Core components and impact of nurse-led integrated care models for home-dwelling older people: A systematic review and meta-analysis.

BACKGROUND: Integrated care models are highly recommended to overcome care fragmentation in the multimorbid older population. Nurses are potentially ideally situated to fulfil the role as care coordinator to guide integrated care. No systematic review has been conducted specifically focusing on the impact of nurse-led integrated care models for older people in community settings. OBJECTIVES: To identify core components of nurse-led integrated care models for the home-dwelling older population; to describe patient, service and process outcomes; and to evaluate the impact of these care models on quality of life, activities of daily living, hospitalisation, emergency department visits, nursing home admissions and mortality. DESIGN: Systematic review and meta-analysis. DATA SOURCES: English, Dutch, French, German and Spanish articles selected from PubMed and CINAHL, hand-search of reference lists of the included articles and grey literature. REVIEW METHODS: A systematic search was conducted to identify prospective experimental or quasi-experimental studies detailing nurse-led integrated care models in the older home-dwelling population. Study characteristics and reported outcomes were tabulated. The core components of the models were mapped using the Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE (SELFIE) framework. A random effects meta-analysis was conducted to study the overall effectiveness of the included care models on health-related quality of life, activities of daily living, hospitalisation, emergency department visits, nursing home admissions or mortality. Risk of bias was appraised using the revised Cochrane risk-of-bias tool for randomized trials and ROBINS-I tool for non-randomized studies. RESULTS: Nineteen studies were included studying a total of 22,168 patients. Core components of integrated care for multimorbid patients such as the involvement of a multidisciplinary team, high risk screening, tailored holistic assessment and an individualized care plan, were performed in a vast majority of the studies; however variability was observed in their operationalisation. Twenty-seven different patient, provider and service outcomes were reported, ranging from 1 to 13 per study. The meta-analyses could not demonstrate a beneficial impact on any of the predefined outcomes. Most included studies were of high risk for several biases. CONCLUSION: The summarized evidence on nurse-led integrated care models in home-dwelling older people is inconclusive and of low quality. Future studies should include key components of implementation research, such as context analyses, process evaluations and proximal outcomes, to strengthen the evidence-base of nurse-led integrated care.

Laser therapy of painful shoulder and shoulder-hand syndrome in treatment of patients after the stroke.

The common complication after stroke is pain and dysfunction of shoulder of paralyzed arm, as well as the swelling of the hand. The aim of this study was to determine the effects of LASER therapy and to correlate with electrotherapy (TENS, stabile galvanization) in subjects after stroke. We analyzed 70 subjects after stroke with pain in shoulder and oedema of paralyzed hand. The examinees were divided in two groups of 35, and they were treated in the Clinic for Physical Medicine and Rehabilitation in Tuzla during 2006 and 2007. Experimental group (EG) had a treatment with LASER, while the control group (CG) was treated with electrotherapy. Both groups had kinesis therapy and ice massage. All patients were examined on the admission and discharge by using the VAS, DASH, Barthel index and FIM. The pain intensity in shoulder was significantly reduced in EG (p<0,0001), swelling is lowered in EG (p=0,01). Barthel index in both groups was significant higher (p<0,01). DASH was significantly improved after LASER therapy in EG (p<0,01). EG had higher level of independency (p<0,01). LASER therapy used on EG shows significantly better results in reducing pain, swelling, disability and improvement of independency.

Check list of symptoms SCL-90-R at persons with extremities amputations.

Multidimensional Inventory Check List of Symptoms (SCL-90-r) is based on self-evaluation and it has been used for determination of level of: somatisation, obsessive-compulsive symptoms, interpersonal sensitivity, depression, anxiety, hostility, phobias, paranoia and psychosis at persons which are exposed to long term emotional and physical stress. Our goal was to determine relations of physical trauma and psychological changes at persons with lower extremities amputations and to determine factors which influence those changes. Thirty seven persons with lower extremities amputations were examined. The sample included 26 (70.2 %) veterans and 11 (29.7 %) civilians with diseases related amputations. They voluntarily filled Check List of Symptoms SCL-90-r. Symptoms Inventory includes 9 dimensions of primary symptoms: SCL1-somatisation, SCL2-obsessive-compulsive symptoms, SCL3-interpersonal sensitivity, SCL4-depression, SCL5-anxiety, SCL6-hostility, SCL7-phobias, SCL8-paranoia, SCL9-psychosis and SCL10-extra scale. Inventory includes 90 statements, each evaluated with five-level scale of disorder. Every answer is graded with 0-4 points. Thirty seven persons with lower extremities amputations and average chronological age 46.2 +/- 10.92 years were analyzed. Considering marital status 30 (81.1 %) of them were married, 4 (10.8 %) were not married and 3 (8.1 %) were widowers. Considering level of amputation 27 of them (73.0 %) had amputation below knee, 5 (13.5 %) of them amputation above knee and 5 of them (13.5 %) foot amputation. SCL-90-r in both groups determined high level of sensitivity, anxiety, hostility and paranoia. Veterans showed higher level of paranoia comparing to civilians (p<0.002), and younger veterans and married ones had higher level of paranoia comparing to other veterans (p<0.01). Persons with amputations below and above knee showed higher level of paranoia comparing those with foot amputation (p<0.001). Persons with lower extremities amputations have considerably more expressed sensitivity, anxiety, hostility and paranoia. These dimensions are related to age, marital status and level of amputation. These determinants are very helpful for planning and creation of psychological support and rehabilitation of persons with lower extremities amputations.

[Recovery of walk in persons with stroke and heart disease]. / Oporavak hoda kod osoba sa mozdanim udarom koji imaju bolesti srca.

The goal of this research is to analyze the differences in recovery of walk of two groups of patients who have suffered the stroke--those who have and have not suffered from heart disease prior to the stroke. Test group consisted of patients who have suffered the stroke, and have been rehabilitated in the Clinic for physical medicine and rehabilitation in Tuzla, in 2003. Patients who have had a heart disease before suffering the stroke and have been treated by a cardiologist comprised the first test group (Group I, N=48), while patients without previous heart disease comprised the second test group (Group II, N=69). In relation to their ability to walk, patients have been divided into three groups: those who are able to walk without help, those who are not able to walk and those who are able to walk with a walking aid. Therapies used include kinesiotherapy, paraffin, criotherapy, and electro procedures. Total number of those rehabilitated in the hospital after the stroke is 117, out of which 45 (38.5 %) were women and 72 (61.5 %) men, with average of 68 +/- 9,2 years of age. According to the kind of stroke suffered, 105 patients have had ischemia (89.7 %) and 12 have had hemorrhagia (10.3 %). The highest number of patients have had paralysis of the left side of the body--48 (41.0 %), then paralysis of the right side--43 (36.8 %) and both sides--15 (12.8 %). In relation to the localization of the changes in the brain detected in the CT, the highest number of patients have had multiply lacunar changes--41 (35,0 %), then changes in parietal area--33 (28.2 %) and temporoparietal area--22 (18.8 %), and a bit less had changes in capsula interna--15 (12.8 %), occipital--3 (2.6 %) and cerebellum--3 (2.6 %). In relation to the heart diseases, most of the patients have had compensated weakness of the heart--20 (41.7 %), suffered infarctus myocardii--8 (16.7 %) and atrial fibrillation--8 (16.7 %), with angina pectoris 6 (12,5 %), with arrhitmia--3 (6.3 %) and heart surgery--3 (6.3 %). In relation to their ability to walk at the moment of their admission to the Clinic, 62 (53.0 %) of them were immobile, while at their discharge from the hospital this number decreased to 15 (12.9 %). 14 patients (12.0 %) were able to walk at the moment of the admission, while at the discharge, this number increased to 47 (40.1 %). Differences are statistically significant at the level of p<0,01 for the patients with heart diseases, and p<0.05 for those without a heart disease. Recovery of ability to walk is significantly better with patients that have had multiple lacunar changes, p<0.001, changes in parietal area, p<0.001 and capsula interna, p<0.01. Average hospitalization for the whole test group was 22 +/- 13,6 days--for the Group I it lasted 24 and for the Group II 21 days. Recovery of ability to walk of patients who suffered the stroke is better (p<0.01) if patients have had heart diseases before the stroke, then if patients did not have a previous heart condition (p<0.05), but the average rehabilitation is longer for 3 days.