Kaat Siebens

A pilot study of expenditures on, and utilization of resources in, health care in adults with congenital heart disease.

BACKGROUND Congenital cardiac disease may be a chronic condition, necessitating life-long follow-up for a substantial proportion of the patients. Such patients, therefore, are often presumed to be high users of resources for health care. Information on utilization of resources in adults with congenital heart disease, however, is scarce. METHODS This retrospective pilot study, performed in Belgium, investigated 192 adults with congenital heart disease to measure the annual expenditures and utilization of health care and compared the findings with data from the general population. We also sought to explore demographic and clinical parameters as predictors for the expenditures. RESULTS Hospitalization was documented in 20.3% of the patients, with a median length of stay of 5 days. The overall payment by health insurance associations in 1997 was 1794.5 ECU per patient, while patients paid on average 189.5 ECU out-of-pocket. For medication, the average reimbursement and out-of-pocket expenses were estimated at 78 ECU and 20 ECU, respectively. Expenditures for patients with congenital heart disease were considerably higher than the age and gender-corrected expenditures for the general population (411.7 ECU), though this difference was accounted for by only one-eighth of the cohort of those with congenital heart disease. In general, higher expenditures were associated with abnormal left ventricular end-diastolic diameter, female gender, functional impairment and higher age, although the explained variance was limited. CONCLUSION Our study has provided pilot data on the economic outcomes for patients with congenital heart diseases. We have identified parameters that could predict expenditure, but which will have to be examined in future research. This is needed to develop guidelines for health insurance for those with congenital heart diseases.

The Role of Nurses in a Chest Pain Unit

The chest pain unit (CPU) provides a service for patients at moderate-to-low risk for acute coronary syndrome (ACS). Although the number of CPUs has continued to grow worldwide, little has been written on the specific role and contribution of nursing in CPUs. The stay of patients in the CPU can be divided into six stages: triage, diagnosis, treatment, observation/monitoring, discharge, and follow-up. CPU nurses are in a unique position to promote evidence-based practice during all of these stages. Deeper insight into the unique role of nurses in CPUs will promote understanding of what type of knowledge, skills, and attitudes are required to provide the services that will contribute to improved quality of care for chest pain patients.

Implementation of the guidelines for the management of patients with chest pain through a critical pathway approach improves length of stay and patient satisfaction but not anxiety.

OBJECTIVE To compare length of stay (LOS), clinical and psychological outcomes, and patient satisfaction before and after implementation of a chest pain critical pathway. DESIGN A pre- and post-test quasi-experimental design. SETTING The Chest Pain Unit (CPU) of the Antwerp University Hospital. PATIENTS Patients admitted to the CPU with symptoms suggestive of an acute coronary syndrome older than 18 years. INTERVENTIONS Implementation of a critical pathway focusing on implementation of the guidelines for the management of chest pain. MAIN OUTCOME MEASURES Patient satisfaction, length of stay and anxiety were evaluated. RESULTS The median LOS of intervention subjects was almost 4 hours shorter than that of control subjects (without, P = 0.04, or with propensity correction, P = 0.019). The overall patient satisfaction with CPU care of the intervention group was significantly higher than that of the control group (without, P < 0.001, or with propensity correction, P < 0.001). Differences in anxiety and occurrences of major adverse cardiac events between the groups were not statistically significant. CONCLUSION A critical pathway can effectively and safely reduce LOS, increase patient satisfaction, and improve adherence to the guidelines for managing patients with chest pain. Anxiety is not statistically significantly reduced by this intervention.

Systematic Review of Clinical Practice Guidelines for the Improvement of Medication Adherence

BackgroundPoor adherence to medications is a significant problem that leads to increased morbidity, mortality, and health care costs. Recommended approaches to address medication adherence vary, and existing practice guidelines are unclear.PurposeThis review evaluated clinical practice guidelines designed to help health care providers address patients’ medication adherence.MethodMultiple search methods were used to identify national or international guidelines addressing medication adherence. We included guidelines published in English, as well as guidelines with an English-language summary or translation.ResultsWe identified 23 guidelines of varying detail and quality. Recommendations were categorized as assessment strategies (n = 20 guidelines); educational strategies (n = 18); behavioral strategies (n = 17); therapeutic relationship, communication, and provider factors (n = 19); and addressing outside influences/co-morbidities (n = 10).ConclusionFuture guidelines should be more clearly guided by research findings and comparative effectiveness methods. When implemented, guidelines will facilitate health care providers and health systems in supporting optimal adherence and improved health outcomes.

Management of patient adherence to medications: protocol for an online survey of doctors, pharmacists and nurses in Europe

Introduction It is widely recognised that many patients do not take prescribed medicines as advised. Research in this field has commonly focused on the role of the patient in non-adherence; however, healthcare professionals can also have a major influence on patient behaviour in taking medicines. This study examines the perceptions, beliefs and behaviours of healthcare professionals—doctors, pharmacists and nurses—about patient medication adherence. Methods and analysis This paper describes the study protocol and online questionnaire used in a cross-sectional survey of healthcare professionals in Europe. The participating countries include Austria, Belgium, France, Greece, The Netherlands, Germany, Poland, Portugal, Switzerland, Hungary, Italy and England. The study population comprises primary care and community-based doctors, pharmacists and nurses involved in the care of adult patients taking prescribed medicines for chronic and acute illnesses. Discussion Knowledge of the nature, extent and variability of the practices of healthcare professionals to support medication adherence could inform future service design, healthcare professional education, policy and research.

A multinational cross-sectional survey of the management of patient medication adherence by European healthcare professionals

Objectives To examine which interventions healthcare professionals use to support patients with taking medicines and their perceptions about the effectiveness of those actions. Design Cross-sectional multinational study. Setting Online survey in Austria, Belgium, England, France, Germany, Hungary, The Netherlands, Poland, Portugal and Switzerland. Participants A total of 3196 healthcare professionals comprising doctors (855), nurses (1047) and pharmacists (1294) currently registered and practising in primary care and community settings. Main outcome measures Primary outcome: Responses to the question ‘I ask patients if they have missed any doses of their medication’ for each profession and in each country. Secondary outcome: Responses to 50 items concerning healthcare professional behaviour to support patients with medication-taking for each profession and in each country. Results Approximately half of the healthcare professionals in the survey ask patients with long-term conditions whether they have missed any doses of their medication on a regular basis. Pharmacists persistently report that they intervene less than the other two professions to support patients with medicines. No country effects were found for the primary outcome. Conclusions Healthcare professionals in Europe are limited in the extent to which they intervene to assist patients having long-term conditions with medication adherence. This represents a missed opportunity to support people with prescribed treatment. These conclusions are based on the largest international survey to date of healthcare professionals’ management of medication adherence.

My patients are better than yours: optimistic bias about patients' medication adherence by European health care professionals.

Objectives The objectives of this study were to determine the perceptions of European physicians, nurses, and pharmacists about the extent of nonadherence by patients in their country relative to their perception of nonadherence by their own patients, and to investigate the occurrence of optimistic bias about medication adherence. The study explored a key cognitive bias for prevalence and likelihood estimates in the context of health care professionals’ beliefs about patients’ use of medicines. Methods A cross-sectional online survey of 3,196 physicians (855), nurses (1,294), and pharmacists (1,047) in ten European countries (Austria, Belgium, England, France, Germany, Hungary, the Netherlands, Poland, Portugal, and Switzerland) was used. Results Participants differed in their perceptions of the prevalence of medication adherence initiation, implementation, and persistence present in their own patients with a chronic illness in comparison to patients with a chronic illness in general. Health care professionals demonstrated optimistic bias for initiation and persistence with medicine taking, perceiving their own patients to be more likely to initiate and persist with treatment than other patients, but reported significantly lower prevalence of medication adherence levels for their own patients than for patients in general. This finding is discussed in terms of motivational and cognitive factors that may foster optimistic bias by health care professionals about their patients, including heightened knowledge of, and positive beliefs about, their own professional competence and service delivery relative to care and treatment provided elsewhere. Conclusion Health care professionals in Europe demonstrated significant differences in their perceptions of medication adherence prevalence by their own patients in comparison to patients in general. Some evidence of optimistic bias by health care professionals about their patients’ behavior is observed. Further social cognitive theory-based research of health care professional beliefs about medication adherence is warranted to enable theory-based practitioner-focused interventions to be tested and implemented.

Development and implementation of a critical pathway for patients with chest pain through action research.

Aims and background: We report on the development and implementation of a critical pathway for patients with chest pain making use of action research. Methods: Firstly the population to be included in the pathway was defined and a coordinator was assigned. Secondly a multidisciplinary workgroup for the development of the pathway was instated. The actual development of the pathway consisted of four major steps: (1) evaluation of the current process of care for the chest pain unit (CPU) patients, (2) evaluation of medical evidence and practice in other hospitals, (3) optimization of the process and (4) actual drafting of the pathway. Finally the pathway development was followed by the implementation of the pathway. Results: A chest pain critical pathway could be successfully developed, leading to (1) a triage flowchart based on the European Society of Cardiology guidelines categorizing patients in different risk groups; (2) CPU and hospital standing orders and protocols for the management of the different risk groups; (3) revision of physician and nursing medical records; and (4) development of admission and discharge brochures for patients and family admitted to the CPU. Conclusion: To our best knowledge this paper is the first to report on the use of action research to develop a critical pathway for patients with symptoms suggestive of an acute coronary syndrome admitted to a chest pain unit. Our experience suggests that it can serve as a means to reach the objective of conceiving and implementing an evidence-based pathway into everyday clinical practice.