Jan Schuling

The Frenchay Activities Index. Assessment of functional status in stroke patients.

Background and Purpose Assessment of functional status in stroke patients is of major importance in both clinical practice and outcome studies. The Frenchay Activities Index has been developed specifically for measuring disability and handicap in stroke patients. The purpose of the study was to evaluate the metric properties of this instrument and to obtain normal values in a group of unselected elderly subjects. Methods The Frenchay Activities Index was tested in a group of stroke patients and a group of unselected subjects aged 65 or older. The functional status of the stroke patients was measured 26 weeks after stroke. Their prestroke status was registered retrospectively. Reliability and validity of the instrument were assessed. Results The mean scores in the prestroke, poststroke, and control group demonstrated differences in functional status. The reliability of unweighted scores (range of Cronbachs α coefficients, 0.78 to 0.87) was sufficient. The construct validity was supported by meaningful correlations between the Frenchay Activities Index and scores on the Barthel Index and Sickness Impact Profile. Principal-components analysis indicated that the Frenchay Activities Index showed two traits: instrumental disability and some aspects of handicap. The reliability of the instrument could be improved by deleting two items and by creating two subscale scores: domestic and outdoors activities. Conclusions The Frenchay Activities Index is a useful stroke-specific instrument to assess functional status. Completion of the questionnaire is easy and takes only a few minutes. Currently, the instrument is suitable for use in patient care and cross-sectional, descriptive studies.

A Stroke-Adapted 30-Item Version of the Sickness Impact Profile to Assess Quality of Life (SA-SIP30)

BACKGROUND AND PURPOSE In view of the growing therapeutic options in stroke, measurement of quality of life has become increasingly relevant as an outcome parameters. The Sickness Impact Profile (SIP) is one of the most widely used measures to assess quality of life. To overcome the major disadvantage of the SIP, its length, we constructed a short stroke adapted 30-item SIP version (SA-SIP30). METHODS Data on the original SIP version were collected for 319 communicative patients at 6 months after stroke. The 12 subscales and the 136 items of the original SIP were reduced to 8 subscales with 30 items in a three step procedure, on the basis of relevancy and homogeneity. Reliability of the SA-SIP30 was evaluated by means of an analysis of homogeneity (Cronbachs alpha coefficient). Different types of validity were assessed: construct, clinical, and external validities. RESULTS Homogeneity of the SA-SIP30 was demonstrated by a high Cronbachs alpha (0.85). Principal component analyses revealed the same two dimensions as in the original SIP (a physical and a psychosocial dimension). The SA-SIP30 could explain 91% of the variation in scores of the original SIP in the same cohort of patients, and 89% in a different cohort. Furthermore, the SA-SIP30 was related to other functional health measures similar to how the original SIP was. We could demonstrate that the SA-SIP30 was able to distinguish patients with lacunar infarctions from patients with cortical or subcortical lesions. CONCLUSIONS We conclude that the SA-SIP30 is a feasible and clinimetrically sound measure to assess quality of life after stroke.

Deprescribing medication in very elderly patients with multimorbidity: the view of Dutch GPs. A qualitative study

BackgroundElderly patients with multimorbidity who are treated according to guidelines use a large number of drugs. This number of drugs increases the risk of adverse drug events (ADEs). Stopping medication may relieve these effects, and thereby improve the patient’s wellbeing. To facilitate management of polypharmacy expert-driven instruments have been developed, sofar with little effect on the patient’s quality of life. Recently, much attention has been paid to shared decision-making in general practice, mainly focusing on patient preferences. This study explores how experienced GPs feel about deprescribing medication in older patients with multimorbidity and to what extent they involve patients in these decisions.MethodsFocusgroups of GPs were used to develop a conceptual framework for understanding and categorizing the GP’s view on the subject. Audiotapes were transcribed verbatim and studied by the first and second author. They selected independently relevant textfragments. In a next step they labeled these fragments and sorted them. From these labelled and sorted fragments central themes were extracted.ResultsGPs discern symptomatic medication and preventive medication; deprescribing the latter category is seen as more difficult by the GPs due to lack of benefit/risk information for these patients.Factors influencing GPs’deprescribing were beliefs concerning patients (patients have no problem with polypharmacy; patients may interpret a proposal to stop preventive medication as a sign of having been given up on; and confronting the patient with a discussion of life expectancy vs quality of life is ‘not done’), guidelines for treatment (GPs feel compelled to prescribe by the present guidelines) and organization of healthcare (collaboration with prescribing medical specialists and dispensing pharmacists.ConclusionsThe GPs’ beliefs concerning elderly patients are a barrier to explore patient preferences when reviewing preventive medication. GPs would welcome decision support when dealing with several guidelines for one patient. Explicit rules for collaborating with medical specialists in this field are required. Training in shared decision making could help GPs to elicit patient preferences.

Risks and causes of death in a community-based stroke population : 1 month and 3 years after stroke

We performed a community-based study on a cohort of 221 stroke patients followed for 3 years. In this paper, we tried to answer the following questions: Is the risk of dying increased throughout the first 3 years after stroke? What are the causes of death after the 1st month? What factors at stroke onset are independent predictors of early and late mortality? The relative risk of death was estimated using age- and sex-specific mortality rates for the Netherlands. Causes of death were registered by the attending physicians, mostly general practitioners. During the 1st month 26% of the patients died. At 1, 2 and 3 years, the cumulative mortality rates were 37, 46 and 54%, respectively. Stroke patients had an increased risk of dying, approximately twice that of the general population, during the 3 years of follow-up. In women, this increased risk was more pronounced than in men. After 1 month, cardiovascular pathology, stroke and diseases resulting from stroke were the causes of death in 70% of the patients, i.e. substantially higher than in the general population, matched for age and sex. Factors predicting mortality after stroke varied over time. Severity of the stroke, preexisting atrial fibrillation and congestive heart failure were associated with early mortality (within 30 days). For 1-month survivors, incontinence and preexisting atrial fibrillation were associated with mortality in the 1st year after stroke. After 1 year, only age was associated with mortality.

Effects of a patient oriented decision aid for prioritising treatment goals in diabetes: pragmatic randomised controlled trial.

Objective To assess the effects of a patient oriented decision aid for prioritising treatment goals in diabetes compared with usual care on patient empowerment and treatment decisions. Design Pragmatic randomised controlled trial. Setting 18 general practices in the north of the Netherlands. Participants 344 patients with type 2 diabetes aged ≤65 years at the time of diagnosis and managed in primary care between April 2011 and August 2012: 225 were allocated to the intervention group and 119 to the usual care group. Intervention The intervention comprised a decision aid for people with diabetes, with individually tailored risk information and treatment options for multiple risk factors. The aid was intended to empower patients to prioritise between clinical domains and to support treatment decisions. It was offered to participants before a regular diabetes check-up and to their healthcare provider during the consultation. Four different formats of the decision aid were included for additional explorative analyses. Main outcome measures The primary outcome was the effects on patient empowerment for setting and achieving goals. The secondary outcomes were changes in the prescribing of drugs to regulate glucose, blood pressure, lipids, and albuminuria. Data were collected through structured questionnaires and automated data extraction from electronic health records during six months before and after the intervention. Results Of all intervention participants, 103 (46%) reported to have received the basic elements of the intervention. For the primary outcome analysis, 199 intervention and 107 control patients with sufficient baseline and follow-up data could be included. The mean empowerment score increased 0.1 on a 5 point scale in the overall intervention group, which was not significantly different from that of the control group (mean difference after adjusting for baseline 0.039, 95% confidence interval −0.056 to 0.134). Lipid regulating drug treatment was intensified in 25% of intervention and 12% of control participants with increased cholesterol levels, which did not reach significance when the intervention was compared with the usual care group (odds ratio 2.54, 95% confidence interval 0.89 to 7.23). Prespecified explorative analyses showed that this effect was significant for the printed version of the decision aid in comparison to usual care (3.90, 1.29 to 11.80). No relevant or significant changes were seen for other treatments. Conclusion We found no evidence that the patient oriented treatment decision aid improves patient empowerment by an important amount. The aid was not used to its full extent in a substantial number of participants. Trial registration Dutch trial register NTR1942.

Care provided by general practitioners to patients with psychotic disorders: a cohort study

BackgroundPatients suffering from psychotic disorders have an increased risk of comorbid somatic diseases such as cardiovascular disorders and diabetes mellitus. Doctor-related factors, such as unfamiliarity with these patients, as well as patient-related factors, such as cognitive disturbance and negative symptoms, contribute to suboptimal health care for these patients.General practitioners (GPs) could play a key role in diagnosing and treating this somatic comorbidity as in the Netherlands, almost all residents are registered at a general practice. This study aims to find out whether there are any differences between the levels of health care provided by GPs to patients with psychotic disorders, compared to other types of patients.MethodsA cohort of patients with an ICPC code of psychosis and two matched control groups, one consisting of patients with other mental problems and the other one of patients without any mental problems, were followed over a period of 5 years.ResultsPatients with psychotic disorders (N = 734) contacted the GP practice more often than patients in the control groups. These patients, both adults (p = 0.051) and the elderly (p < 0.005), received more home visits from their GPs. In the adult group (16 to 65 years old inclusive), the number of consultations was significantly higher among both psychosis patients and the group of patients with other mental problems (p < 0.0005). The number of telephone consultations was significantly higher in both age categories, adult group (p < 0.0005), and > 65 years old (p = 0.007). With regard to chronic illnesses, elderly psychosis patients had fewer contacts related to cardiovascular diseases or chronic lung diseases.ConclusionPatients with psychotic disorders contact the GP practice more frequently than other types of patients. Adult psychosis patients with diabetes mellitus, cardiovascular diseases or chronic lung diseases receive the same amount of health care for these diseases as other primary care patients. The finding that older patients with psychotic disorders are diagnosed with cardiovascular diseases and obstructive lung diseases less frequently than other types of elderly patients requires further study.

What influences the quality of educational encounters between trainer and trainee in vocational training for general practice

This study of educational encounters between a trainer and a trainee in vocational training for general practice investigates the quality of the encounter. The study focuses on the relation between the quality of the encounter and elements such as presence of feedback, duration, use of media, etc. A quality measure based on the Gagné and Briggs model for the design of instructional events was developed. The quality score was correlated with other elements of the encounter as reported in a log diary completed by trainees. In the log diary 45 trainees registered 314 encounters. Quality predictors included duration of the encounter, the number of media (files of patients, professional guidelines) used, the number of follow-up activities and feedback by the trainer on the performance of the trainee. Several elements were identified as contributing to the educational quality of the encounter, such as presence of media, follow-up activities and positive feedback. The trainer can easily control these elements.

Out-of-hours medical care for terminally ill patients: A survey of availability and preferences of general practitioners

Background: Continuity of care is one of the core values of good medical care for terminally ill patients. The availability of one’s own general practitioner (GP) out of hours is regarded as important for personal continuity. Few data are available about the extent of out-of-hours care given by GPs to their terminally ill patients. Aim: The objective of this study was to determine to which level GPs are available out of hours for their own terminally ill patients and to elicit what factors are relevant to this availability. Design and setting: The research questions were investigated using a cross-sectional study of Dutch GPs. A questionnaire was sent to a random sample of 691 Dutch GPs. Results: The response rate was 47% (n = 327). Of the respondents, 86% was willing to provide out-of-hours care for their own terminally ill patients. These figures are higher than reported in previous studies. This study shows that out-of-hours availability correlates most strongly with the GPs’ perception of duties of care. Availability is negatively influenced if the GP is in a salaried job, if he or she works in a city based practice, or if home is far from the practice. A correlation between age, sex, and experience of GPs and availability for out-of- hours care for their terminally ill patients was not confirmed. Conclusions: The reported out-of-hours availability of GPs for terminally ill patients is still high. GPs’ perception of their duty of care might change in the next generations, and the increasing number of salaried GPs, living far from their practice, might threaten out-of-hours availability for terminally ill patients. GPs’ perception of their duty of care might change in the next generations, and the increasing number of salaried GPs living far from their practice might threaten out-of-hours availability for terminally ill patients.

Patient education to users of oral hypoglycemic agents: the perspective of Dutch community pharmacists

The purpose of this study was to indicate which patient education activities directed at users of oral hypoglycemic agents are desirable in Dutch community pharmacies and to explore which preconditions should be considered when implementing the desired activities. A qualitative study was conducted with a panel composed of seven pharmacists and seven technicians with considerable experience in giving advice to people with diabetes mellitus type 2. A consensus method was used, which consisted of a written questionnaire and a feedback discussion, to determine which activities were considered desirable and to identify which other health care providers should be involved. The way these activities should be implemented was explored by a focus-group discussion. The following goals of patient education activities were studied: 1) adherence to the dosage regimen, 2) adherence to lifestyle advices,3) gaining awareness of effects and 4) self-monitoring. According to the members of the panel, patient education activities should be directed primarily at stimulating adherence to the dosage regimen, increasing awareness of side effects and improving the correct technical use of blood glucose meters. Activities directed at lifestyle advice seemed to be less desirable to the pharmacy staff. Preconditions that should be considered when implementing these activities were structural cooperation with GPs and diabetic nurses and specialization of tasks of pharmacy technicians. Our results indicate that deepening of existing tasks, such as stimulating adherence to the dosage regimen is desirable in developing patient education activities at users of oral hypoglycemic agents.

The effect of a patient-oriented treatment decision aid for risk factor management in patients with diabetes (PORTDA-diab): study protocol for a randomised controlled trial

BackgroundTo improve risk factor management in diabetes, we need to support effective interactions between patients and healthcare providers. Our aim is to develop and evaluate a treatment decision aid that offers personalised information on treatment options and outcomes, and is intended to empower patients in taking a proactive role in their disease management. Important features are: (1) involving patients in setting goals together with their provider; (2) encourage them to prioritise on treatments that maximise relevant outcomes; and (3) integration of the decision aid in the practice setting and workflow. As secondary aim, we want to evaluate the impact of different presentation formats, and learn more from the experiences of the healthcare providers and patients with the decision aid.Methods and designWe will conduct a randomised trial comparing four formats of the decision aid in a 2×2 factorial design with a control group. Patients with type 2 diabetes managed in 18 to 20 primary care practices in The Netherlands will be recruited. Excluded are patients with a recent myocardial infarction, stroke, heart failure, angina pectoris, terminal illness, cognitive deficits, >65 years at diagnosis, or not able to read Dutch. The decision aid is offered to the patients immediately before their quarterly practice consultation. The same decision information will be available to the healthcare provider for use during consultation. In addition, the providers receive a set of treatment cards, which they can use to discuss the benefits and risks of different options. Patients in the control group will receive care as usual. We will measure the effect of the intervention on patient empowerment, satisfaction with care, beliefs about medication, negative emotions, health status, prescribed medication, and predicted cardiovascular risk. Data will be collected with questionnaires and automated extraction from medical records in 6 months before and after the intervention.DiscussionThis decision aid is innovative in supporting patients and their healthcare providers to make shared decisions about multiple treatments, using the patient’s data from electronic medical records. The results can contribute to the further development and implementation of electronic decision support tools for the management of chronic diseases.Trial registrationDutch Trial register NTR1942.