Joseph P.M. Diederiks

Lack of Effectiveness of a Multidisciplinary Fall-Prevention Program in Elderly People at Risk: A Randomized, Controlled Trial

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.

Assessing the responsiveness of a functional status measure: The sickness impact profile versus the SIP68

In this study, the Sickness Impact Profile (SIP) and the SIP68 are studied for their ability to detect changes in health-related behavioral status. Methodological approaches toward responsiveness are invented and discussed. Next, literature findings on the responsiveness of the SIP are presented and judged for their validity. The SIP appeared to be able to demonstrate changes in the expected direction and in accordance with changes detected by other instruments. Using data from seven different longitudinal projects in populations with different diagnoses, the responsiveness of both the SIP136 and the SIP68 are subsequently studied and compared. In all populations, changes in functional status were indicated by both instruments. In terms of effect sizes, the SIP136 and the SIP68 do not differ significantly in their responsiveness. Moreover, changes detected by both SIPs appear to be valid representations of changes in health-related functional status.

The nurse specialist as main care-provider for patients with type 2 diabetes in a primary care setting: effects on patient outcomes.

A solution to safeguard high quality diabetes care may be to allocate care to the nurse specialist. By using a one group pretest-posttest design with additional comparisons, this study evaluated effects on patient outcomes of a shared care model with the diabetes nurse as main care-provider for patients with type 2 diabetes in a primary care setting. The shared care model resulted in an improved glycaemic control, additional consultations and other outcomes being equivalent to diabetes care before introduction, with the general practitioner as main care-provider. Assignment of care for patients with type 2 diabetes to nurse specialists seems to be justified.

Effects on quality of care for patients with NIDDM or COPD when the specialised nurse has a central role: a literature review

Chronic care has to be organised in a way that care from any one caregiver is linked up to that provided by others so that disturbing gaps, contradictions and overlaps are avoided. In the search for the most effective and efficient combination of health professionals to deliver care to chronic patients, the role of the specialised nurse has become important. This article reviews a Medline search for publications about the effects of models of care for patients with NIDDM or COPD in which the specialised nurse has a central role. Main features of the models are identified and related to expected and statistically significant effects. In this young domain of effect evaluation ten publications met our criteria. Depending on the division of tasks between care providers, improvements are seen in self-care, quality of life and patient satisfaction, as well as increased medical consumption. More methodologically suitable evaluations with the use of only valid measures are needed.

Relationship between location and activity in injurious falls: an exploratory study

BackgroundKnowledge 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.MethodsAn 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).ResultsWe 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.ConclusionThe 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.

Applying low disease activity criteria using the DAS28 to assess stability in patients with rheumatoid arthritis

Objectives: To examine whether low disease activity criteria using the disease activity score (DAS28) can be applied to identify a reasonably large number of patients with stable low disease activity of rheumatoid arthritis (RA) over a six month period, with the ultimate intention of including these patients in a substitution based, shared care model. Additionally, to assess the reliability of the DAS28 for selecting patients with stable disease from an outpatient population. Methods: Patients regularly seen at the rheumatology outpatient department of the university hospital Maastricht, were invited for assessment of the stability of their RA. The shared care model was intended to provide care to patients with stable, low disease activity of RA by nurse specialists. For this, patients underwent assessments using the DAS28 criteria at entry and three and six months later. Test-retest reliability was assessed for composing measures as well as for the DAS28. Results: Of the 97 outpatients included, one third (31 patients) did not complete the study. Patients with missing data were older and assessed their disease activity as greater than patients with complete data. Applying the low disease activity criteria to assess stability over a period of six months (DAS28(T0)⩽3.2 and DAS28(T6)−DAS28(T0)⩽1.2) resulted in identification of 22/56 (39%) patients with stable, low disease activity of RA. A good similarity score (intraclass correlation coefficient=0.82) for the DAS28 was found. Conclusions: The low disease activity criteria using the DAS28 can be used to select patients with stable, low disease activity of RA from a rheumatic outpatient population.

Development and feasibility of a nurse administered strategy on depression in community-dwelling patients with a chronic physical disease.

This contribution reports on the acceptability and feasibility to nurses and patients of an intervention to ameliorate minor depression among patients with chronic physical diseases. Elderly patients with chronic obstructive pulmonary disease (COPD) and type II Diabetes Mellitus were recruited from 10 general practices. All eligible patients were screened. Twenty-nine patients with minor depression gave their informed consent to participate in this feasibility study. The nurses spent an average of 70 min per visit. Our intervention appeared feasible and acceptable to patients and nurses. For the nurses, it provided an additional tool for a well-known problem. The majority of the patients regarded the intervention as worthwhile and effective. Patients had difficulties in understanding the link between physical complaints and symptoms of depression. The intervention has been further improved on the basis of our experiences, and is now ready to be tested in an effectiveness study.

Organizational and Professional Predictors of Physician Satisfaction

In order to find out whether organizational characteristics and professional attitudes are positive predictors of the job satisfaction of physicians, an analysis is presented, based on a survey of 121 internists in 13 medical departments in Dutch university hospitals. The study indicates that formal structuring of work activities is a positive predictor of work environment satisfaction, whereas size is a negative predictor. Professional attitudes such as service orientation and craftsmanship are strong positive predictors of satisfaction with patient demand. The study also indicates that certification (being a medical specialist or not) positively relates to work load satisfaction. Controlling for certification reveals that the absence of a significant relationship between formal structuring of work activities and work load satisfaction is accoun ted for by a positive correlation for medical specialists and a negative one for residents in training to become specialists. This indicates the importance of a difference in hierarchical position for the relation between formal structuring of work activities and physician satisfaction. The results for hospital physicians are consistent with satisfaction studies in other settings: dependency on bureaucratic procedures is associated with dissatisfaction, while the advantages of bureaucracy — the possibility of creating routines and procedures to limit role ambiguity — are conducive to satisfaction.

A Multidisciplinary Fall Prevention Program for Elderly Persons: A Feasibility Study

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.

Transfer of care for outpatients with stable chronic obstructive pulmonary disease from respiratory care physician to respiratory nurse — a randomized controlled study

Objectives: To assess effects on patient outcomes when care for patients with stable chronic obstructive pulmonary disease (COPD) is transferred from respiratory care physician to respiratory nurse. Methods: A randomized controlled trial was used with a follow-up period of 9 months. Of 720 patients from the respiratory outpatient clinic of the general and teaching hospital in Alkmaar (The Netherlands), 187 were eligible for randomization and gave informed consent. Ninety-three patients received care from the nurse, and 87 received usual care. Outcomes measured were: clinical parameters, health status, self-care behaviour (including knowledge), patient satisfaction, and consultations with key care providers. Results: The respiratory nurse reported more consultations than the respiratory care physician [mean (standard deviation)]: number of consultations 3.1 (0.7) by nurse and 2.0 (0.9) by physician (p = 0.007). Patients cared for by the nurse showed worsening in mean forced vital capacity [—5.5% (13.3%) v. +2.9% (18.2%) with physician; p = 0.004], and no difference in self-assessed condition, while improvements were found for subjective knowledge (p = 0.017), self-assessed rate for coping with COPD (p = 0.045), overall satisfaction (p = 0.003), and the majority of individual indicators of satisfaction. Groups showed no differences for forced expiratory volume in 1 s, body mass index, smoking status, health status, objective knowledge, other items of self-care behaviour, and consultations with key care providers. Discussion: Assignment of care for outpatients with stable COPD to the respiratory nurse, working under a protocol, seems to be justified in terms of patient outcomes.