Emerging technologies and their potential for generating new assistive technologies.

Limited access to assistive technology (AT) is a well-recognized global challenge. Emerging technologies have potential to develop new assistive products and bridge some of the gaps in access to AT. However, limited analyses exist on the potential of these technologies in the AT field. This paper describes a study that aimed to provide an overview of emerging technological developments and their potential for the AT field. It involved conducting a gray literature review and patent analysis to create an overview of the emerging enabling technologies that may foster the development of new AT products and services and identify emerging AT applications. The analysis identified seven enabling technologies that are relevant to the AT field. These are artificial intelligence, emerging human-computer interfaces, sensor technology, robotics, advances in connectivity and computing, additive manufacturing and new materials. Whilst there are over 3.7 million patents related to these enabling technologies, only a fraction of them - 11,000 patents were identified in the analysis specifically related to AT (0.3%). The paper presents some of the promising examples. Overall, the results indicate that there is an enormous potential for new AT solutions that capitalize on emerging technological advances.

High seroprevalence of COVID-19 infection in a large slum in South India; what does it tell us about managing a pandemic and beyond?

People living in urban slums or informal settlements are among the most vulnerable communities, highly susceptible to coronavirus disease 2019 (COVID-19) infection and vulnerable to the consequences of the measures taken to control the spread of the virus. Fear and stigma related to infection, mistrust between officials and the population, the often-asymptomatic nature of the disease is likely to lead to under-reporting. We conducted a cross-sectional study to determine the seroprevalence of COVID-19 infection in a large slum in South India 3 months after the index case and recruited 499 adults (age >18 years). The majority (74.3%) were females and about one-third of the population reported comorbidities. The overall seroprevalence of IgG antibody for COVID-19 was 57.9% (95% CI 53.4-62.3). Age, education, occupation and the presence of reported comorbidities were not associated with seroprevalence (P-value >0.05). Case-to-undetected-infections ratio was 1:195 and infection fatality rate was calculated as 2.94 per 10 000 infections. We estimated seroprevalence of COVID-19 was very high in our study population. The focus in this slum should shift from infection prevention to managing the indirect consequences of the pandemic. We recommend seroprevalence studies in such settings before vaccination to identify the vulnerability of COVID-19 infection to optimise the use of insufficient resources. It is a wake-up call to societies and nations, to dedicate paramount attention to slums into recovery and beyond - to build, restore and maintain health equity for the 'Health and wellbeing of all'.

[The psychometric properties of three self-report screening instruments for identifying frail older people in the community]. / Psychometrische eigenschappen van drie screeningsinstrumenten voor kwetsbaarheid bij thuiswonende ouderen.

BACKGROUND: Frailty can lead towards serious adverse consequences, such as disability. With regard to prevention valid screening instruments are needed to identify frail older people. The aim was to evaluate and compare the psychometric properties of three screening instruments: the Groningen Frailty Indicator (GFI), the Tilburg Frailty Indicator (TFI) and the Sherbrooke Postal Questionnaire (SPQ). For validation purposes the Groningen Activity Restriction Scale (GARS) was added. METHODS: A questionnaire was sent to 687 older people (> or = 70 years). (1) Agreement between instruments, (2) internal consistency, (3) cumulative scalability according to Mokken scale analysis and (4) construct validity were evaluated. RESULTS: The response rate was 77%. Prevalence estimates of frailty ranged from 40% to 59%. The highest agreement was found between the GFI and TFI (Cohen's kappa = 0.74). Cronbach's alpha for the GFI, TFI and SPQ was 0.73, 0.79 and 0.26, respectively. The scalability of the three instruments was inadequate (Loevinger's H: 0.28, 0.30 and 0.09 for GFI, TFI and SPQ, respectively). Frailty scores correlated significantly with each other and with the GARS scores. CONCLUSION: Especially the GFI and TFI seem to be useful to identify frail older people. Further research regarding their predictive validity is still needed.

Impact of environmental factors on community participation of persons with an intellectual disability: a systematic review.

STUDY DESIGN: A systematic review of the literature. OBJECTIVES: To describe which environmental factors have an impact on community participation of persons with an intellectual disability. METHODS: A systematic literature search was conducted for the period of 1996-2006 in Pubmed, CINAHL and PSYCINFO. Search terms were derived from the International Classification of Functioning, Disability and Health. Three investigators assessed the relevance of the studies identified using predefined selection criteria. Aspects of community participation included were: domestic life; interpersonal interactions and relationships; major life areas; community, civic and social life. Environmental factors included were: products and technology; natural environment and human-made changes to environment; support and relationships; attitudes; services, systems and policies. RESULTS: Out of 236 initial hits, 9 quantitative studies and 2 qualitative studies met the predefined selection criteria and were included in the study. Various research instruments were used in the studies and only one study used a conceptual framework. The review allowed the identification of a number of environmental factors positively affecting participation: opportunities to make choices; variety and stimulation of the environment of facilities; opportunities for resident involvement in policy making; small residential facilities; opportunities for autonomy; vocational services; social support; family involvement; assistive technology; and positive staff attitudes. A number of identified environmental factors negatively affecting participation are: lack of transport and not feeling accepted. DISCUSSION: It can be concluded that little has been published about the impact of environmental factors on community participation. Many studies do not clearly define the concept of community participation. Research on the impact of environmental factors on community participation so far seems not to be based on a theoretical framework. Most studies focused on the impact of services on community participation in general.

Existing models and instruments for the selection of assistive technology in rehabilitation practice.

OBJECTIVES: To review models and instruments for the selection and advisory process of assistive technology in the rehabilitation field as reported in the current scientific literature. DESIGN: Systematic literature review. METHODS: A systematic literature search was conducted in MEDLINE (2003-2007). In a peer-review process with four independent investigators, studies were selected according to predefined inclusion and exclusion criteria. Because of the poor publication situation, non-research sources were included as well. The data extracted and compared are: information concerning the selection process for assistive technology, whether a client-centred approach is used during the selection procedure, the use of models and instruments, and their compatibility with the ICF. RESULTS: The search resulted in 16 papers. None of the studies had an experimental design; nine of the publications were literature reviews. There is a lack of reliable and valid models and instruments for the selection process of assistive technology in the scientific literature. The prevalence of the Matching Person and Technology Model from Scherer (1998) is explicit in the publications. The ICF and ISO 9999 are the only classification systems mentioned in relation to assistive technology, although rarely. CONCLUSION: This is a poorly developed field resulting in a lack of evidence-based procedures for AT selection. Such procedures are important to increase consumer satisfaction and the efficiency of AT provision. There is clearly a need for further research in this field.

Community participation of people with an intellectual disability: a review of empirical findings.

STUDY DESIGN: A systematic review of the literature. OBJECTIVES: To investigate community participation of persons with an intellectual disability (ID) as reported in empirical research studies. METHOD: A systematic literature search was conducted for the period of 1996-2006 on PubMed, CINAHL and PSYCINFO. Search terms were derived from the International Classification of Functioning, Disability and Health. Three investigators assessed the relevance of the initially identified studies using predefined content and methodological selection criteria. Included domains of community participation were: (1) domestic life; (2) interpersonal interactions and relationships; (3) major life areas; and (4) community, civic and social life. RESULTS: Of 2936 initial hits, 23 quantitative studies eventually met the selection criteria and were included in the study. Only two studies are based on a theoretical framework. Research instruments were various and were most often ad hoc and not validated. The average number of persons in the social network of people with ID appears to be 3.1, one of them usually being a professional service staff member. People with ID are 3-4 times less employed than non-disabled peers; they are less likely to be employed competitively and are more likely to work in sheltered workshops or in segregated settings than those with other disabilities. People with ID are less likely to be involved in community groups, and leisure activities are mostly solitary and passive in nature. Most of the people with ID had been accompanied in an activity by training/therapeutic staff. CONCLUSION: It can be concluded that on the basis of empirical evidence, within the time frame of this literature search, little is known about community participation of people with ID. Many researchers did not clearly define community participation and were concerned with limited areas of community participation; research is seldom based on a theoretical framework. Most studies focus on people with mild ID, and there are few reports of the subjects' sample. However, one conclusion can consistently be drawn from the review: people with ID living in community settings participate more than people living in a segregated setting, but their participation level is still much lower than non-disabled and other disability groups.

The implementation of an Electronic Nursing Record in a general hospital in the Netherlands: lessons to learn.

This article describes the implementation of an Electronic Nursing Record (ENR) in Maasland Hospital (Orbis Medical and Healthcare group) in Sittard, the Netherlands. Through analysis of documents, structured interviews and participatory observation, a study was made of the plans prior to the introduction of the ENR, how the process proceeded, which enhancing and constraining factors influenced the process and how the nursing staff experienced the introduction of the ENR. The implementation of the system took place in 2006 and 2007. The selection and design of the system was carried out first, followed by a pilot phase. After thorough review and adjustment, the introduction of the ENR in the other wards of the hospital followed according to plan. The implementation process was carried out by several nurses in different roles (project management, project group members, key-users and teachers). The introduction of the system had two objectives: saving time by promoting efficiency and quality improvement by the introduction of standardization in documentation and the use of nursing care plans. The study indicates, however, that no time-efficiency was achieved by using the ENR so far. This had an adverse effect on the acceptance of the system by the nurses. The nurses were positive about the set-up of the implementation process, especially the contribution of the project group, the key-users on the ward and the resources which were made available (the staffing, external expertise and training).

Comparison of two Dutch follow-up care models for spinal cord-injured patients and their impact on health problems, re-admissions and quality of care.

OBJECTIVE: To evaluate whether transmural care for people with spinal cord injury living in the community has more impact on health outcomes than traditional follow-up care within the Netherlands. DESIGN: Quasi-experiment with 12 months of follow-up. SETTING: Eight Dutch rehabilitation centres. SUBJECTS: Thirty-one patients who received transmural care in two ;experimental' rehabilitation centres were compared with a matched sample of 31 patients having received ;usual follow-up care' in six other rehabilitation centres. INTERVENTION: The core component of the transmural care consists of a transmural nurse, who 'liaises' between former patients living in the community, primary care professionals and the rehabilitation team. The transmural care model provides activities to support patients and their family/partners and activities to promote continuity of care. MAIN MEASURES: The prevalence of pressure sores and urinary tract infections; the number and duration of re-admissions to hospital and rehabilitation centre due to pressure sores, bladder and bowel problems; and the experienced quality of follow-up care. RESULTS: The transmural care, as implemented, did not influence the health outcomes. The prevalence of pressure sores, urinary tract infections and the number of re-admissions (due to pressure sores, bladder and bowel problems) was respectively 13, 13 and 4 in the intervention group versus 14, 15 and 6 in the usual follow-up care group. Since the transmural care had been incompletely implemented and there were methodological and practical limitations, we formulated no final conclusions regarding its effectiveness. CONCLUSION: Implementing the transmural care model strictly according to protocol may improve its effectiveness.

Health behaviour of persons with spinal cord injury.

STUDY DESIGN: Postal survey. OBJECTIVE: To describe the health behaviour of persons with spinal cord injury (SCI) living in the community and the relationships between health behaviour, respondent/injury characteristics, and health-related variables: the presence and number of secondary impairments, readmissions in rehabilitation centre and hospital, and perceived health. SETTING: Members of the Dutch Association of Patients with SCI. METHODS: The frequency of health behaviours, that delay or prevent secondary impairments, was assessed by means of a 22-item, self-report questionnaire. The questionnaire was also focused on 13 secondary impairments. RESULTS: The frequency of engaging in health behaviour varied considerably between the respondents. Variance was observed between and within the health behaviours measured. The respondents did not frequently engage in pressure relief methods when sitting/driving in their wheelchair. Almost no statistical differences were observed between health behaviour of subgroups of respondents based on respondent/injury characteristics. However, the total health behaviour scores increased significantly with increasing age and pressure sore prevention was significantly more applied in persons with a complete lesion. Health behaviour was significantly more applied in respondents who had one or more secondary impairments. CONCLUSION: As secondary impairments are prevalent among persons with SCI and education on a healthy lifestyle is a core component of every rehabilitation programme, it is of great importance to rigorously test the efficacy of health behaviours promoted during rehabilitation. Therefore, longitudinal research is recommended.

Non-use of assistive technology in The Netherlands: a non-issue?

PURPOSE: To obtain insight into the prevalence of the non-use of assistive technology in The Netherlands. Relationships between non-use and possible determinants were also investigated. The results of the study might lead to improvement of products and of the service delivery system for assistive technology. METHOD: A study was performed into user satisfaction and the non-use of 14 categories of assistive technology provided by health care insurers. The design was a survey among a stratified sample of users who had received an assistive device, recruited through a sample of health insurance companies. Two independent samples were selected: one in 2001 and one in 2003. Three aspects of non-use were measured. The total number of respondents was 2272. RESULTS: Ninety-two percent of the respondents used the assistive device at the time of the survey. Less than 1% of the respondents never used the device. A majority of the respondents used the assistive device (about) as much as expected and 6% used the assistive device less than expected. Relationships between non-use and other investigated aspects were found. CONCLUSIONS: The average level of non-use of assistive technology found in this study is less than often reported in the literature and varies between the various categories of assistive technology. Improving the quality of the assistive technology and the services, and providing assistive technology that solves the users' problem as much as possible, could enhance the use of assistive technology provided.

[Falls in nursing homes: on average almost two per bed per year, resulting in a fracture in 1.3%]. / Valincidenten in verpleeghuizen: gemiddeld bijna 2 per bed per jaar met bij 1.3% een fractuur als gevolg.

OBJECTIVE: To determine how many falls occur annually in Dutch nursing homes and how many fractures are the result of falls. DESIGN: Written questionnaire study. METHOD: All 371 Dutch nursing homes received a questionnaire requesting information on the number of somatic and psychogeriatric beds and the number of falls and fractures as a result of falls in 2000 and 2001. RESULTS: Of the 371 questionnaires, 202 (54%) were returned. These were distributed as follows over the three types of nursing homes: combined: 151 (75%), somatic: 15 (7%), psychogeriatric: 36 (18%). The average capacity of the participating nursing homes was 180 beds. There was an average of more than 300 reported falls per nursing home: 336 in 2000 (SD: 180; median 314) and 311 in 2001 (SD: 165, median 294). On average, there were almost 2 falls per bed per year. The number of falls per bed in the psychogeriatric group was higher than in the somatic group. There was an average of about 4 fractures per year per nursing home as a result of falls: 4.3 in 2000 (SD: 3.7; median 4.0) and 3.6 in 2oo1 (SD: 2.8; median 3.0). The average number of annual fractures due to a fall was about 23 per 1ooo beds. An average of 1.3% of the falls resulted in a fracture. There were no clear differences here between somatic and psychogeriatric patients. CONCLUSION: The reported number of falls per nursing-home bed averaged almost 2 per year, and an average of 1.3% of these falls resulted in a fracture.

Follow-up care for persons with spinal cord injury living in the community: a systematic review of interventions and their evaluation.

STUDY DESIGN: Systematic review. OBJECTIVES: (1) To describe and compare follow-up care programmes, performed by rehabilitation centres, for persons with spinal cord injury (SCI) and (2) to describe the effects of these programmes regarding the occurrence of secondary impairments, well-being, the quality and costs of care. METHODS: A systematic literature search was conducted in MEDLINE (1972-2003) and CINAHL (1982-2003). Publications were selected about medical and/or nursing follow-up care to SCI patients living in the community performed by or with rehabilitation facilities for SCI patients. The aim of the follow-up care should be a decrease of secondary impairments, an improvement of well-being, an improvement of the quality and/or a decrease of the costs of care. RESULTS: The search resulted in 24 papers. The descriptions of the programmes in these papers were sometimes rather scattered, vague or brief. The most important methods were telemedicine (six programmes; of which five were performed in the same rehabilitation centre), outpatient consulting hours (six programmes), home visits (three programmes, and case management (one programme). Eight other programmes combined several methods (ie outpatient consulting hours, home visits, peer teaching and support, outings, ongoing support, therapy from several care disciplines, SCI education, providing SCI expertise and support to community health-care providers, coordination of care with community nursing agencies). In all, 16 programmes have been evaluated to some degree. In general the quality of the studies was low. Most evaluations were pre-experimental in design. Only three were quasi-experimental, and two programmes were experimental in design. Although several studies claimed positive effects, it was not possible to draw conclusions on the effect of follow-up care on the occurrence of secondary impairments, well-being, the quality and costs of care. CONCLUSION: There is a need for the development, the publication and the well-designed evaluation of follow-up care programmes for persons with SCI.

Burden of support for partners of persons with spinal cord injuries.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: (1) To describe the support given to persons with spinal cord injuries (SCI) by their partners, (2) to describe the perceived burden of support by partners and (3) to examine predictors of perceived burden of support. SETTING: The Netherlands. METHODS: All members of the Dutch patients organisation DON (N = 1004) and their caregivers, if applicable, were invited. Physical disability of the person with SCI was measured using the Barthel Index (BI). A number of secondary conditions, other practical problems and psychosocial problems were recorded. Partner support was described using a list of ADL-support, other practical support and emotional support. Burden of support was measured by a six-item measure (Cronbach's alpha 0.92), Nonparametric descriptive statistics and correlations were used. Linear regression was used to identify predictors of caregiver burden. RESULTS: Responses were obtained from 461 persons with SCI. Of 265 couples, patient as well as partner data were available. Mean age of the partners was 49.4 years (SD 12.2) and 69.8% were women. Mean BI of the persons with SCI was 12.3 (SD 4.7) on a 0-20 scale and 60.4% were seriously disabled (BI < 15). Most partners provided various kinds of support. ADL-support and other practical support were given much more often by partners of persons with serious disability, but less difference was seen regarding emotional support. Professional (paid) support was obtained by 45.3% of all couples. Perceived burden of support was high in 24.8% of partners of persons with serious disabilities against 3.9% of partners of persons with minor disabilities. Significant predictors of caregiver burden were (in order of importance) the amount of ADL support given, psychological problems of the patient, partner age, partner gender, BI score and time after injury (total explained variance 47%). CONCLUSION: A substantial proportion of partners of persons with SCI suffer from serious burden of support. Prevention of caregiver burnout should be part of the lifelong care for persons with SCI.

Transmural care in the rehabilitation sector: implementation experiences with a transmural care model for people with spinal cord injury.

PURPOSES: The purpose of this article is first to describe the development and content of a transmural care model in the rehabilitation sector, which aims to reduce the number and severity of health problems of people with spinal cord injury (SCI) and improve the continuity of care. Second, the purpose is to describe the applicability and implementation experiences of a transmural care model in the rehabilitation sector. METHODS: The transmural care model was developed in cooperation with the Dutch Association of Spinal Cord Injured Patients, community nurses, general practitioners, rehabilitation nurses, rehabilitation managers, physiatrists and researchers. The core component of the care model consists of a transmural nurse, who 'liaises' between people with SCI living in the community, professional primary care professionals and the rehabilitation centre. The transmural care model provides a job description containing activities to support people with SCI and their family/partners and activities to promote continuity of care. The transmural care model was implemented in two Dutch rehabilitation centres. The following three aspects, as experienced by the transmural nurses, were evaluated: the extent to which the care model was implemented; enabling factors and barriers for implementation; strength and weakness of the care model. RESULTS: The transmural care model was not implemented in all its details, with a clear difference between the two rehabilitation centres. Enabling factors and barriers for implementation were found at three levels: 1. the level of the individual professional (e.g. competencies, attitude and motivation), 2. the organisational and financing level (e.g. availability of facilities and finances), and 3. the social context (the opinion of colleagues, managers and other professionals involved with the care). The most important weakness experienced was that there was not enough time to put all the activities into practice. The strength of the care model lies in the combination of support of patients after discharge, support of and cooperation with primary care professionals, and feedback of experiences to the clinical rehabilitation teams. CONCLUSION: We recommend further improving and implementing the care model and encourage other care professionals and researchers to share their implementation experiences of follow-up care innovations for people with SCI.

Effectiveness of provision of outdoor mobility services and devices in The Netherlands.

OBJECTIVE: To answer the following questions: What are the problems encountered by people with outdoor mobility disabilities? What solutions are being offered to them in The Netherlands? How effective are these solutions? How responsive is the IPPA instrument (Individually Prioritized Problem Assessment)? DESIGN: Analysing the results of a follow-up study using the IPPA instrument. SETTING: The Dutch Service for the Disabled Act (SDA, in Dutch: WVG) provision system. This act is responsible for the provision of mobility aids and home adaptations. SUBJECTS: Fifty-nine people with outdoor mobility disabilities. INTERVENTIONS: The provision of outdoor mobility service and devices. MAIN OUTCOME MEASURES: Effectiveness of provisions as measured using IPPA (i.e., the degree to which activities have become less difficult to perform), effect size of IPPA with this intervention. RESULTS: Problems identified by clients are very diverse and specific but can be classified fairly well on the basis of the International Classification of Functioning, Disability and Health (ICF); in the main, the solutions they are provided with are very similar and generic. Effectiveness is excellent at a group level, but insufficient for some at an individual level. The IPPA instrument is highly responsive in this setting. Most mobility problems respondents identified, although very individual and specific, were related to shopping, social visits or leisure activities. These specific sets of problems were solved using 'standard', generic solutions. CONCLUSIONS: The Dutch provision system should be more 'demand oriented' and less 'supply oriented'. IPPA turns out to be a useful, structured and individual-oriented method to evaluate service delivery.

Post-discharge nursing problems of spinal cord injured patients: on which fields can nurses contribute to rehabilitation?

OBJECTIVE: To identify nursing problems of spinal cord injured (SCI) patients after discharge from clinical rehabilitation and to identify gaps in the nursing care regarding the prevention of these problems. DESIGN: The study had an exploratory character and was divided into three phases. Phase 1 had a qualitative nature. Eight patients were interviewed to obtain insight into experienced problems after discharge. In phase 2, a panel of experts regarding nursing care for SCI patients selected nursing problems out of all problems mentioned. Phase 3 consisted of a mailed questionnaire including the nursing problem areas identified in phase 2, which was sent to all patients that were discharged during the last 18 months before the study. SETTING: Specialist rehabilitation centre, The Netherlands. SUBJECTS: Eight patients participated in phase 1 (100% response rate), 35 nurses participated in phase 2 (87.5% response rate) and 35 patients participated in phase 3 (62.5% response rate). RESULTS: The most important nursing problems in the response group appeared to be: limitations to activities of daily living, having difficulties in asking for help (assertiveness), pain, coping with the disability, dependency on personal help and problems with changed bladder regulation. The respondents made several suggestions for improving nursing care, involving both clinical care and care after discharge. CONCLUSIONS: SCI patients experience serious problems after discharge from clinical rehabilitation. Nurses can give input on a wide variety of these problems.

Reliability and validity of the Dutch version of QUEST 2.0 with users of various types of assistive devices.

PURPOSE: In this paper, the Dutch version of the Quebec User Evaluation of Satisfaction with assistive Technology (D-QUEST) is validated in users of a large variety of assistive devices (n=2002). METHOD: D-QUEST consists of a written questionnaire. The respondent rates his or her satisfaction with respect to 12 aspects on a five-point scale. Users of 10 different types of assistive devices participated. Analyses were performed for each type of assistive device. Reliability is tested by analysing internal consistency. Content validity is tested by analysing applicability of the 12 aspects. The non-applicability option for answering questions is studied. Construct validity is tested by analysing correlations with problem solving and with general satisfaction. RESULTS: Reliability proves to be good for all types of assistive devices. Including the non-applicability option improves the feasibility of the instrument without affecting content validity. Correlations between D-QUEST scores on the one hand and problem solving and general satisfaction questions on the other are as expected, supporting validity. CONCLUSIONS: D-QUEST (and therefore also QUEST) proves itself to be a highly applicable, reliable and valid instrument to assess user-satisfaction of users of all kinds of assistive device provisions.

Client satisfaction with service delivery of assistive technology for outdoor mobility.

PURPOSE: In the decentralized Dutch service delivery system, client satisfaction levels for the provision of assistive technology (AT) for outdoor mobility for elderly and disabled persons was measured to investigate whether or not differences exist between local service delivery systems and if so, how these can be explained. METHOD: In June 1999 a postal questionnaire was sent to a random sample of 973 adult users from three local authorities who had received their AT in 1998. Client satisfaction with the service delivery process was measured using seven items (alpha=0.88) added to the 12 items of the QUEST 2.0 scale. Demographic, health status and service delivery outcome characteristics were also measured. RESULTS: The response was 57%, 503 respondents were included in the analysis (mean age 71 years, 68% women). The health status of the respondents was very poor. The characteristics of the clients were comparable between local authorities but differences were found in the provision of AT. Whilst the overall satisfaction was high (1.8) a difference was found between local authorities. The percentage of clients who were 'not completely satisfied' with aspects of the service delivery process varied from 8% to 30%. One of the most important factors involved in the explanation of differences in satisfaction levels between local authorities (R(2)=11.4%) is that of 'delivery time'. CONCLUSION: Differences in clients' satisfaction between service delivery systems do exist and are determined by 'delivery time', 'user opinion', 'access' and 'quality of information'.

[Initiating insulin therapy in patients with diabetes mellitus type 2: in a transmural setting is at least as effective as in an outpatient setting; a retrospective study with a 4-year follow-up]. / Het instellen op insuline van patiënten met diabetes mellitus type 2: in een transmurale organisatievorm minstens even effectief als poliklinisch; een retrospectief onderzoek met 4 jaar follow-up.

OBJECTIVE: Assessing whether the initiation of insulin therapy in patients with diabetes mellitus type 2 can be delivered as effectively in a structured transmural care model as in the more usual outpatients structure. DESIGN: Retrospective comparative cohort study. METHOD: In 1997 data were collected from 52 patients with diabetes mellitus type 2 all of whom were above 40 years of age and transferred to insulin therapy in 1993: 25 in a transmural care setting and 27 in an outpatients setting, both in Amsterdam, the Netherlands. Both groups were treated according to one protocol concerning the initiation and monitoring of insulin therapy, treatment goals and follow-up. Outcome measures were: percentage of glycated haemoglobin (HbA1c), health status, self-care behaviour and patient satisfaction. In 1993 the mean age was (transmural/outpatients setting): 67.5/65.3 years; percentage of men: 32%/48%; mean duration of diabetes: 7.3/10.6 years; HbA1c: 9.1%/9.3%; mean body mass index: 27.4/29.1 kg/m2. RESULTS: In the period 1993-1997 the mean HbA1c decreased from 9.1% to 7.2% in the transmural care group and from 9.3% to 7.6% in the outpatients care group (both: p = 0.000). The percentage of patients with poor glycaemic control (HbA1c > 8%) decreased from 60 to 8 in the transmural care group and from 59 to 15 in the outpatients care group. The percentage of patients with good glycaemic control (HbA1c < 7%) increased from 4 to 52 in the transmural care group and from 11 to 30 in the outpatients care group. No statistically significant differences were found between the patient groups with respect to health status, self-care behaviour and patient satisfaction. CONCLUSION: The transfer of patients with diabetes mellitus type 2 insulin therapy in a shared care setting was at least as effective as in an outpatients setting.