Exploring the Perceptions of the Ageing Experience in Singaporean Older Adults: a Qualitative Study.

Understanding older adults perceptions of health and adaptation processes to ageing can allow for more culturally aligned services and better targeted care. The aim of this exploratory qualitative study was to examine older adults perceptions of physical, psychological and social health and further understand the processes of adaptation and self-management of these health perceptions. Semi-structured in depth interviews (IDI) were conducted with ethnically diverse older adults in Singapore, aged 60 and above. Participants were asked open ended questions about their physical health, psychological health and their current social health and relationships. They were also asked methods of adaptation to these age related changes. In total, forty participants were interviewed. A thematic analysis identified five main themes when exploring perceptions of physical, psychological and social health. These included; 1) Slowing down 2) Relationship harmony 3) Financial harmony 4) Social connectedness and 5) Eating together. Adaptation and self-management of these health perceptions included six additional themes; 1) Keep moving 2) Keep learning; where continued self-determination and resilience was a key method in adapting to negative thoughts about declining physical health 3) Adopting avoidant coping behaviours 4) 'It feels good to do good'; where finding meaning in life was to help others 5) 'Power of Prayer'; which highlighted how older adults relegated responsibilities to a higher spiritual power 6) Social participation; which included engaging in community and religious social activities that all contributed to self-management of older adults psychological health and social health. In conclusion, our study highlighted specific cultural nuances in older adults perceptions of health, particularly psychological and social health. These findings can help develop more targeted intervention programmes and better methods of measuring older adults health, which can assist with the global ageing phenomena.

Improvement of shared decision making in integrated stroke care: a before and after evaluation using a questionnaire survey.

BACKGROUND: Shared decision making (SDM) is at the core of policy measures for making healthcare person-centred. However, the context-sensitive nature of the challenges in integrated stroke care calls for research to facilitate its implementation. This before and after evaluation study identifies factors for implementation and concludes with key recommendations for adoption. METHODS: Data were collected at the start and end of an implementation programme in five stroke services (December 2017 to July 2018). The SDM implementation programme consisted of training for healthcare professionals (HCPs), tailored support, development of decision aids and a social map of local stroke care. Participating HCPs were included in the evaluation study: A questionnaire was sent to 25 HCPs at baseline, followed by 11 in-depth interviews. Data analysis was based on theoretical models for implementation and 51 statements were formulated as a result. Finally, all HCPs were asked to validate and to quantify these statements and to formulate recommendations for further adoption. RESULTS: The majority of respondents said that training of all HCPs is essential. Feedback on consultation and peer observation are considered to help improve performance. In addition, HCPs stated that SDM should also be embedded in multidisciplinary meetings, whereas implementation in the organisation could be facilitated by appointed ambassadors. Time was not seen as an inhibiting factor. According to HCPs, negotiating patients' treatment decisions improves adherence to therapy. Despite possible cognitive or communications issues, all are convinced patients with stroke can be involved in a SDM-process. Relatives play an important role too in the further adoption of SDM. HCPs provided eight recommendations for adoption of SDM in integrated stroke care. CONCLUSIONS: HCPs in our study indicated it is feasible to implement SDM in integrated stroke care and several well-known implementation activities could improve SDM in stroke care. Special attention should be given to the following activities: (1) the appointment of knowledge brokers, (2) agreements between HCPs on roles and responsibilities for specific decision points in the integrated stroke care chain and (3) the timely investigation of patient's preferences in the care process - preferably before starting treatment through discussions in a multidisciplinary meeting.

Understanding changes and stability in the long-term use of technologies by seniors who are aging in place: a dynamical framework.

BACKGROUND: If technologies are to support aging in place, then it is important to develop fundamental knowledge on what causes stability and changes in the use of technologies by seniors. However, longitudinal studies on the long-term use of technologies that have been accepted into the home (i.e., post-implementation use) are very scarce. Many factors potentially could influence post-implementation use, including life events, age-related decline, changes in personal goal orientation, and various types of social influences. The aforementioned factors are likely to be interrelated, adding to the complexity. The goal of this study is to better understand changes and stability in the use of technologies by independent-living seniors, by using a dynamical systems theory approach. METHODS: A longitudinal qualitative field study was conducted involving home visits to 33 community-dwelling seniors in the Netherlands, on three occasions (2012-2014). Interviews were held on technology usage patterns, including reasons for stable, increased, declined and stopped use. Technologies were included if they required electric power in order to function, were intended to be used in or around the home, and could support activities of daily living, personal health or safety, mobility, communication, and physical activity. Thematic analysis was employed, using constant case comparison to better understand dynamics and interplay between factors. In total, 148 technology use patterns by 33 participants were analyzed. RESULTS: A core of six interrelated factors was closely linked to the frequency of technology use: emotional attachment, need compatibility, cues to use, proficiency to use, input of resources, and support. Additionally, disruptive forces (e.g., social influences, competition with alternative means, changes of personal needs) could induce change by affecting these six factors. Furthermore, long-term technology use was in some cases more resilient to disruption than in other cases. Findings were accumulated in a new framework: Dynamics In Technology Use by Seniors (DITUS). CONCLUSIONS: Similar to aging, the use of technologies by older people is complex, dynamic and personal. Periods of stability and change both occur naturally. The DITUS framework can aid in understanding stability and instability of technology use, and in developing and implementing sustainable technological solutions for aging in place.

Effects of tailored telemonitoring on functional status and health-related quality of life in patients with heart failure.

BACKGROUND: Functional status and health-related quality of life (HRQoL) are important in patients with heart failure (HF). Little is known about the effect of telemonitoring on functional status and HRQoL in that population. METHODS AND RESULTS: A total of 382 patients with HF (New York Heart Association class 2-4) were included in a randomised controlled trial to investigate the effect of tailored telemonitoring on improving HRQoL and functional status in HF patients. Randomisation was computer-generated with stratification per centre. At baseline and after 12 months, patients' functional status was determined by metabolic equivalent scores (METS). HRQoL was measured with the EuroQol five dimensions questionnaire (EQ-5D), visual analogue scale (VAS) and Borg rating of perceived exertion scale (Borg). Additional outcome data included number of HF-related outpatient clinic visits and mortality. Telemonitoring was statistically significantly related to an increase in METS after 1 year (regression coefficient 0.318; p = 0.01). Telemonitoring did not improve Borg, EQ-5D or VAS scores after 1 year. EQ-5D [hazard ratio (HR) 0.20, 95% confidence interval (CI) 0.07-0.54], VAS (HR 0.98, 95% CI 0.96-0.99), Borg (HR 1.21, 95% CI 1.11-1.31) and METS (HR 0.73, 95% CI 0.58-0.93) at baseline were significantly associated with survival after 12 months. CONCLUSIONS: Tailored telemonitoring stabilised the functional status of HF patients but did not improve HRQoL. Therefore, telemonitoring may help to prevent deterioration of exercise capacity in patients with HF. However, because our study is a reanalysis of a randomised controlled trial (RCT), this is considered hypothesis-generating and should be confirmed by adequately powered RCTs.

Origins and consequences of technology acquirement by independent-living seniors: towards an integrative model.

BACKGROUND: Living independently can be challenging for seniors. Technologies are expected to help older adults age in place, yet little empirical research is available on how seniors develop a need for technologies, how they acquire these technologies, and how these subsequently affect their lives. Aging is complex, dynamic and personal. But how does this translate to seniors' adoption and acceptance of technology? To better understand origins and consequences of technology acquirement by independent-living seniors, an explorative longitudinal qualitative field study was set up. METHODS: Home visits were made to 33 community-dwelling seniors living in the Netherlands, on three occasions (2012-2014). Semi-structured interviews were conducted on the timeline of acquirements, and people and factors involved in acquirements. Additionally, participants were interviewed on experiences in using technologies since acquirement. Thematic analysis was employed to analyze interview transcripts, using a realist approach to better understand the contexts, mechanisms and outcomes of technology acquirements. RESULTS: Findings were accumulated in a new conceptual model: The Cycle of Technology Acquirement by Independent-Living Seniors (C-TAILS), which provides an integrative perspective on why and how technologies are acquired, and why these may or may not prove to be appropriate and effective, considering an independent-living senior's needs and circumstances at a given point in time. We found that externally driven and purely desire-driven acquirements led to a higher risk of suboptimal use and low levels of need satisfaction. CONCLUSIONS: Technology acquirement by independent-living seniors may be best characterized as a heterogeneous process with many different origins, pathways and consequences. Furthermore, technologies that are acquired in ways that are not congruent with seniors' personal needs and circumstances run a higher risk of proving to be ineffective or inappropriate. Yet, these needs and circumstances are subject to change, and the C-TAILS model can be employed to better understand contexts and mechanisms that come into play.

Improving guideline adherence in the treatment of atrial fibrillation by implementing an integrated chronic care program.

Background / Objectives. Atrial fibrillation (AF) is a very frequent and complex disease often associated with other medical conditions. The Euro Heart Survey (EHS) on AF showed that adherence to guidelines may reduce morbidity and mortality in AF patients. Therefore a nurse-driven, guideline-based, ICT-supported integrated chronic care program (ICCP) was developed and implemented in daily practice. The objective of this study is to evaluate the clinical feasibility of the ICCP, with guideline adherence as the endpoint.Methods. 111 ambulant patients referred for treatment of their AF were enrolled in the ICCP. In this group, patients underwent standardised clinical testing and were subsequently managed by a nurse, supported by a dedicated ICT program and supervised by cardiologists. For comparison, we used a recent historical control group of 102 patients who participated in the Maastricht part of the Euro Heart Survey (EHS) on AF. Results. Guideline adherence was excellent within the ICCP and compared favourably with the EHS-AF data concerning both clinical testing (trigger factors recorded in 100 vs. 44%; echocardiogram performed in 99 vs. 88%; thyroid-stimulating hormone level recorded in 96% vs. 63%) as well as treatment (antithrombotic therapy in 90 vs. 78%; rhythm control avoided in completely asymptomatic patients in 100 vs. 54%; class I drugs avoided in patients with structural heart disease in 90 vs. 95%; rhythm control avoided in permanent AF patients in 100 vs. 92%). Conclusion. The high level of guideline adherence suggests that a nurse-driven, guideline-based, ICT-supported ICCP for AF patients is feasible. (Neth Heart J 2010;18:471-7.).

Identifying potentially cost effective chronic care programs for people with COPD.

OBJECTIVE: To review published evidence regarding the cost effectiveness of multi-component COPD programs and to illustrate how potentially cost effective programs can be identified. METHODS: Systematic search of Medline and Cochrane databases for evaluations of multi-component disease management or chronic care programs for adults with COPD, describing process, intermediate, and end results of care. Data were independently extracted by two reviewers and descriptively summarized. RESULTS: Twenty articles describing 17 unique COPD programs were included. There is little evidence for significant improvements in process and intermediate outcomes, except for increased provision of patient self-management education and improved disease-specific knowledge. Overall, the COPD programs generate end results equivalent to usual care, but programs containing >or=3 components show lower relative risks for hospitalization. There is limited scope for programs to break-even or save money. CONCLUSION: Identifying cost effective multi-component COPD programs remains a challenge due to scarce methodologically sound studies that demonstrate significant improvements on process, intermediate and end results of care. Estimations of potential cost effectiveness of specific programs illustrated in this paper can, in the absence of 'perfect data', support timely decision-making regarding these programs. Nevertheless, well-designed health economic studies are needed to decrease the current decision uncertainty.

Transfer of care for outpatients with stable chronic obstructive pulmonary disease from respiratory care physician to respiratory nurse--a randomized controlled study.

OBJECTIVES: To assess effects on patient outcomes when care for patients with stable chronic obstructive pulmonary disease (COPD) is transferred from respiratory care physician to respiratory nurse. METHODS: A randomized controlled trial was used with a follow-up period of 9 months. Of 720 patients from the respiratory outpatient clinic of the general and teaching hospital in Alkmaar (The Netherlands), 187 were eligible for randomization and gave informed consent. Ninety-three patients received care from the nurse, and 87 received usual care. Outcomes measured were: clinical parameters, health status, self-care behaviour (including knowledge), patient satisfaction, and consultations with key care providers. RESULTS: The respiratory nurse reported more consultations than the respiratory care physician [mean (standard deviation)]: number of consultations 3.1 (0.7) by nurse and 2.0 (0.9) by physician (p = 0.007). Patients cared for by the nurse showed worsening in mean forced vital capacity [-5.5% (13.3%) v. +2.9% (18.2%) with physician; p = 0.004], and no difference in self-assessed condition, while improvements were found for subjective knowledge (p = 0.017), self-assessed rate for coping with COPD (p = 0.045), overall satisfaction (p = 0.003), and the majority of individual indicators of satisfaction. Groups showed no differences for forced expiratory volume in 1 s, body mass index, smoking status, health status, objective knowledge, other items of self-care behaviour, and consultations with key care providers. DISCUSSION: Assignment of care for outpatients with stable COPD to the respiratory nurse, working under a protocol, seems to be justified in terms of patient outcomes.

A disease management programme for patients with diabetes mellitus is associated with improved quality of care within existing budgets.

AIM: To assess the impact of a disease management programme for patients with diabetes mellitus (Type 1 and Type 2) on cost-effectiveness, quality of life and patient self-management. By organizing care in accordance with the principles of disease management, it is aimed to increase quality of care within existing budgets. METHODS: Single-group, pre-post design with 2-year follow-up in 473 patients. RESULTS: Substantial significant improvements in glycaemic control, health-related quality of life (HRQL) and patient self-management were found. No significant changes were detected in total costs of care. The probability that the disease management programme is cost-effective compared with usual care amounts to 74%, expressed in an average saving of 117 per additional life year at 5% improved HRQL. CONCLUSION: Introduction of a disease management programme for patients with diabetes is associated with improved intermediate outcomes within existing budgets. Further research should focus on long-term cost-effectiveness, including diabetic complications and mortality, in a controlled setting or by using decision-analytic modelling techniques.

The Health Technology Assessment-disease management instrument reliably measured methodologic quality of health technology assessments of disease management.

OBJECTIVE: Systematic reviews aim to summarize the evidence in a particular topic area, giving attention to the identified methodologic quality of published research. Because research in a specific area may be susceptible to specific biases, it is assumed that the methodologic quality of Health Technology Assessment (HTA) of disease management cannot properly be measured with the existing methodologic quality assessment instruments. The purpose of this study was to describe to what extent existing instruments are useful in assessing the methodologic quality of HTA of disease management. STUDY DESIGN AND SETTING: An inventory was made of the problems that arise when assessing the methodologic quality of six HTAs of disease management with three different instruments. Based on these findings, a new instrument is proposed and validated. RESULTS: Problems mainly concern the items related to the study design, criteria for selection and restriction of patients, baseline and outcome measures, blinding of patients and providers, and the description of (co)-interventions. CONCLUSION: With its more specific characteristics, the HTA-DM addresses the problems mentioned. The HTA-DM is a reliable instrument for methodologic quality assessment of HTA of disease management in comparison with the other three instruments.

Applying low disease activity criteria using the DAS28 to assess stability in patients with rheumatoid arthritis.

OBJECTIVES: To examine whether low disease activity criteria using the disease activity score (DAS28) can be applied to identify a reasonably large number of patients with stable low disease activity of rheumatoid arthritis (RA) over a six month period, with the ultimate intention of including these patients in a substitution based, shared care model. Additionally, to assess the reliability of the DAS28 for selecting patients with stable disease from an outpatient population. METHODS: Patients regularly seen at the rheumatology outpatient department of the university hospital Maastricht, were invited for assessment of the stability of their RA. The shared care model was intended to provide care to patients with stable, low disease activity of RA by nurse specialists. For this, patients underwent assessments using the DAS28 criteria at entry and three and six months later. Test-retest reliability was assessed for composing measures as well as for the DAS28. RESULTS: Of the 97 outpatients included, one third (31 patients) did not complete the study. Patients with missing data were older and assessed their disease activity as greater than patients with complete data. Applying the low disease activity criteria to assess stability over a period of six months (DAS28(T0)

The nurse specialist as main care-provider for patients with type 2 diabetes in a primary care setting: effects on patient outcomes.

A solution to safeguard high quality diabetes care may be to allocate care to the nurse specialist. By using a one group pretest-posttest design with additional comparisons, this study evaluated effects on patient outcomes of a shared care model with the diabetes nurse as main care-provider for patients with type 2 diabetes in a primary care setting. The shared care model resulted in an improved glycaemic control, additional consultations and other outcomes being equivalent to diabetes care before introduction, with the general practitioner as main care-provider. Assignment of care for patients with type 2 diabetes to nurse specialists seems to be justified.

Participation of general practitioners in disease management: experiences from The Netherlands.

OBJECTIVE: To investigate the extent to which GPs in The Netherlands participate in disease management and how personal opinions, impeding and promoting incentives as well as physician characteristics influence their attitude towards disease management. METHODS: The attitude-model of Fishbein and Ajzen was used to describe the attitude of GPs towards disease management and main influencing factors. After interviewing seventeen representatives of the GPs and testing a questionnaire, the final questionnaire was sent to all GPs in The Netherlands (7680 GPs) barring those involved in the testing of the questionnaire. RESULTS: At least 10.4% of all Dutch GPs are active in disease management. The main factors predicting a positive attitude towards disease management are the following: GPs' opinion that they are improving quality and efficiency of care when executing disease management, presence of a good quality network between actors involved prior to the start of disease management, working in a health centre, and performing sideline activities besides their daily activities as GPs. The main factors predicting a negative attitude are: GPs' opinion that the investment-time is too high, lack of reimbursement for disease management activities, working in a solo practice, and not performing any sideline activities beside their daily activities as GP. CONCLUSIONS: The factors predicting a negative attitude of Dutch GPs towards disease management dominate the factors predicting a positive attitude. The arguments in favour of disease management are matters of belief, for example concerning improvements in the quality of care, while arguments against are more concrete barriers e.g. high workload and financial reimbursement. Placed on the innovation timeline, the 10.4% participation might be taken to represent the start of a trend.

Substitution model with central role for nurse specialist is justified in the care for stable type 2 diabetic outpatients.

AIM OF THE STUDY: Assessment of effects on quality of care, in terms of patient outcomes, when tasks in the care for outpatients with stable type 2 diabetes are transferred from internist to nurse specialist and from outpatient clinic to general practice. BACKGROUND: For the management of chronic diseases with a high prevalence and requiring current monitoring, it is suggested that substitution of care may be an appropriate solution to safeguard high quality care. DESIGN AND METHODS: A 12-month nonequivalent control group design was used. General practitioners (GPs) referring diabetes patients to the University Hospital Maastricht were asked to choose for the traditional model or the nurse specialist model. Informed consent was obtained from patients with stable diabetes type 2 attending these practices. All patients received care according to the model chosen by their GP. Identified outcomes were: clinical status, health status, self-care behaviour, knowledge of diabetes, patient satisfaction, and consultation with care-providers. RESULTS: In the control group (n=47) no patients were treated with oral hypoglycaemic agents (OHA) only. The control group was compared with an intervention subgroup (n=52) also without patients receiving OHA only. Clinical data were available for all patients. Patients without complete data from questionnaires had better mean concentration of HbA1c than patients with complete data (P=0.004). The traditional care model and the nurse specialist model achieved equal outcomes, while glycaemic control of patients in the nurse specialist model improved (from 8.6% to 8.3%) but deteriorated in the traditional model (from 8.6% to 8.8%; P-value between groups=0.001). CONCLUSIONS: The model with nurse specialists taking on roles and tasks beyond those traditionally regarded as their remit as well as new ones, is effective for the care of stable diabetic outpatients.

Effects on quality of care for patients with NIDDM or COPD when the specialised nurse has a central role: a literature review.

Chronic care has to be organised in a way that care from any one caregiver is linked up to that provided by others so that disturbing gaps, contradictions and overlaps are avoided. In the search for the most effective and efficient combination of health professionals to deliver care to chronic patients, the role of the specialised nurse has become important. This article reviews a Medline search for publications about the effects of models of care for patients with NIDDM or COPD in which the specialised nurse has a central role. Main features of the models are identified and related to expected and statistically significant effects. In this young domain of effect evaluation ten publications met our criteria. Depending on the division of tasks between care providers, improvements are seen in self-care, quality of life and patient satisfaction, as well as increased medical consumption. More methodologically suitable evaluations with the use of only valid measures are needed.