The prediction of early mortality following hip fracture surgery in patients aged 90 years and older: the Almelo Hip Fracture Score 90 (AHFS90).

The AHFS90 was developed for the prediction of early mortality in patients ≥ 90 years undergoing hip fracture surgery. The AHFS90 has a good accuracy and in most risk categories a good calibration. In our study population, the AHFS90 yielded a maximum prediction of early mortality of 64.5%. PURPOSE: Identifying hip fracture patients with a high risk of early mortality after surgery could help make treatment decisions and information about the prognosis. This study aims to develop and validate a risk score for predicting early mortality in patients ≥ 90 years undergoing hip fracture surgery (AHFS90). METHODS: Patients ≥ 90 years, surgically treated for a hip fracture, were included. A selection of possible predictors for mortality was made. Missing data were subjected to multiple imputations using chained equations. Logistic regression was performed to develop the AHFS90, which was internally and externally validated. Calibration was assessed using a calibration plot and comparing observed and predicted risks. RESULTS: One hundred and two of the 922 patients (11.1%) died ≤ 30 days following hip fracture surgery. The AHFS90 includes age, gender, dementia, living in a nursing home, ASA score, and hemoglobin level as predictors for early mortality. The AHFS90 had good accuracy (area under the curve 0.72 for geographic cross validation). Predicted risks correspond with observed risks of early mortality in four risk categories. In two risk categories, the AHFS90 overestimates the risk. In one risk category, no mortality was observed; therefore, no analysis was possible. The AHFS90 had a maximal prediction of early mortality of 64.5% in this study population. CONCLUSION: The AHFS90 accurately predicts early mortality after hip fracture surgery in patients ≥ 90 years of age. Predicted risks correspond to observed risks in most risk categories. In our study population, the AHFS90 yielded a maximum prediction of early mortality of 64.5%.

Implementation of a pneumonia prevention protocol to decrease the incidence of postoperative pneumonia in patients after hip fracture surgery.

OBJECTIVE: Postoperative pneumonia is among the most common complications in elderly patients after hip fracture surgery. We implemented a proactive postoperative pneumonia prevention protocol and analyzed the incidence of postoperative pneumonia in elderly patients (≥70 years of age) receiving this protocol after hip fracture surgery versus those receiving usual care before the protocol's implementation at our institution. MATERIALS AND METHODS: From November 2018 to October 2019, the proactive postoperative pneumonia prevention protocol was implemented. The treatment included intensified physical therapy, postoperative pulmonary exercises and oral care, in addition to the usual surgical treatment for elderly patients with hip fracture. The intervention cohort data were compared with a historical control cohort treated from July 2017 to June 2018. The primary outcome of this study was the incidence of postoperative pneumonia in both groups, diagnosed according to the presence of two of three of the following: elevated infection parameters, radiologic examination confirmation of pneumonia of the chest or clinical suspicion. RESULTS: A total of 494 patients (n= 249 in the historical control cohort and n=245 in the intervention cohort) were included. A total of 69 patients developed postoperative pneumonia. The incidence of postoperative pneumonia was significantly lower (6.7 percentage points) in the group receiving the proactive postoperative pneumonia prevention protocol (17.3% in the historical control cohort vs 10.6% in the intervention cohort; p=0.033). DISCUSSION AND CONCLUSION: A proactive postoperative pneumonia prevention protocol showed promise in decreasing the occurrence of postoperative pneumonia after hip fracture surgery in elderly patients.

'Nonagenarians' with a hip fracture: is a different orthogeriatric treatment strategy necessary?

Nonagenarians differ from patients aged 70-79 and 80-89 years in baseline characteristics, complication and mortality rates. Differences increased gradually with age. The results of this study can be used, in combination with the Almelo Hip Fracture Score, to deliver efficiently targeted orthogeriatric treatment to the right patient group. PURPOSE: In previous literature, elderly with a hip fracture are frequently defined as ≥ 70 years. However, given the ageing population and the rapidly increasing number of 'nonagenarians' (aged ≥ 90 years), the question rises whether this definition is still actual. The aim of this study is to determine whether nonagenarians show differences compared to patients aged 70-79 years and patients aged 80-89 years in terms of patient characteristics, complications and mortality rate. METHODS: From April 2008 until December 2016, hip fracture patients aged ≥ 70 years treated according to our orthogeriatric treatment model were included. Patients were divided into three different groups based on age at admission: 70-79 years, 80-89 years and ≥ 90 years. Patient characteristics, risk of early mortality, complications and outcomes were analysed. Risk factors for 30-day mortality in nonagenarians were determined. RESULTS: A total of 1587 patients were included: 465 patients aged 70-80 years, 867 patients aged 80-90 years and 255 patients aged ≥ 90 years. Nonagenarians were more often female and had a lower haemoglobin level at admission. Prefracture, they were more often living in a nursing home, were more dependent in activities of daily living and mobility and had a higher risk of early mortality calculated with the Almelo Hip Fracture Score (AHFS). Post-operative, nonagenarians suffer significantly more often from delirium and anaemia. The 30-day mortality and 1-year mortality were significantly higher. Differences increased gradually with age. CONCLUSION: Nonagenarians differ from patients aged 70-79 and 80-89 years in baseline characteristics, complication and mortality rates. Differences increased gradually with age. The results of this study can be used, in combination with the Almelo Hip Fracture Score, to deliver efficiently targeted orthogeriatric treatment to the right patient group.

Validation of low-cost smartphone-based thermal camera for diabetic foot assessment.

AIMS: Infrared thermal imaging (IR) is not yet routinely implemented for early detection of diabetic foot ulcers (DFU), despite proven clinical effectiveness. Low-cost, smartphone-based IR-cameras are now available and may lower the threshold for implementation, but the quality of these cameras is unknown. We aim to validate a smartphone-based IR-camera against a high-end IR-camera for diabetic foot assessment. METHODS: We acquired plantar IR images of feet of 32 participants with a current or recently healed DFU with the smartphone-based FLIR-One and the high-end FLIR-SC305. Contralateral temperature differences of the entire plantar foot and nine pre-specified regions were compared for validation. Intra-class correlations coefficient (ICC(3,1)) and Bland-Altman plots were used to test agreement. Clinical validity was assessed by calculating statistical measures of diagnostic performance. RESULTS: Almost perfect agreement was found for temperature measurements in both the entire plantar foot and the combined pre-specified regions, respectively, with ICC values of 0.987 and 0.981, Bland-Altman plots' mean Δ = -0.14 and Δ = -0.06. Diagnostic accuracy showed 94% and 93% sensitivity, and 86% and 91% specificity. CONCLUSIONS: The smartphone-based IR-camera shows excellent validity for diabetic foot assessment.

The consistency of care for older patients with a hip fracture: are the results of the integrated orthogeriatric treatment model of the Centre of Geriatric Traumatology consistent 10 years after implementation?

In the past 10 years after implementation, the orthogeriatric treatment model led in general to consistent outcomes for 1555 older adults in terms of most of the complications and mortality. Surgery was more often delayed to 24-48 h after arrival at the hospital, while the length of hospital stay shortened. INTRODUCTION: Since 1 April 2008, patients aged ≥ 70 years presenting themselves with a hip fracture at Ziekenhuisgroep Twente (ZGT) have been treated according to the orthogeriatric treatment model. The aim of this study was to investigate if outcomes of the orthogeriatric treatment model are consistent over the first 10 years after implementation. METHODS: Between 1 April 2008 and 31 December 2016, patients aged ≥ 70 years who were surgically treated at ZGT for a hip fracture were included and divided into three periods equally distributed in time. Patient characteristics, in-hospital logistics, complications, and mortality data were compared between the three periods. RESULTS: A total of 1555 patients were included. There was a shift in the surgical treatment for the fractured neck of femur from dynamic hip screw/cannulated screws to hemiarthroplasty (p < 0.001). Surgery within 24 h after arrival to the hospital decreased (p < 0.001), while surgery within 48 h stayed the same (p = 0.085). Length of hospital stay significantly decreased over time (p < 0.001). Complication rates were consistent except for the number of postoperative anemia, delirium, and urinary tract infections. Mortality rates did not change over the years. CONCLUSIONS: The orthogeriatric treatment model leads in general to consistent outcomes concerning mortality and most of the complications, except for postoperative anemia, delirium, and urinary tract infections. Inconsistent complication rates were influenced by altered diagnosis and treatment protocols. Length of hospital stay reduced, while time to surgery was more often delayed to 24-48 h. Monitoring clinical outcomes of the orthogeriatric treatment model over time is recommended in order to optimize and maintain the quality of care for this frail patient population.

Effectiveness of physiotherapy with telerehabilitation in surgical patients: a systematic review and meta-analysis.

BACKGROUND: Over the last few years, telerehabilitation services have developed rapidly, and patients value benefits such as reduced travelling barriers, flexible exercise hours, and the possibility to better integrate skills into daily life. However, the effects of physiotherapy with telerehabilitation on postoperative functional outcomes compared with usual care in surgical populations are still inconclusive. OBJECTIVES: To study the effectiveness of physiotherapy with telerehabilitation on postoperative functional outcomes and quality of life in surgical patients. DATA SOURCES: Relevant studies were obtained from MEDLINE, EMBASE, CINAHL, the Cochrane Library, PEDro, Google Scholar and the World Health Organization International Clinical Trials Registry Platform. STUDY SELECTION: Randomised controlled trials, controlled clinical trials, quasi-randomised studies and quasi-experimental studies with comparative controls were included with no restrictions in terms of language or date of publication. DATA EXTRACTION AND SYNTHESIS: Methodological quality was assessed using the Cochrane risk of bias tool. Twenty-three records were included for qualitative synthesis. Seven studies were eligible for quantitative synthesis on quality of life, and the overall pooled standardised mean difference was 1.01 (95% confidence interval 0.18 to 1.84), indicating an increase in favour of telerehabilitation in surgical patients. LIMITATIONS: The variety in contents of intervention and outcome measures restricted the performance of a meta-analysis on all clinical outcome measures. CONCLUSIONS: Physiotherapy with telerehabilitation has the potential to increase quality of life, is feasible, and is at least equally effective as usual care in surgical populations. This may be sufficient reason to choose physiotherapy with telerehabilitation for surgical populations, although the overall effectiveness on physical outcomes remains unclear. PROSPERO registration number: CRD42015017744.

Physical behavior and associations with health outcomes in operable NSCLC patients: A prospective study.

OBJECTIVES: Our objectives were to 1) characterize daily physical behavior of operable non-small cell lung cancer (NSCLC) patients, from preoperative to six months postoperative using accelerometry, and explore if physical behavior preoperative or one month postoperative is associated with better health outcomes at six months postoperative. METHODS: A prospective study with 23 patients (13 female) diagnosed with primary NSCLC and scheduled for curative lung resection was performed. Outcome measures were assessed two weeks preoperative, and one, three and six months postoperative, and included accelerometer-derived physical behavior measures and the following health outcomes: six minute walking distance (6MWD), questionnaires concerning health-related quality of life (HRQOL), fatigue and distress. RESULTS: On group average, physical behavior showed significant changes over time. Physical behavior worsened following surgery, but improved between one and six months postoperative, almost reaching preoperative levels. However, physical behavior showed high variability between patients in both amount as well as change over time. More time in moderate-to-vigorous physical activity in bouts of 10 min or longer in the first month postoperative was significantly associated with better 6MWD, HRQOL, distress, and fatigue at six months postoperative. CONCLUSION: As expected, curative lung resection impacts physical behavior. Patients who were more active in the first month following surgery reported better health outcome six months postoperative. The large variability in activity patterns over time observed between patients, suggests that physical behavior 'profiling' through detailed monitoring of physical behavior could facilitate tailored goal setting in interventions that target change in physical behavior.

Physical Behavior Profiles in Chronic Cancer-Related Fatigue.

PURPOSE: Increasing physical activity level is a generally effective intervention goal for patients who suffer from chronic cancer-related fatigue (CCRF). However, patients are unlikely to benefit equally from these interventions, as their behavioral starting points might vary substantially. Therefore, we explored patterns of physical behavior of participants who suffer from CCRF. METHODS: Baseline data of a randomized controlled trial were used for a latent profile analysis on nine accelerometer-derived physical behavior measures, describing levels and patterns of physical activity, moderate-to-vigorous intensity physical activity (MVPA), and sedentary behavior. The relation between participant characteristics and the latent profiles was analyzed. RESULTS: Accelerometer data of 172 participants from the Netherlands was analyzed. Three latent profiles were distinguished that differed most on physical activity level and total time spent in MVPA. Eighty-eight percent of all participants were assigned to a profile with a probability higher than 8. Age and perceiving limitations by comorbid conditions and pain were significant covariates of profile membership. CONCLUSIONS: We distinguished three physical behavior profiles. The differences between the patterns indicate that the heterogeneity of this sample requires patients to have substantially different treatment goals. Further research should test the applicability of these profiles in clinical practice.

Ambulant monitoring and web-accessible home-based exercise program during outpatient follow-up for resected lung cancer survivors: actual use and feasibility in clinical practice.

PURPOSE: The aim of this study is to evaluate the feasibility of a telehealthcare application for operable lung cancer (OLC) patients, consisting of ambulant symptom and physical activity monitoring (S&PAM) and a web-accessible home-based exercise program (WEP), and identify possible barriers for successful adoption and implementation. METHODS: A two-stage mixed methods design was used, in which 22 OLC patients and their treating healthcare professionals (HCPs) participated from pre-surgery to three (stage 1; n = 10) or six (stage 2; n = 12) months post-surgery. Actual use and acceptability (usability, usefulness, and satisfaction) were evaluated. RESULTS: Seventeen OLC patients (age (SD): 59 (8) years; 8 female) actively used the modules. S&PAM use varied from 1 to 11 monitoring days prior to outpatient consultations. Patients used WEP most frequently during the first 5 weeks, with an average of four logins a week. Fifty-eight percent used WEP beyond 7 weeks. No adverse situations occurred, and patients felt confident using the applications. Perceived added value included active lifestyle promotion, decreased anxiety, and accessibility to specialized HCPs. Physiotherapists used WEP as intended. Contrarily, physicians scarcely used information from S&PAM. To promote future adoption, strategies should focus on high-level patient tailoring of the technology, and formalization of including the applications in the clinical workflow. CONCLUSIONS: Ambulant monitoring and web-accessible home exercise is clinically feasible for OLC patients. However, low level of adoption by referring physicians may hamper successful implementation. IMPLICATIONS FOR CANCER SURVIVORS: Patients perceived both ambulant monitoring and web-accessible exercise as an added value to regular care and feasible to use in the period before and after lung resection.

Incidence and prognostic factors of chronic pain after isolated musculoskeletal extremity injury.

BACKGROUND: Chronic pain in patients is usually related to an episode of pain following acute injury, emphasizing the need to prevent progression from acute to chronic pain. Multiple factors in the acute phase might be responsible for perpetuating the pain. The presentation of patients at the emergency department (ED) presents a prime opportunity to identify patients at high risk for chronic pain and to start appropriate treatment. METHODS: The PROTACT study is a prospective follow-up study aiming to estimate the incidence and prognostic factors responsible for the development of chronic pain after musculoskeletal injury. Data including sociodemographic, pain, clinical, injury- or treatment-related and psychological factors of 435 patients were collected from registries and questionnaires at ED visit, 6-week, 3- and 6-month follow-up. RESULTS: At 6 months post-injury, 43.9% of the patients had some degree of pain (Numeric Rating Scale (NRS) ≥1) and 10.1% had chronic pain (NRS ≥4). Patients aged over 40 years, in poor physical health, with pre-injury chronic pain, pain catastrophizing, high urgency level and severe pain at discharge were found to be at high risk for chronic pain. CONCLUSIONS: Two prognostic factors, severe pain at discharge and pain catastrophizing, are potentially modifiable. The implementation of a pain protocol in the ED and the use of cognitive-behavioural techniques involving reducing catastrophizing might be useful.

Relationship between patterns of daily physical activity and fatigue in cancer survivors.

PURPOSE: This study investigated: (1) physical activity behaviour of cancer survivors throughout the day, (2) the relationship between objective and subjective measures of physical activity, and (3) the relationship between daily physical activity and fatigue. METHOD: Physical activity was measured objectively using 3D-accelerometry (expressed in counts per minute (cpm)), and subjectively using a Visual Analogue Scale (VAS; 0-10) implemented on a smartphone in 18 cancer survivors (6 male; age 55.7 ± 10.2 yrs; free from cancer, last treatment ≥three months previously), and matched controls. Fatigue was scored thrice daily on a smartphone (0-10 VAS). RESULTS: Mean daily physical activity of cancer survivors did not deviate from controls (1108 ± 287 cpm versus 1223 ± 371 cpm, p = .305). However, in cancer survivors physical activity significantly decreased from morning to evening (p < .01) and increased levels of fatigue throughout the day were reported (p < .01). Furthermore, a positive correlation was found between levels of fatigue and the magnitude of the decline in physical activity from afternoon to evening (p < .05). Objective and subjective measured physical activity showed low correlations. CONCLUSIONS: This study demonstrated imbalanced activity patterns in cancer survivors. Also, the more a survivor felt fatigued, the greater the decline in activity behaviour throughout the day. The low correlation between objective and subjective physical activity suggests low awareness in cancer survivors about their daily physical activity performed. Ambulatory monitoring provides new insights in both patterns of physical activity and fatigue, which might be a valuable tool to provide activity management more efficiently during treatment of fatigue.

Comparing VO2max determined by using the relation between heart rate and accelerometry with submaximal estimated VO2max.

AIM: An exploratory study to identify parameters that can be used for estimating a subject's cardio-respiratory physical fitness level, expressed as VO2max, from a combination of heart rate and 3D accelerometer data. METHODS: Data were gathered from 41 healthy subjects (23 male, 18 female) aged between 20 and 29 years. The measurement protocol consisted of a sub-maximal single stage treadmill walking test for VO2max estimation followed by a walking test at two different speeds (4 and 5.5 kmh-1) for parameter determination. The relation between measured heart rate and accelerometer output at different walking speeds was used to get an indication of exercise intensity and the corresponding heart rate at that intensity. Regression analysis was performed using general subject measures (age, gender, weight, length, BMI) and intercept and slope of the relation between heart rate and accelerometer output during walking as independent variables to estimate the VO2max. RESULTS: A linear regression model using a combination of the slope and intercept parameters, together with gender revealed the highest percentage of explained variance (R2 = 0.90) and had a standard error of the estimate (SEE) of 2.052 mL O2kg-1min-1 with VO2max. Results are comparable with current commonly used sub-maximal laboratory tests to estimate VO2max. CONCLUSION: The combination of heart rate and accelerometer data seems promising for ambulant estimation of VO2max-.

Cognitive behavioural treatment for chronic fatigue syndrome in a rehabilitation setting: effectiveness and predictors of outcome.

Cognitive behavioural therapy (CBT) was combined with graded exercise therapy (GET) for patients with chronic fatigue syndrome (CFS) in an uncontrolled implementation study of an inpatient multidisciplinary group therapy. During the intake procedure, 160 CFS patients completed a questionnaire on fatigue related measurements, physical impairment, depression, somatic and psychological attributions, somatic focus, and sense of control over symptoms. Pre-treatment physical activity level was measured with an actometer. At baseline, post-treatment and 6-month follow-up individual strength, subjective fatigue and physical impairment, were reassessed. Large effect sizes were found on subjective fatigue (1.2 post-treatment; 1.2 follow-up) and physical impairment (-.9 post-treatment; -.9 follow-up), Clinically significant improvement was found in 33.8% of the participants at post-treatment and 30.6% at follow-up. Individual strength at post-treatment was predicted by level of physical activity before treatment, and by sense of control over symptoms and physical activity at follow-up. Clinically significant improvement in subjective fatigue was predicted by not receiving a disablement insurance benefit, shorter duration of fatigue, higher sense of control over symptoms and, at follow-up by more pre-treatment physical activity. In conclusion, the intervention was effective for CFS patients. Cognitive behavioural factors that perpetuate fatigue symptoms are also predictors of treatment outcome.

The relationship between objectively and subjectively measured activity levels in people with chronic low back pain.

OBJECTIVE: To compare self-report measures of daily activities with objective activity data to determine whether patients with chronic lower back pain report their activity levels as accurately as controls do. DESIGN: A cross-sectional study was performed in patients and controls. SETTING: The study was carried out in the daily environment of the subjects. SUBJECTS: Thirty-two chronic lower back pain patients with symptoms more than three months and 20 healthy controls from the Netherlands, aged 18-65 years. MAIN MEASURES: A tri-axial accelerometer was worn for five weekdays and the Baecke Physical Activity Questionnaire was filled in. Pearson's correlation was calculated to get insight in the awareness of patients and controls. Comparisons of the relationship between the objective and subjective scores of each individual patient with those of the group of controls were used to allocate each patient into subgroups: overestimators, underestimators and aware patients. Physical and psychological characteristics of these groups were explored. RESULTS: Patients showed weak correlations between the objective and subjective scores of physical activity and appear to have problems in estimating their activity levels (r = -0.27), in contrast to controls who showed strong correlations between the objective and subjective scores (r = 0.66). Comparison of the individual relationships of patients with those of controls showed that 44% of the patients were not aware of their activity level. There were relatively more underestimators (30%) than overestimators (14%). Physical characteristics between the three groups tended to be different. CONCLUSIONS: Patient self-reports about their activity level are relatively inaccurate when compared to objective measurements.

Video teleconsultation service: who is needed to do what, to get it implemented in daily care?

INTRODUCTION: In telemedicine, technology is used to deliver services. Because of this, it is expected that various actors other than those involved in traditional care are involved in and need to cooperate, to deliver these services. The aim of this study was to establish a clear understanding of these actors and their roles and interrelationships in the delivery of telemedicine. A video teleconsultation service is used as a study case. METHODS: A business modeling approach as described in the Freeband Business Blueprint Method was used. The method brings together the four domains that make up a business model, that is, service, technology, organization, and finance, and covers the integration of these domains. The method uses several multidisciplinary workshops, addressing each of the four domains. RESULTS: Results of the four domains addressed showed that (1) the video teleconsultation service is a store and put-forward video teleconsult for healthcare providers. The service is accepted and has added value for the quality of care. However, the market is small; (2) the technology consists of a secured Internet Web-based application, standard personal computer, broadband Internet connection, and a digital camera; (3) a new role and probably entity, responsible for delivering the integrated service to the healthcare professionals, was identified; and finally (4) financial reimbursement for the service delivery is expected to be most successful when set up through healthcare insurance companies. Pricing needs to account for the fee of healthcare professionals as well as for technical aspects, education, and future innovation. DISCUSSION: Implementation of the video teleconsult service requires multidisciplinary cooperation and integration. Challenging aspects are the small market size and the slow implementation speed, among others. This supports the argument that accumulation of several telemedicine applications is necessary to make it financially feasible for at least some of the actors.

Daily physical activities in chronic lower back pain patients assessed with accelerometry.

BACKGROUND: Normalization of activities in daily living is an important goal in rehabilitation treatment of chronic lower back pain (CLBP) patients. Clinicians indicate that CLBP patients often show deconditioning but also CLBP patients who seem to be too active are seen. The objective of the present cross-sectional study was to gain more insight into the daily activity pattern of CLBP patients compared to controls, using accelerometry. METHODS: Daily activities were assessed by measuring body movement with a tri-axial accelerometer that was worn for seven consecutive days during waking hours. Measurements were performed in the daily environment (in-doors and out-doors) of the participant. Differences between activity level, time of day and work status were tested. RESULTS: Data were obtained from 29 CLBP patients and 20 controls. Results show that the overall activity levels of patients (mean 0.75; SD 0.43) are not significantly different from those of controls (mean 0.71; SD 0.44). However, patients show significantly higher activity levels in the morning (p<0.001) and significantly lower activity levels in the evening (p<0.01) compared to controls. No significant differences in activity levels were found between leisure time and working days within either group; furthermore no significant differences in activity levels were found between patients with different work status. CONCLUSION: Overall activity levels do not differ significantly between CLBP patients and controls, but the distribution of activities over the day differs significantly.

Evaluating patient care communication in integrated care settings: application of a mixed method approach in cerebral palsy programs.

OBJECTIVE: In this study, we evaluated patient care communication in the integrated care setting of children with cerebral palsy in three Dutch regions in order to identify relevant communication gaps experienced by both parents and involved professionals. DESIGN: A three-step mixed method approach was used starting with a questionnaire to identify communication links in which parents experienced gaps. In subsequent in-depth interviews with parents and focus group meetings with professionals underlying factors were evaluated. RESULTS: In total, 197 parents completed the questionnaire (response 67%); 6% scored negative on parent-professional communication, whereas 17% scored negative on inter-professional communication, especially between the rehabilitation physician and primary care physiotherapy (16%) and (special) education/day care (15%). In-depth interviews among a subset of 20 parents revealed various sources of dissatisfaction such as lack of cooperation and patient centeredness, inappropriate amount of information exchange and professional use of parents as messenger of information. Focus group meetings revealed that professionals recognized these gaps. They attributed them to capacity problems, lack of interdisciplinary guidelines and clear definition of roles, but also a certain hesitance for contact due to unfamiliarity with involved professionals in the care network. CONCLUSIONS: Parents particularly identified gaps in inter-professional communication between (rehabilitation) hospitals and primary care settings. Involved professionals recognized these gaps and primarily attributed them to organizational factors. Improvement initiatives should focus on these factors as well as facilitation of low-threshold contact across the patient's care network.

Daily physical activities of patients with chronic pain or fatigue versus asymptomatic controls. A systematic review.

OBJECTIVE: To gain an insight into the daily physical activity levels of patients with chronic pain or fatigue compared with asymptomatic controls. DATA SOURCES: MEDLINE, EMBASE, PsycINFO, Picarta, Cochrane Database of Systematic Reviews, reference tracking and a manual search of relevant journals. REVIEW METHODS: A systematic, computerized database search of the medical databases up to September 2006 was performed. In addition, a hand search of relevant journals was carried out. Appropriate studies reported on the daily physical activities of adult patients with chronic pain or fatigue and included an asymptomatic control group. Two reviewers independently carried out methodological quality assessment and data extraction. A qualitative analysis was performed. RESULTS: Twelve studies were included, involving five different syndromes. Results show large heterogeneity in methods used and syndromes investigated, which limited evidence. Eleven different methods were used to assess daily physical activities resulting in 16 different outcome parameters. There seem to be differences between the different syndromes, but results are not conclusive. Eight studies reported a lower physical activity level in patients compared with controls. There seems to be a difference in results between studies using objective versus those using subjective methods. CONCLUSIONS: Results reported in the literature with respect to the activity level of patients with chronic pain or fatigue compared with controls were too heterogeneous to give sufficient evidence and were not conclusive.

Evaluating quality of patient care communication in integrated care settings: a mixed method approach.

BACKGROUND: Owing to the involvement of multiple professionals from various institutions, integrated care settings are prone to suboptimal patient care communication. To assure continuity, communication gaps should be identified for targeted improvement initiatives. However, available assessment methods are often one-sided evaluations not appropriate for integrated care settings. OBJECTIVE: We developed an evaluation approach that takes into account the multiple communication links and evaluation perspectives inherent to these settings. In this study, we describe this approach, using the integrated care setting of Cerebral Palsy as illustration. RESULTS: The approach follows a three-step mixed design in which the results of each step are used to mark out the subsequent step's focus. The first step patient questionnaire aims to identify quality gaps experienced by patients, comparing their expectancies and experiences with respect to patient-professional and inter-professional communication. Resulting gaps form the input of in-depth interviews with a subset of patients to evaluate underlying factors of ineffective communication. Resulting factors form the input of the final step's focus group meetings with professionals to corroborate and complete the findings. CONCLUSIONS: By combining methods, the presented approach aims to minimize limitations inherent to the application of single methods. The comprehensiveness of the approach enables its applicability in various integrated care settings. Its sequential design allows for in-depth evaluation of relevant quality gaps. Further research is needed to evaluate the approach's feasibility in practice. In our subsequent study, we present the results of the approach in the integrated care setting of children with Cerebral Palsy in three Dutch care regions.

The receptiveness toward remotely supported myofeedback treatment.

Remotely supported myofeedback treatment (RSMT) is considered to be a potentially valuable alternative to the conventional myofeedback treatment, as it might increase efficiency of care. This study was aimed at examining the receptiveness of potential end users (patients and professionals) with respect to RSMT. By doing so, protocols of RSMT can be developed which fit to the needs of end users and enhance treatment adherence. For both end-user groups, questionnaires were developed focusing on two components of the attitude-social support-self-efficacy (ASE) model. Fifteen patients with neck-shoulder complaints previously treated with conventional myofeedback and 17 professionals participated in the study. Results showed positive attitudes toward RSMT in 53% of the patients, and 67% of them were willing to participate in RSMT. Of the 17 professionals included in the present study 43% reported a positive attitude. In addition, 40% of the patients and 100% of the professionals believed their self-efficacy level to be sufficient for RSMT. In addition to e-consultations, 40% percent of the patients suggested that the optimal frequency of structural in vivo contact with their therapist would be once per 2 weeks, which is less frequent compared to the weekly in vivo contacts in the conventional myofeedback treatment. Professionals emphasized the importance of nonverbal communication and physical interaction (as in in vivo contact) in remote treatment concepts.