Organising health care services for persons with an intellectual disability

Motivating Physical Activity for Individuals with Intellectual Disability through Indoor Bike Cycling and Exergaming

People with intellectual disabilities have more sedentary lifestyles than the general population. Regular physical activity is of both medical and social importance, reducing the risk of cardiovascular disease and promoting functioning in everyday life. Exergames have been envisioned for promoting physical activity; however, most of them are not user-friendly for individuals with intellectual disabilities. In this paper, we report the design, development, and user acceptance of a mobile health solution connected to sensors to motivate physical activity. The system is mounted on an indoor stationary bicycle and an ergometer bike tailored for people with intellectual disabilities. The development process involved the application of user-centered design principles to customize the system for this group. The system was pilot-tested in an institutional house involving six end-users (intervention group) and demonstrated/self-tested to relatives of persons with ID and staff (supervision group). A System Usability Scale and open-ended interview in the supervision group were used to assess the user acceptance and perceived usefulness. Results indicate that the users with an intellectual disability enjoyed using the system, and that respondents believed it was a useful tool to promote physical activity for the users at the institution. The results of this study provide valuable information on beneficial technological interventions to promote regular physical activity for individuals with intellectual disabilities.

Physical Activity With Tailored mHealth Support for Individuals With Intellectual Disabilities: Protocol for a Randomized Controlled Trial

Background

Individuals with intellectual disabilities (IDs) have lower levels of physical activity (PA) and greater barriers for participation in fitness activities compared with members of the general population. As increased PA has positive effects on cardiovascular and psychosocial health, it is exceedingly important to identify effective interventions for use in everyday settings. Mobile health (mHealth) methods such as motion sensor games (exergames) and smartphone reminders for PA have been explored and found to be promising in individuals with IDs.

Objective

The purpose of this study is to examine the effectiveness of an individually tailored PA program with motivational mHealth support on daily levels of PA in youth and adults with IDs.

Methods

The trial uses a randomized controlled design comprising 30 intervention participants and 30 control group participants, aged 16 to 60 years, with sedentary lifestyles or low PA levels. While the controls will receive standard care, the intervention aims to increase the level of PA, measured as steps per day, as the primary outcome. Secondary outcome variables are body mass index, blood pressure, physical performance, social support for PA, self-efficacy in a PA setting, behavior problems, and goal attainment. The intervention involves the delivery of tailored mHealth support, using smartphones or tablets to create structure with focus on the communicative abilities of individual participants. Rewards and feedback are provided in order to motivate individuals to increase participation in PA. Participants in the intervention group, their close relatives, and care staff will be invited to participate in a preintervention goal-setting meeting, where goal attainment scaling will be used to select the participants’ PA goals for the intervention period. All participants will be assessed at baseline, at 3 months, and at 6 months.

Results

Enrollment was planned to start in April 2020 but will be delayed due to the pandemic situation. The main contribution of this paper is a detailed plan to run our study, which will produce new knowledge about tailored mHealth to support PA in individuals with intellectual disabilities.

Conclusions

We expect the new intervention to perform better than standard care in terms of improved PA, improved self-efficacy, and social support for activities. Technology offers new opportunities to promote healthy behaviors. The results of the study will determine the effectiveness and sustainability of a tailored mHealth support intervention to increase PA in youth and adults with IDs.

Trial Registration

ClinicalTrials.gov NCT04079439; https://clinicaltrials.gov/ct2/show/NCT04079439

International Registered Report Identifier (IRRID)

PRR1-10.2196/19213

Barriers and facilitators to mammography among women with intellectual disabilities: a qualitative approach

Although women with intellectual disabilities have the same breast cancer incidence rate as women without intellectual disabilities, they have fewer mammograms and higher mortality rates. Qualitative inquiry was employed to explore barriers and facilitators to mammography among this population. In-depth qualitative interviews were conducted with 30 women with intellectual disabilities and their caregivers in Philadelphia during 2015-2016. Thematic analysis was conducted using inductive and deductive coding. While results provide further evidence for prior research on barriers to mammography among women with intellectual disabilities (e.g. being unprepared, fear of the exam), this study generated novel barriers such as lack of breast ultrasound awareness, sedation failing to work, and lack of mammogram education in adult day programs, and novel facilitators such as extended family support and positive attitudes. Results support the need to address barriers and promote facilitators to improve the breast cancer screening experience among women with intellectual disabilities.

Racial/Ethnic Disparities in Mammogram Frequency Among Women With Intellectual Disability

Little information exists on the associations between intellectual disability (ID) and race/ethnicity on mammogram frequency. This study collected survey and medical record data to examine this relationship. Results indicated that Hispanic and Black women with ID were more likely than White women with ID to have mammograms every 2 years. Participants who live in a state-funded residence, were aged 50+, and had a mild or moderate level of ID impairment were more likely to undergo mammography compared to participants living with family or alone, were <50, and had severe ID impairment. Further research is needed to understand the mechanisms explaining disparities in mammograms between these racial/ethnic groups.

Providing equity of care for patients with intellectual and developmental disabilities in Western Switzerland: a descriptive intervention in a University Hospital

Background

The purpose of this article is to describe an interventional project in a University Hospital. It explains the adjustments that were made to provide good care for patients with intellectual and developmental disabilities in an acute care setting in Western Switzerland. It is not the exposition of the results of a formalised research or study. Rather, this article relates the success story of a project initiated by a small group of passionate people on their free time, that eventually entered in the 2020 strategic planning of the largest hospital of Switzerland.

Switzerland does not have a national policy regarding health needs for patients with intellectual and developmental disabilities. Health care professionals are not trained to identify and meet the specific health needs of this population and little is taught about intellectual and developmental disabilities during undergraduate studies.

Method

The Disability Project was conducted between 2012 and 2017 in Geneva University Hospital, as follows:

Firstly, over sixty working group sessions took place to identify the specific health needs of people with intellectual and developmental disabilities, to identify the barriers to providing equity of care and to prioritize reasonable adjustments. The four following barriers emerged from these meetings:

Lack of awareness of healthcare professionals on specific health issues for patients with intellectual and developmental disabilities, which resulted in a poor healthcare coordination and reduced quality of care.

Communication and information transmission issues between hospital staff, families and supported residential accommodations.

Lack of training or insufficient training of healthcare professionals and hospital staff on intellectual and developmental disabilities.

Inaccessibility of the hospital facilities and buildings for patients with disabilities

Secondly, arising from these priorities, interventions were developed.

Findings

The interventions were eventually applied throughout the hospital. Recommendations and reasonable adjustments were made to provide accessibility and equity of care for patients with intellectual and developmental disabilities.

Conclusion

The Disability Project has achieved many reasonable adjustments in an acute care setting to provide good care and satisfaction for this population and their families.

Safety of People with Intellectual Disabilities in Hospital. What Can the Hospital Pharmacist Do to Improve Quality of Care?

People with intellectual disabilities are vulnerable in healthcare environments. They experience health and healthcare inequalities, and when admitted to general hospitals are at a greater risk of patient safety incidents. This is well known in specialist services, but less recognized within primary or secondary healthcare. The most significant barriers to safer and better healthcare appear to include 'invisibility' of people with intellectual disabilities within health-care systems, widespread lack of staff understanding of intellectual disability, the vulnerabilities of people with intellectual disabilities, and the reasonable adjustment they may need in order to access health-care services. They may be 'invisible' to pharmacists in general hospitals. This article aims to raise awareness among those pharmacists and others providing care and support to people with intellectual disabilities in hospital in relation to how pharmacists can contribute to safety. Medication is the main therapeutic intervention in this population. Research is needed to determine the role of pharmacists in improving health outcomes and reducing health inequalities in this vulnerable population group when they are admitted to general hospitals.

After-hours primary care for people with intellectual disabilities in The Netherlands-Current arrangements and challenges

BACKGROUND

Little is known about the organisation of after-hours primary care for people with intellectual disabilities (ID), and mainstream care is not self-evidently accessible or fit for this group. A first step towards improvement is a greater understanding of current after-hours primary ID care.

AIMS

This study explores the organisation of and experiences with after-hours primary care provided for people with ID in The Netherlands.

METHODS AND PROCEDURES

A telephone survey amongst 68 care provider services including questions on organisational characteristics, problem areas, facilitators, and inhibitors.

OUTCOMES AND RESULTS

A multitude of different after-hours primary care arrangements were found. Primary care physicians (PCPs) were involved in almost all care provider services, often in alliance with PCP cooperatives. Specialised ID physicians had differing roles as gatekeeper, primary caregiver, or consultant. Most problems during the after-hours arose regarding daily care professionals' competences. Facilitators and inhibitors of after-hours primary care were themed around complexity of, and need for, specialised care, multidisciplinary team of professionals, communication and information, and prerequisites at organisational level.

CONCLUSIONS AND IMPLICATIONS

Evidence on specific after-hours health needs of people with ID is needed to strengthen collaboration between specialist ID care services and mainstream healthcare services to adequately provide care.

Implications for public health research of models and theories of disability: a scoping study and evidence synthesis

Background

Public health interventions that are effective in the general population are often assumed to apply to people with impairments. However, the evidence to support this is limited and hence there is a need for public health research to take a more explicit account of disability and the perspectives of people with impairments.

Objectives

(1) To examine the literature on theories and models of disability; (2) to assess whether or not, and how, intervention studies of effectiveness could incorporate more inclusive approaches that are consistent with these theories and models; and (3) to use the findings to draw out implications for improving evaluative study designs and evidence-based practice.

Review methods

The project is a scoping review of the literature. The first stage examines theories and models of disability and reflects on possible connections between theories of disability and public health paradigms. This discussion is used to develop an ethical–empirical decision aid/checklist, informed by a human rights approach to disability and ecological approaches to public health. We apply this decision aid in the second stage of the review to evaluate the extent to which the 30 generic public health reviews of interventions and the 30 disability-specific public health interventions include the diverse experiences of disability. Five deliberation panels were also organised to further refine the decision aid: one with health-care professionals and four with politically and socially active disabled people.

Results

The evidence from the review indicated that there has been limited public health engagement with theories and models of disability. Outcome measures were often insensitive to the experiences of disability. Even when disabled people were included, studies rarely engaged with their experiences in any meaningful way. More inclusive research should reflect how people live and ‘flourish’ with disability.

Limitations

The scoping review provides a broad appraisal of a particular field. It generates ideas for future practice rather than a definite framework for action.

Conclusions

Our ethical–empirical decision aid offers a critical framework with which to evaluate current research practice. It also offers a resource for promoting more ethical and evidence-based public health research that is methodologically robust while being sensitive to the experiences of disability.

Future work

Developing more inclusive research and interventions that avoid conceptualising disability as either a ‘burden’ or ‘problem’ is an important starting point. This includes exploring ways of refining and validating current common outcome measures to ensure that they capture a diverse range of disabling experiences, as well as generating evidence on meaningful ways of engaging a broad range of disabled children and adults in the research process.

Funding

The National Institute for Health Research Public Health Research programme.

An intensive personalised support approach to treating individuals with psychosis and co-morbid mild intellectual disability

OBJECTIVES

To evaluate the clinical benefits and associated cost effectiveness of an intensive personalised support (IPS) approach for clients suffering from psychosis and co-morbid mild intellectual disability (ID).

METHOD

Four individuals with a psychotic disorder and co-morbid mild ID participated in an 18-month IPS rehabilitative intervention. Biopsychosocial measures were used to evaluate clinical effectiveness. A cost analysis was undertaken to examine the cost effectiveness of the intervention.

RESULTS

Reductions in psychopathology including anxiety symptoms were noted in all individuals. In addition, increased functioning and quality of life were demonstrated in all cases. Overall cost reductions were noted in inpatient care, accommodation and legal/emergency expenses.

CONCLUSION

The IPS approach was clinically effective particularly in addressing individual's psychosocial needs, psychological functioning, daily living skills and overall quality of life. Costs had decreased for three of the four individuals, ranging from a 17% to 46% savings. The findings highlight that the intervention was cost effective in most cases at this early stage. However, further research is necessary in order to ascertain if cost savings occur over time.

Organising healthcare services for persons with an intellectual disability

BACKGROUND

When compared to the general population, persons with an intellectual disability have lower life expectancy, higher morbidity, and more difficulty finding and obtaining healthcare. Organisational interventions are used to reconfigure the structure or delivery of healthcare services. This is the first update of the original review.

OBJECTIVES

To assess the effects of organisational interventions of healthcare services for the mental and physical health problems of persons with an intellectual disability.

SEARCH METHODS

For this update we searched CENTRAL, MEDLINE, EMBASE, CINAHL and other databases, from April 2006 to 4 September 2015. We checked reference lists of included studies and consulted experts in the field.

SELECTION CRITERIA

Randomised controlled trials of organisational interventions of healthcare services aimed at improving care of mental and physical health problems of adult persons with an intellectual disability.

DATA COLLECTION AND ANALYSIS

We employed standard methodological procedures as outlined in the Cochrane Handbook of Systematic Reviews of Interventions, in addition to specific guidance from the Cochrane Effective Practice and Organisation of Care (EPOC) Group.

MAIN RESULTS

We identified one new trial from the updated searches.Seven trials (347 participants) met the selection criteria. The interventions varied but had common components: interventions that increased the intensity and frequency of service delivery (4 trials, 200 participants), community-based specialist behaviour therapy (1 trial, 63 participants), and outreach treatment (1 trial, 50 participants). Another trial compared two active arms (traditional counselling and integrated intervention for bereavement, 34 participants).The included studies investigated interventions dealing with the mental health problems of persons with an intellectual disability; none focused on physical health problems. Four studies assessed the effect of organisational interventions on behavioural problems for persons with an intellectual disability, three assessed care giver burden, and three assessed the costs associated with the interventions. None of the included studies reported data on the effect of organisational interventions on adverse events. Most studies were assessed as having low risk of bias.It is uncertain whether interventions that increase the frequency and intensity of delivery or outreach treatment decrease behavioural problems for persons with an intellectual disability (two and one trials respectively, very low certainty evidence). Behavioural problems were slightly decreased by community-based specialist behavioural therapy (one trial, low certainty evidence). Increasing the frequency and intensity of service delivery probably makes little or no difference to care giver burden (MD 0.03, 95% CI -3.48 to 3.54, two trials, moderate certainty evidence). It is uncertain whether outreach treatment makes any difference for care giver burden (one trial, very low certainty evidence). There was very limited evidence regarding costs, with low to very low certainty evidence for the different interventions.

AUTHORS' CONCLUSIONS

There is very limited evidence on the organisation of healthcare services for persons with an intellectual disability. There are currently no well-designed studies focusing on organising the health services of persons with an intellectual disability and concurrent physical problems. There are very few studies of organisational interventions targeting mental health needs and the results of those that were found need corroboration. There is an urgent need for high-quality health services research to identify optimal health services for persons with an intellectual disability and concurrent physical problem.

"Teaches People That I'm More Than a Disability": Using Nominal Group Technique in Patient-Oriented Research for People With Intellectual and Developmental Disabilities

Individuals with intellectual and developmental disabilities (IDD) have complex healthcare needs, which are often unmet. Nominal group technique (NGT) uses a mixed-methods approach, which may engage the IDD population in the research process in a person-centered manner and address the shortcomings of traditional research methods with this population. NGT was used with a group of 10 self-advocates to evaluate a series of healthcare tools created by and for individuals with IDD. Participants provided helpful input about the strengths of these tools and suggestions to improve them. NGT was found to be an effective way to engage all participants in the research process.

A systematic review of hospital experiences of people with intellectual disability

BACKGROUND

People with intellectual disability are at risk of poor hospital experiences and outcomes. The aims were to conduct a content and quality review of research into the acute hospital experiences of both people with intellectual disabilities and their carers, and to identify research gaps.

METHOD

A systematic search was conducted of primary research between 2009 and 2013 that addressed the experiences of the target group in general acute care hospitals. Quality appraisal tools yielded scores for quantitative and qualitative studies, and overarching themes across studies were sought.

RESULTS

Sixteen studies met inclusion criteria. Quality scores were 6/8 for a survey, and 2/11-9/11 (mean =5.25) for qualitative studies/components. Content analysis revealed seven over-arching themes covering individuals' fear of hospital encounters, carer responsibilities, and problems with delivery of care in hospitals including staff knowledge, skills and attitudes.

CONCLUSIONS

Our review of eligible papers revealed that despite 20 years of research and government initiatives, people with intellectual disability continue to have poor hospital experiences. The need for research to identify and investigate care at specific points of encounter across a hospital journey (such as admission, diagnostic testing, placement on a ward, and discharge) as well as to include people with a diversity of disabilities is discussed in terms of potential to influence policy and practice across health and disability sectors.

A systematic review of hospital experiences of people with intellectual disability

BACKGROUND

People with intellectual disability are at risk of poor hospital experiences and outcomes. The aims were to conduct a content and quality review of research into the acute hospital experiences of both people with intellectual disabilities and their carers, and to identify research gaps.

METHOD

A systematic search was conducted of primary research between 2009 and 2013 that addressed the experiences of the target group in general acute care hospitals. Quality appraisal tools yielded scores for quantitative and qualitative studies, and overarching themes across studies were sought.

RESULTS

Sixteen studies met inclusion criteria. Quality scores were 6/8 for a survey, and 2/11-9/11 (mean =5.25) for qualitative studies/components. Content analysis revealed seven over-arching themes covering individuals' fear of hospital encounters, carer responsibilities, and problems with delivery of care in hospitals including staff knowledge, skills and attitudes.

CONCLUSIONS

Our review of eligible papers revealed that despite 20 years of research and government initiatives, people with intellectual disability continue to have poor hospital experiences. The need for research to identify and investigate care at specific points of encounter across a hospital journey (such as admission, diagnostic testing, placement on a ward, and discharge) as well as to include people with a diversity of disabilities is discussed in terms of potential to influence policy and practice across health and disability sectors.

A mixed methods study to develop and pilot a competency assessment tool to support midwifery care of women with intellectual disabilities

BACKGROUND

Recent reports have highlighted the poor quality of health care received by people with intellectual disabilities (otherwise known as 'learning disabilities') in the United Kingdom (UK). UK Confidential Enquiries into maternal deaths have highlighted adverse pregnancy outcomes for women with intellectual disabilities and need for timely and appropriate clinical care.

OBJECTIVES

To develop and test a competency assessment tool to support midwifery care of women with intellectual disabilities.

DESIGN

A mixed methods study.

SETTING

Large inner city maternity unit.

PARTICIPANTS

Midwives and key experts in intellectual disabilities, maternity policy and midwifery education.

METHODS

Phase one comprised a systematic narrative review of the literature. Evidence identified informed phase two which included focus groups and interviews. Emergent themes informed the development of a competency assessment tool which was piloted in phase three.

RESULTS

Phase one: Four primary research papers and two systematic reviews met the review inclusion criteria. Support to develop parenting skills of women with intellectual disabilities was highlighted as was the need to optimise organisation of maternity services. No studies specifically considered midwifery competencies to support women with intellectual disabilities. Phase two: 23 midwives attended three focus groups and individual interviews were conducted with national leaders in intellectual disability (n=6) and midwifery policy and education (n=7). Themes identified included need for individualised care provided by a known midwife, the importance of effective communication skills and need for clear knowledge and understanding of the legislative framework relevant to intellectual disability. Phase three: A convenience sample of 60 midwives was asked to participate in a pilot study to test the tool, 46 (77%) of whom responded. Thirty midwives (65%) felt competent in their ability to recognise intellectual disability and 37 (80%) competent or expert in understanding women have the right to be offered choice and make informed decisions. A high proportion (n=40, 87%) reported little or no knowledge regarding consent issues.

CONCLUSION

Work to inform timely and appropriate care of women with intellectual disability has been neglected in the UK maternity services. Use of a tool could aid assessment of midwifery competencies to support women with intellectual disability and highlight where further midwifery education and development are needed. Evidence of optimal care for women with intellectual disabilities and their families across the continuum of pregnancy and birth is required.

Intellectual disability and mental health problems: a qualitative study of general practitioners' views

OBJECTIVES

To investigate general practitioners' (GPs) experiences in managing patients with intellectual disabilities (ID) and mental and behavioural problems (MBP).

DESIGN

Qualitative study using in-depth interviews.

SETTING

General practice in Hedmark county, Norway.

PARTICIPANTS

10 GPs were qualitatively interviewed about their professional experience regarding patients with ID and MBP. Data were analysed by all authors using systematic text condensation.

RESULTS

The participants' knowledge was primarily experience-based and collaboration with specialists seemed to be individual rather than systemic. The GPs provided divergent attitudes to referral, treatment, collaboration, regular health checks and home visits.

CONCLUSIONS

GPs are in a position to provide evidence-based and individual treatment for both psychological and somatic problems among patients with ID. However, they do not appear to be making use of evidence-based treatment decisions. The GPs feel that they are left alone in decision-making, and find it difficult to find trustworthy collaborative partners. The findings in this study provide useful information for further research in the field.

Review: a systematic review of quality of life measures for people with intellectual disabilities and challenging behaviours

BACKGROUND

The quality of life (QOL) construct is proposed as a method to assess service outcomes for people utilising disability services. With this in mind, the aim of this study was to conduct a systematic review of available QOL measures for people with intellectual disability (ID) to pinpoint psychometrically sound measures that can be routinely used for service evaluation.

METHOD

A systematic search of the disability literature published between 1980 and 2008 was conducted in order to identify appropriate QOL tools for use within an Australian context. Twenty-four QOL instruments were identified and each instrument was then evaluated against a set of psychometric and measurement criteria.

RESULTS

Six of the instruments examined were deemed to be psychometrically sound on the available information. No instruments were found that specifically assess QOL for people with ID who exhibit challenging behaviour. Most of the instruments assess QOL from a subjective perspective, use a questionnaire format and measure only some (not all) of the eight theoretically accepted domains of QOL.

CONCLUSIONS

More instruments that measure QOL need to be developed and rigorously validated. This is especially the case for high-needs disability populations like those individuals that exhibit challenging behaviour or have severe to profound ID, as it is questionable whether existing measures can be used with these populations.

Determinants of mammography in women with intellectual disabilities

BACKGROUND

Women with intellectual disabilities have the same rate of breast cancer as other women but are less likely to undergo screening mammography. Characteristics associated with mammography for women with intellectual disabilities in the United States are unknown.

METHODS

This study was based on a secondary data analysis of the Massachusetts Department of Developmental Services database, comparing women who had a mammogram within 2 years with women who had not on variables related to the ecological model. Bivariate analyses, logistic regression, and assessment of interactions were performed.

RESULTS

The study sample's (n = 2907) mean age was 54.7 years; 58% lived in 24-hour residential settings, 52% received nursing health coordination, and more than 25% had clinical examination needs (eg, sedation). Residential setting, health coordination, and recent influenza vaccination were all associated with mammography. Having a guardian, higher level of activities of daily living needs, and examination needs (requiring sedation or limited wait time for examinations) were associated with lower rates. Interactions between health coordination and examination needs confirmed the potential of the nurse to ameliorate barriers to mammography.

CONCLUSION

Several system-level variables were significantly associated with mammography and, in some cases, seemed to ameliorate intrapersonal/behavioral barriers to mammography. Community agencies caring for intellectually disabled women have potential to impact mammography rates by using health coordination.

A comparison of outpatients with intellectual disability receiving specialised and general services in Ontario's psychiatric hospitals

BACKGROUND

This study compares outpatients with intellectual disability (ID) receiving specialised services to outpatients with ID receiving general services in Ontario's tertiary mental healthcare system in terms of demographics, symptom profile, strengths and resources, and clinical service needs.

METHODS

A secondary analysis of Colorado Client Assessment Record data collected from all tertiary psychiatric hospitals in the province was completed for a stratified random sample of 246 outpatients identified as having ID, from both specialised and general programmes.

RESULTS

Individuals with ID in specialised programmes differed from patients with ID in general programmes with regard to demographics, diagnostic profile, symptom presentation and recommended level of care.

CONCLUSIONS

Further research is required to determine why individuals access some services over others and to evaluate whether specialised services are more appropriate for certain subgroups with ID than others.

Experiences with general practitioners described by families of children with intellectual disabilities and challenging behaviour: a qualitative study

Objective To investigate parents' experiences of follow-up by general practitioners (GPs) of children with intellectual disabilities (ID) and comorbid behavioural and/or psychological problems. Design Qualitative study based on in-depth interviews with parents of children with ID and a broad range of accompanying health problems. Setting County centred study in Norway involving primary and specialist care. Participants Nine parents of seven children with ID, all received services from an assigned GP and a specialist hospital department. Potential participants were identified by the specialist hospital department and purposefully selected by the authors to represent both genders and a range of diagnoses, locations and assigned GPs. Results Three clusters of experiences emerged from the analysis: expectations, relationships and actual use. The participants had low expectations of the GPs' competence and involvement with their child, and primarily used the GP for the treatment of simple somatic problems. Only one child regularly visited their GP for general and mental health check-ups. The participants' experience of their GPs was that they did not have time and were not interested in the behavioural and mental problems of these children. Conclusions Families with children with ID experience a complex healthcare system in situations where they are vulnerable to lack of information, involvement and competence. GPs are part of a stable service system and are in a position to provide security, help and support to these families. Parents' experiences could be improved by regular health checks for their children and GPs being patient, taking time and showing interest in challenging behaviour.

Hospitalisation rates for ambulatory care sensitive conditions for persons with and without an intellectual disability--a population perspective

BACKGROUND

There is evidence that persons with an intellectual disability (ID) face barriers to primary care; however, this has not been extensively studied at the population level. Rates of hospitalisation for ambulatory care sensitive conditions are used as an indicator of access to, and quality of, primary care. The objective of the study was to compare hospitalisation rates for ambulatory care sensitive conditions between persons with and without an ID in a publicly insured population.

METHODS

Persons with an ID were identified among the general population of a Canadian province between 1999 and 2003. Using a list of conditions applicable to persons with an ID, rates of hospitalisations for ambulatory care sensitive conditions for persons with and without an ID were calculated and compared. Regression models were used to adjust for age, sex and place of residence. Hospitalisation rates for specific conditions were also compared, controlling for differences in disease prevalence where possible.

RESULTS

Persons with an ID were consistently hospitalised for ambulatory care sensitive conditions at a higher rate than persons without an ID. Between 1999 and 2003 the adjusted rate ratio (RR) was 6.1 [95% confidence interval (CI) = 5.6, 6.7]. Rate ratios were highest when comparing persons with, to persons without, an ID between the ages of 30-39 (RR = 13.1; 95% CI = 10.6, 16.2) and among urban area dwellers (RR = 7.0; 95% CI = 6.2, 7.9). Hospitalisation rates for epilepsy and schizophrenic disorders were, respectively, 54 and 15 times higher for persons with compared with persons without an ID. Rate ratios for diabetes and asthma remained significant after controlling for the population prevalence of these diseases.

CONCLUSIONS

The large discrepancy in rates of hospitalisation between persons with and without an ID is an indicator of inadequate primary care for this vulnerable population. Decreasing the number of ambulatory care sensitive condition hospitalisations through specialised outpatient programmes for persons with an ID would potentially lead to better health, improved quality of life and cost savings. Future research should include potentially important factors such as disease severity, socio-economic variables and measures of health service organisation in the analysis. International comparisons of ambulatory care sensitive condition hospitalisation rates could point to the benefits and limitations of the health service policy directions adopted by different countries.