Klaske Wynia

Effects of case management for frail older people or those with chronic illness - a systematic review

Background:Financial constraints and quality requirements demand that interventions selected are most effective. A previous systematic review of the effectiveness of the patient advocacy case management model was not found. Objective:The objective of this study was to evaluate the effects of patient advocacy case management on service use and healthcare costs for impaired older people or adults with a chronic somatic disease living in the community. Methods:A literature search was conducted in Medline, CINAHL, and Cochrane databases. Included were English-language randomized controlled trials evaluating service use and costs of the patient advocacy case management model for people with a chronic somatic disease or for impaired older people living in the community. Results:Eight relevant studies were identified and included after evaluation of methodological quality. All studies concerned frail or impaired older people, and one study also included people with a somatic chronic disease. In none of the studies was evidence found for clinically relevant increase of service use and costs, whereas in two studies, it was reported that patient advocacy case management led to decreased service use and to savings in costs. Discussion:Patient advocacy case management does not increase service use and costs and was effective in decreasing service use and costs in two studies. These conclusions are an indication for quality improvement through the combination of its organizational benefits. Therefore, there should be more priority given to further implementation of patient advocacy case management for those with chronic illness and impaired older people. Nursing can play an important role in this development.

Efficacy of desmopressin in patients with multiple sclerosis suffering from bladder dysfunction: a meta-analysis

Objectives –  The current review evaluates the safety and efficacy of desmopressin in patients with multiple sclerosis (MS) who suffer from both daytime and nocturnal voiding frequency and from incontinence.

Consensus definition of fetal growth restriction: a Delphi procedure

To determine, by expert consensus, a definition for early and late fetal growth restriction (FGR) through a Delphi procedure.

Embrace, a model for integrated elderly care : study protocol of a randomized controlled trial on the effectiveness regarding patient outcomes, service use, costs, and quality of care

BackgroundOngoing growth in health care expenditures and changing patterns in the demand for health care challenge societies worldwide. The Chronic Care Model (CCM), combined with classification for care needs based on Kaiser Permanente (KP) Triangle, may offer a suitable framework for change. The aim of the present study is to investigate the effectiveness of Embrace, a population-based model for integrated elderly care, regarding patient outcomes, service use, costs, and quality of care.Methods/DesignThe CCM and the KP Triangle were translated to the Dutch setting and adapted to the full elderly population living in the community. A randomized controlled trial with balanced allocation was designed to test the effectiveness of Embrace. Eligible elderly persons are 75 years and older and enrolled with one of the participating general practitioner practices. Based on scores on the INTERMED-Elderly Self-Assessment and Groningen Frailty Indicator, participants will be stratified into one of three strata: (A) robust; (B) frail; and (C) complex care needs. Next, participants will be randomized per stratum to Embrace or care as usual. Embrace encompasses an Elderly Care Team per general practitioner practice, an Electronic Elderly Record System, decision support instruments, and a self-management support and prevention program – combined with care and support intensity levels increasing from stratum A to stratum C. Primary outcome variables are patient outcomes, service use, costs, and quality of care. Data will be collected at baseline, twelve months after starting date, and during the intervention period.DiscussionThis study could provide evidence for the effectiveness of Embrace.Trial registrationThe Netherlands National Trial Register NTR3039

Broadening the scope on health problems among the chronically neurologically ill with the International Classification of Functioning (ICF)

Purpose. The aim of this study was to determine ICF items indicating health problems for patients with a chronic neurological disorder such as multiple sclerosis, Parkinsons disease and neuromuscular disease. Method. A Delphi study using three disease-specific panels composed of patients and proxies, medical and non-medical health professionals (N = 98). Panels were asked to select items from the International Classification of Functioning, Disability and Health (ICF) reflecting relevant disease-specific health problems. Items appraised as relevant by the panel members were compared with items in established measures namely: the Minimal Record of Disability (MRD) and the Disability and Impact Profile (DIP). Results. Sixty-eight ICF items were considered to be the most relevant, and belonged to four ICF domains. No significant differences were found between the appraisal of items by patients/proxies and health professionals. Agreement across the disease panels appeared to be (very) strong. Differences between the three disease-specific panels were found for the ‘Body Functions and Structures’ domain: consensus was reached by extension of the inclusion criteria. The ICF-item selection covers almost all items of the established measures. The largest contrast was shown in the item selection for the ‘participation’ and ‘environmental factors’ domains. Conclusions. Selected items indicate a broader scope in studying health problems compared with widely used health status measures in neurology, especially for the ICF domains ‘Participation’ and ‘Environmental Factors’.

Decline in Health-Related Quality of Life 6 Months After Coronary Artery Bypass Graft Surgery : The Influence of Anxiety, Depression, and Personality Traits

Background:Although coronary artery bypass graft (CABG) is known to improve health-related quality of life (HRQoL), this improvement does not seem to be realized in all patients who had undergone CABG surgery. Objective:The aim of this study was to test the direct and indirect influence of personality trait Type D on no change-deterioration trajectories HRQoL and the mediating influence of increased symptoms of anxiety and depression. Methods:The hypothesized influence of personality trait Type D on the relationship between increased anxiety and depression and no change-deterioration trajectories in HRQoL was tested with path analysis using structural equation modeling. Results:The results of the current study show that Type D personality comprised a vulnerability factor for poor patient-reported outcomes (ie, HRQoL and distress), and despite significant and clinically relevant benefits also for Type D patients after CABG, their well-being remained poorer than that of non–Type D participants at 6 months. Increased levels of anxiety largely mediated the influence of Type D personality on no change-deterioration trajectories in both physical and mental HRQoL, whereas increased symptoms of depression explained deterioration in physical and mental HRQoL without the influence of Type D personality. Conclusion:There is evidence that increased symptoms of psychological distress is a strong predictor of no change-deterioration trajectories in HRQoL and that this relationship is influenced by personality trait Type D. We conclude that mediating factors, especially increased anxiety and depression, should be treated adequately in post-CABG clinical routine.

Change in disability profile and quality of life in multiple sclerosis patients: a five-year longitudinal study using the Multiple Sclerosis Impact Profile (MSIP):

Background: Evidence on the progress of disease severity in Multiple Sclerosis (MS) is generally limited in scope. Objectives: To examine the course of a broad spectrum of MS-related disabilities and quality of life (QOL) in relation to disease severity, and responsiveness of the Multiple Sclerosis Impact Profile (MSIP). Methods: The mortality rate was calculated after checking the national population register for vital status of the initial cohort. We performed a longitudinal study among 245 patients with MS attending the Groningen MS Center in the Netherlands. We assessed these patients in 2004 and 2009 using a postal survey including the MSIP to evaluate disabilities, the World Health Organization Quality of Life-Abbreviation version (WHOQOL-BREF) to evaluate QOL, and the ambulation question of the Expanded Disability Status Scale (EDSS) to evaluate disease severity. Responsiveness of the MSIP was estimated using standardized response mean (SRM). Results: Increase of disability in the MSIP disability domains and loss of QOL were most prevalent and pronounced in patients with EDSS 0 to < 4.5 in 2004. MSIP and QOL scores were remarkably stable in the higher disease severity groups. Mortality rates were highest (24%) in patients with EDSS ≥ 7 to < 10 in 2004. SRM indices for the MSIP ranged between 0.26 and 0.56. Conclusions: Prominent increases in multiple aspects of disability and loss of QOL occur especially in the early stages in MS. Health care interventions may lead to health and QOL gains, in particular when offered to patients in the first stage of the MS process. Responsiveness was sufficient for nine of the 11 MSIP domains.

Adding a subjective dimension to an ICF-based disability measure for people with multiple sclerosis: development and use of a measure for perception of disabilities

Objective. The subjective dimension of disability, the perception of disability, is a dimension missing from the International Classification of Functioning, Disability and Health (ICF), and from health-related quality of life (HRQOL) instruments. However, it is a highly relevant dimension for clinical practice as perceived disability may identify care needs. We therefore developed a measure for this subjective dimension of disability in multiple sclerosis (MS) and examined the contribution of this dimension to QOL. Method. A measure named the Multiple Sclerosis Impact Profile-Disability Perception (MSIP-DP) was developed to reflect a persons perception of disabilities reported using the original MSIP-disability (MSIP-D) items. MS patients (n = 530) completed both MSIP sections, the medical outcome study short form questionnaire (SF-36), the World Health Organisation Quality Of Life-BREF (WHOQOL-BREF) and questions concerning disease severity. The contribution of disability perception (DP) to QOL in MS was estimated using hierarchical multiple regression analyses after controlling for MS severity. Results. Confirmative factor analysis confirmed the hypothesised disability perception domains that correspond with the related disability domains in the MSIP. DP scales yielded sufficient reliability. DP explained a unique and substantial part of the variance in QOL, particularly the perception of impairments in mental functions. Discussion. Results indicated that the subjective dimension of functioning and health operationalised in the MSIP-DP is a relevant concept in explaining QOL in MS. In clinical practice psychological interventions addressing a patients perception of disability, particularly of impairments in mental functioning, may contribute to QOL.

Design of a Randomised Controlled Trial (RCT) on the effectiveness of a Dutch patient advocacy case management intervention among severely disabled Multiple Sclerosis patients.

BackgroundCase management has been suggested as an innovative strategy that facilitates the improvement of a patients quality of life, reduction of hospital length of stay, optimization of self-care and improvement of satisfaction of patients and professionals involved. However, there is little evidence about the effectiveness of the patient advocacy case management model in clinical practice.Therefore, the objective of our study was to examine the effects of the Dutch patient advocacy case management model for severely disabled Multiple Sclerosis (MS) patients and their caregivers compared to usual care.Methods/designIn this randomized controlled trial the effectiveness of casemanagement on quality of life of patients and their caregivers, quality of care, service use and economic aspects were evaluated. The primary outcomes of this study were quality of life of MS-patients and caregiver burden of caregivers.Furthermore, we examined quality of life of caregivers, quality of care, service use and costs.DiscussionThis is a unique trial in which we examined the effectiveness of case management from a broad perspective. We meticulously prepared this study and applied important features and created important conditions for both intervention and research protocol to increase the likelihood of finding evidence for the effectiveness of patient advocacy case management. Concerning the intervention we anticipated to five important conditions: 1) the contrast between the case management intervention compared to the usual care seems to be large enough to detect intervention effects; 2) we included patients with complex care situations and/or were at risk for critical situations; 3) the case managers were familiar with disease specific health-problems and a broad spectrum of solutions; 4) case managers were competent and authorized to perform a medical neurological examination and worked closely with neurologists specialized in MS; and 5) the case managers had a regional network of professionals and health care organisations at their disposal, and were accepted as a coordinator of care. We also put a lot of effort on the selection of eligible patients, randomization and statistical methods, but also on power analysis, selection of reliable, validated and sensitive outcome measures, and (statistical) control of confounders.Trial registrationDutch Trial Register http://www.trialregister.nl. Trial ID: NTR762.

Experiences of Community-Living Older Adults Receiving Integrated Care Based on the Chronic Care Model : A Qualitative Study

Background Integrated care models aim to solve the problem of fragmented and poorly coordinated care in current healthcare systems. These models aim to be patient-centered by providing continuous and coordinated care and by considering the needs and preferences of patients. The objective of this study was to evaluate the opinions and experiences of community-living older adults with regard to integrated care and support, along with the extent to which it meets their health and social needs. Methods Semi-structured interviews were conducted with 23 older adults receiving integrated care and support through “Embrace,” an integrated care model for community-living older adults that is based on the Chronic Care Model and a population health management model. Embrace is currently fully operational in the northern region of the Netherlands. Data analysis was based on the grounded theory approach. Results Responses of participants concerned two focus areas: 1) Experiences with aging, with the themes “Struggling with health,” “Increasing dependency,” “Decreasing social interaction,” “Loss of control,” and “Fears;” and 2) Experiences with Embrace, with the themes “Relationship with the case manager,” “Interactions,” and “Feeling in control, safe, and secure”. The prospect of becoming dependent and losing control was a key concept in the lives of the older adults interviewed. Embrace reinforced the participants’ ability to stay in control, even if they were dependent on others. Furthermore, participants felt safe and secure, in contrast to the fears of increasing dependency within the standard care system. Conclusion The results indicate that integrated care and support provided through Embrace met the health and social needs of older adults, who were coping with the consequences of aging.