Rehabilitation of Discharged Patients With Chronic Obstructive Pulmonary Disease-Are New Strategies Needed?

BACKGROUND: Rehabilitation after hospital stay implies several benefits for patients with chronic obstructive pulmonary disease (COPD); still few patients are referred and participate in rehabilitation programs. We conducted a case study to investigate the effects of interventions targeting the referral, uptake, and completion for a program of early rehabilitation in the primary health-care sector. METHODS: We undertook targeted initiatives to make patients participate in an individualized rehabilitation program with gradual increased intensity. After discharge, primary care COPD nurses and physiotherapists guided patients through progressing exercises in small groups online. Patients proceeded to class-based exercises, patient education and/or leisure activities, or continued telerehabilitation. We evaluated the effects of the intervention by assessing referral rates, completion, and readmission. RESULTS: Sixteen (23% of discharged patients) patients were referred to rehabilitation. In comparison, only 1 (0.8%) in 131 patients from Vejle hospital was referred to Vejle hospital. Twelve patients completed rehabilitation, all having severe COPD. All started the program within 2 weeks and proceeded to the online-guided exercises within 4 weeks. Study data showed that after 30 days, 1 (6.3%) of the 16 patients in the rehabilitation program had been readmitted compared to 8 (14.8%) of 55 patients who were not referred. After 90 days, 2 (12.5%) and 11 (20.0%) patients were readmitted, respectively. The readmission rate showed a nonsignificant decline in patients participating in rehabilitation. CONCLUSION: This case study showed that the referral rate of patients with COPD to early municipal rehabilitation is extremely low without a targeted effort and still insufficient in spite of a focused intervention. We showed that completion of a municipal rehabilitation program shortly after discharge is possible even for patients with severe COPD. The findings from our pilot study can guide further investigations into the effect of implementation strategies for handovers between health-care sectors to secure early-onset rehabilitation of patients with COPD.

[Chronic obstructive lung disease management programmes do not benefit the coordination of care pathways].

Chronic obstructive lung disease (COLD) is a challenging condition for both primary and secondary health-care providers. Disease management programmes (DMP's) have been expected to lead to evident improvements in the continuum of care for COLD. The utility of a COLD management programme was evaluated in a study based on interviews among general practitioners and COLD specialists. Clinicians preferred short practical guidelines to the DMP. The DMP was found useless as a tool to improve the coordination of care pathways. Complimentary interventions to improve clinical cooperation across sectors are recommended.

[The case manager--from words to deeds?]. / Kontaktpersonordningen--fra navn til gavn?

INTRODUCTION: Allocation of a case manager is now mandatory for both in- and outpatients in Denmark. Case manager allocation is reported quarterly to the regions and results are generally satisfying. Knowledge about fulfillment of the case manager role is, however, sparse. This study aims to examine the degree of fulfillment of the case manager role for a sample of inpatients. MATERIAL AND METHODS: Two medical and two surgical wards participated. Patients were interviewed in relation to discharge while staff assigned as case managers completed a survey. Both patients and case managers answered questions regarding the defined roles as case managers: Planning/coordination, continuous information and discharge planning. RESULTS: 107 of 125 eligible patients were interviewed. Only 25 declared themselves informed about the allocation of a case manager. The patients' assessment of the service provided by the staff in relation to case manager tasks was generally good, but the services were seldom provided by the named case manager. 22% of patients did not experience continuous information, while only 13% did not experience a generally coherent stay in hospital. 110 case managers completed the survey. Less than half felt themselves well informed about the case manager role. Only a few case managers feel that they succeed in fulfilling the role, particularly regarding the participation in discharge planning. CONCLUSION: There seems to be a need for a targeted effort to improve the conditions for case managers in Danish hospitals in order to meet the intentions of this initiative.

[Risk stratification of patients with diabetes mellitus]. / Risikostratificering af patienter med diabetes mellitus.

INTRODUCTION: This paper discusses the optimal distribution of responsibility between general practitioners (GPs) and hospitals for follow-up of patients with chronic diseases. We investigated a set of risk stratification criteria developed to optimize specialist shared care for patients with diabetes mellitus. MATERIAL AND METHODS: We included patients with diabetes from the catchment areas of four diabetes out-patient clinics in southern Denmark. Patients were risk-stratified to 3 follow-up levels (level 1 - follow-up only by their GP, level 2 - intensified follow-up by GP and/or shared care schemes, level 3 - follow-up only in out-patient clinics). The results were subsequently compared with the patients' actual follow-up status. RESULTS: A total of 647 patients (563 type 2 diabetes and 84 type 1 diabetes) were included from 15 GPs. Among these, 139 were stratified to level 1, 409 to level 2 and 99 to level 3. A total of 444 patients were actually being followed by their GP, 129 in shared care and 74 in out-patient clinics. The frequency of out-patient and shared care control varied from 13% to 39% between the four centres. CONCLUSION: Patients generally had a higher risk profile than anticipated. The model could select high-risk patients to be followed in specialized out-patient clinics. The model was less suitable for patients with low or moderate risk, and it should be modified before its general introduction.

[Structured documentation of patients' medical records. A new record structure for emergency admissions is coming]. / Synlig struktureret planlaegning i patientjournalen. En ny journalstruktur for akutte indlaeggelsesforlob pa vej.

INTRODUCTION: In recent years a range of efforts to shorten the length of stay (LOS) for patients admitted to hospitals has been tested. Some studies indicate that this might be accomplished by rigorous planning of patient pathways and structured documentation of medical records. In this study the effect of a structured case record model was tested. METHODS: The new record structure was developed using predefined requirements for content, placement and presentation of documentation. Instruction of staff was followed by a switch to the new model from one day to the next. Collection of data was carried out three months before and five to eight months after implementation of the model. RESULTS: The department succeeded in including well over 50% of all includable patients. However, the analysis encompassed all includable patients (''intention to treat'' principle). The number of cases analysed was 340 before and 353 after implementation of the model. Average LOS was reduced by 1.1 day from before implementation to after implementation. This was not statistically significant. However, the model was subsequently kept in use by the department. DISCUSSION: This pilot study shows a non-significant tendency to shotening of LOS by using a structured case record model. It is important to pay attention to the practical difficulties of implementing new documentation tools.

Repeated measurements of generic indicators: a Danish national program to benchmark and improve quality of care.

OBJECTIVE: To measure performance on the basis of generic (non-diagnoses related) standards of care developed in a national Danish quality improvement programme in departments of internal medicine, and to determine the power of repetitive national audits to increase levels of performance. DESIGN: Multifaceted intervention: national audits in 2001 and 2002 based on the standards of the program, combined with direct contact with heads of departments and a national conference to discuss audit results. SETTING: Seventy-nine and 82 wards in 2001 and 2002, respectively, covering 71% of Danish hospitals receiving medical emergencies. The wards participated on a voluntary basis. PARTICIPANTS: In the first audit round, 3950 patients were admitted as emergencies, while 4068 patients were admitted as emergencies in the second audit. Patients were included without reference to diagnoses. MAIN OUTCOME MEASURES: Correct initial diagnostic assessment, early interdisciplinary action plans, correct drug prescriptions, waiting times for examinations, documented patient information, readmissions, and content and processing time for discharge letters. RESULTS: For the 70 wards participating in both rounds, the general level of performance improved significantly between the two audits: the proportion of patients with correct initial diagnostic assessment increased from 75.9% to 79.4%, the proportion of patients with correct drug prescriptions increased from 83.8% to 85.9%, and the proportion of sufficiently informed patients increased from 32.4% to 36.2% (P < 0.05). The proportion of medical records containing action plans for selected clinical problems (nutritional and functional problems, fever, and treatment of pain) increased from 72.8% to 75.9% (P < 0.05). Length of stay in hospital was significantly related to a correct initial assessment and to waiting time for examinations. Wards with a common medication chart for physicians and nurses had significantly more correct drug prescriptions than wards that did not use a medication chart. Fifty-four (75%) of the participating departments indicated that the result of the first audit round had led to organizational changes in the department. CONCLUSION: Professional self-regulation guided by a multidisciplinary audit tool developed in cooperation with professionals can improve quality of care. It is possible to conduct and repeat a national audit on a voluntary basis.

[The Good Medical Department. The quality of patient information at the departments of internal medicine]. / Den Gode Medicinske Afdeling. Kvaliteten af patientinformation på medicinske afdelinger.

INTRODUCTION: The purpose of this study was to identify the factors that influence the quality of information given in medical departments and to examine the efforts made to ensure the quality and further improvement of this information. The study is part of the research project "The Good Medical Department". MATERIAL AND METHODS: A total of 73 semi-structured interviews were carried out with patients, doctors, nurses and departmental managements. The medical records and nursing case notes were analysed. RESULTS: The quality of information given correlates with the staff's knowledge of the period of hospitalization of their patients. Contact with various doctors and nurses results in patients perceiving statements as being divergent. Information is best communicated in a dialogue. The patients want detailed and written information. Documentation of given information in the medical records was scanty. DISCUSSION: The outcome of this study indicates some areas that can contribute to ensuring the quality and improvement of patient information. Recent studies also describe lack of quality in these areas. It is a question of restructured planning, delegation of responsibility, documentation, written patient information, and training in communication skills.

[Selection of patients referred to gastroscopy from general practice]. / Visitation af patienter henvist til gastroskopi fra almen praksis.

INTRODUCTION: The aim of this study was to investigate whether guidelines for selecting dyspeptic patients for early endoscopy are appropriate and whether referrals from general practitioners give all necessary information. MATERIALS AND METHODS: We carried out a prospective study of consecutive referrals from general practitioners. The patients were referred by general practitioners to the Department of Medical Gastroenterology, Aalborg Hospital, during the period 1 February 1999 to 31 December 1999. The referrals for endoscopy were examined for information about the duration of symptoms, alarm symptoms (anaemia, dysphagia, vomiting, and weight loss), usage of ASA/NSAID, and medical treatment with acid-suppressants. At endoscopy, similar information was recorded on a standardised form for comparison. RESULTS: Two hundred and ninety-nine patients, 150 men and 149 women, were entered in the study. The medium age was 51.3 years (17-95). Ninety-six (32%) patients had organic dyspepsia (ulcer, oesophagitis, cancer). Of 192 (46%) patients selected for early gastroscopy, 88 (46%) were assigned to early examination solely because of age > 45 years, and 21 (11%) solely because of alarm symptoms. All the patients with information about ASA/NSAID medication were older than 45 years. The diagnosis of cancer and ulcer was significantly more often found in the group of patients selected for early gastroscopy 31/192, as compared with the waiting list patients 9/107 (p = 0.004). DISCUSSION: The guidelines for distribution to early and waiting list endoscopy proved to be well suited for priority selection of patients with the highest risk of organic dyspepsia.