Search

Background: The aim of this study is evaluating the (cost-) effectiveness of a multidisciplinary, evidence based care program to improve the management of depression in nursing home residents of somatic and dementia special care units. The care program is an evidence based standardization of the management of depression, including standardized use of measurement instruments and diagnostical methods, and protocolized psychosocial, psychological and pharmacological treatment. Methods/Design: In a 19-month longitudinal controlled study using a stepped wedge design, 14 somatic and 14 dementia special care units will implement the care program. All residents who give informed consent on the participating units will be included. Primary outcomes are the frequency of depression on the units and quality of life of residents on the units. The effect of the care program will be estimated using multilevel regression analysis. Secondary outcomes include accuracy of depression-detection in usual care, prevalence of depression-diagnosis in the intervention group, and response to treatment of depressed residents. An economic evaluation from a health care perspective will also be carried out. Discussion: The care program is expected to be effective in reducing the frequency of depression and in increasing the quality of life of residents. The study will further provide insight in the cost-effectiveness of the care program. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To construct a set of quality indicators (QIs) for dementia diagnosis and management in a primary care setting. DESIGN: RAND modified Delphi method, including a postal survey, a stakeholders consensus meeting, a scientific expert consensus meeting, and a demonstration project. SETTING: Primary care. PARTICIPANTS: General practitioners (GPs), primary care nurses (PCNs), and informal caregivers (ICs) in postal survey and stakeholders consensus meeting. Eight national dementia experts in scientific consensus meeting. Thirteen GPs in the demonstration project. MEASUREMENTS: Mean face validity and feasibility scores. Compliance rates using GPs' electronic medical record data. RESULTS: The initial set consisted of 31 QIs. Most indicators showed moderate or good face validity and feasibility scores. Consensus panels reduced the preliminary set used in the demonstration project to 24 QIs. The overall compliance to the QIs was 45.3%. Discriminative validity of the set was good; significant differences in adherence were found between GPs with high and low levels of patients aged 65 and older in their practice, with and without PCNs, and with positive and negative attitudes toward dementia (all P<.05). Based on the demonstration project, one QI was excluded. The final set consisted of 23 QIs; 15 QIs contained innovative quality criteria on collaboration between GPs and PCNs, referral criteria, and assessment of caregivers' needs. CONCLUSION: This new set of dementia QIs is feasible, reliable, and valid and can be used to improve primary dementia care. Because of the innovative quality criteria, the set is complementary to the existing dementia QIs. [ABSTRACT FROM AUTHOR]

Objective: caregiver effects of geriatric care models focusing primarily at the patient have not been consistently studied. We studied caregiver effects of a nurse-led comprehensive geriatric evaluation and management (GEM) programme for community-dwelling frail older people that showed--in a randomised comparison with usual care--health-related quality of life benefits for the care receivers. Methods: this randomised trial included 110 caregiver/patient dyads who were followed up for 6 months. Primary analyses were intention-to-treat analyses of caregiver burden assessed with Zarit Burden Interview (ZBI; 0-88; higher means more burden). Preplanned subgroup analyses were conducted for cognition, living arrangement and patient/caregiver co-residence. Results: overall, perceived caregiver burden showed no significant differences between study groups in changes over time. However, perceived burden was at baseline more than eight points higher in caregivers sharing a household with patients (n = 23) compared to caregivers living separately (n = 87). The intervention performed better in caregivers living together with the patient than in caregivers living separately (P for interaction = 0.04). Co-resident caregivers experienced six-Zarit point improvement compared with four-point deterioration in the non-co-resident caregivers. Conclusions: GEM at home benefited patients, but maybe not caregivers. Caregiver effects are related to whether caregivers live with the patient or not. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor about diagnosing dementia in primary care.

Objective This study reviews the evidence for effects of combined intervention programmes for both the informal caregiver and the person with dementia. Method Systematic review. Electronic databases and key articles were searched for effect studies of combined programmes, published between January 1992 and February 2005. The resulting 52 reports were scored according to set inclusion criteria. Results Twenty five reports relating to 22 programmes met the inclusion criteria. Various aspects of caregivers' mental health and burden were studied. Best results were obtained regarding general mental health. Other aspects often showed modest and varying results. Caregivers' competence was less often addressed. The effects on the cognitive and physical functioning, behavioural problems and survival of the persons with dementia were modest and inconsistent, whereas their mental health is positively affected and admittance to long stay care is often delayed. Conclusion Combined programmes may improve some, not all, aspects of functioning for caregiver and person with dementia. Care professionals must define their programme goals and target groups before advising their clients on a combined programme. Research may focus on the effects of programmes that were introduced fairly recently and on subgroups of caregivers (female caregivers, depressed caregivers and people with dementia, and minorities). Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To gain insight into the experiences of a palliative care patient and her husband who were living on borrowed time. Methods: A qualitative single case design was used. Systematic content analysis of the interview data, obtained in an in-depth semi-structured interview, from the husband and wife was conducted to extract themes relating to living on borrowed time. Results: Three themes were identified: shifts in the interpretation of physical signs and symptoms, altered view of the future and altered choices and priorities. Conclusion: The identified themes lead to a better understanding of the phenomenon of living on borrowed time. Yet, refinement of, and variation within the themes still need to be studied in order to get more grips on the themes and to be better able to help patients to integrate the ‘new reality’. Practice implications: Our findings can be used to support professionals in the practical application of care when their patients need to integrate the ‘new reality’ and seek new equilibrium, e.g. converted into a conversational guide, or used for educational purposes. [Copyright &y& Elsevier]

Introduction: In the Netherlands, healthcare professionals are able to consult Palliative Care Consultation (PCC) teams about individual patients, for information, support and advice. This study aims to understand which spiritual issues are discussed in these consultations and to determine which factors influence whether they are raised or not. Methods: The national register of the consultations of the PCC teams was analysed for a two-year period. Results: Spiritual issues played a role in 8.4% of palliative care consultations, of which 4.1% were by phone and 18.3% were bedside consultations. Often spiritual issues were raised by the consultant during the exploration of the request from the caregiver; the discipline of the consultant rather than the discipline of the requesting professional or the patient characteristics determined whether or not such issues were raised. The main support given by the consultant was in coaching the professional caregiver on how to address these issues. Discussion: This study demonstrates the important role of PCC team consultants in exploring and identifying the spiritual needs of patients about whom they are consulted. Although continued education in spiritual care for palliative care professionals is essential, PCC team consultants will play an important role in drawing the attention of healthcare professionals to the need to recognize and address the spiritual needs of their patients. [ABSTRACT FROM AUTHOR]

Abstract: Palliative Care Consultation (PCC) teams in The Netherlands give support to professional caregivers in palliative care. In contrast to many other countries, consultants only give advice. They do not give prescriptions. Most consultations are given by phone; in some, the consultant also visits the patient. For two years, the PCC teams registered all consultations prospectively on a standard registration form in a nationwide database. The aim of this study was to obtain more insight into the possible differences between telephone and bedsides consultations with regard to characteristics of consultants, requesting caregivers, and the patients, as well as the number and kind of problems discussed. The data demonstrate that bedside consultations show more variety in requesting caregivers and are conducted more often for patients. Bedside consultations also addressed a higher number of problems and a wider range of domains (e.g., psychological, spiritual, daily functioning, and support for informal caregivers). These results suggest that bedside consultations have a surplus value compared to telephone consultations. More rigorous study is needed to compare the relative merits of different methods of consultations in palliative care. [Copyright &y& Elsevier]

Palliative care in The Netherlands is mainly provided by generalist professionals who are part of the regular health care system. In order to provide good quality palliative care, they need options for training and consultation. Therefore, Palliative Care Consultation (PCC) teams were established, which inform, support, and advise professional caregivers involved with patients in palliative care without taking over responsibility. This study is the first nationwide study on PCC teams. Investigated was the nature and effect of consultations by registration and evaluation of consultations given by 19 PCC teams during a one-year period. Sixty-one percent of the requesting caregivers were primary care professionals and the problems discussed covered the entire field of palliative care, although physical problems played a dominant role. Although the patient was often not seen by the consultant, the consultant appeared to be able to identify more problems than initially discussed by the requesting professional. The types of problems discussed were hardly related to patient characteristics but more related to the discipline of the professional caregiver. According to the requesting professionals, consultation was helpful and contributed to improving the quality of palliative care. [Copyright &y& Elsevier]

This study presents a comprehensive overview of the problems patients experience in a palliative phase of cancer. A two-step qualitative method was used: in-depth interviews with patients and relatives (N=9 patients+7 relatives), followed by interviews (N=31patients+15 relatives) using a checklist to confirm and complete the picture. Quality of life and quality of care domains were addressed. Patients experienced problems in all of these palliative care domains, although individual patients may have experienced only a few problems. Fatigue, feelings of futility, reluctance to accept help, fear of suffering and the fear that help would not be available if needed, were common problems. Communication problems arose when a grudge against a GP had remained, or because one family member tried to spare the other a confrontation with his/her feelings of fear or grief. A comprehensive checklist of relevant problems is presented. [ABSTRACT FROM AUTHOR]

Objective To evaluate the efficiency of the CAMDEX by exploring the contribution of its four main screening measures to the diagnosis of dementia at a memory clinic. Methods A retrospective descriptive study was conducted on the diagnostic practice in a memory clinic regarding all consecutively referred patients who came for a first assessment. A standardised examination based on the CAMDEX included three cognitive tests (CAMCOG, MMSE, IMCT) and a test for functional competence (BDS). The predictive value of the tests was estimated by uni- and multivariate analysis with the clinical dementia diagnosis (yes/no) as dependent variable, taking into account the patients' age, education, gender and sensory ability. Results Of the 180 patients consecutively referred, 150 completed the assessments and entered the study. Multivariate analysis revealed that the CAMCOG-score contributed most to the clinical diagnosis and was consistent with 84% of the clinical diagnoses using the conventional cutoff 79/80. The CAMCOG-score correlated best with the clinical diagnosis, however, at a cutoff score of 81/82. Forty-one patients (27%) scored closely around (±5 points) the CAMCOG cutoff of 79/80. In this group 19 of the total of 23 deviations from the CAMCOG cutoff (83%) occurred. The patients' age, education, gender and visual ability explained some cases where the team's diagnosis deviated from the conventional cutoff score. Conclusion Among four screening measures, after control, the CAMCOG was the only significant predictor for the clinical diagnosis of dementia. To gain efficiency, the screening measures of the CAMDEX protocol may be restricted to the CAMCOG. The interpretation of CAMCOG-scores around the cut-off is problematic. This indicates the need for reference values. Copyright © 2001 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: General practitioners (GPs) are advised to offer advance care planning (ACP) to people with dementia (PWD). In a randomized controlled trial, an educational intervention for GPs aimed at initiating and optimizing ACP proved to be effective. During the intervention most GPs were accompanied by their practice nurse (PN). To provide insights into the intervention's successful components and what could be improved, we conducted a process evaluation and explored implementation, mechanisms of impact and contextual factors. Methods: We used the Medical Research Council guidance for process evaluations. Implementation was explored identifying reach and acceptability. We performed descriptive analyses of participants' characteristics; selection, inclusion and intervention attendance; a GP post-intervention survey on initiating ACP; a post intervention focus group with trainers of the intervention. Mechanisms of impact were explored identifying adoption and appropriateness. We used: participants' intervention ratings; a GP post-intervention survey on conducting ACP; ACP documentation in PWD's medical files; post-intervention interviews with PWD/FC dyads. All data was used to identify contextual factors. Results: The intervention was implemented by a small percentage of the total Dutch GP population invited, who mostly included motivated PWD/FC dyads with relatively little burden, and PWD with limited cognitive decline. The mechanisms of impact for GPs were: interactively learning to initiate ACP with training actors with a heterogeneous group of GPs and PNs. For PWD/FCs dyads, discussing non-medical preferences was most essential regarding their SDM experience and QoL. Some dyads however found ACP stressful and not feasible. Younger female GPs more often initiated ACP. Male PWD and those with mild dementia more often had had ACP. These characteristics and the safe and intimate training setting, were important contextual facilitators. Conclusion: We recommend Interventions aimed at improving ACP initiation with PWD by GPs to include interactive components and discussion of non-medical preferences. A safe environment and a heterogeneous group of participants facilitates such interventions. However, in practice not all FC/PWD dyads will be ready to start. Therefore, it is necessary to check their willingness when ACP is offered. [ABSTRACT FROM AUTHOR]

Background: The number of residents in long-term care facilities (LTCFs) in need of palliative care is growing in the Western world. Therefore, it is foreseen that significantly higher percentages of budgets will be spent on palliative care. However, cost-effectiveness analyses of palliative care interventions in these settings are lacking. Therefore, the objective of this paper was to assess the cost-effectiveness of the 'PACE Steps to Success' intervention. PACE (Palliative Care for Older People) is a 1-year palliative care programme aiming at integrating general palliative care into day-to-day routines in LTCFs, throughout seven EU countries.Methods: A cluster RCT was conducted. LTCFs were randomly assigned to intervention or usual care. LTCFs reported deaths of residents, about whom questionnaires were filled in retrospectively about resource use and quality of the last month of life. A health care perspective was adopted. Direct medical costs, QALYs based on the EQ-5D-5L and costs per quality increase measured with the QOD-LTC were outcome measures.Results: Although outcomes on the EQ-5D-5L remained the same, a significant increase on the QOD-LTC (3.19 points, p value 0.00) and significant cost-savings were achieved in the intervention group (€983.28, p value 0.020). The cost reduction mainly resulted from decreased hospitalization-related costs (€919.51, p value 0.018).Conclusions: Costs decreased and QoL was retained due to the PACE Steps to Success intervention. Significant cost savings and improvement in quality of end of life (care) as measured with the QOD-LTC were achieved. A clinically relevant difference of almost 3 nights shorter hospitalizations in favour of the intervention group was found. This indicates that timely palliative care in the LTCF setting can prevent lengthy hospitalizations while retaining QoL. In line with earlier findings, we conclude that integrating general palliative care into daily routine in LTCFs can be cost-effective.Trial Registration: ISRCTN14741671 . [ABSTRACT FROM AUTHOR]

A letter to the editor about dementia care as a multidisciplinary collaboration is presented.

Background: Several studies have highlighted the need for improvement in palliative care delivered to older people long-term care facilities. However, the available evidence on how to improve palliative care in these settings is weak, especially in Europe. We describe the protocol of the PACE trial aimed to 1) evaluate the effectiveness and cost-effectiveness of the ‘PACE Steps to Success’ palliative care intervention for older people in long-term care facilities, and 2) assess the implementation process and identify facilitators and barriers for implementation in different countries. Methods: We will conduct a multi-facility cluster randomised controlled trial in Belgium, Finland, Italy, the Netherlands, Poland, Switzerland and England. In total, 72 facilities will be randomized to receive the ‘Pace Steps to Success intervention’ or to ‘care as usual’. Primary outcome at resident level: quality of dying (CAD-EOLD); and at staff level: staff knowledge of palliative care (Palliative Care Survey). Secondary outcomes: resident’s quality of end-of-life care, staff self-efficacy, self-perceived educational needs, and opinions on palliative care. Economic outcomes: direct costs and quality-adjusted life years (QALYs). Measurements are performed at baseline and after the intervention. For the resident-level outcomes, facilities report all deaths of residents in and outside the facilities over a previous four-month period and structured questionnaires are sent to (1) the administrator, (2) staff member most involved in care (3) treating general practitioner, and (4) a relative. For the staff-level outcomes, all staff who are working in the facilities are asked to complete a structured questionnaire. A process evaluation will run alongside the effectiveness evaluation in the intervention group using the RE-AIM framework. Discussion: The lack of high quality trials in palliative care has been recognized throughout the field of palliative care research. This cross-national cluster RCT designed to evaluate the impact of the palliative care intervention for long-term care facilities ‘PACE Steps to Success’ in seven countries, will provide important evidence concerning the effectiveness as well as the preconditions for optimal implementation of palliative care in nursing homes, and this within different health care systems. Trial registration: The study is registered at www.isrctn.com – ISRCTN14741671 (FP7-HEALTH-2013-INNOVATION-1 603111) Registration date: July 30, 2015. [ABSTRACT FROM AUTHOR]

Objectives Although a growing number of older people are dying in care homes, palliative care has developed in these settings only recently. Cross-country representative comparative research hardly exists in this area. As part of a large EU-funded project, we aim to undertake representative comparative research in care homes in Europe, to describe and compare 6 countries in terms of (1) resident outcomes, quality and costs of palliative and end-of-life care; and (2) palliative care structures and staff knowledge and attitudes toward palliative care. We also aim to explore country, facility, staff, patient, and care characteristics related to better outcomes at resident level. Design and Methods To obtain a representative nationwide sample, we will conduct a large-scale cross-sectional study of deceased residents in care homes in Belgium, Finland, Italy, the Netherlands, Poland, and the United Kingdom, using proportional stratified random sampling (taking into account region, facility type and bed capacity). In each country, all participating care homes retrospectively report all deaths of residents in and outside the facilities over the previous 3-month period. For each case, structured questionnaires, including validated instruments, are sent to (1) the administrator/manager, (2) staff member most involved in care, (3) treating physician (general practitioner or elderly care physician), and (4) a closely involved relative. It is estimated that, per country, 50 care homes are needed on average to obtain a minimum of 200 deceased residents. Collected data include clinical and sociodemographic characteristics, quality of dying, quality and costs of palliative care and end-of-life care, and palliative care structures at the facility level and country level. To obtain a representative view of staff knowledge and attitudes regarding palliative care, PACE will conduct a cross-sectional study of staff working in the participating care homes. Conclusion Considering the growing challenges associated with aging in all European countries, there is an urgent need to build a robust international comparative evidence base that can inform the development of policies to target improved palliative care in care homes. By describing this research protocol, we hope to inform international research in care homes on how to perform representative end-of-life care research in these settings and better understand which systems are associated with better outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Background: A multidisciplinary, evidence-based care program to improve the management of depression in nursing home residents was implemented and tested using a stepped-wedge design in 23 nursing homes (NHs): “Act in case of Depression” (AiD). Objective: Before effect analyses, to evaluate AiD process data on sampling quality (recruitment and randomization, reach) and intervention quality (relevance and feasibility, extent to which AiD was performed), which can be used for understanding internal and external validity. In this article, a model is presented that divides process evaluation data into first- and second-order process data. Methods: Qualitative and quantitative data based on personal files of residents, interviews of nursing home professionals, and a research database were analyzed according to the following process evaluation components: sampling quality and intervention quality. Setting: Nursing home. Results: The pattern of residents’ informed consent rates differed for dementia special care units and somatic units during the study. The nursing home staff was satisfied with the AiD program and reported that the program was feasible and relevant. With the exception of the first screening step (nursing staff members using a short observer-based depression scale), AiD components were not performed fully by NH staff as prescribed in the AiD protocol. Conclusion: Although NH staff found the program relevant and feasible and was satisfied with the program content, individual AiD components may have different feasibility. The results on sampling quality implied that statistical analyses of AiD effectiveness should account for the type of unit, whereas the findings on intervention quality implied that, next to the type of unit, analyses should account for the extent to which individual AiD program components were performed. In general, our first-order process data evaluation confirmed internal and external validity of the AiD trial, and this evaluation enabled further statistical fine tuning. The importance of evaluating the first-order process data before executing statistical effect analyses is thus underlined. [ABSTRACT FROM AUTHOR]

Abstract: Background: A multidisciplinary, evidence-based care program to improve the management of depression in nursing home residents was implemented and tested using a stepped-wedge design in 23 nursing homes (NHs): “Act in case of Depression” (AiD). Objective: Before effect analyses, to evaluate AiD process data on sampling quality (recruitment and randomization, reach) and intervention quality (relevance and feasibility, extent to which AiD was performed), which can be used for understanding internal and external validity. In this article, a model is presented that divides process evaluation data into first- and second-order process data. Methods: Qualitative and quantitative data based on personal files of residents, interviews of nursing home professionals, and a research database were analyzed according to the following process evaluation components: sampling quality and intervention quality. Setting: Nursing home. Results: The pattern of residents’ informed consent rates differed for dementia special care units and somatic units during the study. The nursing home staff was satisfied with the AiD program and reported that the program was feasible and relevant. With the exception of the first screening step (nursing staff members using a short observer-based depression scale), AiD components were not performed fully by NH staff as prescribed in the AiD protocol. Conclusion: Although NH staff found the program relevant and feasible and was satisfied with the program content, individual AiD components may have different feasibility. The results on sampling quality implied that statistical analyses of AiD effectiveness should account for the type of unit, whereas the findings on intervention quality implied that, next to the type of unit, analyses should account for the extent to which individual AiD program components were performed. In general, our first-order process data evaluation confirmed internal and external validity of the AiD trial, and this evaluation enabled further statistical fine tuning. The importance of evaluating the first-order process data before executing statistical effect analyses is thus underlined. [Copyright &y& Elsevier]

Background: One-half of patients with cancer have pain. In nearly one out of two cancer patients with pain, this was undertreated. Inadequate pain control still remains an important problem in this group of patients. Therefore, in 2008 a national, evidence-based multidisciplinary clinical practice guideline 'pain in patients with cancer' has been developed. Yet, publishing a guideline is not enough. Implementation is needed to improve pain management. An innovative implementation strategy, Short Message Service with Interactive Voice Response (SVS-IVR), has been developed and pilot tested. This study aims to evaluate on effectiveness of this strategy to improve pain reporting, pain measurement and adequate pain therapy. In addition, whether the active role of the patient and involvement of caregivers in pain management may change.Methods/design: A cluster randomised controlled trial with two arms will be performed in six oncology outpatient clinics of hospitals in the Southeastern region of the Netherlands, with three hospitals in the intervention and three in the control condition. Follow-up measurements will be conducted in all hospitals to study the long-term effect of the intervention. The intervention includes training of professionals (medical oncologists, nurses, and general practitioners) and SMS-IVR to report pain in patients with cancer to improve pain reporting by patients, pain management by medical oncologists, nurses, and general practitioners, and decrease pain intensity.Discussion: This innovative implementation strategy with technical tools and the involvement of patients, may enhance the use of the guideline 'pain in patients with cancer' for pain management. Short Message Service alerts may serve as a tool to support self-management of patients. Therefore, the SMS-IVR intervention may increase the feeling of having control over one's life.Trial Registration: [corrected] Netherlands Trial Register (NTR): NTR2739. [ABSTRACT FROM AUTHOR]