RESUMEN
BACKGROUND: In economic evaluations, participants have to report their health care utilization continuously during follow-up. To unburden participants, researchers often collect data intermittently (i.e., in at least 3 months a year). However, comparability of intermittent v. continuous data collection is unknown. Therefore, this study aimed to compare costs estimated with intermittent data collection of health care utilization with those based on continuous data collection. METHODS: We used continuous health care utilization data from a trial with 12 months of follow-up and simulated several intermittent data collection patterns. Then 3 imputation techniques--individual mean (IM), last observation carried forward (LOCF) and next observation carried backward (NOCB)--were used to estimate total annual costs. Estimated annual costs were compared with observed annual costs from continuous data collection both in the original sample and in 1000 bootstrap samples. RESULTS: Analyses showed that intermittent data collection using cost diaries may offer good estimates of the actual total annual health expenditures. However, estimations of groups of costs differ between data collection patterns and imputation methods. The best estimations of annual total costs and groups of costs were obtained by random cohort data collection, using 3 random cohorts, ensuring that at least a third of the participants were measuring costs each month, combined with IM imputation. Intermittent data collection of health expenditures carries a small risk of missing infrequent expensive events. CONCLUSIONS: Continuous cost data collection remains the first choice. However, if intermittent measurement is chosen, we recommend calculating annual costs from intermittent data collection in random cohorts, combined with IM imputation.
Asunto(s)
Recolección de Datos , Servicios de Salud/estadística & datos numéricos , Anciano , Estudios de Cohortes , Femenino , Humanos , MasculinoRESUMEN
BACKGROUND: Knowledge about the circumstances under which injurious falls occur could provide healthcare workers with better tools to prevent falls and fall-related injuries. Therefore, we assessed whether older persons who sustain an injurious fall can be classified into specific fall types, based on a combination of fall location and activity up to the moment of the fall. In addition, we assessed whether specific injurious fall types are related to causes of the fall, consequences of the fall, socio-demographic characteristics, and health-related characteristics. METHODS: An exploratory, cross-sectional study design was used to identify injurious fall types. The study population comprised 333 community-dwelling Dutch elderly people aged 65 years or over who attended an accident and emergency department after a fall. All participants received a self-administered questionnaire after being discharged home. The questionnaire comprised items concerning circumstances of the injurious fall, causes of the fall, consequences of the fall, socio-demographic characteristics and health-related characteristics. Injurious fall types were distinguished by analyzing data by means of HOMALS (homogeneity analysis by means of alternating least squares). RESULTS: We identified 4 injurious fall types: 1) Indoor falls related to lavatory visits (hall and bathroom); 2) Indoor falls during other activities of daily living; 3) Outdoor falls near the home during instrumental activities of daily living; 4) Outdoor falls away from home, occurring during walking, cycling, and shopping for groceries. These injurious fall types were significantly related to age, cause of the fall, activity avoidance and daily functioning. CONCLUSION: The face validity of the injurious fall typology is obvious. However, we found no relationship between the injurious fall types and severity of the consequences of the fall. Nevertheless, there appears to be a difference between the prevalence of fractures and the cause of the fall between the injurious fall types. Our data suggests that with regard to prevention of serious injuries, we should pay special attention to outdoor fallers and indoor fallers during lavatory visits. In addition, we should have special attention for causes of the fall. However, the conclusions reached in this exploratory analysis are tentative and need to be validated in a separate dataset.
Asunto(s)
Accidentes por Caídas , Accidentes Domésticos , Características de la Residencia , Índice de Severidad de la Enfermedad , Accidentes por Caídas/prevención & control , Accidentes por Caídas/estadística & datos numéricos , Accidentes Domésticos/prevención & control , Accidentes Domésticos/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Masculino , Países Bajos , Características de la Residencia/estadística & datos numéricos , Factores de RiesgoRESUMEN
OBJECTIVE: To gain insight into the contribution of the occupational-therapy part of a multidisciplinary fall prevention programme towards the reduction of falls and functional decline. DESIGN: A descriptive and exploratory study. METHODS: Data were collected in the context of a randomized controlled trial that found no effect of a multidisciplinary fall prevention programme. The study population comprised 166 participants, two occupational therapists (OTs), and one official from each of the five participating municipalities. Data were collected on the recommendations arising from the OT part of the programme, the extent to which those recommendations were implemented and what OTs did to stimulate implementation of behaviour change. RESULTS: The occupational-therapy programme resulted in 457 recommendations; 65% of the recommendations regarding services and assistive devices were implemented. It took on average six months to implement recommended home modifications. Advice on behaviour change predominantly comprised recommendations to reduce risky behaviour. CONCLUSION: To improve the occupational-therapy programme more rapid implementation of recommendations is suggested. Second, participants should be supported to achieve recommended changes. Furthermore, occupational therapists should use theory-based techniques to stimulate behaviour change and use follow-up visits to promote maintenance of the desired behaviour.
Asunto(s)
Accidentes por Caídas/prevención & control , Accidentes Domésticos/prevención & control , Terapia Ocupacional/métodos , Dispositivos de Autoayuda , Anciano , Servicios de Atención de Salud a Domicilio , Vivienda , Humanos , Países Bajos , Evaluación de Programas y Proyectos de Salud , Ensayos Clínicos Controlados Aleatorios como Asunto , Conducta de Reducción del RiesgoRESUMEN
BACKGROUND: Falls are a major health threat to older community-living people, and initiatives to prevent falls should be a public health priority. We evaluated a Dutch version of a successful British fall prevention programme. Results of this Dutch study showed no effects on falls or daily functioning. In parallel to the effect evaluation, we carried out a detailed process evaluation to assess the feasibility of our multidisciplinary fall prevention programme. The present study reports on the results of this process evaluation. METHODS: Our fall prevention programme comprised a medical and occupational-therapy assessment, resulting in recommendations and/or referrals to other services if indicated. We used self-administered questionnaires, structured telephone interviews, structured recording forms, structured face-to-face interviews and a plenary group discussion to collect data from participants allocated to the intervention group (n = 166) and from all practitioners who performed the assessments (n = 8). The following outcomes were assessed: the extent to which the multidisciplinary fall prevention programme was performed according to protocol, the nature of the recommendations and referrals provided to the participants, participants' self-reported compliance and participants' and practitioners' opinions about the programme. RESULTS: Both participants and practitioners judged the programme to be feasible. The programme was largely performed according to protocol. The number of referrals and recommendations ensuing from the medical assessment was relatively small. Participants' self-reported compliance as regards contacting their GP to be informed of the recommendations and/or referrals was low to moderate. However, self-reported compliance with such referrals and recommendations was reasonable to good. A large majority of participants reported they had benefited from the programme. CONCLUSION: The results of the present study show that the programme was feasible for both practitioners and participants. Main factors that seem to be responsible for the lack of effectiveness are the relatively low number of referrals and recommendations ensuing from the medical assessments and participants' low compliance as regards contacting their GP about the results of the medical assessment. We do not recommend implementing the programme in its present form in regular care. TRIAL REGISTRATION: ISRCTN64716113.
Asunto(s)
Accidentes por Caídas/prevención & control , Accidentes Domésticos/prevención & control , Actividades Cotidianas , Anciano Frágil/psicología , Evaluación Geriátrica , Terapia Ocupacional/estadística & datos numéricos , Evaluación de Programas y Proyectos de Salud , Derivación y Consulta/estadística & datos numéricos , Accidentes por Caídas/estadística & datos numéricos , Accidentes Domésticos/estadística & datos numéricos , Anciano , Protocolos Clínicos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Medicina Familiar y Comunitaria , Estudios de Factibilidad , Fracturas Óseas/etiología , Fracturas Óseas/prevención & control , Geriatría , Humanos , Comunicación Interdisciplinaria , Países Bajos , Evaluación de Procesos y Resultados en Atención de Salud , Cooperación del Paciente/estadística & datos numéricos , Dispositivos de Autoayuda/estadística & datos numéricosRESUMEN
OBJECTIVES: To assess whether a pragmatic multidisciplinary fall-prevention program was more effective than usual care in preventing new falls and functional decline in elderly people. DESIGN: A two-group, randomized, controlled trial with 12 months of follow-up. SETTING: University hospital and home-based intervention, the Netherlands. PARTICIPANTS: Three hundred thirty-three community-dwelling Dutch people aged 65 and over who were seen in an emergency department after a fall. INTERVENTION: Participants in the intervention group underwent a detailed medical and occupational-therapy assessment to evaluate and address risk factors for recurrent falls, followed by recommendations and referral if indicated. People in the control group received usual care. MEASUREMENTS: Number of people sustaining a fall (fall calendar) and daily functioning (Frenchay Activity Index). RESULTS: Results showed no statistically significantly favorable effects on falls (odds ratio=0.86, 95% confidence interval (CI)=0.50-1.49) or daily functioning (regression coefficient=0.37, CI=-0.90 to 1.63) after 12 months of follow-up. CONCLUSION: The multidisciplinary fall-prevention program was not effective in preventing falls and functional decline in this Dutch healthcare setting. Implementing the program in its present form in the Netherlands is not recommended. This trial shows that there can be considerable discrepancy between the "ideal" (experimental) version of a program and the implemented version of the same program. The importance of implementation research in assessing feasibility and effectiveness of such a program in a specific healthcare setting is therefore stressed.
Asunto(s)
Accidentes por Caídas/prevención & control , Fracturas Óseas/prevención & control , Luxaciones Articulares/prevención & control , Grupo de Atención al Paciente , Heridas y Lesiones/prevención & control , Actividades Cotidianas/clasificación , Anciano , Anciano de 80 o más Años , Ejercicio Físico , Estudios de Factibilidad , Femenino , Estudios de Seguimiento , Evaluación Geriátrica , Humanos , Masculino , Limitación de la Movilidad , Países Bajos , Proyectos Piloto , Medición de Riesgo , Resultado del TratamientoRESUMEN
Falling is a common problem among elderly people and has many negative consequences. In the Netherlands, there is a need for effective fall prevention interventions aimed at elderly persons with an increased risk of falling. For this reason, we adapted a successful British fall prevention program comprising a medical occupational therapy assessment to the Dutch health care setting. This article describes the adaptation of this program and a pilot study to assess its feasibility in Dutch health care according to the implementers of the intervention as well as the participants (n = 21). This study showed that the Dutch intervention protocol is feasible in Dutch health care for both participants and implementers of the program. However, minor refinement of the intervention is warranted to improve its feasibility. The structured approach to adapt and pretest an intervention protocol appeared to be essential when aiming to implement a complex intervention program in a different health care setting.
Asunto(s)
Accidentes por Caídas/prevención & control , Enfermería Geriátrica/organización & administración , Terapia Ocupacional/organización & administración , Grupo de Atención al Paciente/organización & administración , Accidentes por Caídas/estadística & datos numéricos , Actividades Cotidianas , Anciano , Medicina Familiar y Comunitaria/organización & administración , Estudios de Factibilidad , Femenino , Evaluación Geriátrica , Directrices para la Planificación en Salud , Humanos , Masculino , Evaluación de Necesidades , Países Bajos , Evaluación en Enfermería , Investigación en Evaluación de Enfermería , Evaluación de Resultado en la Atención de Salud , Proyectos Piloto , Evaluación de Programas y Proyectos de Salud , Derivación y Consulta , Medición de RiesgoRESUMEN
OBJECTIVES: Multidisciplinary and multifactorial interventions seem to be effective in preventing falls. We aimed to assess the cost-effectiveness of a multidisciplinary fall prevention program compared with usual Dutch healthcare in community-dwelling people 65 years of age or older who experienced a fall. METHODS: Cost-effectiveness and cost-utility analysis were performed from a societal perspective. Falls and healthcare utilization were continuously measured for 12 months. Daily functioning and quality of life were measured at baseline, after 4 and 12 months. Bootstrap analyses were performed to estimate uncertainty of the findings and sensitivity analysis to assess the generalizability of assumptions made. RESULTS: One hundred sixty-six participants were randomly allocated to the experimental group and 167 to the control group. The overall response rate was 74 percent. Healthcare and patient and family costs of both groups were comparable. Our analyses showed no effect of the intervention program on falls, daily functioning, or quality of life measures. CONCLUSIONS: The multidisciplinary intervention program to prevent falls was not cost-effective compared with usual care in the Netherlands. Notwithstanding our findings, however, falls still have an important impact on society and individuals in terms of costs and effects. Economic evaluations studying promising interventions to prevent falls, therefore, remain necessary.
Asunto(s)
Accidentes por Caídas/economía , Accidentes por Caídas/prevención & control , Geriatría , Terapia Ocupacional , Características de la Residencia , Actividades Cotidianas , Anciano , Análisis Costo-Beneficio , Femenino , Evaluación Geriátrica , Humanos , Masculino , Calidad de Vida , Resultado del TratamientoRESUMEN
OBJECTIVE: To find out if administration of melatonin facilitates discontinuation of benzodiazepine (BD) therapy in patients with insomnia. METHOD: A placebo controlled trial in nine general practices in the Netherlands. Long-term users of benzodiazepines were asked by their GP to participate in a discontinuation program in combination with melatonin or placebo. The intervention and follow-up period lasted one year. During this period participants received four questionnaires about their use of sleeping medication and several health instruments. The urine of all participants was tested for the presence of benzodiazepines, as proof of the discontinuation. MAIN OUTCOME MEASURE: The discontinuation of benzodiazepine use measured by questionnaires and urine samples at three assessment points. RESULTS: A total of 503 long-term users were selected by the GPs, of whom 38 patients (16M/22F) participated. After one year 40% had stopped their benzodiazepine use, both in the intervention group on melatonin and in the placebo control group. Comparing stoppers and non-stoppers did not reveal significant differences in benzodiazepine use, or awareness of problematic use. CONCLUSION: Our findings do not conclusively indicate that melatonin is helpful for the discontinuation of the use of benzodiazepines, but the average dose of benzodiazepines in the group was low. Further investigation is necessary, with special attention to the possible influence of the daily dose on the facilitation effect of melatonin.
Asunto(s)
Benzodiazepinas/uso terapéutico , Hipnóticos y Sedantes/uso terapéutico , Melatonina/uso terapéutico , Trastornos del Inicio y del Mantenimiento del Sueño/tratamiento farmacológico , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Caracteres SexualesRESUMEN
In a qualitative study, 22 stroke patients undergoing rehabilitation in three nursing homes were interviewed about constraints on and improvements in their autonomy and about approaches of health professionals regarding autonomy. The data were analysed using grounded theory, with a particular focus on the process of regaining autonomy. An approach by the health professionals that was responsive to changes in the patients' autonomy was found to be helpful for restoration of their autonomy. Two patterns in health professionals' approach appeared to be facilitatory: (1) from full support on admission through moderate support and supervision, to reduced supervision at discharge; and (2) from paternalism on admission through partial paternalism (regarding treatment) to shared decision making at discharge. The approach experienced by the patients did not always match their desires regarding their autonomy. Support and supervision were reduced over time, but paternalism was often continued too long. Additionally, the patients experienced a lack of information. Tailoring interventions to patients' progress in autonomy would stimulate their active participation in rehabilitation and in decision making, and would improve patients' preparation for autonomous living after discharge.
Asunto(s)
Relaciones Enfermero-Paciente , Casas de Salud , Autonomía Personal , Rehabilitación de Accidente Cerebrovascular , Actividades Cotidianas , Humanos , Autocuidado , Accidente Cerebrovascular/enfermeríaRESUMEN
BACKGROUND: To perform out-of-hours primary care, Dutch general practitioners (GPs) have organised themselves in large-scale GP cooperatives. Roughly, two models of out-of-hours care can be distinguished; GP cooperatives working separate from the hospital emergency department (ED) and GP cooperatives integrated with the hospital ED. Research has shown differences in care utilisation between these two models; a significant shift in the integrated model from utilisation of ED care to primary care. These differences may have implications on costs, however, until now this has not been investigated. This study was performed to provide insight in costs of these two different models of out-of-hours care. METHODS: Annual reports of two GP cooperatives (one separate from and one integrated with a hospital emergency department) in 2003 were analysed on costs and use of out-of-hours care. Costs were calculated per capita. Comparisons were made between the two cooperatives. In addition, a comparison was made between the costs of the hospital ED of the integrated model before and after the set up of the GP cooperative were analysed. RESULTS: Costs per capita of the GP cooperative in the integrated model were slightly higher than in the separate model (epsilon 11.47 and epsilon 10.54 respectively). Differences were mainly caused by personnel and other costs, including transportation, interest, cleaning, computers and overhead. Despite a significant reduction in patients utilising ED care as a result of the introduction of the GP cooperative integrated within the ED, the costs of the ED remained the same. CONCLUSION: The study results show that the costs of primary care appear to be more dependent on the size of the population the cooperative covers than on the way the GP cooperative is organised, i.e. separated versus integrated. In addition, despite the substantial reduction of patients, locating the GP cooperative at the same site as the ED was found to have little effect on costs of the ED. Sharing more facilities and personnel between the ED and the GP cooperative may improve cost-efficiency.
Asunto(s)
Atención Posterior/economía , Redes Comunitarias/organización & administración , Costos y Análisis de Costo/estadística & datos numéricos , Prestación Integrada de Atención de Salud/organización & administración , Servicio de Urgencia en Hospital/organización & administración , Medicina Familiar y Comunitaria/organización & administración , Atención Primaria de Salud/economía , Atención Posterior/estadística & datos numéricos , Informes Anuales como Asunto , Redes Comunitarias/economía , Conducta Cooperativa , Prestación Integrada de Atención de Salud/economía , Servicio de Urgencia en Hospital/estadística & datos numéricos , Medicina Familiar y Comunitaria/economía , Humanos , Modelos Organizacionales , Países Bajos , Atención Primaria de Salud/estadística & datos numéricosRESUMEN
BACKGROUND: Demented nursing home patients are at high risk for falls. Falls and associated injuries can have a considerable influence on the autonomy and quality of life of patients. The prevention of falls among demented patients is therefore an important issue. In order to intervene in an efficient way in this group of patients, it is important to systematically evaluate the fall risk profile of each individual patient so that for each patient tailor-made preventive measures can be taken. Therefore, the objective of the present study is to develop a feasible and evidence based multidisciplinary fall risk evaluation tool to be used for tailoring preventive interventions to the needs of individual demented patients. METHODS: To develop this multidisciplinary fall risk evaluation tool we have chosen to combine scientific evidence on the one hand and experts' opinions on the other hand. Firstly, relevant risk factors for falling in elderly persons were gathered from the literature. Secondly, a group of Dutch experts in the field of falls and fall prevention in the elderly were consulted to judge the suitability of these risk factors for use in a multidisciplinary fall risk evaluation tool for demented nursing home patients. Thirdly, in order to generate a compact list of the most relevant risk factors for falling in demented elderly, all risk factors had to fulfill a set of criteria indicating their relevance for this specific target population. Lastly the final list of risk factors resulting from the above mentioned procedure was presented to the expert group. The members were also asked to give their opinion about the practical use of the tool. RESULTS: The multidisciplinary fall risk evaluation tool we developed includes the following items: previous falls, use of medication, locomotor functions, and (correct) choice and use of assistive and protective devices. The tool is developed for the multidisciplinary teams of the nursing homes. CONCLUSION: This evidence and practice based multidisciplinary fall risk evaluation tool targets the preventive interventions aimed to prevent falls and their negative consequences in demented nursing home patients.
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Accidentes por Caídas/prevención & control , Enfermedad de Alzheimer , Evaluación Geriátrica/métodos , Hogares para Ancianos/normas , Casas de Salud/normas , Medición de Riesgo/métodos , Accidentes por Caídas/estadística & datos numéricos , Anciano , Consenso , Medicina Basada en la Evidencia , Femenino , Humanos , Masculino , Países Bajos , Planificación de Atención al Paciente , Desarrollo de Programa , Factores de RiesgoRESUMEN
Systematic, computerized search in Medline, the Cochrane Library, Eric, PsychINFO and Embase files, 1980-2003, selecting descriptions of prospective intervention trials with good methodological design, testing effects of social support interventions on health outcomes in primary and outpatient care for type 2 diabetes. Six controlled trials were reviewed. They defined, modified, and measured social support in various ways, and scored outcomes with varying measures. Gender differences and the right amount of support seem important. Promising new forms of social support: group consultations (better HbA1c and lifestyle), Internet or telephone-based peer support (improved perceived support, increased physical activity, respectively), and social support groups (improved knowledge and psychosocial functioning). No improved diabetes control by classic forms of support, e.g. from spouse (but weight loss in women) and family and friends (no differences). It is tentatively concluded that this review supports the hypothesis that specific social support interventions affect patient self-care and diabetes outcomes. New forms of social support may be discussed and incorporated in the work of diabetes teams, and offered to patients as new possibilities to help them adjust to a life with (type 2) diabetes and make information-based decisions. Only in the group consultations study, diabetes control was protected. More well-designed research testing the effects of specific social support interventions on patient self-care, lifestyle adaptations, and outcomes of diabetes care, is warranted.
Asunto(s)
Diabetes Mellitus Tipo 2/psicología , Apoyo Social , Consejo , Femenino , Humanos , Internet , Relaciones Interpersonales , Masculino , Educación del Paciente como Asunto/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto , Autocuidado , Esposos/psicologíaRESUMEN
OBJECTIVE: To determine the effect of an out-of-hours primary care physician (PCP) cooperative on the caseload at the emergency department (ED) and to study characteristics of patients utilizing out-of-hours care. DESIGN: A pre-post intervention design was used. During a 3-week period before and a 3-week period after establishing the PCP cooperative, all patient records with out-of-hours primary and emergency care were analyzed. SETTING: Primary care in Maastricht (the Netherlands) is delivered by 59 PCPs. Primary care physicians formerly organized out-of-hours care in small locum groups. In January 2000, out-of-hours primary care was reorganized, and a PCP cooperative was established. This cooperative is located at the ED of the University Hospital Maastricht, the city's only hospital, which has no emergency medicine specialists. MAIN OUTCOME MEASURES: The number of patients utilizing out-of-hours care, their age and sex, diagnoses, post-ED care, and serious adverse events. RESULTS: After establishing the PCP cooperative, the proportion of patients utilizing emergency care decreased by 53%, and the proportion of patients utilizing primary care increased by 25%. The shift was the largest for patients with musculoskeletal disorders or skin problems. There were fewer hospital admissions, and fewer subsequent referrals to the patient's own PCP and medical specialists. No substantial change in new outpatient visits at the hospital or in mortality occurred. CONCLUSIONS: In the city of Maastricht, the Netherlands, the PCP cooperative reduced the use of hospital emergency care during out-of-hours care.
Asunto(s)
Atención Posterior/estadística & datos numéricos , Servicios de Salud Comunitaria/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Medicina Familiar y Comunitaria/tendencias , Derivación y Consulta/estadística & datos numéricos , Adolescente , Adulto , Atención Posterior/organización & administración , Niño , Preescolar , Medicina Familiar y Comunitaria/organización & administración , Femenino , Accesibilidad a los Servicios de Salud , Humanos , Lactante , Masculino , Persona de Mediana Edad , Países Bajos , Aceptación de la Atención de Salud/estadística & datos numéricos , Atención Primaria de Salud/organización & administraciónRESUMEN
BACKGROUND: Little is known about the care process after patients have contacted a GP cooperative for out-of-hours care. The objective of this study was to determine the proportion of patients who seek follow-up care after contact with a GP cooperative for out-of-hours care, and to gain insight into factors that are related to this follow-up care. METHODS: A total of 2805 patients who contacted a GP cooperative for out-of-hours care were sent a questionnaire. They were asked whether they had attended their own GP within a week after their contact with the cooperative, and for what reason. To investigate whether other variables are related to follow-up care, a logistic regression analysis was applied. Variables that entered in this analysis were patient characteristics (age, gender, etc.) and patient opinion on correctness of diagnosis, urgency and severity of the medical complaint. RESULTS: The response rate was 42%. In total, 48% of the patients received follow-up care from their own GP. Only 20% were referred or advised to attend their own GP. Others attended because their medical condition worsened or because they were concerned about their complaint. Variables that predicted follow-up care were the patient's opinion on the correctness of the diagnosis, patient's health insurance, and severity of the medical problem. CONCLUSION: Almost half of all patients in this study who contacted the GP cooperative for out-of-hours care attended their own GP during office hours within a week, for the same medical complaint. The most important factor that predicted follow-up care from the patient's own GP after an out-of-hours contact was the patient's degree of confidence in the diagnosis established at the GP cooperative. Despite the limited generalisability, this study is a first step in providing insight into the dimension of follow-up care after a patient has contacted the GP cooperative for out-of-hours primary care.
Asunto(s)
Atención Posterior/estadística & datos numéricos , Continuidad de la Atención al Paciente/estadística & datos numéricos , Medicina Familiar y Comunitaria/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Adolescente , Adulto , Factores de Edad , Anciano , Niño , Preescolar , Redes Comunitarias/estadística & datos numéricos , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Países Bajos , Visita a Consultorio Médico , Encuestas y CuestionariosRESUMEN
BACKGROUND: In recent years, Dutch general practitioner (GP) out-of-hours service has been reorganised into large-scale GP cooperatives. Until now little is known about GPs' experiences with working at these cooperatives for out-of-hours care. The purpose of this study is to gain insight into GPs' satisfaction with working at GP cooperatives for out-of-hours care in separated and integrated cooperatives. METHODS: A GP cooperative separate from the hospital Accident and Emergency (A&E) department, and a GP cooperative integrated within the A&E department of another hospital. Both cooperatives are situated in adjacent geographic regions in the South of The Netherlands. One hundred GPs were interviewed by telephone; fifty GPs working at the separated GP cooperative and fifty GPs from the integrated GP cooperative. Opinions on different aspects of GP cooperatives for out-of-hours care were measured, and regression analysis was performed to investigate if these could be related to GP satisfaction with out-of-hours care organisation. RESULTS: GPs from the separated model were more satisfied with the organisation of out-of-hours care than GPs from the integrated model (70 vs. 60 on a scale score from 0 to 100; P = 0.020). Satisfaction about out-of-hours care organisation was related to opinions on workload, guarantee of gatekeeper function, and attitude towards out-of-hours care as being an essential part of general practice. Cooperation with medical specialists was much more appreciated at the integrated model (77 vs. 48; P < 0.001) versus the separated model. CONCLUSION: GPs in this study appear to be generally satisfied with the organisation of GP cooperatives for out-of-hours care. Furthermore, GPs working at the separated cooperative seem to be more satisfied compared to GPs working at the integrated cooperative.
Asunto(s)
Atención Posterior , Citas y Horarios , Actitud del Personal de Salud , Servicio de Urgencia en Hospital/organización & administración , Médicos de Familia/psicología , Adulto , Conducta Cooperativa , Prestación Integrada de Atención de Salud , Medicina Familiar y Comunitaria/organización & administración , Femenino , Humanos , Relaciones Interprofesionales , Masculino , Persona de Mediana Edad , Países Bajos , Derivación y Consulta , Encuestas y CuestionariosRESUMEN
BACKGROUND: Falls are common among community-dwelling elderly people and can have a considerable impact on quality of life and healthcare costs. People who have sustained a fall are at greater risk of falling again.We replicated a British randomised controlled trial which demonstrated the effectiveness of a multidisciplinary intervention programme to prevent falls. The objective is to describe the design of a replication study evaluating a multidisciplinary intervention programme on recurrent falls and functional decline among elderly persons at risk. The study consists of an effect evaluation, an economic evaluation and a process evaluation. METHODS/DESIGN: The programme is aimed at community-dwelling elderly people aged 65 years or over who have visited an accident and emergency department (A&E department) or a general practitioners' cooperative (GP cooperative) because of a fall. The design involves a two-group randomised controlled trial. Participants are followed for twelve months after baseline. The intervention programme consists of a detailed medical and occupational therapy assessment with referral to relevant services if indicated. People in the control group receive usual care. The main outcome measures of the effect evaluation are number of falls and daily functioning. The economic evaluation will be performed from a societal perspective. A process evaluation will be carried out to evaluate the feasibility of the intervention programme.
Asunto(s)
Accidentes por Caídas/prevención & control , Servicios de Salud para Ancianos/organización & administración , Accidentes Domésticos/prevención & control , Anciano , Análisis Costo-Beneficio , Planificación Ambiental , Ejercicio Físico , Humanos , Educación del Paciente como Asunto , Evaluación de Programas y Proyectos de Salud , Proyectos de Investigación , Medición de RiesgoRESUMEN
INTRODUCTION: At Maastricht University, the integration of knowledge, skills and attitudes in preclinical medical education is promoted by an 'Adoption Programme', where students carry out assignments in a general practice setting. The assignments are explained and discussed in practical medical coaching groups. The aim of this study was to examine the relationships between the elements that affect learning in the programme. METHOD: Data from the evaluation questionnaires of 188 medical students were used to test a causal model of learning in the programme. A distinction was made between 'action' and 'reflection on action'. We examined the relationships between perceived instructiveness (the programme's value as a learning experience) and the following variables: comprehensibility; feasibility and execution of the assignments; time spent on the assignments, and the direct and indirect influences of the hosting general practitioner (GP) and the practical medical coaching group. RESULTS: Performing the assignments had little effect on perceived instructiveness. Coaching by the hosting GP influenced the execution of assignments mainly by its effect on feasibility. Coaching by the GP and in the practical medical coaching groups barely affected perceived instructiveness. DISCUSSION AND CONCLUSION: The model gives insight into the contribution of aspects of the Adoption Programme to student learning. The results are probably negatively influenced by the insufficient priority given to the Adoption Programme in the practical medical coaching groups and by inadequate instruction given to the GPs for the purposes of their coaching role. More careful planning of patient-related assignments is recommended. Reflection on assignments and feedback on procedures are needed to lift practical experience onto a higher educational level.
Asunto(s)
Educación de Pregrado en Medicina/métodos , Evaluación Educacional/normas , Actitud del Personal de Salud , Competencia Clínica/normas , Curriculum , Educación de Pregrado en Medicina/normas , Humanos , Médicos de Familia/organización & administración , Atención Primaria de Salud/métodos , Evaluación de Programas y Proyectos de Salud , Reproducibilidad de los ResultadosRESUMEN
This paper reports on a grounded theory interview-based study with 13 family members aged 28-80 years caring for terminally ill people at home (with a life expectancy of 3 months or less) in the Netherlands. The project was approved by the ethics committee of the Maastricht University Hospital. The aim of this study was to explore the experiences of family caregivers, their needs for home care, and which health services they receive. Data were analysed using the constant comparative method. 'Vulnerability' was identified as the core category. Caring for a terminally ill person at home requires continuous balancing between care burden and capacity to cope. Whether or not the carer will succeed in keeping in optimum balance is dependent on a number of factors impinging on the caregiver's vulnerability. Care burden, restricted activities, fear, insecurity, loneliness, facing death, lack of emotional, practical and information-related support were identified from the data as factors having the potential to increase the caregiver's vulnerability, and may be risk factors for fatigue and burnout. Continuing previous activities, hope, keeping control, satisfaction and good support are factors which may decrease the caregiver's vulnerability, and may protect against fatigue and burnout. The experiences of the caregivers in our study showed that the support from informal and professional caregivers was not sufficient. Education and practical tools may make professionals more sensitive for the vulnerable position of family caregivers, even when these caregivers do not show their vulnerability.
Asunto(s)
Cuidadores/psicología , Servicios de Atención de Salud a Domicilio , Atención Domiciliaria de Salud/psicología , Estrés Psicológico , Cuidado Terminal , Adulto , Anciano , Anciano de 80 o más Años , Relaciones Familiares , Femenino , Servicios de Atención de Salud a Domicilio/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Países Bajos , Cuidados Paliativos , Cuidado Terminal/psicologíaRESUMEN
This paper describes the results of a detailed evaluation of the intervention process of a multifactorial home visit programme aimed at preventing falls and mobility impairments among elderly persons living in the community. The aim of the study is to provide insight in factors related to the intervention process that may have influenced the effectiveness of this home visit programme. The programme consisted of five home visits performed by a community nurse over a period of 1 year. During the home visits the participants were screened for risk factors potentially influencing falls and mobility. The screening was followed by recommendations, referrals, and other actions aimed at dealing with the hazards observed. Data regarding the intervention process were gathered by means of interviews with nurses and participants, and by means of structured forms and questionnaires administered by the nurses during the intervention period. We conclude that our 1-year multifactorial home visit programme consisting of five home visits is feasible for nurses and participants. Despite this, it seems to be an unsuitable intervention technique to reduce falls and mobility impairments among elderly people at risk.