Effectiveness of Food-Based Fortification in Older People. A Systematic Review and Meta-Analysis.

BACKGROUND: Early intervention with nutritional support has been found to stop weight loss in older people malnourished or at risk of malnutrition. Enriched food could be a more attractive alternative to improve meals, than conventional oral nutritional supplements. AIMS: To determine the effectiveness of food-based fortification to prevent risk of malnutrition in elderly patients in community or institutionalized elderly patients. METHODS: A systematic review was conducted of randomized controlled trials, quasi-experimental, and interrupted time series including a longitudinal analysis. PARTICIPANTS: Elderly patients who are institutionalized, hospitalized or community-dwelling, with a minimum average age of 65 years. All type of patient groups, with the exception of people in critical care, or those who were recovering from cancer treatment, were included. INTERVENTION: Studies had to compare food-based fortification against alternatives. Studies that used oral nutritional supplementation such as commercial sip feeds, vitamin or mineral supplements were excluded. The search was conducted in Cochrane, CINAHL, PubMed, EMBASE, LILACS, and Cuiden. An independent peer review was carried out. RESULTS: From 1011 studies obtained, 7 were included for the systematic review, with 588 participants. It was possible to perform meta-analysis of four studies that provided results on caloric and protein intake. Food-based fortification yielded positive results in the total amount of ingested calories and protein. Nevertheless, due to the small number of participants and the poor quality of some studies, further high quality studies are required to provide reliable evidence. IMPLICATIONS FOR PRACTICE: Despite the limited evidence, due to their simplicity, low cost, and positive results in protein and calories intake, simple dietary interventions based on the food-based fortification or densification with protein or energy of the standard diet could be considered in patients at risk of malnutrition.

[Utility and validity of indicators from the Nursing Outcomes Classification as a support tool for diagnosing Ineffective Self Health Management in patients with chronic conditions in primary health care]. / Utilidad y validez de un instrumento basado en indicadores de la Nursing Outcomes Classification como ayuda al diagnóstico de pacientes crónicos de At.

BACKGROUND: Self-care and management of therapeutic regime (drugs adherence, preventive behaviours and development of healthy life-styles) are key components for managing chronic diseases. Nursing has standardized languages which describe many of these situations, such as the diagnosis "Ineffective Self Health Management" (ISHM) or many of the Nursing Outcomes Classification (NOC) indicators. The aims of this study were to determine the interobserver reliability of a NOC-based instrument for assessment and aid in diagnosis of the ISHM in patients with chronic conditions in Primary Health Care, to determine its diagnostic validity and to describe the prevalence of patients with this problem. METHODS: Cross-sectional validation study developed in the provinces of Málaga, Cádiz and Almería from 2006 to 2009. Each patient was assessed by 3 independent observers: the first two observers evaluated scoring of the NOC indicators and the third one acted as the "gold-standard". RESULTS: Two hundred and twenty-eight patients were included, 37.7% of them with more than one chronic condition. NOC indicators showed a high interobserver reliability (ICC>0,70) and a consistency (Cronbach's alpha: 0.81). With a cut-point of 10.5, sensitivity was 61% and specificity 85%, and the area under the curve was 0.81 (CI95%: 0.77 to 0.85). The prevalence of patients with ISHM was 36% (CI 95%: 34 to 40). CONCLUSIONS: The use of NOC indicators allows evaluation of management of the therapeutic regime in people with chronic conditions with a satisfactory validity and it provides new approaches for dealing with this problem.

Utilidad y validez de un instrumento basado en indicadores de la Nursing Outcomes Classification como ayuda al diagnóstico de pacientes crónicos de Atención Primaria con gestión ineficiente de la salud propia / Utility and validity of indicators from the Nursing Outcomes Classification as a support tool for diagnosing Ineffective Self Health Management in patients with chronic conditions in Primary Health Care

Fundamento. El autocuidado y el manejo del régimen terapéutico por parte del paciente (adherencia a su medicación, conductas preventivas y desarrollo de estilos de vida saludables) son componentes clave del abordaje de las enfermedades crónicas. La enfermería dispone de lenguajes estandarizados para describir muchas de estas situaciones, como el diagnóstico ”gestión ineficiente dela propia salud” (GIPS) o muchos indicadores de la Clasificación de Resultados de Enfermería (NOC). Los objetivos de este estudio, pretenden conocer la fiabilidad inter observador de un instrumento de valoración y ayuda al diagnóstico de la GIPS en pacientes crónicos que acuden a consultas de Atención Primaria, basado en indicadores NOC, además de determinar su validez diagnóstica y describir la prevalencia de pacientes con este problema. Material y métodos. Estudio observacional transversal de validación, en las provincias de Málaga, Cádiz y Almería durante los años 2006 a 2009. Cada paciente era valorado por 3 observadores de forma independiente: una pareja evaluaba la puntuación de los distintos indicadores y un tercer observador experto actuaba como patrón oro .Resultados. Doscientos veintiocho pacientes fueron incluidos, con un 37,7% de ellos con más de un proceso crónico concomitante. Los indicadores NOC mostraron una alta fiabilidad inter observador (CCI>0,70) y una consistencia interna buena (alfa de Cronbach:0,81). Con un punto de corte en 10,5, se obtuvo una sensibilidad del61% y una especificidad del 85%, con un área bajo la curva de 0,81(IC95%: 0,77 a 0,85). La prevalencia de pacientes con GIPS fue del36% (IC 95%: 34 a 40).Conclusiones. El uso de indicadores de la NOC permite valorar el manejo del régimen terapéutico en pacientes crónicos, con una validez aceptable y aporta nuevos enfoques para el abordaje de este problema(AU)

Background. Self-care and management of therapeutic regime(drugs adherence, preventive behave ours and development of healthy life-styles) are key components for managing chronic diseases. Nursing has standardized languages which describe many of these situations, such as the diagnosis “Ineffective Self Health Management” (ISHM) or many of the Nursing Outcomes Classification (NOC) indicators. The aims of this study were to determine the inter observer reliability of a NOC-based instrument for assessment and aid in diagnosis of the ISHM in patients with chronic conditions in Primary Health Care, to determine its diagnostic validity and to describe the prevalence of patients with this problem. Methods. Cross-sectional validation study developed in the provinces of Málaga, Cádiz and Almería from 2006 to 2009. Each patient was assessed by 3 independent observers: the first twoobservers evaluated scoring of the NOC indicators and the third one acted as the “gold-standard”. Results. Two hundred and twenty-eight patients were included,37.7% of them with more than one chronic condition. NOC indicators showed a high inter observer reliability (ICC>0,70) and a consistency (Cronbach’s alpha: 0.81). With a cut-point of 10.5,sensitivity was 61% and specificity 85%, and the area under the curve was 0.81 (CI95%: 0.77 to 0.85). The prevalence of patients with ISHM was 36% (CI 95%: 34 to 40).Conclusions. The use of NOC indicators allows evaluation of management of the therapeutic regime in people with chronic conditions with a satisfactory validity and it provides new approaches for dealing with this problem(AU)

The association between nursing diagnoses, resource utilisation and patient and caregiver outcomes in a nurse-led home care service: longitudinal study.

BACKGROUND: The information generated by nurses through standardised nursing languages is insufficiently evaluated and exploited, mainly in home care services, as is its potential impact on outcomes. OBJECTIVES: To find out how often nursing diagnoses are made during nursing home care visits, and to explore their relation with use of resources, mortality, institutionalisation and satisfaction. DESIGN: Observational, longitudinal follow-up study. SETTINGS: Home care services delivered by Primary Healthcare Districts in Málaga, Costa del Sol, Almería and Granada, in Spain. PARTICIPANTS: Patients and caregivers who initiated the Home Care Programme. METHODS: The accumulated incidence of nursing diagnosis was analysed over 34 months of follow-up. Diagnoses were made by nurse case managers in their daily practice. Several regression models were devised to analyse their linkage with the use of resources, mortality, institutionalisation and satisfaction. RESULTS: Two hundred and forty-seven subjects were included (129 patients and 118 caregivers). 93.8 had been diagnosed (2.8 diagnoses per subject). Risk of caregiver strain and mobility impairment accounted for 40% of total home visits (p=0.033). Significant differences were observed in the use of physiotherapy and rehabilitation services. The home visits for caregivers were, in 78% of cases, due to the recipient's baseline functional status. No relation was detected for institutionalisation or for patient satisfaction. There was a higher rate of anxiety diagnosed in the caregiver when the recipient was at greater risk for mortality (RR: 2.08 CI 95%: 1.26-3.42) (p=0.012). CONCLUSIONS: These data confirm results from other studies which find nursing diagnoses to be sound predictors of resources use. Their synergy with other case-mix systems in home care should be investigated.

Effectiveness of a nurse-led case management home care model in Primary Health Care. A quasi-experimental, controlled, multi-centre study.

BACKGROUND: Demand for home care services has increased considerably, along with the growing complexity of cases and variability among resources and providers. Designing services that guarantee co-ordination and integration for providers and levels of care is of paramount importance. The aim of this study is to determine the effectiveness of a new case-management based, home care delivery model which has been implemented in Andalusia (Spain). METHODS: Quasi-experimental, controlled, non-randomised, multi-centre study on the population receiving home care services comparing the outcomes of the new model, which included nurse-led case management, versus the conventional one. Primary endpoints: functional status, satisfaction and use of healthcare resources. Secondary endpoints: recruitment and caregiver burden, mortality, institutionalisation, quality of life and family function. Analyses were performed at base-line, and at two, six and twelve months. A bivariate analysis was conducted with the Student's t-test, Mann-Whitney's U, and the chi squared test. Kaplan-Meier and log-rank tests were performed to compare survival and institutionalisation. A multivariate analysis was performed to pinpoint factors that impact on improvement of functional ability. RESULTS: Base-line differences in functional capacity - significantly lower in the intervention group (RR: 1.52 95%CI: 1.05-2.21; p = 0.0016) - disappeared at six months (RR: 1.31 95%CI: 0.87-1.98; p = 0.178). At six months, caregiver burden showed a slight reduction in the intervention group, whereas it increased notably in the control group (base-line Zarit Test: 57.06 95%CI: 54.77-59.34 vs. 60.50 95%CI: 53.63-67.37; p = 0.264), (Zarit Test at six months: 53.79 95%CI: 49.67-57.92 vs. 66.26 95%CI: 60.66-71.86 p = 0.002). Patients in the intervention group received more physiotherapy (7.92 CI95%: 5.22-10.62 vs. 3.24 95%CI: 1.37-5.310; p = 0.0001) and, on average, required fewer home care visits (9.40 95%CI: 7.89-10.92 vs.11.30 95%CI: 9.10-14.54). No differences were found in terms of frequency of visits to A&E or hospital re-admissions. Furthermore, patients in the control group perceived higher levels of satisfaction (16.88; 95%CI: 16.32-17.43; range: 0-21, vs. 14.65 95%CI: 13.61-15.68; p = 0,001). CONCLUSION: A home care service model that includes nurse-led case management streamlines access to healthcare services and resources, while impacting positively on patients' functional ability and caregiver burden, with increased levels of satisfaction. TRIAL REGISTRATION: ISRCTN44054549.

Recursos humanos en los Servicios de Salud: ¿decisiones políticas o política de decisiones? / Health care staff: political decisions or policy of decision making?

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[Nursing consultation for chronic patients]. / Consulta de enfermería para pacientes crónicos.

Nursing consultation for chronic patients forms part of the list of primary health care services for the coverage provided and due to the general public's satisfaction. However, the content and the results offered can be improved and the need to reorient this service has been proposed for quite some time. Strategies to succeed in developing a pure nursing contribution vis-a-vis our patients' health, that which we call an independent dimension in nursing, pass through the construction of a nursing vision which many of us lack as a consequence of a structured professional development along the lines of the biomedical model in which the nursing paradigm was transmitted more in the theoretical field than in the practical. By referring to Doka and Riopelle, we analyze the stages through which a patient afflicted by a physical disease passes and the tasks which he and his family should fulfill, in order to find an equivalence between these and some of the nursing diagnoses published by the North American Nursing Diagnosis Association (NANDA). The nursing diagnoses so obtained are compared to those which a panel of experts, belonging on Methodology Commission of the Malaga Sanitary District, by consensus identified as the most prevalent among this population. The degree of coincidences was high, which encourages us to continue along this vein in the nursing consultations for chronic patients.

[Application of diagnoses to a disabled population]. / Diagnósticos aplicados a población incapacitada. Un estudio.

The application of a charting system designed in the C.S. "El Palo" has permitted the medical staff to detect nursing problems among its disabled population of health care patients. By using this system to categorize various diagnoses, it has been possible to study their incidence and help to prioritize their needs during continuing education sessions. The diagnostic profile of their disabled population include. Affected by physical immobility; Alteration of well being: pain; Difficulties with urinary elimination; Difficulties with intestinal elimination.

[Detection by a computer program of drug interactions in chronic patients. Its practical usefulness in a health center]. / Detección de interacciones medicamentosas en pacientes crónicos mediante un programa informático. Utilidad práctica en un centro de salud.

OBJECTIVES: To evaluate a computer programme which was used to detect drug interactions (DI) from the Long Treatment Cards (LTC) and to analyse the factors possibly linked to these interactions. DESIGN: An observational, descriptive study. SETTING: Primary Health Care: an urban Health Centre. PATIENTS: The reference context was 1,640 chronic patients being cared for at a nursing clinic. We selected 141 cases at random by taking 10 LTCs from each list. (Alpha risk = 0.05; Confidence Interval = 0.05). RESULTS: The sample was mainly feminine (2:1), with an average age of 67. The most common diagnosis was Diabetes or AHT. 55% had accumulated 4 or more medicines per card, with multiple medication most common among men. The programme enabled 58 drug interactions, affecting 34% of the LTCs, to be identified. CONCLUSIONS: Special attention should be paid to the LTCs with 7 or more drugs prescribed because of their association with DI and NIV. The programme's efficacy would increase, both if the DIs were more accurately defined and if the programme could be computerised and applied massively to chronic treatments.