Health care for older people

Challenges in preventing cardiovascular complications in type 2 diabetes in primary care

BACKGROUND

Prevalence of type 2 diabetes mellitus (DM2) continues to increase worldwide. The associated cardiovascular morbidity and mortality are high.

OBJECTIVES

To study daily practice in preventing cardiovascular disease (CVD) in an unselected primary care patient population with DM2, and to study factors influencing the care delivered.

METHODS

Cross-sectional univariate and multivariate analyses of baseline data from a primary care population-based sample of patients with DM2, participating in a shared care project in the Netherlands.

RESULTS

Of 1269 patients invited, 1149 (91%) participated. Hypertension was present in 78% of patients, 63% whom were treated, 41% successfully. Lipid profile abnormalities were present in 51% of patients, 22% of whom were treated, 54% successfully. The treatment rates for lipid profile abnormalities were positively correlated with younger age and the registration of the lipid profile by the GP. For hypertension the treatment rates were higher for patients who were female, of an advanced age, in the presence of CVD, and/or whose blood pressure had been registered by the GP.

CONCLUSION

A gap exists between recommended care and the care patients with DM2 in the primary care setting. Diagnosed CVD and the accurate registration with higher treatment rates. Improvement strategies could be directed at primary prevention of CVD and improving the registration of cardiovascular risk factors.

Quality of care for elderly residents in nursing homes and elderly people living at home: controlled observational study

OBJECTIVES

To assess the quality of care given to elderly people and compare the care given to residents in nursing homes with those living in their own homes.

DESIGN

Controlled observational study.

SETTING

Primary care, Bristol.

SUBJECTS

Elderly individuals (aged > or =65 years) registered with three general practices, of whom 172 were residents in nursing homes (cases) and 526 lived at home (matched controls).

MAIN OUTCOME MEASURES

The quality of clinical care given to patients was measured against explicit standards. Quality indicators were derived from national sources and agreed with participating general practitioners.

RESULTS

The overall standard of care was inadequate when judged against the quality indicators, irrespective of where patients lived. The overall prescribing of beneficial drugs for some conditions was deficient--for example, only 38% (11/29) (95% confidence interval 20% to 58%) of patients were prescribed beta blockers after myocardial infarction. The proportion of patients with heart disease or diabetes who had had their blood pressure measured in the past two years (heart disease) or past year (diabetes) was lower among those living in nursing homes: for heart disease, 74% (17/23) v 96% (122/127) (adjusted odds ratio 0.18, 0.04 to 0.75); for diabetes, 62% (8/13) v 96% (50/52) (adjusted odds ratio 0.05, 0.01 to 0.38). In terms of potentially harmful prescribing, significantly more patients in nursing homes were prescribed neuroleptic medication (28% (49/172) v 11% (56/526) (3.82, 2.37 to 6.17)) and laxatives (39% (67/172) v 16% (85/526) (2.79, 1.79 to 4.36)). Nursing home residents were less likely to have the appropriate diagnostic Read code linked to their prescribed neuroleptic drug (0.22, 0.07 to 0.71).

CONCLUSIONS

The quality of medical care that elderly patients receive in one UK city, particularly those in nursing homes, is inadequate. We suggest that better coordinated care for these patients would avoid the problems of overuse of unnecessary or harmful drugs, underuse of beneficial drugs, and poor monitoring of chronic disease.

Older people as health service consumers 2: health and illness in a village context

Involving users in the future shaping and development of health care services is part of the drive to restore public confidence in the NHS (NHS Executive 2002). A fundamental part of this process is working in partnership with patients, and attempting to include marginalized groups. Illness, infirmity and lack of knowledge may prevent older people from being actively involved in decisions about health care services, and the culture to which they belong may act as a further barrier. For true partnership and patient involvement, there needs to be a common understanding of the meaning of health and illness. This article discusses the prevailing cultural health beliefs within an elderly, white village community in South England.