Triage of frail elderly with reduced exercise tolerance in primary care (TREE). a clustered randomized diagnostic study

BMC Public Health, May 2012

Background Exercise reduced tolerance and breathlessness are common in the elderly and can result in substantial loss in functionality and health related quality of life. Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are common underlying causes, but can be difficult to disentangle due to overlap in symptomatology. In addition, other potential causes such as obesity, anaemia, renal dysfunction and thyroid disorders may be involved. We aim to assess whether screening of frail elderly with reduced exercise tolerance leads to high detection rates of HF, COPD, or alternative diagnoses, and whether detection of these diseases would result in changes in patient management and increase in both functionality and quality of life. Methods/Design A cluster randomized diagnostic trial. Primary care practices are randomized to the diagnostic-treatment strategy (screening) or care as usual. Patient population: Frail (defined as having three or more chronic or vitality threatening diseases and/or receiving five or more drugs chronically during the last year) community-dwelling persons aged 65 years and older selected from the electronic medical files of the participating general practitioners. Those with reduced exercise tolerance or moderate to severe dyspnoea (≥2 score on the Medical Research Counsel dyspnoea scale) are included in the study. The diagnostic screening in the intervention group includes history taking, physical examination, electrocardiography, spirometry, blood tests, and echocardiography. Subsequently, participants with new diagnoses will be managed according to clinical guidelines. Participants in the control arm receive care as usual. All participants fill out health status and other relevant questionnaires at baseline and after 6 months of follow-up. Discussion This study will generate information on the yield of screening for previously unrecognized HF, COPD and other chronic diseases in frail elderly with reduced exercise tolerance and/or exercise induced dyspnoea. The cluster randomized comparison will reveal whether this yield will result in subsequent improvements in functional health and/or health related quality of life. Trial registration ClinicalTrials.gov NCT01148719

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Triage of frail elderly with reduced exercise tolerance in primary care (TREE). a clustered randomized diagnostic study

Yvonne van Mourik 0 Karel GM Moons 0 Loes CM Bertens 0 Johannes B Reitsma 0 Arno W Hoes 0 Frans H Rutten 0 0 Julius Center for Health Sciences and Primary care, University Medical Center Utrecht , PO box 85500Stratenum 6.131, 3508AB, Utrecht , the Netherlands Background: Exercise reduced tolerance and breathlessness are common in the elderly and can result in substantial loss in functionality and health related quality of life. Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are common underlying causes, but can be difficult to disentangle due to overlap in symptomatology. In addition, other potential causes such as obesity, anaemia, renal dysfunction and thyroid disorders may be involved. We aim to assess whether screening of frail elderly with reduced exercise tolerance leads to high detection rates of HF, COPD, or alternative diagnoses, and whether detection of these diseases would result in changes in patient management and increase in both functionality and quality of life. Methods/Design: A cluster randomized diagnostic trial. Primary care practices are randomized to the diagnostictreatment strategy (screening) or care as usual. Patient population: Frail (defined as having three or more chronic or vitality threatening diseases and/or receiving five or more drugs chronically during the last year) community-dwelling persons aged 65 years and older selected from the electronic medical files of the participating general practitioners. Those with reduced exercise tolerance or moderate to severe dyspnoea (2 score on the Medical Research Counsel dyspnoea scale) are included in the study. The diagnostic screening in the intervention group includes history taking, physical examination, electrocardiography, spirometry, blood tests, and echocardiography. Subsequently, participants with new diagnoses will be managed according to clinical guidelines. Participants in the control arm receive care as usual. All participants fill out health status and other relevant questionnaires at baseline and after 6 months of follow-up. Discussion: This study will generate information on the yield of screening for previously unrecognized HF, COPD and other chronic diseases in frail elderly with reduced exercise tolerance and/or exercise induced dyspnoea. The cluster randomized comparison will reveal whether this yield will result in subsequent improvements in functional health and/or health related quality of life. Trial registration: ClinicalTrials.gov NCT01148719 - Background Reduced exercise tolerance and exercise induced dyspnoea are very common complaints in the elderly, with prevalence rates varying from 20% to 60% [1,2]. In many of the elderly with these complaints heart failure (HF) and/or chronic obstructive pulmonary disease (COPD) may be involved [2]. Multiple causes, however, should be considered, including obesity, anaemia, renal dysfunction and thyroid disorders. Because of overlap in clinical presentation [3-5], it is difficult to disentangle HF and COPD in the clinical assessment, resulting in both false-negative and false-positive diagnoses of both diseases in primary care [6-10], with subsequent undertreatment and unnecessary drug therapy, respectively. We suspect that especially in the frail, i.e. those prescribed multiple drugs and with multimorbidity, the prevalence of unrecognized underlying disease causing reduced exercise is potentially high. For both COPD and HF, but also for other possible underlying diseases such as anaemia and thyroid disorders, effective interventions (i.e. life style interventions and drugs) are available that can improve symptoms, functionality and quality of life and may reduce hospital admissions and mortality [4,11]. Potentially, a substantial beneficial effect in health outcome can be achieved by performing diagnostic tests (screening) in the early course of these diseases. We designed a cluster randomized trial to examine whether screening frail elderly for HF, COPD, and easy to detect other diseases (such as renal dysfunction, anaemia and thyroid disorders) yields a high proportion of previously unrecognized disease and whether subsequent targeted interventions improves patient outcome. Moreover, we will assess whether such a strategy is cost-effective. To determine the yield of screening for previously unrecognized HF, COPD and other chronic diseases (like anaemia, renal dysfunction, thyroid disorders) in frail elderly with reduced exercise tolerance and/ or exercise induced dyspnoea. To assess the effect of the diagnostic screening and subsequent targeted interventions on functional health and health related quality of life after 6 months of follow-up. To assess the cost-effectiveness of screening and subsequent targeted management. To identify the most cost-effective combination of screening tests. screening program (with subsequent targeted interventions in newly detected diseases) compared to usual care on the number of previously unrecogni (...truncated)


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Yvonne van Mourik, Karel GM Moons, Loes CM Bertens, Johannes B Reitsma, Arno W Hoes, Frans H Rutten. Triage of frail elderly with reduced exercise tolerance in primary care (TREE). a clustered randomized diagnostic study, BMC Public Health, 2012, pp. 385, 12, DOI: 10.1186/1471-2458-12-385