Augustinus J.P. Schrijvers

Quality of life and the ICIDH: towards an integrated conceptual model for rehabilitation outcomes research

Objective: The development of the International Classification of Impairments, Disabilities and Handicaps (ICIDH) has led to the assessment of a wider range of relevant rehabilitation outcomes, but a need for a further broadening exists. In this article, a new proposal for an extended ICIDH is made. Method: Review of the literature on quality of life and of attempts to integrate the World Health Organization (WHO) biopsychosocial model and the ICIDH. Results: Our review shows three operationalizations of the concept of quality of life: as health, as well-being and, preferably, as a superordinate construct. None of the attempts to integrate the WHO biopsychosocial model have been entirely successful. Our new proposal is characterized by (a) incorporation of the organ, person and social levels of the ICIDH, (b) distinction between objective and subjective aspects of quality of life as a second axis in the model, resulting in somatic sensations as the subjective part of the organ level, perceived health as the subjective part of the person level and domainspecific life satisfaction as the subjective part of the social level, and (c) separation of the concept of general well-being or happiness as being distinct from the ICIDH. The proposal model is intended to serve as a framework in which different outcomes can be positioned in relation to each other. Conclusion: Our model is intuitively appealing and remains close to familiar concepts and models. However, it is as yet far from perfect, and we hope to provoke discussion to help further refinement.

Effects of telemonitoring in patients with chronic obstructive pulmonary disease.

The objective of this study was to determine the effects of a homebased telemonitoring device, The Health Buddy (HB), on health consumption and health-related quality of life (HRQoL) in patients with moderate to severe chronic obstructive pulmonary disease (COPD). The HB provides daily symptom-surveillance by a case manager and education to enhance disease knowledge and self-management. A nonrandomized controlled multicenter study was established comparing the effectiveness of telemonitoring as an add-on to care as usual with a follow-up of 6 months. Four hospitals took part in the experimental group and 2 hospitals formed an equivalent control group with 59 and 56 patients, respectively. HRQoL was measured by the Clinical COPD Questionnaire. Healthcare consumption was assessed using medical records in the 6 months preceding study entry and during the study. Compared with the control group, the HB group showed a significant decrease in hospital admission rates (HB -0.11 +/- 1.16 vs. control +0.27 +/- 1.0, p = 0.02) and in the total number of exacerbations (HB -0.35 +/- 1.4 vs. control +0.32 +/- 1.2, p = 0.004). There was a tendency toward decreased hospital days and outpatient visits. No significant changes in HRQoL were observed at follow-up between both study groups. Despite inherent limitations of the study, these findings suggest that adopting telemonitoring in everyday clinical practice is feasible and can substantially improve care and decrease healthcare utilization of patients with moderate to severe COPD.

Reliability and validity of the Manchester Triage System in a general emergency department patient population in the Netherlands: results of a simulation study

Objective: To assess the reliability and validity of the Manchester Triage System (MTS) in a general emergency department patient population. Methods: A prospective evaluation study was conducted in two general hospitals in the Netherlands. Emergency department nurses from both hospitals triaged 50 patient vignettes into one of five triage categories in the MTS. Triage ratings were compared with the ratings of two Dutch MTS experts to measure inter-rater reliability. Nineteen days after triaging the patient vignettes, triage nurses were asked to rate the same vignettes again to measure test-retest reliability. Reliability in relation to the work experience of emergency department nurses was also studied. Validity was assessed by calculating percentages for overtriage, undertriage, sensitivity and specificity. Results: Inter-rater reliability was “substantial” (weighted kappa 0.62 (95% CI 0.60 to 0.65)) and test-retest reliability was high (intraclass correlation coefficient 0.75 (95% CI 0.72 to 0.77)). No significant association was found between the experience of emergency department nurses and the reliability score (kappa). Undertriage occurred more frequently than overtriage, especially in elderly patients (25.3% vs 7.6%). Sensitivity for urgent patients in the MTS was 53.2% and specificity was 95.1%. The patient vignettes representing children aged <16 years revealed a higher sensitivity (83.3%). Conclusions: Inter-rater reliability is “moderate” to “substantial” and test-retest reliability is high. The reliability of the MTS is not influenced by nurses’ work experience. Undertriage mainly occurs in the MTS categories orange and yellow. The MTS is more sensitive for children who need immediate or urgent care than for other patients in the emergency department.

The Utrecht Health Project: Optimization of routine healthcare data for research

BackgroundResearch on the impact of changes in healthcare policy, developments in community and public health and determinants of health and disease during lifetime may effectively make use of routine healthcare data. These data, however, need to meet minimal criteria for quality and completeness. Research opportunities are further improved when routine data are supplemented with a standardized ‘baseline’ assessment of the full population. This formed the basis for a new study initiated in a newly developed large residential area in Leidsche Rijn, part of the city of Utrecht, the Netherlands.MethodsAll new inhabitants are invited by their general practitioner to participate in the Utrecht Health Project (UHP). Informed consent is obtained and an individual health profile (IHP) is made by dedicated research nurses. The IHP is the starting point for the UHP research database as well as for the primary care electronic medical records. Follow-up data are collected through continuous linkage with the computerized medical files recorded by the general practitioners. UHP staff in each practice takes care of quality management of registration as well as data handling.ResultsCurrently, over 60 of invited new residents in the area have given informed consent with participation steadily increasing.DiscussionThe Utrecht Health Project combines key elements of traditional epidemiologic cohort studies with the current power of routine electronic medical record keeping in primary care. The research approach optimizes routine health care data for use in scientific research.

Effect of an action plan with ongoing support by a case manager on exacerbation-related outcome in patients with COPD: a multicentre randomised controlled trial

Background An individualised action plan (AP) is a potentially effective method of helping patients with chronic obstructive pulmonary disease (COPD) to recognise and anticipate early exacerbation symptoms. This multicentre randomised controlled trial evaluates the hypothesis that individualised APs reduce exacerbation recovery time. Methods Two hundred and thirty-three patients with COPD (age 65±10 years, forced expiratory volume in 1 s 56±21% predicted) were randomised to receive either an individualised AP (n=111) or care as usual (n=122). The AP provides individualised treatment prescriptions (pharmaceutical and non-pharmaceutical) related to a colour-coded symptom status to enhance an adequate response to periods of symptom deterioration (reinforced at 1 and 4 months). Exacerbation onset was defined using the Anthonisen symptom diary card algorithm. Every 3 days the Clinical COPD Questionnaire (CCQ) was assessed to evaluate the longitudinal course of health status. The primary outcome was health status recovery in the event of an exacerbation. Results During the 6-month follow-up period there was no difference in exacerbation rates and healthcare utilisation between the two groups. Cox-adjusted survival analysis including frailty showed enhanced health status recovery (HR 1.58; 95% CI 0.96 to 2.60) and reduced length of the exacerbation (HR 1.30; 95% CI 0.92 to 1.84). The mean difference in symptom recovery time was −3.68 days (95% CI −7.32 to −0.04). Mixed model repeated measure analysis showed that an AP decreased the impact of exacerbations on health status both in the prodromal and early post-onset periods. Between-group differences in CCQ scores were above the minimal clinically relevant difference of 0.4 points (3.0±0.7 vs 3.4±0.9; p≤0.01). Conclusion This study shows that an individualised AP, including ongoing support by a case manager, decreases the impact of exacerbations on health status and tends to accelerate recovery. APs can be considered a key component of self-management programmes in patients with COPD.

The epidemiology of total hip replacement in the Netherlands and Sweden - Present status and future needs

By combining data from the Discharge registers and the census bureaus in The Netherlands and Sweden, we calculated the age-specific incidences of primary total hip replacement (THR), studied the demographic profile of the population receiving THR and predicted demands. In the period 1986-1997, the number of THRs increased by 20% in Sweden to 10,000 operations (113/100,000 inhabitants) and by 68% to 17,400 operations (112/100,000 inhabitants) in The Netherlands. Of this increase 3% and 15% could be explained by changes in the age-profile and size of the population, respectively. Although the overall incidence of THR was similar in both countries in 1997, we found that, after correction for differences in population structure, the incidence of THR was 20% higher in The Netherlands. In Sweden, relatively more men were operated on than in The Netherlands. We also found that in Sweden, but not in the Netherlands, relatively more older people were operated on in 1997 than in 1987. Assuming no further change in the age- and sex-specific arthroplasty rates, the predicted annual number of total hip replacements by the year 2020 will increase by at least one fourth in Sweden and almost one half in The Netherlands.

Clustering of health-related behaviors, health outcomes and demographics in Dutch adolescents: A cross-sectional study

BackgroundRecent studies show several health-related behaviors to cluster in adolescents. This has important implications for public health. Interrelated behaviors have been shown to be most effectively targeted by multimodal interventions addressing wider-ranging improvements in lifestyle instead of via separate interventions targeting individual behaviors. However, few previous studies have taken into account a broad, multi-disciplinary range of health-related behaviors and connected these behavioral patterns to health-related outcomes. This paper presents an analysis of the clustering of a broad range of health-related behaviors with relevant demographic factors and several health-related outcomes in adolescents.MethodsSelf-report questionnaire data were collected from a sample of 2,690 Dutch high school adolescents. Behavioral patterns were deducted via Principal Components Analysis. Subsequently a Two-Step Cluster Analysis was used to identify groups of adolescents with similar behavioral patterns and health-related outcomes.ResultsFour distinct behavioral patterns describe the analyzed individual behaviors: 1- risk-prone behavior, 2- bully behavior, 3- problematic screen time use, and 4- sedentary behavior. Subsequent cluster analysis identified four clusters of adolescents. Multi-problem behavior was associated with problematic physical and psychosocial health outcomes, as opposed to those exerting relatively few unhealthy behaviors. These associations were relatively independent of demographics such as ethnicity, gender and socio-economic status.ConclusionsThe results show that health-related behaviors tend to cluster, indicating that specific behavioral patterns underlie individual health behaviors. In addition, specific patterns of health-related behaviors were associated with specific health outcomes and demographic factors. In general, unhealthy behavior on account of multiple health-related behaviors was associated with both poor psychosocial and physical health. These findings have significant meaning for future public health programs, which should be more tailored with use of such knowledge on behavioral clustering via e.g. Transfer Learning.

The Effects of Adolescent Health-Related Behavior on Academic Performance A Systematic Review of the Longitudinal Evidence

Schools are increasingly involved in efforts to promote health and healthy behavior among their adolescent students, but are healthier students better learners? This synthesis of the empirical, longitudinal literature investigated the effects of the most predominant health-related behaviors—namely, alcohol and marijuana use, smoking, nutrition, physical activity, sexual intercourse, bullying, and screen time use (television, Internet, video games)—on the academic performance of adolescents. Thirty studies dating back to 1992 were retrieved from the medical, psychological, educational, and social science literature. Healthy nutrition and team sports participation were found to have a positive effect on academic performance, whereas the effects of alcohol use, smoking, early sexual intercourse, bullying, and certain screen time behaviors were overall negative. Generally, all relations of health-related behaviors and academic performance were dependent on contextual factors and were often mediated by psychosocial problems, social structures, and demographics. Findings were interpreted with use of sociological theories.

Action Plan to enhance self-management and early detection of exacerbations in COPD patients; a multicenter RCT

BackgroundEarly detection of exacerbations by COPD patients initiating prompt interventions has shown to be clinically relevant. Until now, research failed to identify the effectiveness of a written individualized Action Plan (AP) to achieve this.Methods/DesignThe current multicenter, single-blind RCT with a follow-up period of 6 months, evaluates the hypothesis that individualized APs reduce exacerbation recovery time. Patients are included from regular respiratory nurse clinics and allocated to either usual care or the AP intervention. The AP provides individualized treatment prescriptions (pharmaceutical and non-pharmaceutical) related to a color coded symptom status (reinforcement at 1 and 4 months). Although usually not possible in self-management trials, we ensured blinding of patients, using a modified informed consent procedure in which patients give consent to postponed information. Exacerbations in both study arms are defined using the Anthonisen symptom diary-card algorithm. The Clinical COPD Questionnaire (CCQ) is assessed every 3-days. CCQ-recovery time of an exacerbation is the primary study outcome. Additionally, healthcare utilization, anxiety, depression, treatment delay, and self-efficacy are assessed at baseline and 6 months. We aim at including 245 COPD patients from 7 hospitals and 5 general practices to capture the a-priori sample size of at least 73 exacerbations per study arm.DiscussionThis RCT identifies if an AP is an effective component of self-management in patients with COPD and clearly differentiates from existing studies in its design, outcome measures and generalizability of the results considering that the study is carried out in multiple sites including general practices.Trial RegistrationNCT00879281

Evaluation of trauma care by comparing mortality risks and admission policy in a Dutch trauma region

OBJECTIVE To evaluate the effectiveness of trauma care in the Netherlands compared to UK norms and in terms of mortality risks in three groups of patients. The hypothesis was that there is no difference in risk of hospital death between major trauma patients transferred from another hospital to the trauma centre and patients directly admitted to the trauma centre. METHODS Trauma admissions (n=17,023) during the period 2000-2006 in 12 emergency departments were selected from a regional trauma registry database. In the analysis, the dependent variable was death within 30 days of admission. W-Statistics (W(s)) was used to compare outcomes of the total Dutch trauma population and the population admitted to the trauma centre, with norms for England and Wales. The effect of direct admission to a non-trauma centre and immediate admission to a trauma centre for major trauma patients versus indirect admission was tested in a logistic model and adjusted for confounding. RESULTS 444 (2.6%) patients died within 30 days of admission. 6.1% of all patients were major trauma patients. W(s) resulted in 1.39 (95% CI 1.08-1.70) more observed survivors per 100 admitted trauma patients standardised for case mix using UK norms. W(s) of trauma patients in the trauma centre resulted in 0.85 (95% CI 0.44-1.27) more survivors than expected. Patients directly admitted to a trauma centre or a non-trauma centre without transfer were found to have a non-significant increasing risk of mortality (OR 1.5 (95% CI 0.7-3.4) and 1.9 (95% CI 0.9-4.1), respectively) compared to patients transferred from another hospital to a trauma centre. CONCLUSION Trauma care in this Dutch province is performing better than expected comparing to the norms for the England and Wales. The admission policy of transporting major trauma patients to the nearest hospital and, if necessary, then transferring them to the trauma centre, seems legitimate in Dutch trauma care.