Kaja Põlluste

Patient satisfaction with care is associated with personal choice of physician

OBJECTIVE To evaluate whether choosing ones own primary care doctor is associated with patient satisfaction with primary health care. To evaluate factors related to populations satisfaction with primary health care. POPULATION A random sample of Estonian adult population (N=997). STUDY DESIGN Cross-sectional study using a pre-categorized questionnaire which was compiled by the research group of the University of Tartu and the research provider EMOR. RESULTS Altogether 68% of the respondents had been listed in their personal physician. Their overall satisfaction with the physician as well as satisfaction with several aspects of primary health care were significantly higher compared with those of unregistered respondents. Although some other factors (practice size, patient age, health status) also influenced patient satisfaction, presence of a personal physician appeared the most important predictor of high satisfaction with physicians punctuality and understanding, effectiveness of prescribed therapy, clarity of explanations given by the physician as well as with overall satisfaction with the physician. CONCLUSION Personal doctor system is associated with patient satisfaction with different aspects of care.

Public health reforms in Estonia: impact on the health of the population

The health of the population has worsened in most countries in central and eastern Europe during the transition period, but little has been written about the reforms in the field of public health during this time, and little evidence has been presented on the links between these reforms and the health of the population. We describe public health reforms in Estonia, focusing on the institutional structure, the reform rationale, the specific proposals and reform processes, the achievements and limitations, and the wider impact of the reforms.1 To describe trends in the health of the population, we use life expectancy, infant mortality, rate of abortions per 100 live births, morbidity rates (tuberculosis, HIV, sexually transmitted diseases), and the level of individual risk factors (smoking, diet, alcohol consumption). The study is based mainly on an analysis of previously published reports and official statistics. After the political changes in the beginning of the 1990s, the importance of a population based approach to public health was recognised in Estonia, and the understanding and application of the concept of health promotion became more comprehensive.2–4 In 1993 the Ministry of Social Affairs was established and included a Department of Public Health (fig 1, box 1), which was seen as a source of modern health promotion in Estonia. Health promotion was introduced in the curriculum of medical and nursing training at the University of Tartu, and public health training for civil servants and teaching staff was started.4 5 Fig 1 Organisation of health services in Estonia In general, democracy is considered to be good for the health of the population.6 When starting to build up a democratic society in the beginning of the 1990s, Estonia, like most other countries in central and eastern Europe, experienced a rapid worsening in population health indicators. …

Assistive devices, home adjustments and external help in rheumatoid arthritis

Purpose: To explain the determinants of adaptation with disease and self-management of patients with rheumatoid arthritis (RA) in Estonia, focusing on the use of assistive devices, home adjustments and the need for external help. Method: A random sample (n = 1259) of adult Estonian RA patients was selected from the Estonian Health Insurance Fund Database. The patients completed a self-administered questionnaire, which included information about their socio-demographic and disease characteristics, the costs of care, quality of life, use of assistive devices, home adjustments and the need for external help. Regression analysis was used to analyse the predictors of patient’s adaptation with disease and self-management. Results: Twenty-six percent of the respondents used assistive devices, 20% had made home adjustments and 37% needed external help. Disabilities and physical impairments predicted the use of assistive devices, home adjustments and the need for external help. The use of medical rehabilitation services predicted the less frequent use of assistive devices, while female gender and single status predicted a more expressed need for external help. Conclusions: Disability and physical impairment are the most important determinants of the use of various technical aids and home adjustments. These factors, along with the female gender and single status of the patient, predict help-dependence. Implications for Rehabilitation Rheumatoid arthritis (RA) is a chronic progressive disease that can lead to joint damage, resulting in chronic pain, loss of function and disability. To reduce the difficulties and to manage their everyday lives, RA patients often require personal care, home adjustments or need to use assistive devices. A study based on a representative sample of Estonian RA patients demonstrated that disability and physical impairment are the most important determinants of the use of various technical aids and home adjustments. In RA, the female gender and single status of the patient predict a more expressed need for external help.

Primary care in Baltic countries: A comparison of progress and present systems

OBJECTIVES This study aims to compare the organisation of primary care (PC) systems in Estonia, Latvia and Lithuania, focusing on the structure and process of service delivery, and to discuss the suitability of the PHAMEU instrument for international comparison of PC systems. METHODS The data were collected in the framework of PHAMEU project during 2009-2010. The selected indicators were used to describe and compare the structure and process of PC in Estonia, Latvia and Lithuania. RESULTS The results showed that the coordination of PC services, legislative framework, service delivery, quality requirements and PC financing principles are rather similar in all three Baltic countries. Population coverage for PC services, cost sharing for some services, and the employment status of family doctors differs by country. The PHAMEU instrument was most applicable for the description and comparison of the structure of PC and some aspects of the process. Information about patient outcome and quality of care was neither available nor reliable enough. CONCLUSION The development of PC systems in Baltic countries has been rather similar, but some aspects also differ between the countries. Use of a standardized instrument allows for international comparison, but assumes standardised data collection procedures in comparable countries.

Adverse lifestyle and health-related quality of life: gender differences in patients with and without chronic conditions

Objectives: The aim was to investigate the relationship between the main lifestyle-related factors and health-related quality of life (HRQoL) in a sample of patients with and without chronic conditions (CCs) with respect to the gender differences in both groups. Methods: A cross-sectional study was conducted on 1061 patients (of which 308 had no CCs and 753 of those had one or more CCs) recruited at primary health care centres and the Internal Medicine Clinic at Tartu University Hospital in Estonia. Data were collected during 2012–2014. The patient’s age, self-reported smoking status, alcohol consumption (assessed by Alcohol Use Disorders Identification Test) and body mass index were used as independent variables to predict the physical component scores (PCS) and mental component scores (MCS) of HRQoL (assessed by SF-36). Results: Smoking had a negative association with both physical and mental components of HRQoL only in women with CCs. Further, the PCS of chronically ill women was negatively associated with the higher body mass index. Harmful drinking had a negative association with the HRQoL in all patient groups, except with the PCS in women with CC. Light alcohol consumption without symptoms of harmful use or dependency had a positive association with the physical and mental HRQoL in all patient groups, except with the MCS in women without CCs. Conclusion: Adverse lifestyle had the most expressed association with HRQoL in women with CCs. Light alcohol consumption had a positive association, but harmful use of alcohol had an inverse association with HRQoL irrespective of patients’ gender or health status.

Cultural adaptation of quality of life measures

We read with interest the article entitled ‘The Rheumatoid Arthritis Quality of Life (RAQoL) for Sweden: adaptation and validation’ by Hedin et al, which was published in the Scandinavian Journal of Rheumatology (1). A new language version of this internationally accepted outcome measure opens opportunities to broaden multinational research on the quality of life (QoL) of rheumatoid arthritis (RA) patients. This official version of the Swedish RAQoL, produced by the dual panel translation method, has shown psychometric properties similar to those demonstrated for the Estonian version of the RAQoL (2). Because of its geographical proximity and tradition of scientific cooperation, Sweden is one of the countries Estonia would be expected to join with in medical research projects. Therefore, the development of a Swedish version of the RAQoL that used the approved adaptation procedure is of importance to rheumatological research in Estonia. Despite the proximity of Sweden and Estonia there are considerable differences between the countries in terms of history and culture that should be considered when comparative QoL research is planned. Different cultures and societies have unique concepts of QoL. This diversity of concepts can confound QoL research in the health sciences. Before selecting a QoL tool developed in and for another country, it is necessary to determine how the instrument will work in the context of the proposed research study. An instrument that has performed well in the country of origin can lose validity when applied in a different social context. Standard validation processes are less likely to be of value where the local QoL concept differs from that of the culture where the measure was developed. Ten semi-structured qualitative interviews with RA patients were conducted during the development of the Estonian version of the RAQoL to assess the suitability of the instrument. Thematic analysis conducted on the generated data indicated that the measure was highly relevant to patients; it was concluded that the RAQoL was an appropriate measure of QoL for use with Estonian RA patients (3). However, three QoL issues that were important for Estonian RA patients were not covered by the RAQoL. These were changes in role performance, communication with the medical system and financial issues related to obtaining the necessities of life. An assumption was made that failure to assess these specific issues might lead to an underestimation of the impact of RA on Estonian patients’ QoL. To determine the importance of the missing issues for Estonian RA patients, two additional validation strategies were applied. First, analysis was undertaken of data derived from a separate study that had used six focus groups to investigate RA patients’ satisfaction with health care. The transcripts of these

Insulin Resistance in Early Rheumatoid Arthritis Is Associated with Low Appendicular Lean Mass

In established rheumatoid arthritis (RA), the presence of insulin resistance (IR) is well proven but, in the early stage of the disease, data are inconclusive. We evaluated the presence of IR and associations with body composition (BC) parameters among early RA (ERA) and control subjects. The study group consisted of 92 ERA and 321 control subjects. Using homeostatic model assessment of IR (HOMA-IR), the cut-off value for IR was 2.15. 56% of the ERA patients and 25% of the controls had IR. Of the BC parameters, patients with early RA had less fat-free mass and appendicular lean mass (ALM). In multivariable model, ERA group (b-Coefficient) (4.8, CI: 2.6–8.8), male gender (7.7, CI: 2.7–22.1), and fat mass index (1.2, CI: 1.1–1.4) were associated with IR. Insulin-resistant ERA patients had higher inflammatory markers and higher disease activity. In the multivariable model in the ERA group, IR was associated with male gender (b-Coefficient) (7.4, CI: 153–34.9), high disease activity (6.2, CI: 1.7–22.2), and lower ALM (0.03, CI: 0.001–0.97). IR develops in the early stage of RA in the majority of patients. IR is more common among males and is associated with RA disease activity and lower ALM.

Alkoholi tarvitamise muutused lühinõustamise järel ja seos elukvaliteediga perearsti poole pöördunud patsientide hulgas

Taust ja eesmark. On teada, et luhinoustamisel on positiivne moju patsientide alkoholitarvitamise harjumustele. Too eesmark oli hinnata alkoholitarvitamise ja tervisega seotud elukvaliteedi hinnangute muutusi perearstikeskuses teostatud luhinoustamine jarel alkoholi liigtarvitavate patsientide hulgas. Metoodika. 12 kuu pikkuses prospektiivses uuringus osales 93 alkoholi liigtarvitavat ja luhinoustamist saanud uuritavat. Uuritavate alkoholitarvitamist moodeti AUDITi ( Alcohol Use Disorders Identification Test ) kusimustiku ning tervisega seotud elukvaliteedi SF-36 kusimustiku abil enne luhinoustamist ja 12 kuud hiljem. AUDITi skoori ja tervisega seotud elukvaliteedi muutuste seoseid hinnati lineaarse regressiooni abil. Tulemused. Aasta hiljem kordusvisiidil moodetud tulemustest selgus, et 81,7%-l uuritavatest oli vorreldes noustamiseelse hindamisega AUDITi skoor oluliselt vahenenud (12,3 ± 0,5 kuni 7,5 ± 0,5 punkti; p < 0,001). Nende kehalist tervist kirjeldavate komponentide uldskoor suurenes keskmiselt 7,8 punkti vorra (68,3 ± 2,5 kuni 76,1 ± 2,0; p < 0,05), vaimset tervist kirjeldavate komponentide uldskoor suurenes keskmiselt 5,7 punkti vorra (68,2 ± 2,5 kuni 73,9 ± 2,0; p = 0,068). AUDITi skoori vahenemine seostus kehalise tervise komponentide uldskoori suurenemisega, kuid ei seostunud vaimse tervise komponentide uldskoori muutusega. Jareldused. Alkoholitarvitamise vahenemine luhinoustamise jarel on seotud patsiendi enda hinnatud tervisega seotud elukvaliteedi kehalist tervist kirjeldavate komponentide uldskoori suurenemisega. Eesti Arst 2016; 95(10):628–636

Advanced Nursing Practice for Older People

The world population is rapidly aging. Between 2000 and 2050, the proportion of the worlds population over 60 years will double from about 11% to 22%. The absolute number of people aged 60 years and over is expected to increase from 605 million to 2 billion over the same period [1]. Although more developed countries have the oldest population profiles, the vast majority of older people—and the most rapidly aging populations—are in less developed countries. Between 2010 and 2050, the number of older people in less developed countries is projected to increase more than 250 percent, compared with a 71-percent increase in the developed countries [2]. Older people are considered one particular group of the population which needs and uses many health services of different nature, and the use of services is increasing with age. The aging of population has also resulted in increased interest in long-term care—in home care as well as in institutional care (residential and community care). The rising demand for long term-care is latest described in a three-year EU project titled INTERLINKS—health systems and long-term care for older people involving 13 countries in modelling INTERfaces and LINKS between prevention and rehabilitation to indicate new approaches and to improve policy and practice in long-term care [3]. To be responsive to the needs of older people, the continuity and quality of care should be improved by more effective management of care and improve the communication as well as interaction between patients, their family members, care providers, and politicians. It is important that the health services provided to the older population be responsive not only to their physical but also to the mental and emotional needs. In this process the nurses have a remarkable role, which, however, sometimes may not to be noted enough. The papers published in this issue cover different fields of the organisation and content of nursing for older people from different parts of the world. The provision of care for older people has undergone several changes and reforms to find best solutions and balance between existing resources and increasing demands. For example, S. Kato et al. propose models for designing long-term care service plans and care programs for older people in Japan; in the country, where more than 60% of population is aged over 60. One of the most important aspects for older persons is the independency of decision making for their future care and maintaining the autonomy, regardless of staying home with help from the municipality or moving to the nursing home. These aspects are discussed in three papers (A. Breitholtz et al., M. Riedl et al., and D. Goodridge). Also, some specific areas are presented as, for example, oral health care from the nursing perspective (K. Salamone et al.) and coping with the partners health problems (S. Marnocha and M. Marnocha). Finally, besides those who receive the care, one may not forget the caregivers too. In this issue, two research papers from Scandinavia focus on the nurses and caregivers experiences and ethical values (M. Frilund et al. and S. Salin et al.). We hope that this issue provides interest to broad audience not only for nursing professionals, but also for other health and social care professionals while advanced nursing for older people like any other activity in health care can be most successful in team work. Kaja Polluste Pirkko Routasalo Lisbeth Fagerstrom Lis Wagner