McMaster researchers trial primary care program for older adults

A primary care program promoting the health of older adults was well received by family medical practices but lacked clinical benefits, says a study led by McMaster University researchers, published in the Annals of Family Medicine.

The Health Teams Advancing Patient Experience: Strengthening Quality (TAPESTRY) ran in six sites across Ontario from March 2018 to August 2019. The randomized clinical control trial (RCT) recruited 599 patients aged 70 years and older.

Health TAPESTRY integrates four key components including trained volunteers conducting home visits to gather health and social information from patients; interprofessional primary health care teams providing health care to patients and working with them to meet their health goals; using technology to collect and share data; and building links between patients and community resources.

“This intervention aligns with best-practice research and the principles of primary care,” said Dee Mangin, professor of the Department of Family Medicine, research lead for Health TAPESTRY and the David Braley Chair in Family Medicine.

The study evaluated the feasibility of implementing Health TAPESTRY across six family health team (FHT) sites in Ontario and reproducing the positive effects found in the research team’s first RCT. The first study, which took place in Hamilton, Ontario, found that patients who participated in the intervention walked more, had fewer hospitalizations and saw their primary care team more often.

“In the spread and scale of programs, it is critical to understand factors related to successful implementation and the replication of effectiveness when adapted in real-world contexts,” said Mangin.

In the case of Health TAPESTRY, the program was successfully implemented at all six FHTs. At 12 months, the program was a part of the routine workflow for FHT members.

However, the study showed no significant differences for the primary health outcomes between patients receiving Health TAPESTRY compared to those receiving usual care. The program did not impact number of hospitalizations or total physical activity.

“In research, a randomized trial occurs in a tightly controlled manner, then if successful, is implemented flexibly according to local context and it is assumed that RCT effectiveness is reproduced. But this flexibility may lead to a dilution of effects when the approach is translated into practice,” said Doug Oliver, associate professor of the Department of Family Medicine and implementation lead of Health TAPESTRY.

David Price, professor of the Department of Family Medicine and executive lead of Health TAPESTRY, said that “Even though the six sites implemented the program as intended, local contextual differences, such as patient populations, health care team characteristics, clinic workflow, and integration with other levels of the health care system likely led to the varying effectiveness of Health TAPESTRY.”

The study authors voice that these findings do not invalidate the initial RCT results, but rather highlight a real-world tension between proving efficacy in a controlled context and achieving scale-up as part of effective routine care.

Researchers say the results reinforce the importance of trials conducted under less-controlled conditions and raise questions about future methods and limitations to such complex research in primary care settings.

The research team is now exploring other components of Health TAPESTRY, including volunteer retention, technology integration, and cost-effectiveness, with publications forthcoming.