Caregiver Burden Is Reduced by Social Support Services for Non-Dependent Elderly Persons: Pre-Post Study of 569 Caregivers.

BACKGROUND: Informal care provided by family caregivers (FCGs) to elderly persons is associated with a high risk of burden and poor health status. Social support services (3S) for the elderly persons were characterized by assistance in various activities of daily living. This study aimed to analyze the impact of 3S on the burden of FCGs of elderly persons living in the community and identify factors associated with changes in their burden. METHODS: This pre-post study was performed in the southeast of France: FCGs of non-dependent elderly persons still living at home who received a 3S were consecutively included. FCG burden was assessed with the Mini-Zarit scale before the setting up of the 3S (pre-3S) and 6 months after (post-3S). RESULTS: A total of 569 FCGs were included in the study. Mean age of the FCGs was 62.9 years old (±13.3), 67% were women, 61.2% were children or stepchildren. Burden was present for 81% of FCGs. In most cases, 3S targeted household chores (95.8%); 59.8% of elderly persons and their FCGs were fully satisfied. The improvement in burden was greater for FCGs perceiving less obstacles post-3S in helping elderly persons (OR = 4.083) but also for FCGs fully satisfied with the 3S (OR = 2.809) and for FCGs whose perceived health status had improved post-3S (OR = 2.090). CONCLUSIONS: FCGs of non-dependent elderly persons experience a burden similar to those of dependent elderly persons. The implementation of a 3S in daily life helps to reduce their burden.

Perceived Health and Quality of Life in Patients With CKD, Including Those With Kidney Failure: Findings From National Surveys in France.

RATIONALE & OBJECTIVE: Health-related quality of life (HRQoL) is a major outcome measure increasingly used in patients with chronic kidney disease (CKD). We evaluated the association between different stages of CKD and the physical and mental health domains of HRQoL. STUDY DESIGN: Cross-sectional study. SETTING & PARTICIPANTS: 2,693 outpatients with moderate (stage 3, estimated glomerular filtration rate [eGFR], 30-60mL/min/1.73m2) or advanced (stages 4-5, estimated glomerular filtration rate<30mL/min/1.73m2, not on kidney replacement therapy [KRT]) CKD under the care of a nephrologist at 1 of 40 nationally representative facilities, 1,658 patients with a functioning kidney transplant, 1,251 patients on maintenance dialysis randomly selected from the national Renal Epidemiology and Information Network registry, and 20,574 participants in the French Decennial Health Survey, representative of the general population. PREDICTOR: Severity of kidney disease (moderate CKD, advanced CKD, maintenance dialysis as KRT, and functioning kidney transplant as KRT), compared with a sample of the general population. OUTCOMES: HRQoL scores assessed using the Medical Outcomes Study 36-Item Short Form Health Survey or the Kidney Disease Quality of Life 36 scale. ANALYTICAL APPROACH: Age- and sex-standardized (to the general population) prevalence of poor or fair health status was estimated for each study kidney disease group. Analysis of variance was used to estimate adjusted differences in mean physical and mental health scores between the kidney disease subgroups and the general population. RESULTS: Mean age was 67.2±12.6 (SD) years for patients with non-KRT-requiring CKD, 69.3±17.7 years for dialysis patients, and 55.3±14.2 years for those with functioning kidney transplants; 60% were men. Age- and sex-standardized health status was perceived as fair or poor in 27% of those with moderate CKD,>40% of those with advanced CKD or receiving dialysis, 12% with a functioning transplant, and 3% of the general population sample. HRQoL physical scores (adjusted for age, sex, education, obesity, and diabetes) were significantly lower in patients in all CKD subgroups than in the general population. For patients receiving dialysis, the magnitude of the difference in physical score versus the general population exceeded 4.5 points, the minimal clinically important difference for this score in this study; for both kidney transplant recipients and patients with advanced CKD, the magnitude of the difference was close to this threshold. For mental score, only dialysis patients had a score that differed from that of the general population by more than the minimal clinically important difference. LIMITATIONS: Cross-sectional study design for each subpopulation. CONCLUSIONS: This study highlights the degree to which perceived physical health is lower in the setting of CKD than in the general population, even in the absence of kidney failure, and calls for greater attention to CKD-related quality of life.

Stress and burnout among professionals working in the emergency department in a French university hospital: Prevalence and associated factors.

BACKGROUND: Work-related stress is a significant health and safety concern. OBJECTIVES: To assess the prevalence of burnout and occupational stress among emergency department (ED) professionals and to identify associated factors. METHODS: A cross-sectional study included all ED professionals of a French university hospital. Data were collected using the French versions of the Maslach Burnout Inventory and the Karasek Job Content Questionnaire. RESULTS: Of the 166 respondents (75.8%), 19.3% reported burnout and 27.1% job strain. Factors associated with burnout were work-related dissatisfaction, fear of making mistakes, lack of time to perform tasks, and being younger. Those factors associated with job strain were having at least one sick leave in the past year, being affected by hard work, interpersonal conflicts at workplace, and sleep disorders. CONCLUSIONS: Compared to the literature, our results showed a lower prevalence of burnout among physicians but similar among paramedics. The proportion of professionals with job strain was higher than that of the whole French working population. Organizational factors and the work environment were the primary causes of burnout and job strain, while being younger was the only associated sociodemographic factor. The identification of professionals experiencing difficulty is essential to ensure patient safety, particularly in the high-risk field of emergency medicine.

Burnout Syndrome among Emergency Department Staff: Prevalence and Associated Factors.

OBJECTIVES: Emergency department (ED) professionals are exposed to burnout syndrome due to excessive workload and high demands for care. The objective of our study was to assess the prevalence burnout among all ED staff and to determine associated factors. METHODS: A cross-sectional survey was conducted in 3 EDs. The data were collected using a standardized questionnaire. It included demographical and occupational data, general health questions, burnout level (Maslach Burnout Inventory), job strain (Karasek), and quality of life (Medical Outcome Study Short Form). RESULTS: Of the 529 professionals working in EDs, 379 responses were collected (participation rate of 71.6%). Emotional exhaustion (EE) and depersonalization (DP), the major components of burnout, were reported, respectively, by 15.8% and 29.6% of the professionals. Burnout prevalence was 34.6%, defined as a severely abnormal level of either EE or DP. The medical category was significantly more affected by the burnout compared with their colleagues: nearly one ED physician out of two had a burnout (50.7%). In the multivariate analysis of covariance, job strain and a low mental component score were the two main factors independently associated with burnout (p < 0.05). CONCLUSION: The results of our study show that ED professionals are a vulnerable group. Preventive approaches to stress and burnout are needed to promote quality of work life.

End-stage renal disease treated in Provence-Alpes Côte d'Azur: 12-years follow-up and forecast to the year 2030.

BACKGROUND: This study describes the time trend of renal replacement therapy for end-stage renal disease (ESRD) in the Provence-Alpes Côte d'Azur region (PACA) between 2004 and 2015, and forecasts up to 2030. METHODS: A longitudinal study was conducted on all ESRD patients treated in PACA and recorded in the French Renal Epidemiology and Information Network (REIN) during this period. Time trends and forecasts to 2030 were analyzed using Poisson regression models. RESULTS: Since 2004, the number of new patients has steadily increased by 3.4% per year (95% CI, 2.8-3.9, p < 0.001) and the number of patients receiving RRT has increased by 3.7% per year (RR 1.037, 95% CI: 1.034-1.039, p < 0.001). If these trends continue, the PACA region will be face with 7371 patients on dialysis and 3891 with a functional renal transplant who will need to be managed in 2030. The two most significant growth rates were the percentage of obese people (RR 1.140, 95% CI: 1.131-1.149, p < 0.001) and those with diabetes (RR 1.070, 95% CI; 1.064-1.075, p < 0.001). CONCLUSION: This study highlights the increase in the number of ESRD patients over 12 years, with no prospect of stabilization. These findings allow us to anticipate the quality and quantity of care offered and to propose more preventive measures to combat obesity and diabetes.

[Factors affecting the choice of peritoneal dialysis: Perspective of patients and nephrologists]. / Facteurs influençant le choix de la dialyse péritonéale : le point de vue des patients et des néphrologues.

PURPOSE: To identify factors related to the choice of peritoneal dialysis as a first dialysis technique: the viewpoint of patients and viewpoint of nephrologists. METHODS: A retrospective multicenter study, type case-control was conducted in patients starting dialysis between 2010 and 2014 in 4 dialysis facilities in the PACA region. Nephrologists take care of patients included in the study were also interviewed. Data were collected using two standardized questionnaires: One for the patient and one for the nephrologists and using the French REIN registry. RESULTS: One hundred and fifty patients were interviewed, the average age was 63.7 years. The medical contraindication for PD was present in 26.7%. Among patients eligible for both dialysis techniques, 46.7% had a preference for DP, 31.8% for HD and 21.5% did not have any preference. Patient preference is strongly influenced by information and the duration of predialysis nephrologist care (referral of nephrologist). The main factors related to personal choice of peritoneal dialysis are autonomy and desire for autonomy. Emergency dialysis influences negatively the choice of the PD. CONCLUSION: A third of eligible patients for the 2 techniques could and wanted to be on PD. The limitations for PD are mainly related to professional practices. Better information could increase the utilization of PD to 32%.

[Comparison of peritoneal dialysis and hemodialysis survival in Provence-Alpes-Côte d'Azur]. / Étude comparative de survie entre les techniques de dialyse : dialyse péritonéale versus hémodialyse en région Provence-Alpes-Côte d'Azur.

PURPOSE: To analyze and compare survival of patients initially treated with peritoneal dialysis (PD) or hemodialysis (HD). METHODS: We used data from the French REIN registry. We included all patients aged 18 years or more who started dialysis between 1st January 2004 and 12 December 2012 in Provence-Alpes-Côte d'Azur Region (PACA). These patients were followed up until 30 June 2014. Survival curves were generated using the Kaplan-Meier technique and tested using the log-rank test. Variables predictive of all-cause mortality were determined using Cox regression models. The propensity score was used. MAIN RESULTS: Survival was similar between initial dialysis modalities: PD and HD, even after adjusting for the propensity score. But, when we exclude the patients who had switched from one technique of dialysis to another, survival was better in HD patients. According to the multivariate analysis, advanced age and the lack of walking autonomy appear to be associated with an increase in mortality in dialysis patients. But, the presence of hypertension improve the survival in this cohort. CONCLUSION: The survival is similar between hemodialysis and peritoneal dialysis.

Predictive factors for early unplanned rehospitalization of older adults after an ED visit: role of the caregiver burden.

BACKGROUND AND AIMS: For older adults, an Emergency Department (ED) visit represents a period of vulnerability that extends beyond the visit itself. This study aimed to determine the impact of the role of caregiver, and geriatric conditions of patients on early unplanned rehospitalization (EUR) within 3 months after an ED visit. METHODS: This prospective longitudinal experimental study included consecutively 173 patients aged 75 and older admitted in an ED over a 2-week period (18.7% of the total visits). Only older patients having a caregiver were analyzed (78.0%, n = 135). Medical conditions and a comprehensive geriatric assessment were recorded for each patient. All caregivers were interviewed about their tasks and emotional impact using the short Zarit Burden Inventory. Three months after, patients or their caregivers were called about the vital status, and EUR of patients. RESULTS: Among the patients included, 64.2% had an EUR and 28.9% of their caregivers reported a high level of burden. EUR was strongly associated with a high caregiver burden (OR 8.7, 95% CI 1.5-49.8). No association was found for patient's medical or geriatric status. Caregivers reported a significantly high burden when patients were malnourished, or were at risk of adverse health outcomes based on the ISAR scale, and when they had greater disabilities in IADLs and ADLs, or cognitive impairments. CONCLUSIONS: Many hospital readmissions after an ED visit may be preventable by identifying caregiver's high burden. Reasons that lead to this high burden should be checked at the first visit.

A study comparing care between nurses and doctors in the French prehospital setting: the case of hypoglycemia.

INTRODUCTION: The objective of this study was to compare the quality of care between French nurses and physicians in the prehospital management of hypoglycemic patients. METHODS: Response times, concordance with medical protocols/recommendations, quality of medical records, and percentage of hospitalized patients were evaluated. RESULTS: A total of 33 patients were treated for hypoglycemia by the nurse group and 41 by the physician group. The groups were similar in terms of response rates (mean time of 00:08 ± 00:06 minutes for nurses and 00:10 ± 00:09 minutes for doctors). For 51 patients not requiring hospitalization, the proportion was similar in each group (47.1% and 52.9% for nurses and doctors, respectively). The nurse group showed significantly higher mean scores for concordance with recommendations (P < .001) and quality of medical records (P = .005). DISCUSSION: In the management of hypoglycemic patients, the quality of care of an emergency ambulance team composed of nurses was comparable to that of doctors.

Nonurgent patients in emergency departments: rational or irresponsible consumers? Perceptions of professionals and patients.

BACKGROUND: For several decades, overcrowding in emergency departments (EDs) has been intensifying due to the increased number of patients seeking care in EDs. Demand growth is partly due to misuse of EDs by patients who seek care for nonurgent problems. This study explores the reasons why people with nonurgent complaints choose to come to EDs, and how ED health professionals perceive the phenomenon of "nonurgency". RESULTS: Semi-structured interviews were conducted in 10 EDs with 87 nonurgent patients and 34 health professionals. Interviews of patients revealed three themes: (1) fulfilled health care needs, (2) barriers to primary care providers (PCPs), and (3) convenience. Patients chose EDs as discerning health consumers: they preferred EDs because they had difficulties obtaining a rapid appointment. Access to technical facilities in EDs spares the patient from being overwhelmed with appointments with various specialists. Four themes were identified from the interviews of health professionals: (1) the problem of defining a nonurgent visit, (2) explanations for patients' use of EDs for nonurgent complaints, (3) consequences of nonurgent visits, and (4) solutions to counter this tendency. CONCLUSIONS: Studies on the underlying reasons patients opt for the ED, as well as on their decision-making process, are lacking. The present study highlighted discrepancies between the perceptions of ED patients and those of health professionals, with a special focus on patient behaviour. To explain the use of ED, health professionals based themselves on the acuity and urgency of medical problems, while patients focused on rational reasons to initiate care in the ED (accessibility to health care resources, and the context in which the medical problem occurred). In spite of some limitations due to the slightly outdated nature of our data, as well as the difficulty of categorizing nonurgent situations, our findings show the importance of conducting a detailed analysis of the demand for health care. Understanding it is crucial, as it is the main determining factor in the utilization of health care resources, and provides promising insights into the phenomenon of ED usage increase. For reforms to be successful, the process of decision-making for unscheduled patients will have to be thoroughly investigated.

[Trend of travelling times for haemodialysis patients in the Provence-Alpes-Côte-d'Azur region between 1995 and 2008]. / Évolution du temps de transport des patients hémodialysés en région Provence-Alpes-Côte-d'Azur entre 1995 et 2008.

OBJECTIVE: We analysed the trend of travel-times for haemodialysis patients in the Provence-Alpes-Côte-d'Azur region between 1995 and 2008 in relation with the reforms concerning the health care provision of haemodialysis. METHODS: We conducted this study using data from three cross sectional surveys for 1995, 1999 and 2002, including all dialysis patients, and from the Renal Epidemiology and Information Network register for 2008. The data focuses on sociodemographic, medical characteristics and travel-times for haemodialysis patients. RESULTS: The number of haemodialysis patients increased from 1807 patients in 1995 to 3141 in 2008. The travel-time has decreased steadily between 1995 and 2008 (18.2 min versus 15, P<0.0001). The number of patients with a travel-time more than 45 min decreased from 7.2 to 3.5% between 1995 and 2008. The number of dialysis facilities has increased steadily between 1995 and 2008. CONCLUSION: The favorable trend in the health care provision has resulted in an improvement of accessibility by reducing travel-times.

Be careful with triage in emergency departments: interobserver agreement on 1,578 patients in France.

BACKGROUND: For several decades, emergency departments (EDs) utilization has increased, inducing ED overcrowding in many countries. This phenomenon is related partly to an excessive number of nonurgent patients. To resolve ED overcrowding and to decrease nonurgent visits, the most common solution has been to triage the ED patients to identify potentially nonurgent patients, i.e. which could have been dealt with by general practitioner. The objective of this study was to measure agreement among ED health professionals on the urgency of an ED visit, and to determine if the level of agreement is consistent among different sub-groups based on following explicit criteria: age, medical status, type of referral to the ED, investigations performed in the ED, and the discharge from the ED. METHODS: We conducted a multicentric cross-sectional study to compare agreement between nurses and physicians on categorization of ED visits into urgent or nonurgent. Subgroups stratified by criteria characterizing the ED visit were analyzed in relation to the outcome of the visit. RESULTS: Of 1,928 ED patients, 350 were excluded because data were lacking. The overall nurse-physician agreement on categorization was moderate (kappa = 0.43). The levels of agreement within all subgroups were variable and low. The highest agreement concerned three subgroups of complaints: cranial injury (kappa = 0.61), gynaecological (kappa = 0.66) and toxicology complaints (kappa = 1.00). The lowest agreement concerned two subgroups: urinary-nephrology (kappa = 0.09) and hospitalization (kappa = 0.20). When categorization of ED visits into urgent or nonurgent cases was compared to hospitalization, ED physicians had higher sensitivity and specificity than nurses (respectively 94.9% versus 89.5%, and 43.1% versus 30.9%). CONCLUSIONS: The lack of physician-nurse agreement and the inability to predict hospitalization have important implications for patient safety. When urgency screening is used to determine treatment priority, disagreement might not matter because all patients in the ED are seen and treated. But using assessments as the basis for refusal of care to potential nonurgent patients raises legal, ethical, and safety issues. Managed care organizations should be cautious when applying such criteria to restrict access to EDs.

ED patients: how nonurgent are they? Systematic review of the emergency medicine literature.

Nonurgent visits to emergency departments (ED) are a controversial issue; they have been negatively associated with crowding and costs. We have conducted a critical review of the literature regarding methods for categorizing ED visits into urgent or nonurgent and analyzed the proportions of nonurgent ED visits. We found 51 methods of categorization. Seventeen categorizations conducted prospectively in triage areas were based on somatic complaint and/or vital sign collection. Categorizations conducted retrospectively (n = 34) were based on the diagnosis, the results of tests obtained during the ED visit, and hospital admission. The proportions of nonurgent ED visits varied considerably: 4.8% to 90%, with a median of 32%. Comparisons of methods of categorization in the same population showed variability in levels of agreement. Our review has highlighted the lack of reliability and reproducibility.

Nonurgent patients in the emergency department? A French formula to prevent misuse.

BACKGROUND: Overcrowding in emergency department (EDs) is partly due to the use of EDs by nonurgent patients. In France, the authorities responded to the problem by creating primary care units (PCUs): alternative structures located near hospitals. The aims of the study were to assess the willingness of nonurgent patients to be reoriented to a PCU and to collect the reasons that prompted them to accept or refuse. METHODS: We carried out a cross sectional survey on patients' use of EDs. The study was conducted in a French hospital ED. Patients were interviewed about their use of health services, ED visits, referrals, activities of daily living, and insurance coverage status. Patients' medical data were also collected. RESULTS: 85 patients considered nonurgent by a triage nurse were asked to respond to a questionnaire. Sex ratio was 1.4; mean age was 36.3 +/- 11.7 years.Most patients went to the ED autonomously (76%); one third (31.8%) had consulted a physician. The main reasons for using the ED were difficulty to get an appointment with a general practitioner (22.3%), feelings of pain (68.5%), and the availability of medical services in the ED, like imaging, laboratory tests, and drug prescriptions (37.6%). Traumatisms and wounds were the main medical reasons for going to the ED (43.5%).More than two-thirds of responders (68%) were willing to be reoriented towards PCUs. In the multivariate analysis, only employment and the level of urgency perceived by the patient were associated with the willingness to accept reorientation. Employed persons were 4.5 times more likely to accept reorientation (OR = 4.5 CI (1.6-12.9)). Inversely, persons who perceived a high level of urgency were the least likely to accept reorientation (OR = 0.9 CI (0.8-0.9). CONCLUSIONS: Our study provides information on the willingness of ED patients to accept reorientation and shows the limits of its feasibility. Alternative structures such as PCUs near the ED seem to respond appropriately to the growing demands of nonurgent patients. Reorientation, however, will be successful only if the new structures adapt their opening hours to the needs of nonurgent patients and if their physicians can perform specific technical skills.