The effects of aftercare on chronic patients and frail elderly patients when discharged from hospital: a systematic review.

The purpose of this systematic review was an assessment of the efficacy of aftercare in chronic patients and the frail elderly when discharged from hospital, as regards quality of life, compliance, costs, medical consumption and quality of care. In pursuit of this goal, 17 publications on the effects of aftercare after discharge from hospital were examined. A systematic assessment of methodological quality by two blinded independent reviewers resulted in a consensus score (0-100 points), based on four categories: the study population, description of the interventions, measurement of the outcome and the analysis and presentation of the data. Only three of the 17 studies scored more than 50 points, indicating that most of the studies were of poor methodological quality. The most prevalent methodological problems were that co-interventions were not avoided, a placebo group was lacking, the assessment was not blinded and the analysis was not made on the basis of the intention-to-treat principle. The majority of the studies did not report clear beneficial effects in favour of the intervention group. The positive effects reported were limited to costs and quality of care.

Effects of specialized community nursing care in patients with chronic obstructive pulmonary disease.

OBJECTIVE: To investigate the effects of specialized respiratory home nursing care after discharge from a pulmonary rehabilitation center. DESIGN: Pretest-posttest control group design. Patients in the experimental group were visited by a nurse who specializes in respiratory care, whereas the control group received care from nurses who did not specialize in respiratory care. SETTING: Data were collected on admission, at program discharge, and 4 months and 9 months after discharge from a pulmonary rehabilitation center. PATIENTS: One hundred fifteen patients were included in the study and observed for 1 year. OUTCOME MEASURES: Health-related quality of life (HRQL), coping strategies, compliance, hospitalization, and satisfaction with the care provided. RESULTS: Complete data sets were obtained from 78 patients with severe airflow obstruction (FEV1 = 41%; predicted +/- SD = 15). Corrections were made for the selective nonresponse, but did not lead to adjustments in outcome scores. In both groups, HRQL scores improved between admission and discharge, but deteriorated 4 months and 9 months after discharge. The only statistically significant short-term effect was found on the "activities" component of HRQL in favor of the control group. No differences were found between groups regarding coping, compliance, and hospitalization. Patients in the experimental group, however, were more satisfied with the care provided by the specialized community nurses. CONCLUSIONS: The treatment intervention of specialized respiratory home nursing might not have been specific or intensive enough to result in outcome benefits. Secondly, the initial benefits from baseline pulmonary rehabilitation alone may have led to positive outcomes in both patient groups.

Long-term outcome of pulmonary rehabilitation in patients with COPD.

BACKGROUND: This study investigates the long-term benefits of pulmonary rehabilitation in terms of health-related quality of life (HRQL). Such information is of particular importance in developing strategies for aftercare at home which aim to maintain the initial improvements seen after rehabilitation. METHODS: Criteria for inclusion were diagnosis of COPD, age 40 to 80 years, and completion of an inpatient pulmonary rehabilitation program. HRQL was assessed by the St. George Respiratory Questionnaire, and the component "well-being" from the Medical Psychological Questionnaire for Lung Diseases. Patient characteristics included lung function parameters such as FEV1, the diffusion capacity for carbon monoxide and maximal inspiratory mouth pressure, age, socio-economic variables, and exercise tolerance evaluated by a 12-min walking test. To define patients in whom long-term benefits were sustained 9 months postdischarge, cases were clustered using hierarchical cluster analysis, based on the HRQL scores at discharge. RESULTS: Complete data sets were obtained from 77 patients. Two groups of cases were clustered. Patient characteristics were essentially the same in both groups. HRQL differed significantly between groups on admission, at discharge, and at follow-up. Within-group analysis revealed that patients in group 1 (n=44) had "moderate" scores on HRQL on admission, a significant improvement between admission and discharge, followed by a significant deterioration of HRQL at follow-up. Group 2 (n=33) had "severely" impaired HRQL on admission, little improvement after rehabilitation, and remained in fairly stable condition 9 months postdischarge. CONCLUSIONS: Results suggest that patients with COPD require a differentiated aftercare program of postdischarge pulmonary rehabilitation.

[Ranking and weighing of quality criteria. An application of criteria concerning nursing follow-up care of COPD patients]. / Rangordenen en wegen van kwaliteitscriteria. Een toepassing op criteria aangaande verpleegkundige nazorg aan CARA-patiënten.

The primary question in this survey was: Is it possible for a panel of experts, by means of existing measurement scales, to weigh and rank criteria in order to get a more refined judgement of quality. For this purpose 134 criteria were presented to a panel of experts using the Delphi-method. In two Delphi-rounds the panel selected 28 most important and 18 least important criteria by means of the VAS and the Coombsscale. This resulted in a selection of 34% of the original number of 134 criteria. The results proved it to be possible, to rank and weigh criteria by means of the VAS and Coombsscale in a Delphi-survey. If it is desired that a numerical value be attributed to criteria which differ little on a notional continuum, the Coombsscale appears to be most suitable. The VAS is not adequate in reaching 70% consensus in regarding least important criteria in a group of existing criteria.

Determinants of health-related quality of life in patients with chronic obstructive pulmonary disease.

BACKGROUND: The consequences of chronic obstructive pulmonary disease (COPD) on daily life, encapsulated by the term "health-related quality of life" (HRQL), are important in determining appropriate home care. There is a need to understand the relative contribution of respiratory impairment, physical disability, coping, age, and socioeconomic variables on HRQL. METHODS: Patients with COPD were recruited on admission to a pulmonary rehabilitation centre. Respiratory impairment was assessed by lung function tests and physical disability was evaluated by a 12 minute walking test. HRQL was assessed by means of the St George's Respiratory Questionnaire (SGRQ) measuring "symptoms", "activity", and "impact". Because the SGRQ does not include a measure of "well being", this was taken from the medical psychological questionnaire for lung diseases. The COPD coping questionnaire and a questionnaire covering basic socioeconomic variables were also used. RESULTS: One hundred and twenty six patients of mean (SD) age 65 (9) years and mean (SD) forced expiratory volume in one second (FEV1) 39 (9)% predicted were included. The scores on the SGRQ indicated severe impairment. Correlations were found between lung function parameters, 12 minute walking test, and the HRQL "activity" and "impact" components. Coping strategies were correlated with the "activity", "impact", and "well being" components. No correlations were found between age, socioeconomic variables, and HRQL. FEV1, 12 minute walking test, and the coping strategies "avoidance" and "emotional reaction" were the best predictors of HRQL. CONCLUSION: In patients with COPD methods of improving physical performance and teaching adequate coping strategies should be considered in order to improve HRQL.

Process standards of nursing care for patients with COPD: validation of standards and criteria by the Delphi technique.

It is common for professional literature to describe quality of care as based on standards. Yet little attention is given to the steps that precede the establishment of these standards. This study answers the question. "Which nursing care standards and criteria should be developed for chronic obstructive pulmonary disease (COPD) patients discharged from a pulmonary rehabilitation center? "Our approach included the following steps: delineating the scope of care and service, identifying indicators, and formulating standards and identifying criteria. Aspects of care included are: establishment and maintenance of a good care relationship with the patient; delineation of the care needs during the home visit; provision of health education, advice, and instruction; support in psychosocial problems; and coordination and continuity of the service. These standards and criteria were validated by the Delphi technique.