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QUESTION: In nursing home (NH) residents, does an intervention combining low intensity exercise and incontinence care offset its costs by reducing selected health conditions?
4 NHs in the US.
190 NH residents (mean age 88 y, 85% women) with urinary incontinence who did not have catheters, could follow a simple 1 step instruction, and were not on Medicare Part A reimbursement for post-acute skilled care or terminal illness. Follow up was 91% at 8 weeks and 78% at 32 weeks.
Patients were allocated to an 8 month exercise programme (Functional Incidental Training [FIT]) (n=92) or to usual care (n=98). The FIT intervention was implemented every 2 hours during the day for 5 days per week and involved prompts to toilet and changing if wet, encouragement to walk (or wheel their wheelchairs), repeat sit to stands up to 8 times, and practise upper body resistance training (arm curls or arm raises) once per day when in bed. Patients were offered fluids after each exercise trial.
Main cost and outcome measures
Acute conditions relating to physical inactivity, incontinence, or immobility including conditions of the dermatological, genitourinary, gastrointestinal, respiratory, endocrine, neurological, and cardiovascular systems; and falls, pain, and psychiatric and nutritional disturbances. Costs of tests and treatments were assessed using 1997–98 Medicare and Medicaid reimbursement amounts at a rate of 80%.
The FIT and usual care groups did not differ for the incidence of any acute conditions. Multivariable analyses were done to control for differences at baseline and follow up. When acute conditions were analysed together, FIT showed a non-significant 10% reduction in the number of fitness related sickness episodes. Of the acute conditions analysed separately, only falls showed a significant reduction (odds ratio 0.46, p<0.04) associated with FIT. The groups did not differ for cost of assessment and treatment of acute conditions between baseline and intervention periods (table⇓).
In nursing home residents, low intensity exercise plus incontinence care did not reduce the incidence or costs of acute conditions more than usual care.
Previous studies have shown the beneficial effects of exercise for older adults,1–,3 but no consensus exists on the appropriate quantity, quality, or intensity of exercise necessary to promote improved health and function in this population. Hence, it is difficult to know what would work best for frail older adults. Latham et al and Schnelle et al explore the transferability of what has been learnt in clinical research into the delivery of efficient and cost effective interventions in 2 groups of frail older adults.
The goal of the study by Latham et al was to identify an intervention that could be easily and inexpensively incorporated into existing home healthcare services. To decrease the complexity and improve the feasibility of the intervention, Latham et al selected 1 component of a multifaceted exercise programme and a 1 time dose of vitamin D for testing. However, neither simple quadriceps training nor vitamin D supplementation alone was sufficient to prevent falls in older adults who had recently been admitted to hospital.
The purpose of the study by Schnelle et al was to determine if reducing the incidence of costly health conditions could offset additional staffing requirements needed to implement the intervention. However, the study was powered for a 16% improvement in outcomes, rather than the more modest 10% improvement achieved in the study. According to Schnelle et al and others,4 direct comparison of costs without weighting improvements in functionality and other desired outcomes may not be the best approach to determine if an intervention is worth the extra cost.
The results of these studies are relevant to nurses who work in long term care and community settings with frail older adults. The findings increase our knowledge of factors that affect the translation of clinical research into everyday practice. Firstly, the intervention dose must be carefully considered; single strategies may not be effective for individuals with complex problems and needs. As Latham et al noted, an exercise programme using more muscle groups or performed for a longer duration may have been more effective, and other studies have shown the effectiveness of more complex exercise regimens, albeit not typically on such a frail population.5 The vitamin D supplementation dose was not sufficient to correct elevated parathyroid hormone concentrations that may be responsible for compromising muscle strength.5 Both calcium and vitamin D in sufficient quantities may be required to achieve the improvement sought.5
Secondly, cost of the intervention may not be the most appropriate criterion for adoption into practice. Although it was hoped that the benefits might be gained at no extra cost, this is rarely achieved in health care. Decisions about resource allocation should be made on the basis of information about costs and benefits. The exercise and incontinence intervention tested in the NH clinical trial6 on which the economic analysis was based resulted in improvement or prevented decline in mobility, upper body strength, and continence in most of the intervention group patients. However, Schnelle et al found that the staffing requirements needed to implement the intervention (1 aide to 5 patients) exceeded the staff resources available in most (92%) NHs and were not offset by reductions in other costly care. Staffing limitations may therefore prevent the successful transfer of this and similar exercise and incontinence interventions to NH clinical practice. The data reported in this study provide evidence that nurses’ aide staffing ratios advocated in recent government studies and by consumer groups7 as necessary to provide high quality NH care are justified.