ABSTRACT
OBJECTIVE: In this paper a new checklist (CLCE-24) for identification of cognitive and emotional problems after stroke is presented. The CLCE-24 is intended to support a clinical interview by health care professionals other than the trained (neuro)psychologist. METHODS: Patients were interviewed with the CLCE-24, 6 months post stroke. Usability was determined by interviews. Quality of the self-report version was determined using reference instruments (MMSE, CAMCOG). RESULTS: Sixty-nine patients participated in the study (37 men; mean age 66 years). Both patients and assessors were positive about the use of the CLCE-24. Eighty percent of the patients had cognitive and/or emotional problems (73% cognitive; 51% emotional problems). Patients with complaints on the CLCE-24 also showed problems on the MMSE and the CAMCOG (p<0.05). The CLCE-24 was a predictor of the MMSE and CAMCOG (Adj. R(2)=0.13 and 0.16, respectively) at 12 months post stroke. Internal consistency of the CLCE-24 was good (alpha of 0.81). CONCLUSIONS: The CLCE-24 is a usable and valid instrument for cognitive screening by health care professionals in the stroke service in the chronic phase after stroke.
Subject(s)
Cognition Disorders/etiology , Expressed Emotion , Mass Screening/methods , Mood Disorders/etiology , Stroke/complications , Surveys and Questionnaires , Aged , Cognition Disorders/diagnosis , Female , Humans , Male , Mood Disorders/diagnosis , Neuropsychological Tests , Reproducibility of Results , Severity of Illness Index , Stroke/diagnostic imaging , Tomography, X-Ray ComputedABSTRACT
BACKGROUND AND PURPOSE: Cognitive and emotional problems are common after stroke and screening is essential. In this paper a new screening instrument is presented and its usability is investigated. METHODS: A group of stroke patients (N = 69) were interviewed using the new instrument, the CLCE-24, six months post stroke. Moreover extensive neuropsychological testing was conducted (including MMSE/CAMCOG). RESULTS: Patients, relatives and assessors (a psychologist) were positive about its use. The interview with the CLCE-24 took 11.1 minutes on average (5-35 minutes). Eighty percent of the patients had complaints; 73% had cognitive problems, while 51% had emotional problems. Patients with at least one complaint on the CLCE-24 scored lower on the MMSE (t=2.5; p = 0.01) and the CAMCOG (t= 2.5; p= 0.02) compared to patients without complaints. CONCLUSIONS: The CLCE-24 can be applied by professionals in primary care for identification of cognitive and emotional complaints after stroke. Further research and implementation in clinical practice and the stroke service is recommended.
Subject(s)
Cognition Disorders/diagnosis , Emotions , Neuropsychological Tests , Stroke/complications , Stroke/psychology , Aged , Cognition Disorders/etiology , Female , Humans , Male , Mass Screening/methods , Netherlands , Time FactorsABSTRACT
The practice guideline 'CVA' from the Dutch College of General Practitioners provides guidelines for the management of stroke patients. The guideline is in agreement with the changing insights about the benefits of stroke-units and thrombolysis. The most important recommendations are the following. In the acute phase, most patients with a cerebrovascular accident should be referred for admission to a stroke-unit. Exceptions are patients with only slight neurological disability and patients with severe comorbidity. Patients with a CVA that started less than three hours ago should be referred for emergency thrombolytic therapy in regions where this possibility exists. In situations in which the general practitioner considers a home visit to involve an unacceptable loss of time, he may decide to refer on the basis of the results of the 'face-arm-speech-time' (FAST) test, which can be administered by telephone. For patients that remain at home, the general practitioner sees to the early start of a rehabilitation programme, and takes the initiative if necessary. The general practitioner can support stroke patients with permanent neurological deficits by considering them to be chronically ill patients requiring regular check-ups.
Subject(s)
Patient Care Management/methods , Physicians, Family/standards , Practice Patterns, Physicians' , Stroke/diagnosis , Stroke/therapy , Emergency Medical Services , Humans , Netherlands , Societies, Medical , Thrombolytic TherapyABSTRACT
The growing number of elderly and chronically ill people causes an increasing demand for care. New patterns in care for geriatric patients are required, to guarantee geriatric care in the future. In the Transmural Model for Geriatric Care, the geriatric nurse practitioner participates in geriatric home consultation. The geriatric nurse practitioner makes the home visits of the geriatrician. First experiences with home consultation by geriatric nurse practitioner are positive. The input of the geriatric nurse practitioner in home consultation has two goals: care substitution and improvement of quality of care. Substitution of care enlarges the possibilities of the geriatrician, which are limited now, because of the enormous demand for geriatric care. The specific tasks of the geriatric nurse practitioner are functional assessment and care coordination.
Subject(s)
Geriatric Assessment , Geriatric Nursing/organization & administration , House Calls , Nurse Practitioners , Nurse's Role , Referral and Consultation , Aged , Female , Geriatric Nursing/methods , Humans , Interviews as Topic , Male , Netherlands , Quality of Health Care/standardsABSTRACT
OBJECTIVE: To assess whether shared care for stroke patients results in better patient outcome, higher patient satisfaction and different use of healthcare services. DESIGN: Prospective, comparative cohort study. SETTING: Two regions in The Netherlands with different healthcare models for stroke patients: a shared care model (stroke service) and a usual care setting. PATIENTS: Stroke patients with a survival rate of more than six months, who initially were admitted to the Stroke Service of the University Hospital Maastricht (experimental group) in the second half of 1997 and to a middle sized hospital in the western part of The Netherlands between March 1997 and March 1999 (control group). MAIN OUTCOME MEASURES: Functional health status according to the SIP-68, EuroQol, Barthel Index and Rankin Scale, patient satisfaction and use of healthcare services. RESULTS: In total 103 patients were included in this study: 58 in the experimental group and 45 in the control group. Six months after stroke, 64% of the surviving patients in the experimental group had returned home, compared to 42% in the control group (p<0.05). This difference could not be explained by differences in health status, which was comparable at that time. Patients in the shared care model scored higher on patient satisfaction, whereas patients in the usual care group received a higher volume of home care. CONCLUSIONS: The Stroke Service Maastricht resulted in a higher number of patients who returned home after stroke, but not in a better health status. Since patients in the usual care group received a higher volume of healthcare in the period of rehabilitation, the Stroke Service Maastricht might be more efficient.
ABSTRACT
The project "Infusion Therapy at Home" studied the practice of parenteral infusion therapy at home. Among the treatment modalities was the administration of morphine infusions to terminally ill patients. With infusion of morphine, patients were pain-free on 73% of the treatment days. Quality of care, quality of life, and costs were acceptable.
Subject(s)
Analgesics, Opioid/administration & dosage , Analgesics, Opioid/therapeutic use , Morphine/administration & dosage , Morphine/therapeutic use , Pain/drug therapy , Adolescent , Adult , Aged , Aged, 80 and over , Female , Home Care Services , Humans , Infusions, Intravenous , Male , Middle Aged , Pain/etiology , Prospective Studies , Terminal CareABSTRACT
BACKGROUND: In a population of 85 general practitioners diagnostic test ordering behaviour has been changed by means of repeated individual feedback provided since 1985. OBJECTIVES: We studied practitioner and practice characteristics which may explain differences in test ordering behaviour and in the extent to which general practitioners tend to change their behaviour according to the feedback. METHOD: In order to trace such variables, 75 general practitioners were interviewed. In our study request data from individual general practitioners were related to data from several questionnaires. RESULTS: We found no practice characteristics which were of influence on the number of test requests by the general practitioner. Explanatory practitioner characteristics for this were found to be years of experience and working hours per week in practice. CONCLUSIONS: More years of experience as a general practitioner and a shorter duration of consultations correlated with a better response to advice given in the feedback.
Subject(s)
Clinical Laboratory Techniques , Family Practice , Practice Patterns, Physicians' , Adult , Feedback , Female , Health Knowledge, Attitudes, Practice , Humans , Male , Netherlands , Physicians, Family/education , Physicians, Family/psychology , Surveys and QuestionnairesABSTRACT
Joint consultation sessions between general practitioners (GPs) and specialists to examine patients for whom decisions about referral are difficult are thought to be helpful, but their effects have not been evaluated. In a randomised, controlled trial we studied the effects of joint sessions of GPs and orthopaedic surgeons on referral and intervention rates. During 1.5 years, 12 GPs (in groups of three) held monthly joint consultation sessions with four participating orthopaedic surgeons: patients were seen by one orthopaedic surgeon in the presence of three GPs. Patients were included in the trial if the GP was uncertain about the diagnostic or therapeutic management and if referral was considered; and excluded if referral was urgently necessary or if there was some other clear indication for referral. By a randomised consent design, patients were assigned to joint consultation sessions (n = 144) or a usual-care control group (n = 128). A year later the patients were examined by an independent orthopaedic surgeon. There were significantly fewer referrals (51/144 [35%] vs 87/128 [68%], p < 0.01) and diagnostic actions in the intervention group than in the control group, without negative effects on health or functional status. More patients in the intervention group were symptom-free at 1 year (35% vs 24%, p < 0.05). Joint consultation sessions of GPs and orthopaedic surgeons within the framework of general practice resulted in more efficient care, with better targeted examination, treatment, and referrals.
Subject(s)
Family Practice , Movement Disorders/diagnosis , Orthopedics , Patient Care Team/organization & administration , Female , Humans , Interprofessional Relations , Male , Middle Aged , Movement Disorders/therapy , Referral and Consultation/organization & administration , Regression AnalysisABSTRACT
BACKGROUND: Individual feedback on general practitioners' requests for tests can improve the quality of their test ordering behaviour. Little is known of the side effects on hospital referral behaviour when the use of tests is reduced through feedback. AIM: A study was undertaken to explore changes in general practitioners' hospital referral rates in a region where their use of diagnostic tests is reduced through feedback. METHOD: Trends in test requests and of first referrals to specialists were compared among 64 general practitioners in the Maastricht region of the Netherlands where routine feedback on test ordering behaviour is provided by the diagnostic coordinating centre. RESULTS: Reduction in diagnostic test use was not accompanied by a higher hospital referral rate, not even for specialties related to tests discussed in feedback. Good responders to feedback had decreased hospital referral rates in contrast to increased rates for poor responders (P < 0.01). CONCLUSION: Reducing the volume of general practitioners' diagnostic tests through feedback does not lead to more specialist referrals. Together with lower test use, fewer hospital referrals were seen.
Subject(s)
Diagnostic Tests, Routine/statistics & numerical data , Family Practice/statistics & numerical data , Referral and Consultation/statistics & numerical data , Humans , Retrospective Studies , WorkloadABSTRACT
Feedback can be described as a way to provide information on doctors' performance to enable changes in future behaviour. Feedback is used with the aim of changing test-ordering behaviour. It can lead to reductions in test usage and cost savings. It is not sufficiently clear, however, whether feedback leads to more appropriate test use. Since 1985, the Diagnostic Coordinating Center Maastricht has been giving feedback on diagnostic tests as a routine health care activity to all family doctors in its region. Both quantity and quality of requests are discussed. In a randomised, controlled trial over 2.5 years, discussion of tests not included previously was added to the existing routine feedback. One group of family doctors (n = 39) received feedback on test-group A (electrocardiography, endoscopy, cervical smears, and allergy tests), the other (n = 40) on test-group B (radiographic and ultrasonographic tests). Thus, each group of doctors acted as a control group for the other. Changes in volume and rationality of requests were analysed. The number of requests decreased during the trial (p = 0.036). Request numbers decreased particularly for test-group A (p = 0.04). The proportion of requests that were non-rational decreased more in the intervention than in the control groups (p = 0.009). Rationality improved predominantly for test-group B (p = 0.043). Thus, routine feedback can change the quantity and quality of requests.
Subject(s)
Diagnostic Services/statistics & numerical data , Feedback , Humans , Physicians/psychologyABSTRACT
In order to obtain insight into general practitioners' (GPs) point of view regarding climacteric problems and possible treatment, a survey was conducted among 195 GPs in the Limburg Province in the Netherlands. Ultimately, 159 GPs participated (response-rate 82%). The GPs were either members of the Society for the Improvement of the Expertise of GPs, or filled out the questionnaire previous to participation in a medical training course. The climacteric and its typically related complaints were generally well recognized by the surveyed GPs. Ninety-five percent of the GPs were of the opinion that women with climacteric complaints need some kind of medical help, and 62% were found to prescribe medication, mainly hormone replacement therapy (HRT). Remarkably, 75% of all GPs were of the opinion that prescribing HRT for climacteric complaints is a form of medicalization. Twelve percent of the GPs stated they never prescribe HRT for solely preventive purposes. In case of preventive treatment merely 32% of the GPs prescribed HRT for a period longer than 5 years.
