applied this definition to a r and om sample of persons 65 years of age and older enrolled in managed care plans , 21 % of elders were classified as vulnerable . Target Conditions for Assessing Quality of Care We selected the target conditions for quality -of-care assessment using literature review s and a formal group-judgment process . Target conditions were conceptualized as prevalent , important to health status and quality of life , having outcomes affected by medical care , feasible to measure , and geriatric . The Clinical Committee used these criteria to select 21 diseases , geriatric syndromes , physiologic impairments , and clinical situations ( see the Methods article for a list of these 21 conditions ) . The Policy Advisory Committee added a 22nd condition , continuity and coordination of care . According to national survey estimates , the prevalence of the selected conditions ranged from 10 % to 50 % among community-dwelling elders . These conditions accounted for at least 43 % of acute hospital admissions and 33 % of office visits for persons 65 years of age and older . The process of selecting the conditions is discussed in detail elsewhere ( 11 ) . Developing  Quality -of-Care Indicators  for Vulnerable Elders Clinical experts developed potential quality indicators for each target condition using existing guidelines and clinical opinion . Indicators covered the domains of prevention , diagnosis , treatment , and follow-up . Structured literature review s were then performed to assess the evidence supporting a link between the proposed processes of care and improved outcomes in older adults . We subsequently presented the proposed quality indicators and the literature syntheses to panels of experts in geriatric care and medical specialists . These expert panels considered the indicators ' validity and feasibility . On the basis of the panels ' ratings and a comprehensive review of the set by the Clinical Committee , we developed a set of 236  quality indicators  covering the 22 conditions . The Methods article describes this process in detail . This set of indicators was review ed and modified by the American College of PhysiciansAmerican Society of Internal Medicine ( ACPASIM ) Task Force on Aging . The full set of quality indicators with the literature substantiation for 11 of the conditions constitute the remainder of this supplement . A review of the accepted quality indicators reveals their decidedly geriatric nature . Many of them focus on the transfer of information between the health care provider and the patient or patient 's proxy . In addition to disease management , the indicators pay attention to detecting classically underidentified conditions , such as depression , dementia , and functional impairment . Consideration of proportionate care , informed consent , and end-of-life issues permeates the set . Implementing the Quality Indicators We developed instruments to implement the quality indicators using information collected from three sources : the medical record , a patient ( or , if necessary , proxy ) interview , and administrative data . Medical records include all inpatient and outpatient care over a 1-year period . The interview is design ed to be conducted by telephone with the patient to identify aspects of care that are not well captured in the medical record . The  quality indicators  presented here are currently undergoing feasibility testing in two managed care plans . Scoring the quality indicators accounts for clinical circumstances , patient preferences , and patient prognosis . The scoring of each quality indicator accounts for these factors at the following five levels : 1 . Any chart documentation indicating that a care process does not apply to the patient excludes application of this indicator to the patient . 2 . Any care process that is contraindicated because of comorbidity , allergy , or intolerance ( such as contraindications to medication ) excludes application of the indicator to the patient . 3 . If an indicator states that a care process should be offered to a patient , this indicator is satisfied if the care process occurs , if the medical record ( or patient interview ) indicates that the patient rejected the care process , or if the medical record ( or patient interview ) documents that the care process was offered to the patient . 4 . If the medical record contains documentation or if during an interview a patient states that he or she would not want , under any circumstances , to be hospitalized , then the 11 indicators that would require hospitalization do not apply . Similarly , a preference not to accept surgery would exclude from application to that patient the 9 indicators that prescribe surgery or procedures that would lead to surgery . 5 . If a patient has advanced dementia or a chart-documented poor prognosis ( expected survival < 6 months ) , then Background There are growing worldwide concerns about the ability of primary health care systems to manage the major burden of illness in young people . Over two thirds of premature adult deaths result from risks that manifest in adolescence , including injury , neuropsychiatric problems and consequences of risky behaviours . One policy response is to better reorientate primary health services towards prevention and early intervention . Currently , however , there is insufficient evidence to support this recommendation for young people . This paper describes the design and implementation of a trial testing an intervention to promote psychosocial risk screening of all young people attending general practice and to respond to identified risks using motivational interviewing . Main outcomes : clinicians ’ detection of risk-taking and emotional distress , young people ’s intention to change and reduction of risk taking . Secondary outcomes : pathways to care , trust in the clinician and likelihood of returning for future visits . The design of the economic and process evaluation are not detailed in this protocol . Methods PARTY is a cluster r and omised trial recruiting 42 general practice s in Victoria , Australia . Baseline measures include : youth friendly practice characteristics ; practice staff ’s self-perceived competency in young people ’s care and clinicians ’ detection and response to risk taking behaviours and emotional distress  in 14–24 year olds , attending the practice . Practice s are then stratified by a social disadvantage index and billing methods and r and omised . Intervention practice s receive : nine hours of training and tools ; feedback of their baseline data and two practice visits over six weeks . Comparison practice s receive a three hour seminar in youth friendly practice only . Six weeks post-intervention , 30 consecutive young people are interviewed post-consultation from each practice and followed-up for self-reported risk taking behaviour and emotional distress three and 12 months post consultation . Discussion The PARTY trial is the first to examine the effectiveness and efficiency of a  psychosocial risk screening and counselling intervention for young people attending primary care . It will provide important data on health risk profiles of young people attending general practice and on the effects of the intervention on engagement with primary care and health outcomes over 12 months . Trial registration IS RCT Background The case has been made for more and better theory-informed process evaluations within trials in an effort to facilitate insightful underst and ings of how interventions work . In this paper , we provide an explanation of implementation processes from one of the first national implementation research r and omized controlled trials with embedded process evaluation conducted within acute care , and a proposed extension to the Promoting Action on Research Implementation in Health Services ( PARIHS ) framework . Methods The PARIHS framework was prospect ively applied to guide decisions about intervention design , data collection , and analysis processes in a trial focussed on reducing peri-operative fasting times . In order to capture a holistic picture of implementation processes , the same data were collected across 19 participating hospitals irrespective of allocation to intervention . This paper reports on findings from data collected from a purposive sample of 151 staff and patients pre- and post-intervention . Data were analysed using content analysis within , and then across data sets . Results A robust and uncontested evidence base was a necessary , but not sufficient condition for practice change , in that individual staff and patient responses such as caution influenced decision making . The implementation context was challenging , in which individuals and teams were bounded by professional issues , communication challenges , power and a lack of clarity for the authority and responsibility for practice change . Progress was made in sites where processes were aligned with existing initiatives . Additionally , facilitators reported engaging in many intervention implementation activities , some of which result in practice changes , but not significant improvements to outcomes . Conclusions This study provided an opportunity for reflection on the comprehensiveness of the PARIHS framework . Consistent with the underlying tenant of PARIHS , a multi-faceted and dynamic story of implementation was evident . However , the prominent role that individuals played as part of the interaction between evidence and context is not currently explicit within the framework . We propose that successful implementation of evidence into practice is a planned facilitated process involving an interplay between individuals , evidence , and context to promote evidence -informed practice . This proposal will enhance the potential of the PARIHS framework for explanation , and ensure theoretical development both informs and responds to the evidence base for implementation . Trial registration IS RCT N18046709 - Peri-operative Implementation Study Evaluation ( PoISE ) OBJECTIVE This longitudinal study was design ed to assess the effect of an educational training package for primary health care teams in accident prevention for older people , with reference to the incidence of accidents and their associated economic consequence . METHODS Nineteen general practice s in the West Midl and s serving a population of 138 397 were allocated r and omly at the practice level either to receive  training  or continue normal practice . Study data was collated from the initial telephone call , reporting an accident , to the surgery , advice/treatment given at the practice and /or the community , casualty , inpatient care , written correspondence to the patient 's GP and any subsequent follow-up visits for accidents to people aged 65 years or older . RESULTS One thous and , six hundred and sixty-six ( 8.2 % ) patients aged 65 years or older registered with the participating practice s experienced one accident or more , costing the NHS pound 1.4 million . Extrapolated nationally , annual costs to the NHS for accidents to older people amount to pound 568 million . The educational package had no significant impact on the incidence of accidents . A paucity of general safety advice was given [ 48 ( 1.8 % ) occasions ] . CONCLUSIONS Budgets are being eroded and patients are suffering unnecessarily due to lack of accident prevention advice . This should be considered a priority within the primary health care team . Educational packages alone do not appear to be a cost-effective approach to accident prevention in primary care OBJECTIVE To assess the incremental costs and cost effectiveness of implementing a home based muscle strengthening and balance retraining programme that reduced falls and injuries in older women . DESIGN An economic evaluation carried out within a r and omised controlled trial with two years of follow up . Participants were individually prescribed an exercise programme ( exercise group , n=116 ) or received usual care and social visits ( control group , n=117 ) . SETTING 17 general practice s in Dunedin , New Zeal and . PARTICIPANTS Women aged 80 years and older living in the community and invited by their general practitioner to take part . MAIN OUTCOME MEASURES Number of falls and injuries related to falls , costs of implementing the intervention , healthcare service costs result ing from falls and total healthcare service costs during the trial . Cost effectiveness was measured as the incremental cost of implementing the exercise programme per fall event prevented . MAIN RESULTS 27 % of total hospital costs during the trial were related to falls . However , there were no significant differences in health service costs between the two groups . Implementing the exercise programme for one and two years respectively cost $ 314 and $ 265 ( 1995 New Zeal and dollars ) per fall prevented , and $ 457 and $ 426 per fall result ing in a moderate or serious injury prevented . CONCLUSIONS The costs result ing from falls make up a substantial proportion of the hospital costs for older people . Despite a reduction in falls as a result of this home exercise programme there was no significant reduction in healthcare costs . However , the results reported will provide information on the cost effectiveness of the programme for those making decisions on falls prevention strategies Background : multifactorial falls prevention programmes for older people have been proved to reduce falls . However , evidence of their cost-effectiveness is mixed . Design : economic evaluation alongside pragmatic r and omised controlled trial . Intervention : r and omised trial of 364 people aged ≥70 , living in the community , recruited via GP and identified as high risk of falling . Both arms received a falls prevention information leaflet . The intervention arm were also offered a ( day hospital ) multidisciplinary falls prevention programme , including physiotherapy , occupational therapy , nurse , medical review and referral to other specialists . Measurements : self-reported falls , as collected in 12 monthly diaries . Levels of health re source use associated with the falls prevention programme , screening ( both attributed to intervention arm only ) and other health-care contacts were monitored . Mean NHS costs and falls per person per year were estimated for both arms , along with the incremental cost-effectiveness ratio ( ICER ) and cost effectiveness acceptability curve . Results : in the base-case analysis , the mean falls programme cost was £ 349 per person . This , coupled with higher screening and other health-care costs , result ed in a mean incremental cost of £ 578 for the intervention arm . The mean falls rate was lower in the intervention arm ( 2.07 per person/year ) , compared with the control arm ( 2.24 ) . The estimated ICER was £ 3,320 per fall averted . Conclusions : the estimated ICER was £ 3,320 per fall averted . Future research should focus on adherence to the intervention and an assessment of impact on quality of life Background An ageing population , a growing prevalence of chronic diseases and limited financial re sources for health care underpin the importance of prevention of disabling health disorders and care dependency in the elderly . A wide variety of measures is generally available for the prevention of falls and fall-related injuries . The spectrum ranges from diagnostic procedures for identifying individuals at risk of falling to complex interventions for the removal or reduction of identified risk factors . However , the clinical and economic effectiveness of the majority of recommended strategies for fall prevention is unclear . Against this background , the literature analyses in this HTA report aim to support decision-making for effective and efficient fall prevention . Research questions The pivotal research question addresses the effectiveness of single interventions and complex programmes for the prevention of falls and fall-related injuries . The target population are the elderly ( > 60 years ) , living in their own housing or in long term care facilities . Further research questions refer to the cost-effectiveness of fall prevention measures , and their ethical , social and legal implication s. Methods Systematic literature search es were performed in 31 data bases covering the publication period from January 2003 to January 2010 . While the effectiveness of interventions is solely assessed on the basis of r and omised controlled trials ( RCT ) , the assessment of the effectiveness of diagnostic procedures also considers prospect i ve accuracy studies . In order to clarify social , ethical and legal aspects all studies deemed relevant with regard to content were taken into consideration , irrespective of their study design . Study selection and critical appraisal were conducted by two independent assessors . Due to clinical heterogeneity of the studies no meta-analyses were performed . Results Out of 12,000 references retrieved by literature search es , 184 meet the inclusion criteria . However , to a variable degree the validity of their results must be rated as compromised due to different biasing factors . In summary , it appears that the performance of tests or the application of parameters to identify individuals at risk of falling yields little or no clinical ly relevant information . Positive effects of exercise interventions  may be expected in relatively young and healthy seniors , while studies indicate opposite effects in the fragile elderly . For this specific vulnerable population the modification of the housing environment shows protective effects . A low number of studies , low quality of studies or inconsistent results lead to the conclusion that the effectiveness of the following interventions has to be rated unclear yet : correction of vision disorders , modification of psychotropic medication , vitamin D supplementation , nutritional supplements , psychological interventions , education of nursing personnel , multiple and multifactorial programs as well as the application of hip protectors . For the context of the German health care system the  economic evaluations of fall prevention  retrieved by the literature search es yield very few useful results . Cost-effectiveness calculations of fall prevention are mostly based on weak effectiveness data as well as on epidemiological and cost data from foreign health care systems . Ethical analysis demonstrates ambivalent views of the target population concerning fall risk and the necessity of fall prevention . The willingness to take up preventive measures depends on a variety of personal factors , the quality of information , guidance and decision-making , the prevention program itself and social support . The analysis of papers regarding legal issues shows three main challenges : the uncertainty of which st and ard of care has to be expected with regard to fall prevention , the necessity to consider the specific conditions of every single case when measures for fall prevention are applied , and the difficulty to balance the rights to autonomous decision making and physical integrity . Discussion and conclusions The assessment of clinical effectiveness of interventions for fall prevention is complicated by inherent method ological problems ( esp . absence of blinding ) and meaningful clinical heterogeneity of available studies . Therefore meta-analyses are not appropriate , and single study results are difficult to interpret . Both problems also impair the informative value of economic analyses . With this background it has to be stated that current recommendations regarding fall prevention in the elderly are not fully supported by scientific evidence . In particular , for the generation of new recommendations the dependency of probable effects on specific characteristics of the target population s or care setting s should be taken into consideration . This also applies to the variable factors influencing the willingness of the target population to take up and pursue preventive measures . In the planning of future studies equal weight should be placed on method ological rigour ( freedom from biases ) and transferability of results into routine care . Economic analyses require input of German data , either in form of a “ piggy back study “ or in form of a modelling study that reflects the structures of the German health care system and is based on German epidemiological and cost data Pediatric asthma is a growing public health issue , disproportionately affecting low-income people and people of color . Exposure to indoor asthma triggers plays an important role in the development and exacerbation of asthma . We describe the implementation of the Seattle-King County Healthy Homes Project , a r and omized , controlled trial of an outreach/education intervention to improve asthma-related health status by reducing exposure to allergens and irritants in the home . We r and omly assigned 274 low-income children with asthma ages 4 - 12 to either a high- or a low-intensity group . In the high-intensity group , community health workers called Community Home Environmental Specialists ( CHES ) conducted initial home environmental assessment s , provided individualized action plans , and made additional visits over a 12-month period to provide education and social support , encouragement of participant actions , provision of material s to reduce exposures ( including bedding encasements ) , assistance with roach and rodent eradication , and advocacy for improved housing conditions . Members of the low-intensity group received the initial assessment , home action plan , limited education during the assessment visit , and bedding encasements . We describe the recruitment and training of CHES and challenges they faced and explain the assessment and exposure reduction protocol s addressing dust mites , mold , tobacco smoke , pets , cockroaches , rodents , dust , moisture , and toxic or hazardous chemicals . We also discuss the gap between the practice s recommended in the literature and what is feasible in the home . We accomplished home interventions and participants found the project very useful . The project was limited in resolving structural housing quality issues that contributed to exposure to indoor triggers
In this area , there are examples of good and moderate quality studies which confirm the cost-effectiveness of diverse physical activity interventions in fall prevention .
Background Healthy ageing and health promotion ( HP ) actions for older people have become an important health sector priority .
At the same time , the application of economic evaluation methods in the field of health interventions in order to support allocative decision processes is of growing importance .
The aims of the review were to analyze what the existing evidence is on cost-effectiveness of HP and /or primary prevention ( PP ) programmes for older people whilst providing deeper insight into method ological aspects of such studies , their overall quality and issues related to practical implementation of results .