Artículo de revisión

 

Effectiveness of intervention programs in primary care for the robust elderly

 

Eficacia de los programas de intervención en atención primaria para adultos mayores robustos

 

Kenio Costa-de Lima, PhD,(1) Renato Peixoto-Veras, PhD,(2) Célia Pereira-Caldas, PhD,(2) Luciana-Branco da Motta, PhD,(2) Diego Bonfada, MSc en Enf,(1) Marquiony Marques-dos Santos, MSC,(1) Dyego Leandro Bezerra-de Souza, PhD,(1) Javier Jerez-Roig, MSC.(3)

 

(1) Rio Grande do Norte Federal University. Brazil.

(2) State University of Rio de Janeiro. Brazil.

(3) Can Misses Hospital Ibiza, Spain.

 

Corresponding author

 


Abstract

Objective. This study aimed to search the literature for intervention programs in primary care with a multiprofes-sional character, specifically directed at the robust elderly, and with viable and cost-effective interventions.

Materials and methods.The search strategies were applied in Cochrane, Lilacs, Pubmed, Scopus, WHOLIS, Embase, Medcarib, Scielo, Web of Science, and PAHO databases.

Results. 3 665 articles were found and 32 remained for analysis, grouped into four categories: care management; multidisciplinary intervention; interventions on the basis of risk; and educational interventions with health professionals.

Conclusion. Strategies such as domestic interventions can promote health and functionality of elderlies, as well as reduce mortality, use of the health system and costs. Besides that, the use of hard and light-hard technologies are important for risk prevention and care management for the elderly.There is a need to create programs for risk prevention and effective management of elderly care at the primary level.

Key words: ambulatory care; primary health care; aging; comparative effectiveness research.


Resumen

Objetivo. Buscar en la literatura programas de intervención en atención primaria de carácter multiprofesional, dirigidos especialmente a los adultos mayores robustos, con modelos viables y rentables de intervención.

Material y métodos. Las estrategias de búsqueda se aplicaron en las bases de datos Cochrane, Lilacs, Pubmed, Scopus, WHOLIS, Embase, Medcarib, Scielo, Web of Science y la OPS.

Resultados. Se encontraron 3 665 artículos, de los cuales 32 permanecieron para el análisis agrupados en cuatro categorías: gestión de cuidados, intervención multidisciplinaria, intervenciones sobre la base del riesgo e intervenciones educativas con profesionales de la salud.

Conclusiones. Las estrategias como las intervenciones domiciliarias pueden promover la salud y la funcionalidad de las personas mayores, así como reducir la mortalidad, el uso del sistema de salud y los costos. El uso de las tecnologías duras y ligeras-duras, junto con la creación de programas de cuidado de ancianos en el nivel primario, es importante para el cuidado de la salud de las personas mayores.

Palabras clave: atención ambulatoria; atención primaria de salud; envejecimiento; investigación sobre la eficacia comparativa.


 

Demographic transition occasioned by the aging world population brings with it relevant social impacts, especially in the field of health, since the proportional increase of elderly people is generally followed by changes in a population's morbidity-mortality indicators. In this scenario, the epidemiological profile tends to present an increase in the prevalence of non-communicable chronic diseases, as opposed to acute losses that are typical of infectious and parasitical conditions.1'2 Such changes mainly require strategic planning, expansion of the health care network, costs assessment, training and development of health professionals, and the construction of care management tools for the elderly, particularly in primary care.

Despite the importance of the consensus regarding prevention services and health promotion since the 1978 Alma-Ata Conference, in practice the supremacy of a model of assistance persists that is centered on the execution of hospital procedures, super specialized, individualized and guided by the biological paradigm for the health/sickness process.3'4 This is of profound concern when facing population aging because the strategies for prevention and health promotion are indispensable for the early diagnosis of risks and diseases, access to adequate treatment, better quality of life, and for combatting physical and cognitive deficiencies, excessive use of medications and other conditions that promote fragility among the elderly.5'6

Notwithstanding, the model centered on the illness-hospital-treatment triad demonstrates its hegemony even in the scientific universe, where the greater part of studies published in indexed periodicals are geared toward the frail elderly or focus their interest on specific diseases. In contrast, the literature lacks research on primary care strategies oriented toward the robust elderly, those who are independent enough for the principal activities of daily living and with medical conditions under control.7'8

Faced with this antagonism, the importance of literature reviews reveals itself, that is, instruments that synthesize what is produced on a global level on a particular theme, in this specific case the synthesis of knowledge related to robust adult primary care as an element that makes possible the reorientation of practices targeting this population This is essentially justified by departing from the premise that however much these individuals maintain intact functional capacities, they are still vulnerable to the effects of the aging process. Thus, the aim of this work was to search the literature for intervention programs in primary care with a multiprofessional character, specifically directed at the robust elderly, and with viable and cost-effective interventions.

 

Materials and methods

This study is about the care level that orients itself on the primary care demands coming from the elderly. For theoretical and clinical reasons that differentiate the treatment of the fragile elderly, we have chosen to produce separate analyses for these groups, thus this particular study has as its focus the robust elderly.

In October 2013 a review of the scientific literature was conducted, respecting the criteria of Beyea and Nicoll,9 which establishes the following steps for conducting an integrative review: definition of the databases for the search, establishment of criteria for sample selection, identification of the overview of search strategies, building a record of the data, analysis of the data, interpretation of the results, and, lastly, presentation of the review from the selection of selected articles.

The databases consulted were Cochrane, Lilacs, Pubmed, Scopus, WHOLIS, Embase, Medcarib, Scielo, Web of Science and PAHO with search strategies "ambulatory care" or "primary care" and "aged" or "aged, 80 and over" or "elderly" or "health services for the aged" and "program evaluation" or "health evaluation" or "effectiveness"/ "health services for the aged" and "primary health care" or "primary care" and not "frail elderly". The studies selected were those with a quantitative approach that dealt with primary health care for the elderly and development of programs or health actions aimed at the robust elderly. The effectiveness of the programs was analyzed following the criteria established by Assis and colleagues10 and Araújo and colleagues.11

National and international articles were included in the review, without time delimitation, published in English, Portuguese or Spanish. Excluded were editorials, summaries, conference proceedings, as well as doctoral dissertations and master's theses. Initially, the five researchers jointly conducted the search in the Pubmed database and from the number of articles found an agreement was reached regarding wich articles to select after assessment, as a way to ensure that the examiners were in calibration with each other. Articles for full text reading were included based on the title and abstract and, finally, the reviewers performed a detailed analysis of the studies that met the eligibility criteria. Data extraction was performed by means of annotated indexing. The results were displayed in tables and classified by thematic areas according to article content. The discussion was organized to identify successful experiences around the challenge of reflecting on the creation of primary care models for robust elderly.

 

Results

The number of studies found and selected during the search process is detailed in figure 1.

Based on the search strategies in the 10 databases, 3 665 articles were found. After the initial selection based on title and abstract, and subsequent exclusion of duplicates, 252 articles were selected a priori. We then proceeded to read the papers to apply the other criteria for inclusion adopted by the study, resulting in 32 documents selected to comprise the final analysis. These documents were read in their entirety. The results are presented below.

The studies shown in table I treat the care management of elderly in primary care. The programs used different strategies to improve the management of care, such as regular meetings of the primary care team, information technologies to facilitate the clinical practice and boost the consistency of care, in addition to encouraging the acceptance of preventive care home visits by means of letters and no-cost home visits. Improvements were identified, such as the reduction of mortality and costs per individual, an increase in the performance of early detection screening tests for specific diseases and the percentage of immunizations. In longitudinal studies the interventionperiod ranged from 1 to 2 years. Of these, one studied the effectiveness of the results 20 months after completion of the intervention.

Table II shows the 10 studies that performed a multidisciplinary intervention directed at the elderly. The strategies most used in the programs were physical activity, health education, social actions in the community, and adjustments in the pharmacological treatment of the elderly and the individual health maintenance plan and illness prevention. Five programs utilized home visits. The duration of the interventions ranged from three months to two years.

Four studies performed follow-ups in a period between 3 and 12 months after the completion of the program, and one study utilized a cohort of 10 years of monitoring.23 Nine studies reported positive results, such as reduction in the number of hospitalizations and medical visits, satisfaction of the elderly and health professionals involved, increase in the level of physical activity and improvement in the quality of life, increase in the functional capacity, and decrease in costs related to use of the health system.

The studies displayed in table III discuss primary care programs, with a focus on potential risk interventions for various elderly health-related problems: falls, physical incapacity, depression, cognitive deficit, hypertension, sedentary lifestyle, and improper diet. Twelve articles were found, published in an interval of 18 years between 1993 and 2011. Only one of the articles is not a clinical trial.32 In the experimental studies, the shortest intervention lasted on average 69 minutes and the longest lasted 24 months. Two of them performed follow-ups to assess long term results and the health professionals most present in the interventions were physicians and nurses. Two of the studies did not present significant results from a statistical standpoint.36'37

The studies that performed educational interventions with health professionals (table IV) used interdisciplinarity as a focus to improve the care of the elderly in primary care. The time of intervention was between 1 and 3 years and only one study, which evaluated improvements in the prescriptions performed by pharmacists, did not attain positive results. Two studies did the evaluation in a stratified way for age groups of 75 and 80 years, and both verified that only in the group with 80 year olds the interventions produced significant improvements. In relation to sex, one study observed that the intervention was able to reduce mortality and improve functional capacity only with the women.40

 

Discussion

A health service for the elderly should be considered to attend to people in different conditions of functionality. In addition, the structure and organization of the primary care service should be interlinked with the other levels of care, to meet the demands and facilitate the effectiveness of the system. In this sense, the intention of this study was to look for actions developed in primary care, performed by a group of professionals or multi-disciplinary team, aimed at robust elderly. Because we are dealing with functionally independent individuals who are nonetheless vulnerable to the effects of the aging process, the primary care action should necessarily have as a focus the maintenance of functionality and quality of life of this population.

Improvements in the management of care emerge as a key element in the maintenance of elderly functionality. The continuity of contact between the health team and the patient, whether through home visits or outpatient visits, resulted in improvements in functional capacity, reductions in mortality, hospitalization rates, number of days hospitalized, average cost per hospitalization and overall expenditure of the health system per individual.12'14'15'20'21'23'24'30'42 The criteria for continuity in care, however, need to be evaluated in order to ensure a low-cost service without harming the monitoring and maintenance of the health condition of the elderly patients. Wolinsky and colleagues15analyzed two characteristics related to continuity of care: the eight month interval between outpatient visits and the patient's link to the same physician for those visits. Both measures of continuity were associated with lower mortality, even after adjusting for demographic variables, socioeconomic status, social support, lifestyle and morbidity.

The home visits were one of the forms of contact commonly developed in the programs between the team and the elderly. These were performed mainly by nurses, with a frequency that varied betweenmonthly and twice-yearly resulting in evaluation actions, health promotion and maintenance, as well as prevention of complications. Although there is still some controversy in the scientific literature, systematic reviews have suggested that home interventions can promote the health conditions and functionality of the elderly, as well as reduce mortality, use of the health care system and costs.23'30

The utilization of information technology was proposed by two studies as an efficient method to improve the use of early detection exams for diseases and functional alterations common among the elderly, such as osteoporosis, diabetes, hypertension, and vitamin B12 deficiency.13'16 The computerization of the clinical practice, by means of electronic prompters and periodic check-up appointment reminders, were also strategies used by primary care physicians to increase the annual flu and pneumococcus vaccination rate, as well as assist in the prevention of health risks for the elderly.16'36 The alliance between health teams and information technology professionals may be considered, therefore, as an essential component for health services. Traditionally, technology is used more as an instrument in the organization of care on a secondary or tertiary level. The studies included in this review, despite showing strategies that are still incipient, indicate the need to expand the use of such technologies in primary care.

The interventions focused on risks are important for elderly primary care because they endeavor, ultimately, to maintain or improve the quality of life and functional capacity, fundamental conditions for detaining the increasing frailty of these individuals. In this sense, five studies were identified that focus on the topics mentioned above.33'34'37-39 However, the research of Ploeg and colleagues,37 which aimed to analyze the quality of life, functional state and mortality among elderly with more than 75 years, did not obtain statistically significant results, despite presenting a methodologically sound format. The authors confirmed that the primary prevention with people above this age range has less effect on the quality of life when compared with interventions with younger elderly.

The notion of primary risk prevention as a strategy to decrease costs was addressed by Peña and colleagues30 and James and colleagues.28 The link between costs and risks has been a challenge for public and private health systems, mainly in relation to the allocation of resources. Nevertheless, only two articles focused on this theme were published. This demonstrates the need to intensify the scientific discussion on the economics of health care with the aim of building solid instruments for coherent decision-making from a financial and management standpoint, especially in the field of elderly health care.

The majority of studies on risk focused their interventions on specific problems: those related to increased arterial hypertension, as well as proposals for interventions to combat this condition;30'31 intervention programs related to the risk of falls32'33'35and interventions to avoid depression.29'33 Doubtless, this type of concern is important, however by focusing the interventions on specific problems, they do not consider the reality of the majority of elderly who, in general, present various risk conditions and more than two chronic diseases. In these conditions, such interventions have little concrete impact on the quality of life or general clinical condition of the majority of elderly. Thus, it becomes clear the importance of risk intervention programs for the elderly in primary care that break with the logic of the unidirectional view of illnesses and complications, and advances in the sense of performing broader assessments that are also more consistent with the health/sickness process among elderly people.

Another central point of this discussion is the realization of multidisciplinary interventions in primary care. On this point, suffice it to underscore that the great majority of programs include the figure of the physician on the health team and, frequently, the primary care physician. In addition to this health professional, the presence of nursing professionals is also common, comprising the traditional doctor-nurse binary in primary care. Other health professionals, among others that can contribute substantially to the team, today are still seldom present in the primary care programs. In the present study we did not find research comparing the efficacy of different types of multi disciplinary teams. It seems that there is a consensus in the scientific literature on the necessity of these teams to deal with elderly people, generally with multiple and concomitant chronic illnesses, requiring a comprehensive approach.

Work in teams is complex, nevertheless, and currently it is not clear whether the participation of other health professionals in the planning of the treatment performed by physicians and nurses is able to obtain greater benefits for the health of the elderly, nor even if these multi disciplinary programs are more cost effective.32

With regard to the work of the multidisciplinary team in primary care, another key point is the professional training of its members in addressing the special needs of elderly patients. Based on this point, some studies present proposals for educational interventions with the health professional.40-43 The educational interventions with general practitioners and other health professionals had as their main objectives the fostering of interdisciplinarity and improvements in the diagnosis of functional capacity. Avlund and colleagues (2007)43 utilized fatigue in daily activities as a main element for preventive diagnosis of functional incapacity. Through the educational work of the team involved with the home visits they achieved significant results for the group of 80 years and older.

This article had some limitations because some of the texts initially selected from the databases were not available as complete documents and we were not able to obtain them through bibliographic substitution or even by contacting the authors. The number of documents not located was nevertheless small in relation to the total number of articles analyzed, limiting possible detriment. The work of searching for and reviewing the articles was done by five researchers separately. Nonetheless, to limit the effect of information bias a prior meeting was held with the researchers to standardize the search strategy and calibrate the selection of articles. During the analyses two more meetings were held to discuss remaining doubts regarding the inclusion or exclusion of articles.

 

Conclusions

One can perceive the importance of more traditional strategies in the outpatient sphere, such as home interventions, that can promote a condition of health and functionality for the elderly as well as reduce mortality, use of the health system and costs. Notwithstanding, one of the studies indicated that preventive strategies have less clinical and economic effect with the elderly over 75 years old. Concurrently, this review showed that the use of hard and light-hard technologies,* traditionally more common at tertiary and secondary care levels, are important for risk prevention and care management for the elderly.

Gaps were detected in the area of knowledge, given that few directly dealt with the discussions on strategies to reduce primary care costs. Moreover, for the elderly in primary care it became apparent that it is important to have risk prevention strategies that break with the logic of the unidirectional way of seeing illnesses and complications, and to advance in the sense of performing assessments that are broader and more consistent with the health/ illness process of the elderly. The multiprofessional work demonstrated its efficacy, although still centered on the physician-nurse binary. No studies were found comparing the efficacy of different types of multi disciplinary teams, despite being aware of the existing demands, suppressed due to the absence of other health professionals in the primary care.

Moreover, the vast maj ority of studies found in this review were performed in Europe or the United States, and in less proportion in Asia and Latin America. The development of research in Latin American countries is important because they represent different realities, cultural and individual biopsychosocial differences that, in turn, can interfere with the efficiency and effectiveness of the strategies developed in primary health care.

 

References

1. United Nations, Department of Economic and Social Affairs, Population Division.World population prospects: the 2010 revision. New York: UN, 2011.         

2. Omram AR.The epidemiologic transitions theory of the epidemiology of population change. Bulletin of the World Health Organization 2001 ;79(2): 161-170.         

3. Nicholas JA Hall WJ. Screening and preventive services for older adults. Mt Sinai J Med 2011;78:498-508.         

4. Mendes IAC. Development and health: the declaration of Alma-Ata and posterior movements. Rev LatAm Enfermagem 2004;12(3):447-448.         

5. Boyd CM, DarerJ, Boult L, Fried LRWu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. J Am Med Assoc 2005;294:716-724.         

6. Holmboe E, Kim N, Cohen S, Curry M, Elwell A Petrillo, MK, et al. Primary care physicians, office based practice, and the meaning of quality improvement.Am J Med 2005; 118:917-922.         

7. Vass M, Avlund K, Kvist K, Hendriksen C, Andersen CK, Keiding N. Structured home visits to older people. Are they only of benefit for women? A randomised controlled trial. Scand J Prim Health Care 2004;22:106-111.         

8. Moraes EN. Atenção à saúde do idoso: aspectos conceituais. Brasilia: Organização Pan-Americana da Saúde, 2012.         

9. Beyea SC, Nicoll ELH. Writing an integrative review. Aorn J 1998;67(4):877-880.         

10. Assis M, Hartz ZMA, Valla W. Programas de promoção da saúde do idoso: urna revisão da literatura científica no período de 1990 a 2002. Ciencia & Saúde Coletiva 2004;9(3):557-581.         

11. Araújo LF, Coelho CG, Mendonça ET, Vaz AVM, Siqueira-Batista R, Cotta RMM. Evidencias da contribuição dos programas de assistência ao idoso na promoção do envelhecimento saudável no Brasil. Rev Panam Salud Publica 201 1;30(1):80-86.         

12. German PS, Burton LC, Shapiro S, Steinwachs DM, Tsuji I, Paglia MJ, et al. Extended coverage for preventive services for the elderly: Response andresults in a demonstration population. Am j public health 1995;85(3):379-386.         

13. Toth-Pal E, Nilsson GH, Furhoff AK. Clinical effect of computer generated physician reminders in health screening in primary health care - a controlled clinical trial of preventive services among the elderly. Int J Med Inform 2004;73(9):695-703.         

14. Peleg R, Press Y, Asher M, Pugachev T, Glicensztain H, Lederman M, et al. An intervention program to reduce the number of hospitalizations of elderly patients in a primary care clinic. BMC Health Serv Res 2008;6(8):36-42.         

15. Wolinsky FD, Bentler SE, Liu L, Geweke JF, Cook EA Obrizan M, et al. Continuity of care with a primary care physician and mortality in older adults. J Gerontol A Biol Sci Med Sci 2010;65(4):421-428.         

16. Loo TS, Davis RB, Lipsitz LA, Irish J, Bates CK, Agarwal K, et al. Electronic medical record reminders and panel management to improve primary care of elderly patients. Arch Intern Med 2011;171 (17): 1552-1558.         

17. Fishman PA, Johnson EA, Coleman K, Larson EB, Hsu C, Ross TR, et al. Impact on seniors of the patient-centered medical home: evidence from a pilot study. Gerontologist 2012;52(5):703-711.         

18. Burton LC, Steinwachs DM, German PS, Shapiro S, Brant LJ, Richards TM, et al. Preventive services for the elderly: would coverage affect utilization and costs under Medicare? Am J Public Health 1995;85(3):387-391.         

19. Sommers LS, Marton Kl, Barbaccia JC, Randolph J. Physician, nurse, and social worker collaboration in primary care for chronically ill seniors. Arch Intern Med 2000; 160(12): 1825-1833.         

20. Coleman EA, Eilertsen TB, Kramer AM, Magid DJ, Beck A, Conner D. Reducing emergency visits in older adults with chronic illness. Eff Clin Pract 2001;4(2):49-57.         

21. Vass M, Avlund K, Kvist K, Hendriksen C, Andersen CK, Keiding N. Structured home visits to older people. Are they only of benefit for women? Scand Prim Health Care 2004;22(2):106-111.         

22. Kerse N, Elley CR, Robinson E, Arroll B. Is physical activity counseling effective for older people? J Am Geriatr Soc 2005;53(11): 1951 -1956.         

23. Sahlen KG, Lófgren C, Mari-Hellner B, Lindholm L. Preventive home visits to older people are cost-effective. Scand J Public Health 2008;36(3):265-271.         

24. Levine, MD, Ross TR, Balderson BH, Phelan EA. Implementing group medical visits for older adults at group health cooperative.) Am Geriatr Soc 2010;58(1):168-I72.         

25. Masud-Rana AKM, Wahlin A, Stalsby-Lundborg C, Nahar-Kabir Z. Impact of health education on health-related quality of life among elderly persons: results from a community-based intervention study in rural Bangladesh. Health Promotion International 2009;24(1):36-45.         

26. Fagan PJ, SchusterAB, Boyd C, Marsteller JA, Griswold M, Murphy SME, et al. Chronic care improvement in primary care: evaluation of an integrated pay-for-performance and practice-based care coordination program among elderly patients with diabetes. Health Serv Res 2010;45(6): 1763-1782.         

27. Molina-LópezT, Domínguez-Camacho JC, Palma-Morgado D, Caraballo-Camacho Mde L, Morales-Serna JC, López-Rubio S. A review of the medication in polymedicated elderly with vascular risk. Aten Primaria 2012;44(8):453-460.         

28. Fies JF, Bloch DA, Harrington H, Richardson N, Beck R. Two-year results of a randomized controlled trial of a health promotion program in a retiree population: the Bank of America study. Am J Med 1993;94:455-462.         

29. Wallace Jl, Buchner DM, Grothaus L, Leveille S, Tyll L, LaCroix AZ, et al., Implementation and effectiveness of a community-based health promotion program for older adults. J Gerontol A Biol Sci Med Sci I998;53A(4):M301-M306.         

30. García-Peña C, Thorogood M, Wonderling D, Reyes-Frausto S. Economic analysis of a pragmatic randomised trial of home visits by a nurse to elderly people with hypertension in Mexico. Salud Publica Mex 2002;44(1):14-20.         

31. Figar S, Waisman G, De-Quiros FG, Galarza C, Marchetti M, Loria GR, et al. Narrowing the gap in hypertension: effectiveness of a complex antihypertensive program in the elderly. Dis Manag 2004;7(3):235-243.         

32. Mitchell E. Prevention of falls in older people: the Weymouth and Portland project. Nurs Older People 2004; 16(2): 14-16.         

33. Sjösten NM, Salonoja M, Piirtola M, Vahlberg TJ, Isoaho R, Hyttinen HK, et al. A multifactorial fall prevention programme in the community-dwelling aged: predictors of adherence. Eur J Public Health 2007; 17(5):464-470.         

34.Shumway-Cook A, Silver IF, LeMier M, York S, Cummings R, Koepsell TD. Effectiveness of a community-based multifactorial intervention on falls and fall risk factors in community-living older adults: a randomized, controlled trial. J Gerontol A Biol Sci Med Sci 2007;62( 12): 1420-1427.         

35. Wyman JF, Croghan CF, Nachreiner NM, Gross CR, Stock HH, Jalley K, et al. Effectiveness of education and individualized counseling in reducing environmental hazards in the homes of community-dwelling older women. J Am Geriatr Soc 2007;55( 10): 1548-1556.         

36. Harari D, Lliffe S, Kharicha K, Egger M, Gillmann G, von Renteln-Kruse W, et al. Promotion of health in older people: a randomised controlled trial of health risk appraisal in British general practice. Age and Ageing 2008;37(5):565-571.         

37. Ploeg J, Brazil K, Hutchison B, Kaczorowski J, Dalby DM, Goldsmith CH, et al. Effect of reventive primary care outreach on health related quality of life among older adults at risk of functional decline: randomised controlled trial. BMJ 2010;340:c 1480.         

38. Min LC, Reuben DB, Adams J, Shekelle PG, Ganz DA, Roth CR, et al. Does better quality of care for falls and urinary incontinence result in better participant-reported outcomes? J Am Geriatr Soc 2011;59(8): 1435-1443.         

39. Drennan V, Levenson R, Goodman C, Evans C. The workforce in health and social care services to older people: developing an education and training strategy. Nurse EducToday 2004;24(5):402-408.         

40. Avlund K, Vass M, Hendriksen C. Education of preventive home visitors: the effects on change in tiredness in daily activities. Eur J Ageing 2007;4:125-131.         

41. Kronborg C, Vass M, Lauridsen J, Avlund K. Cost effectiveness of preventive home visits to the elderly: economic evaluation alongside randomized controlled study. Eur J Health Econ 2006;7(4):238-246.         

42. Avlund K, Vass M, Kvist K, Hendriksen C, Keiding N. Educational intervention toward preventive home visitors reduced functional decline in community-living older women. J Clin epidemiol 2007;60(9):954-962.         

43. RichmondS, Morton V, Cross B, Chi-Key-Wong I, Russel I, et al. Effectiveness of shared pharmaceutical care for older patients: respect trial findings. Br J Gen Pract 2010;59:14-20.         

44. Merhy EE, Chakkour M, Stéfano E, Stéfano ME, Santos CM, Rodrigues RA. Em busca de ferramentas analisadoras das tecnologías em saúde. A informação e o dia a dia de um serviço, interrogando e gerindo trabalho em saúde. In: Merhy EE, Onocko R, org. Agir em saúde: urn desafio para o público. São Paulo, SP: Hucitec/Lugar Editorial, 1997:113-150.         

 

Received on: June 10,2014
Accepted on: April 13,2015

 

Corresponding author:
Dr. Célia Pereira Caldas.
State University of Rio de Janeiro.
Av Edison Passos 15, apto 204 - Alto da BoaVista.
20531-073 Rio de Janeiro, RJ, Brazil.
E-mail: celpcaldas@hotmail.com

 

Declaration of conflict of interests. The authors declare that they have no conflict of interests.

 

Nota

* Hard technology: technological equipment like machinery, equipment, standards, organizational structures. Light-hard technology: well-structured knowledge present in the health work process, such as clinical work, epidemiology, among others. Light technology: relational technologies like bonding, listening.44

Instituto Nacional de Salud Pública Cuernavaca - Morelos - Mexico
E-mail: spm@insp3.insp.mx