[Residents in supported housing and factors related to moving towards independent living]. / RIBW-bewoners en de factoren die samenhangen met een overgang naar een andere woonsituatie.

BACKGROUND: Few data are available on predictors for the transition of individuals with mental illness to more independent forms of housing.
AIM: To analyse which variables predict the transition of individuals with severe mental illness from supported housing within the Dutch community housing programs (CHP) to more independent ways of living.
METHOD: Data of 1569 participants were analysed using Cox regression analysis.
RESULTS: Individuals with a personality disorder, current alcohol misuse or who received ambulant care prior to admission in CHP had the highest probability of moving to a more independent way of living. Individuals who received clinical care prior to admission in CHP, individuals with admission in Supported Housing, and individuals with a history of substance dependency had the highest probability of clinical relapse.
CONCLUSION: The predictors found in this study can be used as a starting point both for hypotheses for additional aetiological research and for guidelines covering specific interventions.

Assessment of the oral health condition of nursing home residents by primary care nurses.

We interviewed 36 primary care nurses in three Dutch nursing homes regarding the functional oral health and dental treatment needs of 331 care-dependent residents (average age 77.8 years). The nurses assessed the residents' oral health condition as good (8.3 on a scale of 0 to 10). Edentulous residents wearing dentures were considered to have better functional oral health than dentate residents wearing partial dentures and edentulous residents not wearing dentures. According to the nurses, only 9% of the residents required dental treatment. This finding is in contrast with an intraoral study of the same population, in which dentists determined that 73% of the residents needed dental treatment.

Integrated versus incidental dental care in nursing homes.

PURPOSE/AIM: In most of the 334 Dutch nursing homes, incidental dental care is provided upon indication by the medical and nursing staff. However, more and more nursing homes offer integrated dental care, where a dentist works on a structural basis in facilities within the home. METHODS: To evaluate the costs and effects of integrated versus incidental care, we studied the oral status and treatment needs in two nursing homes in the same city with 175 and 120 residents an average age of 81.7 and 79.3 years, respectively. RESULTS: In the integrated care home, the dentist spent an average 2.2 hours/year per resident at a cost of €229 for the dentist's work and €143 for laboratory costs. In the incidental care home, these values were 0.1 hours/year per resident at a cost of €15 for the dentist's work and €20 for laboratory costs. CONCLUSIONS: With integrated care, 55.6% of the residents had no oral treatment need versus 13.1% for incidental care, more edentulous residents wore dentures, and residents had less soft tissue pathology.

Assessment of parenting and developmental problems in toddlers: development and feasibility of a structured interview.

BACKGROUND: Assessment of (early signs of) parenting and developmental problems in young children by preventive child health care (CHC) workers is recommended, but no validated instruments exist. The aim of this project was to develop and test an instrument for early detection and assessment of problems in toddlers, using the perspectives and experience of both the parent and the professional. METHODS: Using an iterative process, we adapted and expanded a structured interview on need for parenting support into the Structured Problem Analysis of Raising Kids (SPARK). The SPARK consists of 16 subject areas, ranging from somatic health to family issues. The SPARK was tested in daily practice for feasibility and discriminative capacity. The sample consisted of all toddlers aged 18 months living in Zeeland, a province of the Netherlands, during the study period (n= 1140). RESULTS: The response rate was 97.8%. Although the median level of support needed according to the SPARK was low, 4.5% of the toddlers and their parents required intensive help or immediate action. The risk assessment showed 2.9% high, 16.5% increased and 80.6% low risk for parenting and developmental problems. The risk assessment of the CHC professional was associated with known risk factors for child maltreatment. CONCLUSIONS: This study shows that a structured interview, named the SPARK, is feasible in daily practice and clarifies risks and care needs for parenting and developmental problems in toddlers.

The impact of using different symptom-based exacerbation algorithms in patients with COPD.

Not all exacerbations are captured by reliance on healthcare contacts. Symptom-based exacerbation definitions have shown to provide more adequate measures of exacerbation rates, severity and duration. However, no consensus has been reached on what is the most useful method and algorithm to identify these events. This article provides an overview of the existing symptom-based definitions and tests the hypothesis that differences in exacerbation characteristics depend on the algorithms used. We systematically reviewed symptom-based methods and algorithms used in the literature, and quantified the impact of the four most referenced algorithms on exacerbation-related outcome using an existing chronic obstructive pulmonary disease (COPD) cohort (n = 137). We identified 51 studies meeting our criteria using 14 widely varying symptom algorithms to define onset, severity and recovery. The most (71%) frequently referenced algorithm (modified Anthonisen) identified an incidence rate of 1.7 episodes·patient-yr⁻¹ (95% CI 1.4-2.1), while for requiring only one major or two major symptoms this was 1.9 episodes·patient-yr⁻¹ (95% CI 1.6-2.3) and 1.5 episodes·patient-yr⁻¹ (95% CI 0.6-1.0), respectively. Studies were generally lacking methods to enhance validity and accuracy of symptom recording. This review revealed large inconsistencies in definitions, methods and accuracy to define symptom-based COPD exacerbations. We demonstrated that minor changes in symptom criteria substantially affect incidence rates, clustering type and classification of exacerbations.

Predicting admission and mortality with the Emergency Severity Index and the Manchester Triage System: a retrospective observational study.

OBJECTIVE: To compare the degree to which the Emergency Severity Index (ESI) and the Manchester Triage System (MTS) predict admission and mortality. METHODS: A retrospective observational study of four emergency department (ED) databases was conducted. Patients who presented to the ED between 1 January and 18 July 2006 and were triaged with the ESI or MTS were included in the study. RESULTS: 37 974 patients triaged with the ESI and 34 258 patients triaged with the MTS were included. The likelihood of admission decreased significantly with urgency categories in both populations, and was greater for patients triaged with the ESI than with the MTS. Mortality rates were low in both populations. Most patients who died were triaged in the most urgent triage categories of both systems. CONCLUSION: Both the ESI and MTS predicted admission well. The ESI was a better predictor of admission than the MTS. Mortality is associated with urgency categories of both triage systems.

Reliability and validity of the Manchester Triage System in a general emergency department patient population in the Netherlands: results of a simulation study.

OBJECTIVE: To assess the reliability and validity of the Manchester Triage System (MTS) in a general emergency department patient population. METHODS: A prospective evaluation study was conducted in two general hospitals in the Netherlands. Emergency department nurses from both hospitals triaged 50 patient vignettes into one of five triage categories in the MTS. Triage ratings were compared with the ratings of two Dutch MTS experts to measure inter-rater reliability. Nineteen days after triaging the patient vignettes, triage nurses were asked to rate the same vignettes again to measure test-retest reliability. Reliability in relation to the work experience of emergency department nurses was also studied. Validity was assessed by calculating percentages for overtriage, undertriage, sensitivity and specificity. RESULTS: Inter-rater reliability was "substantial" (weighted kappa 0.62 (95% CI 0.60 to 0.65)) and test-retest reliability was high (intraclass correlation coefficient 0.75 (95% CI 0.72 to 0.77)). No significant association was found between the experience of emergency department nurses and the reliability score (kappa). Undertriage occurred more frequently than overtriage, especially in elderly patients (25.3% vs 7.6%). Sensitivity for urgent patients in the MTS was 53.2% and specificity was 95.1%. The patient vignettes representing children aged <16 years revealed a higher sensitivity (83.3%). CONCLUSIONS: Inter-rater reliability is "moderate" to "substantial" and test-retest reliability is high. The reliability of the MTS is not influenced by nurses' work experience. Undertriage mainly occurs in the MTS categories orange and yellow. The MTS is more sensitive for children who need immediate or urgent care than for other patients in the emergency department.

Systematic review of the effects of chronic disease management on quality-of-life in people with chronic obstructive pulmonary disease.

INTRODUCTION: Chronic disease management for patients with chronic obstructive pulmonary disease (COPD) may improve quality, outcomes and access to care. OBJECTIVE: To investigate effectiveness of chronic disease management programmes on the quality-of-life of people with COPD. METHODS: Medline and Embase (1995-2005) were searched for relevant articles, and reference lists and abstracts were searched for controlled trials of chronic disease management programmes for patients with COPD. Quality-of-life was assessed as an outcome parameter. Two reviewers independently reviewed each paper for methodological quality and extracted the data. RESULTS: We found 10 randomized-controlled trials comparing chronic disease management with routine care. Patient populations, health-care professionals, intensity, and content of the intervention were heterogeneous. Different instruments were used to assess quality of life. Five out of 10 studies showed statistically significant positive outcomes on one or more domains of the quality of life instruments. Three studies, partly located in primary care, showed positive results. CONCLUSIONS: All chronic disease management projects for people with COPD involving primary care improved quality of life. In most of the studies, aspects of chronic disease management were applied to a limited extent. Quality of randomized-controlled trials was not optimal. More research is needed on chronic disease management programmes in patients with COPD across primary and secondary care.

Identification of patients at high risk of noncompliance in substance dependence treatment.

Noncompliance in substance dependence treatment seriously threatens its effectiveness. Pretreatment identification of those at the highest risk allows targeting of specific compliance enhancing interventions to those who may benefit most from it. In a cohort of 292 patients entering a 30-day treatment program for substance abuse treatment, several potential predictors of noncompliance were recorded before treatment. Compliance was registered when treatment was discontinued before the 30th day. Logistic regression was used to identify independent predictors of noncompliance and the area under the receiver-operating characteristic (ROC) curve was quantified to assess their joint predictive value. Mean age was 35 years, 80% were male. During follow-up 31% became noncompliant. Independent predictors of noncompliance were male gender, less than 10 years of education, severity of medical and drug problems, and behavioral intention to comply with treatment. The area under the ROC curve was 0.70 (95% CI: 0.64-0.76). In conclusion, noncompliance in a substance abuse treatment program can be predicted using five easy to assess patient characteristics. These results may be useful in preventing noncompliant behavior early in treatment by motivational counseling strategies.

An assessment of occupational health care in the Netherlands (1996-2005).

BACKGROUND: The extensive Dutch occupational health care system of the past decade has not led to the desired outcomes, namely, a decrease of work absenteeism and the associated costs. AIM: To assess the differences between in-house and external occupational health care services in the process quality of occupational health care provided. METHODS: In total, 26 interviews were conducted with chief executive officers of occupational health services (OHS). The responses and other relevant policy documents were analysed and described. A key component of this process was to compare differences between in-house and external services. RESULTS: Notable differences in quality were found to exist between in-house and external occupational health care systems, with the in-house occupational health care services offering the highest process quality. CONCLUSION: Our findings suggest that the effectiveness of OHS is mainly dependent on their structure (in-house versus external) and on economic factors (profit driven versus not for profit).

Prediction of pressure ulcer development in hospitalized patients: a tool for risk assessment.

OBJECTIVES: To identify independent predictors for development of pressure ulcers in hospitalized patients and to develop a simple prediction rule for pressure ulcer development. DESIGN: The Prevention and Pressure Ulcer Risk Score Evaluation (prePURSE) study is a prospective cohort study in which patients are followed up once a week until pressure ulcer occurrence, discharge from hospital, or length of stay over 12 weeks. Data were collected between January 1999 and June 2000. SETTING: Two large hospitals in the Netherlands. PARTICIPANTS: Adult patients admitted to the surgical, internal, neurological and geriatric wards for more than 5 days were eligible. A consecutive sample of 1536 patients was visited, 1431 (93%) of whom agreed to participate. Complete follow up data were available for 1229 (80%) patients. MAIN OUTCOME MEASURES: Occurrence of a pressure ulcer grade 2 or worse during admission to hospital. RESULTS: Independent predictors of pressure ulcers were age, weight at admission, abnormal appearance of the skin, friction and shear, and planned surgery in coming week. The area under the curve of the final prediction rule was 0.70 after bootstrapping. At a cut off score of 20, 42% of the patient weeks were identified as at risk for pressure ulcer development, thus correctly identifying 70% of the patient weeks in which a pressure ulcer occurred. CONCLUSION: A simple clinical prediction rule based on five patient characteristics may help to identify patients at increased risk for pressure ulcer development and in need of preventive measures.

[A primary care program in old age psychiatry: background, implementation and first experiences]. / Eerstelijns programma voor ouderenpsychiatrie (EPO): achtergrond, implementatie en eerste ervaring.

The specific characteristics of elderly people, who are likely to develop somatic and psychiatric co-morbidity, and cognitive deterioration, require tailored support in primary care. The first results of a support programme for the elderly in primary care are encouraging. Further research will show whether the EPO has sufficient added value for both the GP and the patient to justify large-scale introduction.

Eerstelijns Programma voor Ouderenpsychiatrie (EPO): Achtergrond, implementatie en eerste ervaring.

A Primary Care Program in old age psychiatry: Background, implementation and first experiences. Since 1999, the GP has been assigned the role of the "gatekeeper of mental health care". The aim of which is to treat as many mental problems as possible in primary health care. The generally complicated mental health problems in the elderly confront the GP with difficult diagnostic, treatment, and referral issues. Psychological problems are often masked by somatic complaints and rarely lead to referrals or adequate treatment. Many GPs use support programmes from second-line mental health care, yet nearly all these programs are executed by mental health care units for adults. In mid-western Utrecht, GPs have indicated a distinctive requirement for a support programme specifically aimed at elderly people with mental problems. The specific characteristics of elderly people, who are likely to develop somatic and psychiatric co-morbidity, and cognitive deterioration, require tailored support in primary care. The first results of a support programme for the elderly in primary care are encouraging. Further research will show whether the EPO has sufficient added value for both the GP and the patient to justify large-scale introduction.

Patient-reported outcome in total hip replacement. A comparison of five instruments of health status.

Our aim was to define the minimum set of patient-reported outcome measures which are required to assess health status after total hip replacement (THR). In 114 patients, we compared the pre-operative characteristics and sensitivity to change of the Oxford hip score (OHS), the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), the SF-36, the SF-12 (derived from the SF-36), and the Euroqol questionnaire (EQ-5D). At one year after operation, very large effect sizes were found for the disease-specific measures, the physical domains of the SF-12, SF-36 and the EQ-5Dindex (1.3 to 3.0). Patients in Charnley class A showed more change in the OHS, WOMAC pain and function, the physical domains of the SF-36 and the EQ-5Dvas (p < 0.05) compared with those in the Charnley B and C group. In this group, the effect size for the OHS more than doubled the effect sizes of WOMAC pain and physical function. We found high correlations and correlations of change between the OHS, the WOMAC, the physical domains of the SF-12 and the SF-36 and EQ-5Dindex. The SF-36 and EQ-5D scores at one year after operation approached those of the general population. Furthermore, we found a binomial distribution of the pre-operative EQ-5Dindex score and a pre-operative discrepancy and post-operative agreement between the EQ-5Dvas and EQ-5Dindex. We recommend the use of the OHS and SF-12 in the assessment of THR. The SF-36 may be used in circumstances when smaller changes in health status are investigated, for example in the follow-up of THR. The EQ-5D is useful in situations in which utility values are needed in order to calculate cost-effectiveness or quality-adjusted life years (QALYs), such as in the assessment of new techniques in THR.

Do integrated mental healthcare organisations facilitate process quality in the treatment of people with schizophrenia and related psychoses?

OBJECTIVE: The objective of this study is to investigate the influence of mergers of ambulatory and mental healthcare organisations on the process quality of care for persons suffering from schizophrenia or related psychoses. THEORY: On the basis of the theory of Donabedian we assume the relationships between three types of quality in healthcare: structure quality, process quality and outcome quality. This study focuses on the influences of structure quality, i.e. years since merger and catchment area size upon process quality. METHODS: Criteria according to Tugwell for evaluating healthcare were used to describe the process quality of schizophrenia care, resulting in a process quality questionnaire with 6 subscales and 21 items. Leading psychiatrists of 31 Dutch mental healthcare organisations, covering 89% of the country, answered the questionnaire. Both programmes and documents from the responding institutions and schizophrenia projects were analysed. Correlations of two determinants, age of the merged organisation and catchment area size, were made with total scale scores and the sub scores of the questionnaire. RESULTS: The response rate was 97% (31/32). Twenty-two organisations (71%) had a score of more than 50% on the used scale, 8 (29%) scored less. Two evidence-based interventions were implemented in more than 50% of the organisations, three in less than 50%. A low degree of implementation occurs in establishing care for people with schizophrenia from ethnic minorities, standardising diagnostic procedures and continuity of care. No significant relationship between the age of the merged organisation ('age') and the total process quality of schizophrenia care was found, however, the relationships between age and the subscales availability of interventions and integrated treatment were significant. No association was found between the size of the MHO's catchment area and any of the used subscales. CONCLUSIONS: The age of integration of residential and ambulatory mental health institutions correlates significantly with two subscales of process quality of schizophrenia care, i.e. availability of interventions and treatment. Catchment area size is not significantly associated with process quality or any of the subscales. Despite the mentioned positive effects, the overall picture of schizophrenia care is not very positive. Additional forces other than merely integration of ambulatory and residential services are needed for the further implementation of evidence-based interventions, diagnostic standards and continuity of care. The development of a national 'schizophrenia standard' (like in other countries) in relation with implementation plans and strategies to evaluate care on a regional level is recommended as well as further research on patient outcomes in relation to mergers of mental healthcare organisations.

Objectivity in needs assessment practice: admission to a residential home.

In 1997, the Dutch government installed independent agencies to assess the long-term care needs of individual clients and to give advice on the allocation of appropriate services. Needs assessors assess, among other things, the eligibility of clients requesting admission to a residential home. According to guidelines, needs assessors should do this objectively and independently from care providers and health care insurers. The present paper examines how needs assessors explore the clients' expressed needs, determine their normative needs and advise on allocation. Needs assessors perform these tasks in a situation where a clear professional framework is absent, and moreover, residential home capacity is limited. A qualitative study was undertaken, observing 13 house calls of clients requesting admission to a residential home. Furthermore, interviews were held with all needs assessors and a document analysis was made. It was found that needs assessors use comparable methods in exploring the clients' motivation and assessing their needs in the relevant areas, apparently using a professional framework. However, when transforming the needs of clients into an adequate allocation, needs assessors struggled with interpretation of criteria and included their personal ideas of services into the allocation decision. The paper concludes with the suggestion that further professionalisation may lead to a greater uniformity in needs assessment practice, and will assist needs assessors in the difficult task of transforming clients' needs into long-term care allocation advice.

Client satisfaction with service delivery of assistive technology for outdoor mobility.

PURPOSE: In the decentralized Dutch service delivery system, client satisfaction levels for the provision of assistive technology (AT) for outdoor mobility for elderly and disabled persons was measured to investigate whether or not differences exist between local service delivery systems and if so, how these can be explained. METHOD: In June 1999 a postal questionnaire was sent to a random sample of 973 adult users from three local authorities who had received their AT in 1998. Client satisfaction with the service delivery process was measured using seven items (alpha=0.88) added to the 12 items of the QUEST 2.0 scale. Demographic, health status and service delivery outcome characteristics were also measured. RESULTS: The response was 57%, 503 respondents were included in the analysis (mean age 71 years, 68% women). The health status of the respondents was very poor. The characteristics of the clients were comparable between local authorities but differences were found in the provision of AT. Whilst the overall satisfaction was high (1.8) a difference was found between local authorities. The percentage of clients who were 'not completely satisfied' with aspects of the service delivery process varied from 8% to 30%. One of the most important factors involved in the explanation of differences in satisfaction levels between local authorities (R(2)=11.4%) is that of 'delivery time'. CONCLUSION: Differences in clients' satisfaction between service delivery systems do exist and are determined by 'delivery time', 'user opinion', 'access' and 'quality of information'.

Classifying the probability of urinary incontinence in psychogeriatric nursing home patients.

Urinary incontinence (UI) frequently occurs in psychogeriatric nursing home patients. In general the personnel involved in the care for these patients act on incontinence noted. Patients are not monitored or classified according to likelihood or severity of incontinence. This study was conducted to develop and validate a model for the classification of the likelihood of UI in demented nursing home patients. A multi-center cross-sectional study was conducted using data on clinical and functional status of 692 subjects. Subjects were subdivided in a Derivation set of 532 patients and a Validation set of 160 patients. The data were ascertained with questionnaires completed by physicians and nursing staff. All psychogeriatric wards (25) of four Dutch nursing homes were included. Using univariate logistic regression analysis on the derivation set we identified correlates of UI among 22 clinical and functional patient characteristics. Subsequently, we developed a classification model for prevalent UI, including independent patient characteristics by means of multivariable logistic regression. Next, we stratified patients into groups with varying likelihood's of UI based on the model developed. Subsequently, we transformed the model to an easy applicable classification rule for the identification of patient subgroups with high or low likelihood on UI. Finally, the rule was validated on the validation set. The independent multivariate factors associated with urinary incontinence were impaired ADL and mobility, diminished alertness and fecal impaction. After transforming the regression model to an easy classification rule, the scores ranged from 0 to 7. The area under the curve was 0.88 (95% Confidence Interval (CI): 0.85-0.91) in the derivation set. In the validation set a similar area under the curve was obtained (0.90 (95% CI: 0.85-0.95)). Among subjects with none of the associated factors the rule classified 0.5% as incontinent patients. In case all associated factors were present the proportion classified as incontinent increased to 91%. In conclusion, the developed classification rule provides means to stratifying nursing home patients according to their likelihood of being incontinent of urine.

Quality of regional individual needs assessment agencies regulating access to long term-care services: a client perspective.

PURPOSE: To determine if and how the outcome quality from a client perspective is related to process characteristics and structure of Regional Individual Needs Assessment Agencies (RIOs) regulating access to long-term care services in The Netherlands. THEORY: Because of decentralised responsibilities, ultimo 1999 85 RIOs were set up. RIOs differ in their structural and process characteristics. This could lead to differences in client quality. Insight into factors relating to client quality (e.g. client satisfaction) can improve the needs assessment process. METHODS: Eighteen RIOs participated in this study. These RIOs each selected 120 clients, filled in forms about their needs assessment procedures and sent them a questionnaire assessing judgements, experiences and satisfaction with the RIO. RESULTS: We received 1916 RIO-forms and 1062 client questionnaires. Eighty-two percent of the clients were satisfied with the RIO, the percentages not satisfied clients varied from 10 to 29% among items and working procedures. Satisfaction is mostly related to what is actually done for the client. Information aspects and providing choices are important determinants of client quality with the RIO. CONCLUSION: In improving quality seen from a client perspective, one should focus on what is actually done for the client, rather than looking at the RIOs structure.