Outcomes as experienced by older patients after hospitalisation: satisfaction, acceptance, frustration and hope-a grounded theory study

Background

outcomes of hospitalisation are often described in quantitative terms. It is unknown how older frail patients describe their own outcomes.

Objective

to discover how older frail persons describe their own hospitalisation outcomes and the meaning of these outcomes for their daily lives.

Design

Constructivist Grounded Theory approach.

Participants

frail older people discharged from hospital.

Methods

Open interviews in the participant’s home. Transcripts were coded inductively according to the Constructivist Grounded Theory approach.

Results

Twenty-four interviews were conducted involving 20 unique participants. Although for some participants hospitalisation was just a ripple, for others, it was a turning point. It could have positive or negative impacts on outcomes, including remaining alive, disease, fatigue/condition, complaints, daily functioning, social activities and intimate relationships, hobbies, living situation and mental well-being. Few participants were completely satisfied, but for many, a discrepancy between expectation and reality existed. Some participants could accept this, others remained hopeful and some were frustrated. Factors associated with these categories were research and treatment options, (un)clarity about the situation, setting the bar too high or pushing boundaries, confidence in physicians, character traits and social factors.

Conclusions

of the persons whose outcomes did not meet their expectations, some were frustrated, others hopeful and others accepted the situation. The following interventions can help patients to accept: clear communication about options and expectations before, during and after hospitalisation; giving room for emotions; help finding social support, encouragement to engage in pleasant activities and find meaning in small things. For some patients, psychological treatment may be needed.

Adaptation of the Patient Benefit Assessment Scale for Hospitalised Older Patients: development, reliability and validity of the P-BAS picture version

Background

The Patient Benefit Assessment Scale for Hospitalised Older Patients (P-BAS HOP) is a tool developed to both identify the priorities of the individual patient and to measure the outcomes relevant to him/her, resulting in a Patient Benefit Index (PBI), indicating how much benefit the patient had experienced from the hospitalisation. The reliability and the validity of the P-BAS HOP appeared to be not yet satisfactory and therefore the aims of this study were to adapt the P-BAS HOP and transform it into a picture version, resulting in the P-BAS-P, and to evaluate its feasibility, reliability, validity, responsiveness and interpretability.

Methods

Process of instrument development and evaluation performed among hospitalised older patients including pilot tests using Three-Step Test-Interviews (TSTI), test-retest reliability on baseline and follow-up, comparing the PBI with Intraclass Correlation Coefficient (ICC), and hypothesis testing to evaluate the construct validity. Responsiveness of individual P-BAS-P scores and the PBI with two different weighing schemes were evaluated using anchor questions. Interpretability of the PBI was evaluated with the visual anchor-based minimal important change (MIC) distribution method and computation of smallest detectable change (SDC) based on ICC.

Results

Fourteen hospitalised older patients participated in TSTIs at baseline and 13 at follow-up after discharge. After several adaptations, the P-BAS-P appeared feasible with good interviewer’s instructions. The pictures were considered relevant and helpful by the participants. Reliability was tested with 41 participants at baseline and 50 at follow-up. ICC between PBI₁ and PBI₂ of baseline test and retest was 0.76, respectively 0.73. At follow-up 0.86, respectively 0.85.

For the construct validity, tested in 169 participants, hypotheses regarding importance of goals were confirmed. Regarding status of goals, only the follow-up status was confirmed, baseline and change were not. The responsiveness of the individual scores and PBI were weak, resulting in poor interpretability with many misclassifications. The SDC was larger than the MIC.

Conclusions

The P-BAS-P appeared to be a feasible instrument, but there were methodological barriers for the evaluation of the reliability, validity, and responsiveness. We therefore recommend further research into the P-BAS-P.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02708-7.

Goal-based outcomes of hospitalisation of older adults are predicted by gender, confidence, quality of life and type of goals

PURPOSE

Although patient-reported outcome measures (PROMs) might reflect relevant outcomes from patient perspective, they do not always reflect what the individual patient finds important. Our objectives were to assess which PROM was best suited to evaluate patient-relevant outcomes of hospitalisation and to assess which factors predicted this PROM.

METHODS

A longitudinal study was conducted among hospitalised older patients. Three PROMs were compared with the anchor question 'How much have you benefited from the admission?': a general quality of life measure: EQ-5D; a measure of daily functioning: Katz-15 and a goal-based measure: achievement of self-defined goals. Predictors were examined using logistic regression analyses.

RESULTS

We had 185 cases with baseline and follow-up. Accomplishment of self-defined goals showed a large correlation with the anchor question, whereas EQ-5D and Katz-15 showed no significant correlations. The final regression model had four predictors: being man, having higher confidence in goal achievement and good/excellent quality of life increased the odds for goal accomplishment, while having goals in the category alleviating complaints reduced the odds.

CONCLUSION

Accomplishment of individual goals represented the benefit experienced by participants best. Subjective indicators of health and functioning are better predictors of goal accomplishment than objective ones. According to participant experience, the hospital appeared successful in managing disease-specific problems, but less successful in ameliorating complaints. Medical decision-making should not only be based on medical indicators, but the input of the patient is at least as important. Quality of life, goals and confidence should be discussed. More attention is needed for symptom experience.

Reliability and validity of the Patient Benefit Assessment Scale for Hospitalised Older Patients (P-BAS HOP)

BACKGROUND

The Patient Benefit Assessment Scale for Hospitalised Older Patients (P-BAS HOP) is a tool which is capable of both identifying the priorities of the individual patient and measuring the outcomes relevant to him/her, resulting in a Patient Benefit Index (PBI) with range 0-3, indicating how much benefit the patient had experienced from the admission. The aim of this study was to evaluate the reliability, validity, responsiveness and interpretability of the P-BAS HOP.

METHODS

A longitudinal study among hospitalised older patients with a baseline interview during hospitalisation and a follow-up by telephone 3 months after discharge. Test-retest reliability of the baseline and follow-up questionnaire were tested. Percentage of agreement, Cohen's kappa with quadratic weighting and maximum attainable kappa were calculated per item. The PBI was calculated for both test and retest of baseline and follow-up and compared with Intraclass Correlation Coefficient (ICC). Construct validity was tested by evaluating pre-defined hypotheses comparing the priority of goals with experienced symptoms or limitations at admission and the achievement of goals with progression or deterioration of other constructs. Responsiveness was evaluated by correlating the PBI with the anchor question 'How much did you benefit from the admission?'. This question was also used to evaluate the interpretability of the PBI with the visual anchor-based minimal important change distribution method.

RESULTS

Reliability was tested with 53 participants at baseline and 72 at follow-up. Mean weighted kappa of the baseline items was 0.38. ICC between PBI of the test and retest was 0.77. Mean weighted kappa of the follow-up items was 0.51. ICC between PBI of the test and retest was 0.62. For the construct validity, tested in 451 participants, all baseline hypotheses were confirmed. From the follow-up hypotheses, tested in 344 participants, five of seven were confirmed. The Spearman's correlation coefficient between the PBI and the anchor question was 0.51. The optimal cut-off point was 0.7 for 'no important benefit' and 1.4 points for 'important benefit' on the PBI.

CONCLUSIONS

Although the concept seems promising, the reliability and validity of the P-BAS HOP appeared to be not yet satisfactory. We therefore recommend adapting the P-BAS HOP.

Development of a new tool for the assessment of patient-defined benefit in hospitalised older patients: the Patient Benefit Assessment Scale for Hospitalised Older Patients (P-BAS HOP)

OBJECTIVES

To support the shift from disease-oriented towards goal-oriented care, we aimed to develop a tool which is capable both to identify priorities of an individual older hospitalised patient and to measure the outcomes relevant to him.

DESIGN

Mixed-methods design with open interviews, three step test interviews (TSTIs) and a quantitative field test.

SETTING

University teaching hospital and a regional teaching hospital.

PARTICIPANTS

Hospitalised patients ages 70 years and older.

RESULTS

The Patient Benefit Assessment Scale for Hospitalised Older Patients (P-BAS HOP) consists of a baseline questionnaire and an evaluation questionnaire. Items were based on 15 qualitative interviews with hospitalised older patients. Feedback from a panel of four community-dwelling older persons resulted in some adaptations to wording and one additional item. Twenty-six hospitalised older patients participated in TSTIs with Version 1 of the baseline questionnaire, revealing indications for a good content validity and barriers in completion behaviour, global understanding and understanding of individual items, which were solved with several adaptations. Four additions were made by participants. After TSTIs with ten patients with the evaluation questionnaire, one adaptation was made. A field test with 91 hospitalised older patients revealed a small number of missing values.To enhance the feasibility, the number of items was reduced from 32 to 22, based on correlations and mean impact score. The field test was repeated with 104 other patients in a regional teaching hospital. To enhance the understanding, the tool was split into two phases. This version was tested with TSTIs with eight patients and appeared to be understandable. The final version was an interview-based tool and took about 11 min to complete.

CONCLUSIONS

The P-BAS HOP is a potentially suitable tool to identify priorities and relevant outcomes of the individual patient. Further research is needed to investigate its validity, reliability and responsiveness.

Use of dementia care mapping in the care for older people with intellectual disabilities: A mixed-method study

Background

The ageing of people with intellectual disabilities, with associated morbidity like dementia, calls for new types of care. Person‐centred methods may support care staff in providing this, an example being Dementia Care Mapping (DCM). DCM has been shown to be feasible in ID‐care. We examined the experiences of ID‐professionals in using DCM.

Methods

We performed a mixed‐methods study, using quantitative data from care staff (N = 136) and qualitative data (focus‐groups, individual interviews) from care staff, group home managers and DCM‐in‐intellectual disabilities mappers (N = 53).

Results

DCM provided new insights into the behaviours of clients, enabled professional reflection and gave new knowledge and skills regarding dementia and person‐centred care. Appreciation of DCM further increased after the second cycle of application.

Conclusion

DCM is perceived as valuable in ID‐care. Further assessment is needed of its effectiveness in ID‐care with respect to quality of care, staff‐client interactions and job performance.

Goals of older hospitalised patients: a qualitative descriptive study

OBJECTIVES

Since the population continues ageing and the number of patients with multiple chronic diseases is rising in Western countries, a shift is recommended from disease oriented towards goal-oriented healthcare. As little is known about individual goals and preferences of older hospitalised patients, the aim of this study is to elucidate the goals of a diverse group of older hospitalised patients.

DESIGN

Qualitative descriptive method with open interviews analysed with inductive content analysis.

SETTING

A university teaching hospital and a regional teaching hospital.

PARTICIPANTS

Twenty-eight hospitalised patients aged 70 years and older.

RESULTS

Some older hospitalised patients initially had difficulties describing concrete goals, but after probing all were able to state more concrete goals. A great diversity of goals were categorised into wanting to know what the matter is, controlling disease, staying alive, improving condition, alleviating complaints, improving daily functioning, improving/maintaining social functioning, resuming work/hobbies and regaining/maintaining autonomy.

CONCLUSIONS

Older hospitalised patients have a diversity of goals in different domains. Discussing goals with older patients is not a common practice yet. Timely discussions about goals should be encouraged because individual goals are not self-evident and this discussion can guide decision making, especially in patients with multimorbidity and frailty. Aids can be helpful to facilitate the discussion about goals and evaluate the outcomes of hospitalisation.

Effects of Dementia Care Mapping on job satisfaction and caring skills of staff caring for older people with intellectual disabilities: A quasi-experimental study

Background

The ageing of people with intellectual disabilities, involving consequences like dementia, creates a need for methods to support care staff. One promising method is Dementia Care Mapping (DCM). This study examined the effect of DCM on job satisfaction and care skills of ID‐care staff.

Methods

We performed a quasi‐experimental study in 23 group homes for older people with intellectual disabilities in the Netherlands. Among staff, we assessed job satisfaction and care skills as primary outcomes and work experience measures as secondary outcomes (N = 227).

Results

Dementia Care Mapping achieved no significantly better effect than care as usual (CAU) for primary outcomes on job satisfaction (MWSS‐HC) and working skills (P‐CAT). Effect sizes varied from −0.18 to −0.66. We also found no differences for any of the secondary outcomes.

Conclusion

Dementia Care Mapping does not increase job satisfaction and care skills of staff caring for older people with intellectual disabilities. This result differs from previous findings and deserves further study.

Effects of Dementia Care Mapping on well-being and quality of life of older people with intellectual disability: A quasi-experimental study

Background

The ageing of people with intellectual disability, accompanied with consequences like dementia, challenges intellectual disability‐care staff and creates a need for supporting methods, with Dementia Care Mapping (DCM) as a promising possibility. This study examined the effect of DCM on the quality of life of older people with intellectual disability.

Methods

We performed a quasi‐experimental study in 23 group homes for older people with intellectual disability in the Netherlands, comparing DCM (n = 113) with care‐as‐usual (CAU; n = 111). Using three measures, we assessed the staff‐reported quality of life of older people with intellectual disability.

Results

DCM achieved no significantly better or worse quality of life than CAU. Effect sizes varied from 0.01 to −0.22. Adjustments for covariates and restriction of analyses to people with dementia yielded similar results.

Conclusion

The finding that DCM does not increase quality of life of older people with intellectual disability contradicts previous findings and deserves further study.

The first use of dementia care mapping in the care for older people with intellectual disability: a process analysis according to the RE-AIM framework

INTRODUCTION

The aging of the population with intellectual disability (ID), with associated conseqences as dementia, creates a need for evidence-based methods to support staff. Dementia Care Mapping (DCM) is perceived to be valuable in dementia care and promising in ID-care. The aim of this study was to evaluate the process of the first use of DCM in ID-care.

METHODS

DCM was used among older people with ID and care-staff in 12 group homes of six organisations. We obtained data on the first use of DCM in ID-care via focus-group discussions and face-to-face interviews with: care-staff (N = 24), managers (N = 10), behavioural specialists (N = 7), DCM-ID mappers (N = 12), and DCM-trainers (N = 2). We used the RE-AIM framework for a thematic process-analysis.

RESULTS

All available staff (94%) participated in DCM (reach). Regarding its efficacy, staff considered DCM valuable; it provided them new knowledge and skills. Participants intended to adopt DCM, by continuing and expanding its use in their organisations. DCM was implemented as intended, and strictly monitored and supported by DCM-trainers. As for maintenance, DCM was further tailored to ID-care and a version for individual ID-care settings was developed, both as standards for international use. To sustain the use of DCM in ID-care, a multidisciplinary, interorganisational learning network was established.

CONCLUSION

DCM tailored to ID-care proved to be an appropriate and valuable method to support staff in their work with aging clients, and it allows for further implementation. This is a first step to obtain an evidence-based method in ID-care for older clients.

Dementia care mapping to support staff in the care of people with intellectual disability and dementia: a feasibility study

BACKGROUND

The number of people with intellectual disability and dementia increases; this combination causes behavioural changes. Dementia Care Mapping (DCM) supports staff in dementia care in nursing homes and may be useful in intellectual disability-care. This qualitative study examines the feasibility of DCM for older people with intellectual disability and dementia.

METHODS

The present authors obtained data in focus groups and interviews with professional users and analysed using a framework for feasibility studies. With experts in dementia and intellectual disability researches, the present authors determined the overall feasibility.

RESULTS

DCM was found to be feasible in intellectual disability-care, regarding five domains of feasibility. Staff reported DCM to be useful and valuable and addresses to their demand for skills and knowledge. All professional users found DCM feasible in intellectual disability-care, which was confirmed by experts.

CONCLUSIONS

DCM is feasible in intellectual disability-care. When fully tailored to intellectual disability-care, DCM is useful and provides opportunities to assess its effectiveness.

Validation of the Dutch version of the itching cognitions questionnaire

The purpose of this study was to examine the reliability and validity of the Dutch itching cognitions questionnaire (ICQ). This by origin German questionnaire, the Juckreiz Kognitons Fragebogen consists of two subscales: catastrophizing and helpless coping and problem-focused coping, and measures itch-related coping. The results were compared with the German and Japanese validation studies. The Dutch ICQ was completed by 171 patients with chronic pruritic skin diseases. Reliability was evaluated by determining internal consistency, mean inter-item correlation, and item-total correlation. Cronbach's alpha was .90 (catastrophizing and helpless coping) and .81 (problem-focused coping). The mean inter-item correlations for the subscales were .48 (catastrophizing and helpless coping) and .30 (problem-focused coping). The item-total correlations range from .57 to .76 (catastrophizing and helpless coping) and from .32 to .57 (problem-focused coping). Confirmatory factor analysis indicated a good fit of the model and support construct validity. Concurrent validity was determined by examining correlations of the ICQ with intensity of itching and scratching, depression, and anxiety. The correlations of the subscale catastrophizing and helpless coping with intensity of itching and intensity of scratching are .28 (p < .01) and .32 (p < .01), respectively. The correlation between the subscale problem-focused coping and intensity of itching is .23 (p < .01). No significant correlation exists between problem-focused coping and intensity of scratching. Correlations between both subscales and anxiety and depression vary from .33 to .58 (p < .01). It was concluded that the Dutch version of the ICQ is a reliable and valid instrument.

A job-related fitness test for the Dutch police

BACKGROUND

The variety of tasks that characterize police work highlights the importance of being in good physical condition.

AIMS

To take a first step at standardizing the administration of a job-related test to assess a person's ability to perform the physical demands of the core tasks of police work. The principal research questions were: are test scores related to gender, age and function and are test scores related to body mass index (BMI) and the number of hours of physical exercise?

METHODS

Data of 6999 police officers, geographically spread over all parts of The Netherlands, who completed a physical competence test over a 1 year period were analysed.

RESULTS

Women performed the test significantly more slowly than men. The mean test score was also related to age; the older a person the longer it took to complete the test. A higher BMI was associated with less hours of body exercise a week and a slower test performance, both in women and men.

CONCLUSIONS

The differences in individual test scores, based on gender and age, have implications for future strategy within the police force. From a viewpoint of 'same job, same standard' one has to accept that test-score differences may lead to the exclusion of certain staff. However, from a viewpoint of 'diversity as a business issue', one may have to accept that on average, both female and older police officers are physically less tailored to their jobs than their male and younger colleagues.

Prevalence of chronic health conditions in children with intellectual disability: a systematic literature review

A systematic review of the prevalence rates of chronic health conditions in populations of children with intellectual disability was provided. We identified 2,994 relevant studies by searching Medline, Cinahl, and PsycINFO databases from 1996 to 2008. We included the 31 studies that had sufficient methodological quality. The 6 most prevalent chronic health conditions in children with intellectual disability were epilepsy (22.0/100), cerebral palsy (19.8/100), any anxiety disorder (17.1/100), oppositional defiant disorder (12.4/100), Down syndrome (11.0/100), and autistic disorder (10.1/100). The reported prevalence rates of chronic health conditions in this population was much higher than in the general population. However, both the number of studies that were included and the number of chronic health conditions they reported about were limited. There is an urgent need for better evidence on the prevalence of chronic health conditions among children with intellectual disability.

Limited concordance between teachers, parents and healthcare professionals on the presence of chronic diseases in ID-adolescents

Evidence on teachers' knowledge about somatic and mental chronic diseases among ID-adolescent compared to the knowledge parents and healthcare professionals have, is limited. The aim of this study is: (1) to assess the knowledge of teachers on the presence of chronic diseases in ID-adolescents; (2) to compare teachers with parents and healthcare professionals and parents with healthcare professionals regarding the knowledge on the presence of chronic diseases in ID-adolescents. We obtained data on 1044 ID-adolescents attending secondary schools, fully covering one region of the Netherlands. Teachers, parents and general practitioners (GPs) of the adolescents completed a questionnaire about the occurrence of chronic diseases in their child during the previous 12 months. The questionnaire was derived from the Dutch National Permanent Survey on Living Conditions questionnaire periodically administered in a representative population sample (n ≈ 10,000). Concordance between teachers, parents and healthcare professionals on the presence of chronic diseases in ID-adolescents was relatively low. In about half of all 66 dyads the concordance was for the most part fair and just in 10 dyads good to very good; nine of these latter cases concerned somatic chronic diseases. In addition, teachers reported mostly lower prevalence rates of chronic diseases in ID-adolescents compared to the parents, in particular on mental chronic diseases. Although prevalence rates of chronic diseases among ID-adolescents are very high, knowledge on this among teachers is limited. While information on chronic diseases in ID-adolescents is available among different informants, the disagreement between them reflects different points of view between the informants and probably indicates a lack of communication. The communication among teachers, parents and GPs should be improved to combine the knowledge and information on the presence of chronic diseases in ID-adolescents. This may provide opportunities to improve the support of these adolescents in their school career and in their transition from school to work.

Prevalence of chronic diseases in adolescents with intellectual disability

Valid community-based data on the prevalence of chronic diseases in adolescents (12-18 years) with intellectual disability (ID-adolescents) are scarce. The aim of this study was to assess the prevalence rates and the nature of chronic diseases in a population of ID-adolescents and to compare them with the rates among adolescents in the general population. Therefore, we obtained data on 1083 ID-adolescents attending secondary schools, day care centers or living in residential centers fully covering one region of The Netherlands. Parents of the adolescents completed a questionnaire about the occurrence of chronic diseases in their child during the previous 12 months and about background characteristics. The questionnaire was derived from the Dutch National Permanent Survey on Living Conditions questionnaire periodically administered in a representative population sample (n approximately = 10,000). Prevalence rates of chronic diseases in ID-adolescents were compared with those in adolescents in the Dutch general population. Among ID-adolescents, high prevalence rates of a wide range of chronic diseases were found. The five most prevalent were: ADHD (21.1%), PDD-NOS (14.0%), dyslexia (13.9%), migraine or chronic headache (12.7%), and autistic disorder (10.9%). These prevalence rates were all higher (p<0.05) than among adolescents in the general population. Of all ID-adolescents, 62.9% was reported to have at least one chronic disease. The burden of chronic diseases among ID-adolescents is very high, showing a high need for adequate care. These high prevalence rates should alert policymakers and clinicians regarding the widespread of chronic diseases among ID-adolescents.

Pervasive developmental disorder behavior in adolescents with intellectual disability and co-occurring somatic chronic diseases

Evidence on the association between somatic chronic diseases in ID-adolescents and the full range of pervasive developmental disorder behavior (PDD behavior) is scarce. The aim of the present study is to assess the association between somatic chronic diseases in ID-adolescents and mild PDD behavior. We obtained data on 1044 ID-adolescents, aged 12-18, attending secondary schools in the Netherlands. Parents of the adolescents completed the Dutch version of the Children's Social Behavior Questionnaire (CSBQ) parent version, covering a wide range of PDD behavior, and questions about chronic diseases and background characteristics of their child. ID-adolescents with somatic chronic diseases showed more PDD behavior, in particular milder forms, than their peers without chronic diseases. In addition, ID-adolescents with somatic chronic diseases in combination with pervasive development disorders (PDD) and attention deficit hyperactivity disorder (ADHD) also showed more PDD behavior than their peers with only PDD/ADHD. Clinicians should be extra alert on PDD behavior, in particular the milder forms, in ID-adolescents when somatic chronic diseases are present. However, to strengthen our results about the relationship between somatic chronic diseases in ID-adolescents and PDD behavior studies are needed using both the CSBQ and standardized diagnostic instruments.

Emotional and behavioural problems in adolescents with intellectual disability with and without chronic diseases

BACKGROUND

Adolescents with intellectual disability (ID) (ID-adolescents) and adolescents with chronic diseases are both more likely to have emotional and behavioural problems. The aim of this study was to assess the association between chronic diseases in ID-adolescents and emotional and behavioural problems in a large school-based sample.

METHODS

We obtained data on 1044 ID-adolescents, aged 12-18 years, attending secondary schools in the Netherlands. Parents of the adolescents completed the Dutch version of the Strengths and Difficulties Questionnaire and questions about chronic diseases in their child and about the background of the child.

RESULTS

Prevalence rates of emotional and behavioural problems were generally high in ID-adolescents with chronic diseases (45%), compared with ID-adolescents without chronic diseases (17%). The likelihood of emotional and behavioural problems was high in ID-adolescents with two [odds ratios (OR) 4.47; 95% CI: 2.97-6.74] or more than two chronic diseases (OR 8.01; 95% CI: 5.18-12.39) and for ID-adolescents with mental chronic diseases (OR 4.56; 95% CI: 3.21-6.47). Also ID-adolescents with somatic chronic diseases had a high likelihood of emotional and behavioural problems (OR 1.99; 95% CI: 1.33-2.99), in particular in the combination of somatic and mental chronic diseases (OR 5.16; 95% CI: 3.46-7.71).

CONCLUSIONS

The current study showed that chronic diseases in ID-adolescents, in particular mental chronic diseases, largely increase the likelihood of emotional and behavioural problems. This should be taken in the provision and planning of care for ID-adolescents.

Accepting or declining dialysis: considerations taken into account by elderly patients with end-stage renal disease

BACKGROUND

Elderly patients with end-stage renal disease have to make a difficult decision whether or not to start dialysis. This study explores the considerations taken into account by these patients in decision-making regarding renal replacement therapy.

METHOD

In-depth interviews were conducted to gain an enhanced understanding of the considerations in treatment decision-making. Fourteen patients aged 65 years or older participated in the interviews, of whom 8 patients had made the decision to start, and 6 patients the decision to decline, dialysis.

RESULTS

All participating patients had a variety of health problems, but appeared to have normal cognitive functions. Patients who declined dialysis were older and more often men and widow(er)s compared with patients who accepted dialysis. Patients chose to start dialysis because they enjoyed life, were not prepared to face the end of life, felt they had no other choice or had care-giving responsibilities for family members. Patients declined dialysis because of the speculated loss of autonomy, their age-associated decrease in vitality, distance from dialysis center and reluctance to think about the future.

CONCLUSION

Results suggest that patients' decisions to decline or accept dialysis are not based on the effectiveness of the treatment, but rather on personal values, beliefs and feelings toward life, suffering and death, and the expected difficulties in fitting the treatment into their life.

Differences between physicians in the likelihood of referral and acceptance of elderly patients for dialysis influence of age and comorbidity

Background. Incidence of dialysis in elderly patients in the Netherlands is low compared to other countries. This study aims to assess the impact of patients' age and comorbidity on the likelihood of referral and acceptance of patients for dialysis and whether this is affected by physician characteristics. Methods. A vignette study was performed on 209 primary care physicians, 162 non-nephrology specialists and 20 nephrologists working in northern Netherlands. Physicians were offered six vignettes concerning case reports of patients with end-stage renal disease (ESRD) and varying comorbidities or circumstances and asked about the likelihood of referral/acceptance of the patient in the given circumstances. Results. The likelihood of referral within groups of physicians varied widely, especially within the group of primary care physicians and non-nephrology specialists, but was not affected by characteristics of the physicians. The likelihood of referral or acceptance of patients for dialysis depended on the patient's age, and type and severity of comorbidity. In general, primary care physicians and non-nephrology specialists were less likely to refer than nephrologists were willing to accept. Differences within and between groups of physicians to accept or refer were larger for 80-year-old patients than for 65-year-old patients. The differences were wider concerning patients with less severe shortness of breath and cognitive impairments and more severe diabetes and social impairments. Hardly any differences were found for patients with cancer. Conclusion. Patients' age and comorbidities affect the likelihood of referral. Differences between groups of physicians suggest that there is insufficient agreement on the extent to which these factors should affect the referral/acceptance of patients for dialysis. These findings underline the need for more research into circumstances under which patients might benefit from dialysis. Guidelines should be developed to improve the referral of elderly and less healthy patients.

Differences between physicians in the likelihood of referral and acceptance of elderly patients for dialysis-influence of age and comorbidity

BACKGROUND

Incidence of dialysis in elderly patients in the Netherlands is low compared to other countries. This study aims to assess the impact of patients' age and comorbidity on the likelihood of referral and acceptance of patients for dialysis and whether this is affected by physician characteristics.

METHODS

A vignette study was performed among 209 primary care physicians, 162 non-nephrology specialists and 20 nephrologists working in the north of the Netherlands. Physicians were offered six vignettes concerning case-reports of patients with end-stage renal disease (ESRD) and varying comorbidities or circumstances and asked about the likelihood of referral/acceptance of the patient in the given circumstances.

RESULTS

The likelihood of referral within groups of physicians varied widely, especially within the group of primary care physicians and non-nephrology specialists, but was not affected by characteristics of physicians. The likelihood of referral or acceptance of patients for dialysis depended on the patient's age, and type and severity of comorbidity. In general, primary care physicians and non-nephrology specialists were less likely to refer than nephrologists were to accept. Differences within and between groups of physicians were larger for 80- than for 65-year-old patients, and for patients with less severe shortness of breath and cognitive impairments and more severe diabetes and social impairments. Hardly any differences were found for patients with cancer.

CONCLUSION

Patients' age and comorbidities affect the likelihood of referral. Differences between groups of physicians suggest that there is insufficient agreement on the extent to which these factors should affect the referral/acceptance of patients for dialysis. These findings underline the need for more research into circumstances under which patients might benefit from dialysis. Guidelines should be developed to improve the referral of elderly and less healthy patients.

Disability insurance: can underwriting criteria for the self-employed be based on predictors used for disability amongst employees?

OBJECTIVE

This study aims to trace risk factors for disability amongst the self-employed. Knowledge about these risk factors can contribute to more evidence-based underwriting criteria for disability insurance.

BACKGROUND

The trend towards privatization of social disability services in certain insurance markets creates a need to consider the appropriateness of underwriting criteria in applications for individual private disability insurance.

METHODS

The authors performed a literature study and undertook a consultation amongst experts.

RESULTS

More than 350 articles were traced. Only one article precisely matches the field of research: risk factors in underwriting disability insurance for the self-employed. Risk factors and medical characteristics in long-term disability are not identical between the employed and self-employed populations. Relevant risk factors for the self-employed are gender, age, occupational class, socioeconomic status, medical consumption, lifestyle, coping behavior, previous sick leave, replacement ratio and policy terms.

CONCLUSIONS

The scarce amount of research on risk factors for disability amongst the self-employed forces insurers to rely on the limited statistical data available and pragmatic interpretation of this data. Underwriting criteria for the self-employed can partially be based on predictors for disability for employees. Whether the self-employed and employees are exposed to different risk factors or are basically different populations needs further research. The holistic approach of the International Classification of Functioning, Disability and Health model as a framework for developing a risk assessment model, with a strong focus on personal and environmental factors, will bring the current medical model at the underwriting stage more in line with the social model at claim stage.

[Which objectively assessed limitations in health status, activities of daily living, or in psychological and social spheres are decisive for referral to a nursing home or to a home for the aged]

Which type of limitation is most decisive for a positive indication for a residential home or a somatic or psycho-geriatric nursing home, and to what extent do data on living situation (independent, adapted or intramural) and the social situation (alone or living together) influence this qualification? To obtain an answer to this question three experiments with an integrated, objective and independent assessment-for-care system were set up in the Netherlands. We studied one of them, in the town of Meppel, started in 1996. The study population consisted of all older people living in and around Meppel who had a positive indication for either a residential home, or a somatic or psycho-geriatric nursing home (N = 206 in 1998). Differences in limitations were computed by means of analysis of variance and the types of limitation and their impact on the type of allocated institutions were computed by logistic regression. The limitations only partially explain the types of indication. Indication for a residential home is based on physical limitations. When these increase they become a contra-indication for a residential home and a somatic nursing home indication is given. Mental limitations primarily yield indications for psycho-geriatric nursing homes. Social limitations have a higher incidence among persons with an indication for a somatic nursing home but cannot fully explain this indication. Persons with a residential home indication were significantly more often from an adapted living situation background. The living situation -alone or together-does not have an impact on the indication. We may not conclude that the assessment took place objectively, for, based on the registration it is impossible to conclude for what criteria a person was indicated for a specific type of institution. The objective of assessment, the allocation and distribution of collectively financed care in residential homes and nursing homes based on verifiable assessment methodology could not be realised.

[Consideration of mental symptoms and physical disabilities in deciding upon placement in a residential home versus a nursing home]

This study analysed 235 applications of elderly people for residential home and nursing home care. The applications were submitted to a Dutch municipal care allocation board. Based on the 1994 registration data from this board the impact of physical restrictions and mental problems on the care allocation for residential or nursing homes and connected care was studied. Physical complaints were measured with an adl and an hdl scale (Activities of Daily Living and Household Activities of Daily Living), mental problems were assessed by means of the Reality, Orientation and Restlessness Scales. Persons with an admission allocation for a nursing home (both psychogeriatric and somatic) had the highest scores on all scales; persons allocated to the residential home and related care had significantly lower scores. Above-mentioned scales have been combined into care level categories. Fifty seven persons, however, appeared not to have any physical or mental problems despite a care allocation to the residential home or related care. Contextual problems (housing, social contacts, endurance-capacity of relatives and friends) were particularly decisive in this case. Moderately severe problems, both physical and mental, generally resulted in an allocation to the residential home or related care. Serious problems usually result in allocation to the somatic or the psychogeriatric nursing home. Combined serious problems (75%) tended to result in an allocation to the psychogeriatric nursing home. This study is preliminary to the development of a care allocating instrument.

[Use of a homomorphic filter in combination with surface coils in MR tomography]

A new method for correcting the signal intensity from surface coil (homomorphic filters) was evaluated in 40 examinations. With this filter it is possible to compensate for signal loss when using surface coils for deep tissues and to avoid excessive signals from the surface. The method does not, however, provide any additional information. Properly used, there were no false positive findings, nor was there any loss of abnormal findings. The use of homomorphic filters is therefore safe and sensible.