A multidisciplinary home visit program led to improved quality of life for homebound patients with advanced Parkinson's disease (PD), a new study suggests.
Researchers from the Fresco Institute of Parkinson's and Movement Disorders at New York University (NYU) Langone Medical Center in New York City, who pioneered the program, report that despite advanced age, high baseline Unified Parkinson's Disease Rating Scale (UPDRS) score, and PD progression, the home visit program improved most quality of life domains assessed.
"We have all these wonderful resources in the clinic but as Parkinson's progresses you reach this terrible paradox where the patient may be so disabled that they can't get to the clinic and they become estranged from care," investigator Jori Fleisher, MD, noted in an interview with Medscape Medical News.
Last week, at the 4th World Parkinson Congress in Portland, Oregon, Dr Fleisher described the program and some preliminary outcomes in a subset of 27 participating patients.
"Amazing" Results
As part of the program, patients with advanced PD who meet Medicare criteria for homebound status receive four quarterly home visits over 12 months. Each visit lasts about 90 minutes and includes an evaluation by a movement disorders specialist, social worker, and registered nurse, including detailed history of symptoms, falls, and healthcare use; physical examination, including the UPDRS; medication reconciliation; psychosocial evaluation and follow-up; and referral to in-home services. Quality of life (Neuro-QoL) is measured at the first and fourth visits.
"We bring our patient-centered approach at NYU to the patient," Dr Fleisher said.
At baseline, the 27 patients in the current analysis were 81 years of age on average and had had PD for an average of 10 years. Their mean UPDRS total score was 65. Forty percent live alone, and 55% had been hospitalized in the past 12 months.
Among 22 patients completing visit 4, total UPDRS increased by a mean of 12 points. Yet despite the expected progression of functional and motor disability over 1 year, quality of life improved in 7 of 8 Neuro-QoL domains, Dr Fleisher reported.
Quality-of-Life Scores Before and After Treatment
| Neuro-QoL Domain | Baseline T Scores | Change in Score From Baseline |
| Stigma | 53.4 | –1.8 |
| Fatigue | 51.8 | –1.9 |
| Depression | 51.6 | –0.6 |
| Anxiety | 54.9 | –0.7 |
| Emotional/behavioral dyscontrol | 52.0 | –1.4 |
| Positive affect/well-being | 47.3 | –2.0 |
| Ability to participate in social roles/activities | 42.2 | 1.4 |
| Satisfaction with social roles/activities | 40.6 | 0.5 |
"This is really a very sick group of patients. We thought maybe we could help mitigate how quickly quality of life declines, and what we found is that we stabilized or improved quality of life in our patients, which is amazing," Dr Fleisher said.
Medication Errors Common
Sarah Oyler, BSN, RN, is part of the home visit team at the Fresco Institute. In a separate poster, she reported a preliminary assessment of medication errors encountered during her home visits with patients.
"We saw that medication errors happen quite frequently and there is evidence in the literature to suggest that in PD specifically, medication nonadherence affects over two thirds of patients," she noted in an interview with Medscape Medical News.
"Even with the nurse looking at the medication errors at every visit, patients continued to make errors," Oyler noted.
The most common types of detected errors were errors of commission (33%), in which the patient was taking a medication that was not known to the provider or that they were told to discontinue. The second most common type of errors were errors of frequency (28%), followed by errors of omission (25%).
Most medication errors were discovered during the third visit (61% had at least 1 error), and new errors continued to be detected at the fourth visit.
"It's important that the nurse continuously look at medications with patients and caregivers. Since these patients are homebound, these medication errors would go undetected if we didn't see them and look for them in the home," Oyler said.
Dr Fleisher said the patients enjoy the home visits and say there are "highly satisfied." The team has now seen almost 100 patients and done more than 300 home visits, and they continue to follow most of these patients. In the future, they'd like to do a cost analysis to see exactly what the program costs and see whether it saves money in terms of healthcare utilization.
This research was supported by the Edmond J. Safra Philanthropic Foundation, the National Parkinson Foundation, and The Parkinson Alliance. The authors have disclosed no relevant financial relationships.
4th World Parkinson Congress. Poster P18.02 and P22.03. Presented September 23, 2016.
http://www.medscape.com/viewarticle/869502
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