Organizational arrangements as a key to enhancing innovativeness and efficiency - analysis of a restructuring hospital in Finland.

BACKGROUND: Challenged to innovate and improve efficiency both at the policy level and in everyday work, many health care organizations are undergoing radical change. However, in many earlier studies, the significance of individuals' perceptions of their organization and its innovativeness and efficiency during restructuring is not well acknowledged. Our study examines how various organizational arrangements; performance-, hierarchy-, tradition-, and leader-focused types, as well as collaborative and fragmented ones, connect to reaching innovativeness and efficiency in health care during restructuring. METHOD: We built on previous organization and management research, innovation studies, and on research focusing in health care restructuring, and conducted an exploratory quantitative case study in a public sector hospital in Finland. Data comprising 447 responses from 19 professional groups across the hospital was analyzed using hierarchical regression analysis. RESULTS: Our results demonstrate that multiple, co-existing organizational arrangements can promote innovation and efficiency. The perceptions of the organizational members of the nature of their organization need to be generally positive and reflect future-orientation to show positive connections with efficiency and innovativeness; fragmentation in the members' perceptions of the character of their organization and their inability to go beyond established organizational traditions pose risks of inefficiency and stagnation rather than fruitful exploration. Our study further shows, somewhat surprisingly, that while collaborative organizational arrangements are positively related to increases in perceived efficiency, the same does not apply to innovativeness. CONCLUSIONS: Our study addresses understudied, yet inherently important aspects in providing high-quality health care: the relationships between different organizational arrangements and exploitation and exploration-related outcomes. In particular, examination of individuals' perceptions (that may have even more weight for the subsequent developments than the actual situation) adds insight to the existing knowledge that has addressed more objective factors. Implications on how to support high levels of performance are drawn for management of professional and pluralistic organizations undergoing restructuring. Our findings also generate information that is useful for policy making concerned with public sector health care.

Associations of neuroticism with falls in older adults: do psychological factors mediate the association?

OBJECTIVES: Neuroticism predicts falls in older people. In addition, concern about falling and depressive symptoms are associated with fall risk. This study examined whether concern about falling and depressive symptoms mediate the association between neuroticism and falls. METHOD: Cross-sectional data on 314 community-dwelling people aged 70-85 years were utilized. Neuroticism was assessed with a short modified form of the Eysenck Personality Inventory. Indoor and outdoor falls during the past year were self-reported. Concern about falling was assessed with the Falls Efficacy Scale-International and depressive symptoms with the Geriatric Depression Scale-15. Path modeling was used to examine the associations between variables. RESULTS: Mediating pathways linking neuroticism and falls were found: neuroticism was positively associated with concern about falling, which was subsequently linked to indoor falls (indirect effect ß = 0.34, p = 0.002) and recurrent outdoor falls (ß = 0.19, p = 0.045). Moreover, a pathway from neuroticism to indoor falls through depressive symptoms was also found (ß = 0.21, p = 0.054). In other words, higher neuroticism was associated with higher concern about falling and depressive symptoms, both of which were linked to falls. The associations were independent of age, sex, use of psychotropic, chronic diseases, persistent pain, physical performance, physical activity, and executive functioning that are known risk factors for falls. DISCUSSION: The results indicate that concern about falling and depressive symptoms mediate the association between neuroticism and falling. Longitudinal studies are needed to confirm the causality of the findings and to examine the potential to reduce falls by targeting concern about falling and depressive symptoms among older adults higher in neuroticism.

Effects of physical and cognitive training on gait speed and cognition in older adults: A randomized controlled trial.

Gait speed is a measure of health and functioning. Physical and cognitive determinants of gait are amenable to interventions, but best practices remain unclear. We investigated the effects of a 12-month physical and cognitive training (PTCT) on gait speed, dual-task cost in gait speed, and executive functions (EFs) compared with physical training (PT) (ISRCTN52388040). Community-dwelling older adults, who did not meet physical activity recommendations, were recruited (n = 314). PT included supervised walking/balance (once weekly) and resistance/balance training (once weekly), home exercises (2-3 times weekly), and moderate aerobic activity 150 min/week in bouts of >10 min. PTCT included the PT and computer training (CT) on EFs 15-20 min, 3-4 times weekly. The primary outcome was gait speed. Secondary outcomes were 6-min walking distance, dual-task cost in gait speed, and EF (Stroop and Trail Making B-A). The trial was completed by 93% of the participants (age 74.5 [SD3.8] years; 60% women). Mean adherence to supervised sessions was 59%-72% in PT and 62%-77% in PTCT. Home exercises and CT were performed on average 1.9 times/week. Weekly minutes spent in aerobic activities were 188 (median 169) in PT and 207 (median 180) in PTCT. No significant interactions were observed for gait speed (PTCT-PT, 0.02; 95%CI -0.03, 0.08), walking distance (-3.8; -16.9, 9.3) or dual-task cost (-0.22; -1.74, 1.30). Stroop improvement was greater after PTCT than PT (-6.9; -13.0, -0.8). Complementing physical training with EFs training is not essential for promotion of gait speed. For EF's, complementing physical training with targeted cognitive training provides additional benefit.

Promoting safe walking among older people: the effects of a physical and cognitive training intervention vs. physical training alone on mobility and falls among older community-dwelling men and women (the PASSWORD study): design and methods of a randomized controlled trial.

BACKGROUND: Safe and stable walking is a complex process involving the interaction of neuromuscular, sensory and cognitive functions. As physical and cognitive functions deteriorate with ageing, training of both functions may have more beneficial effects on walking and falls prevention than either alone. This article describes the study design, recruitment strategies and interventions of the PASSWORD study investigating whether a combination of physical and cognitive training (PTCT) has greater effects on walking speed, dual-task cost in walking speed, fall incidence and executive functions compared to physical training (PT) alone among 70-85-year-old community-dwelling sedentary or at most moderately physically active men and women. METHODS: Community-dwelling sedentary or at most moderately physically active, men and women living in the city of Jyväskylä will be recruited and randomized into physical training (PT) and physical and cognitive training (PTCT). The 12-month interventions include supervised training sessions and home exercises. Both groups attend physical training intervention, which follows the current physical activity guidelines. The PTCT group performes also a web-based computer program targeting executive functions. Outcomes will be assessed at baseline and at 6 and 12 months thereafter. Falls data are collected during the interventions and the subsequent one-year follow-up. The primary outcome is 10-m walking speed. Secondary outcomes include 6-min walking distance, dual-task cost in walking speed, fall incidence and executive function assessed with color Stroop and Trail Making A and B tests. Explanatory outcomes include e.g. body composition and bone characteristics, physical performance, physical activity, life-space mobility, fall-related self-efficacy, emotional well-being and personality characteristics. DISCUSSION: The study is designed to capture the additive and possible synergistic effects of physical and cognitive training. When completed, the study will provide new knowledge on the effects of physical and cognitive training on the prevention of walking limitations and rate of falls in older people. The expected results will be of value in informing strategies designed to promote safe walking among older people and may have a significant health and socio-economic impact. TRIAL REGISTRATION: ISRCTN52388040 .

A supportive home visit program for older adults implemented by non-professionals: feasibility and effects on physical performance and quality of life at one year--a pilot study.

Knowledge of supportive home rehabilitative procedures is needed to improve the independent home training and psychosocial wellbeing of older people. The primary focus of this study was to assess the feasibility of a home visit program involving the use of non-professional home rehabilitation assistants (HRAs) support among elderly. The secondary objective was to investigate the effects to physical performance and health-related quality of life (HRQL) of older people. A controlled intervention study was implemented at two war veterans' rehabilitation centers in Finland. The study included 22 long-term unemployed people aged 26-58 years, who were educated in HRA tasks and 417 community-dwelling persons aged 65-99 years, who participated in 10-28 days of inpatient rehabilitation. The intervention group (IG) received 10-14-month physiotherapist-supervised HRA home visit program. The control group (CG) received no home visit intervention. Additional information was collected to assess the feasibility of the intervention. Structured interviews were carried out. Physical performance was evaluated through several validated tests, pain with the Visual Analog Scale (VAS), and HRQL with the Leipad questionnaire. The HRAs adopted their supporting role through the social activation of the rehabilitees and continued to study to become practical nurses. At 10-14 months, HRQL among women (p=0.029) and chair rising among men (p=0.028) improved in the IG but declined in the CG. The supportive home visit program was feasible and improved the HRQL in women and chair rising in men. This model could motivate long-term unemployed people to educate themselves.

Benefits of home-based rocking-chair exercise for physical performance in community-dwelling elderly women: a randomized controlled trial.

BACKGROUND AND AIMS: Home-based exercise is a viable alternative for older adults with difficulties in exercise opportunities outside the home. The aim of this study was to investigate the benefits of home-based rocking-chair training, and its effects on the physical performance of elderly women. METHODS: Community- dwelling women (n=51) aged 73-87 years were randomly assigned to the rocking-chair group (RCG, n=26) or control group (CG, n=25) by drawing lots. Baseline and outcome measurements were hand grip strength, maximal isometric knee extension, maximal walking speed over 10 meters, rising from a chair five times, and the Berg Balance Scale (BBS). The RCG carried out a six-week rocking-chair training program at home, involving ten sessions per week, twice a day for 15 minutes per session, and ten different movements. The CG continued their usual daily lives. After three months, the RCG responded to a mail questionnaire. RESULTS: After the intervention, the RCG improved and the CG declined. The data showed significant interactions of group by time in the BBS score (p=0.001), maximal knee extension strength (p=0.006) and maximal walking speed (p=0.046), which indicates that the change between groups during the follow-up period was significant. Adherence to the training protocol was high (96%). After three months, the exercise program had become a regular home exercise habit for 88.5% of the subjects. CONCLUSIONS: Results indicate that home-based elderly women benefit from this easily implemented rocking-chair exercise program. The subjects became motivated to participate in training and continued the exercises. This is a promising alternative exercise method for maintaining physical activity and leads to improvements in physical performance.

The effect of geriatric rehabilitation on physical performance and pain in men and women.

In the developed countries, people are living longer and the number of aged persons is growing. Knowledge on the effectiveness of rehabilitative procedures is needed and information in physical performance between men and women is scarce. An intervention study was carried out in two war veterans' rehabilitation centers in Finland to examine the effects of geriatric inpatient rehabilitation on physical performance and pain in elderly men and women. The study included 441 community-dwelling persons with a mean age of 83 years. A clinical assessment and a structured interview were carried out. Cognitive capacity was evaluated with the mini-mental state examination (MMSE). Physical performance was measured through several validated tests. Pain was measured with the visual analogy scale (VAS). The rehabilitation was carried out with the standard rehabilitation protocol. Both men and women showed a statistically significant improvement in physical performance tests. The experience of pain and disease symptoms diminished significantly in both sexes (p<0.001). The intervention showed that women improved more than men. It showed significant interactions of group by time in knee extension strength (p=0.033), the experience of pain reduction (p=0.002) and disease symptoms (p=0.040). Inpatient geriatric rehabilitation appeared to have a positive effect on physical performance and the experience of pain in elderly people. The differences between the sexes in the experience of pain, disease symptoms and in the knee extension strength could provide a new perspective in the planning of more individual rehabilitation interventions.

Mobility performance and its sensory, psychomotor and musculoskeletal determinants from age 75 to age 80.

BACKGROUND AND AIMS: Prospective studies on the simultaneous effects of multiple determinants on objectively assessed mobility are few. The aim of this study was to analyse mobility performance, its stability and sensory, psychomotor and musculoskeletal determinants in an older population from age 75 to age 80. METHODS: Sixty-three men and 121 women aged 75 participated at baseline and, five years later, in the follow-up phase of this population-based prospective study. Maximal walking speed and step-mounting height were assessed at baseline and follow-up. Maximal isometric knee extension strength, standing balance on force platform, reaction time, visual acuity and limitations in range of motion (ROM) of hips and knees were assessed at baseline. Structural equation modeling was used to analyse the associations. RESULTS: The stability of mobility performance from baseline to the five-year follow- up was high (coefficient 0.80 in men, 0.78 in women). In men, knee extension strength, standing balance, ROM limitations and visual acuity explained 69% of the variation in mobility performance at baseline and, indirectly, 59% of that variation at follow-up. Among women, knee extension strength, standing balance, visual acuity and reaction time explained 52% of the variation of mobility performance at baseline and, indirectly, 30% at the five-year follow-up. CONCLUSIONS: Results indicate that the predictive effects of sensory, psychomotor and musculoskeletal functions on mobility performance extend over five years in older people. In seeking to prevent mobility limitations, vision, reaction time and lower extremity ROM need to be targeted, in addition to muscle strength and balance.

[Home rehabilitation assistant improves the quality of life of the elderly]. / Kotikuntoutumisavustajan tuki parantaa iäkkäiden elämänlaatua.

We investigated the health status, functional ability, mood and quality of life of 464 persons undergoing a rehabilitation period in two centers for care and rehabilition for war veterans' by comprehensive interviews and measurements of functional ability. The investigation involved a 2 to 4-week period in a rehabilitation unit and a controlled investigation with a home rehabilitation assistant for one year. Hand grip strength, knee extension strength and walking speed, among other things, improved during the institutional rehabilitation period. The rehabilitation period study included no control group. During the one-year follow-up, those participating in the home rehabilitation assistant intervention considered their quality of life and health better than in the beginning of the study.

Mobility limitations and cognitive deficits as predictors of institutionalization among community-dwelling older people.

PURPOSE: Mobility limitations and cognitive disorders have often been observed as risks for institutionalization. However, their combined effects on risk of institutionalization among initially community-dwelling older people have been less well reported. DESIGN: A prospective cohort study with 10-year surveillance on institutionalization. SUBJECTS: Study population (n = 476) consisted of 75- and 80-year-old people who were community-dwelling, had not been diagnosed with dementia, and participated in tests on walking speed and cognitive capacity at a research centre. MEASURES: Cognitive capacity was measured with three validated psychometric tests that were from the Wechsler Adult Intelligence Scale, Wechsler Memory Scale and Schaie-Thurstone Adult Mental Abilities Test. Mobility was measured with walking speed over a 10-m distance. Exclusive distribution based study groups were formed with cut-offs at the lowest third as follows: no limitation, solely mobility limitation, solely cognitive deficits, and combined mobility limitation and cognitive deficits. Cox proportional hazards model was used to determine the relative risks of institutionalization for the study groups. RESULTS: Eleven percent of the participants were institutionalized during the 10-year surveillance. The risk for institutionalization was 4.9 times greater (95% confidence interval: 2.1-11.2) for those who had co-existing mobility limitations and cognitive deficits than for those with no limitations. CONCLUSIONS: The findings show that the accumulation of limitations in physical and cognitive performance substantially decreases the possibility for a person remaining at home. This might be due to a decreased reserve capacity and ineffective compensatory strategies. Therefore, interventions targeted to improve even one limitation, or prevent accumulation of these risk factors, could significantly reduce the risk of institutionalization.

Multidimensional health assessment of 75- and 80-year-old men and women: a five-year prospective study.

BACKGROUND AND AIMS: There are no earlier reports of regular multidimensional health check programs in elderly people. The aim of this study was to establish the number and type of previously unrecognized health conditions in two cohorts of elderly people examined twice during a 5-year period, and to determine how these conditions were subsequently evaluated and treated. METHODS: This population-based study, carried out at a university research center in Finland, consisted of a multidimensional and multiphased health assessment including interviews, health questionnaires and medical examinations and tests, and follow-up of subsequent examinations and treatment. Participants were all 75- (N = 388) and 80-year-old (N = 291) people residing in the city of Jyväskylä in 1989 and 1990 respectively. RESULTS: A total of 780 health assessments were carried out, 500 at baseline and 280 five years later. Large numbers of previously unrecognized conditions were found on both occasions, ranging from tumors to impacted cerumen. At baseline, 180 persons (36% of those assessed) were referred for further examinations or treatment, at follow-up 127 (45%). Half of the referred persons received treatment, 13-39% were evaluated but not treated. For 12-33%, no information was obtained on post-hoc events. CONCLUSIONS: Comprehensive health assessments in older people reveal a large number of previously unrecognized conditions that require further examination and/or treatment, suggesting the need for systematic and regular assessments of health and functional capacity.

Changes in household composition as determinant of changes in functional ability among old men and women.

The aims of this article were 1) to describe changes in functional ability from ages 75 to 80 among men and women in three Nordic localities, and 2) to analyze whether these changes are determined by changes in household composition from ages 70 to 75. The present analyses include the persons who participated in the NORA follow-up study of 75-80 year-old men and women in Jyväskylä, Finland (N=243), Göteborg, Sweden (N=226), and Glostrup, Denmark (N=274). Functional ability was measured by tiredness and need for help in Physical and Instrumental Activities of Daily Living (PADL and IADL). Changes in functional ability are described as 1) sustained good, 2) decreased, 3) improved, and 4) sustained poor, and changes in household composition as 1) sustained living alone, 2) from living with others to living alone, and 3) sustained living with others. Number of chronic diseases and home help were included as covariates in the multivariate analyses. A large proportion of men and women had sustained good functional ability from age 75 to 80, but we observed both improvement and deterioration over time. For example, with regard to need for help in PADL: 64/59% of the mer/women had sustained good function, 19/21% deteriorated, 3/6% improved, and 14/14% had sustained poor function. Among the women in need of help at age 75, those who lived alone/became alone had a higher risk of sustained need for help from age 75 to 80 compared to women who lived with others [adjusted OR=4.0 (1.3-12.2/4.4 (0.7-26.9)]. This was not seen among the poor-functioning men. It is concluded that poor-functioning, single-living women are at higher risk of not regaining functional ability compared to cohabiting women.

Tiredness in daily activities among nondisabled old people as determinant of onset of disability.

The purpose of this article was to examine whether self-reported tiredness in daily activities at age 75 is an independent determinant of onset of disability at 5-year follow-up. The investigation is based on two subgroups of nondisabled participants of 75 year olds who survived and participated in the follow-up study 5 years later (n = 510 and 429). Persons who felt tired in their daily activities had a larger risk of becoming disabled in mobility (OR = 3.2, 95% CI = 1.4-7.6) and in daily activities (OR = 2.1, 95% CI = 1.0-4.2) compared to persons without tiredness. In addition, persons with poor cognitive function, little diversity in social relations and no physical activity had an independent risk of onset of disability. The results indicate that it is important to take it seriously when older people complain about tiredness in daily activities, as these people are at higher risk of becoming disabled than others.