Perinatal outcome in singleton pregnancies complicated with preeclampsia and eclampsia in Ecuador.

Preeclampsia in Ecuador is an understudied subject since available epidemiological data are scarce. The aim of this study was to describe perinatal outcomes among singleton pregnancies complicated with preeclampsia and eclampsia in a sample of low-income Ecuadorian women. Pregnant women complicated with preeclampsia (mild and severe) and eclampsia (defined according to criteria of the ACOG) delivering at the Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil, Ecuador were surveyed with a structured questionnaire containing maternal (socio-demographic) and neonatal data. Perinatal outcomes were compared according to severity of clinical presentation. A total of 163 women with preeclampsia [mild (23.9%), severe (68.7%) and eclampsia (7.4%)] were surveyed. Perinatal mortality and stillbirth rate was similar among studied groups (mild vs. severe preeclampsia/eclampsia cases). However, severe cases displayed higher rates of adverse perinatal outcomes: lower birth Apgar scores, more preterm births, and more low birth weight and small for gestational age infants. Caesarean-section rate and the number of admissions to intensive or intermediate neonatal care were higher in severe cases. A similar trend was found when analysis excluded preterm gestations. In conclusion, in this specific low-income Ecuadorian population perinatal outcome was adverse in pregnancies complicated with severe preeclampsia/eclampsia.

Knowledge and practice of family planning and HIV-prevention behaviour among just delivered adolescents in Ecuador: the problem of adolescent pregnancies.

BACKGROUND: Adolescents constitute a high risk population for the spreading of sexually transmitted diseases, among them HIV/AIDS. Knowledge regarding reproductive issues among them is a key point in order to establish appropriate prevention programs. OBJECTIVE: Obtain information regarding the knowledge and practice related to family planning and HIV-prevention behaviour among adolescents of low income. METHODS: Adolescents aged 19 or less delivering at the Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil, Ecuador were surveyed in the immediate postpartum period with a structured questionnaire designed for the purpose. RESULTS: During the study period, 357 pregnant adolescents were surveyed. Mean age was 17.2 +/- 1.4 years, 30.8% were aged 16 or less. Demographical and obstetrical history differences were found when comparing adolescents in relation to age and educational level. A high rate of mothers had unplanned pregnancies (63.3%) or did not know what family planning was (49.6%). Despite high knowledge of what a condom or an oral contraceptive was, few had used them in the past. The most frequently known family planning methods in this series, which was age dependent, were: oral contraceptives (90.2%), condoms (84.9%), parenteral (66.7%) and intrauterine devices (63.3%). The majority knew what HIV/AIDS infection was, the most important sources of knowledge being: television, high school source, and family or relatives. A high rate of adolescents had never had an HIV test performed in the past with one prior tested adolescent resulting in a positive result. There was a high rate of knowledge regarding the most frequent HIV transmission routes: sexual intercourse, contact with infected blood and vertical transmission. In this series, although condom use was the most known way for HIV protection, only 22.2% answered having intercourse protected with this method. CONCLUSION: In this adolescent series, older age was related to higher knowledge in family planning methods; in global despite finding a relatively high knowledge in family planning and HIV related issues, contraception use and HIV protection behaviour was low.

Urgency coding as a dynamic tool in management of waiting lists for psychogeriatric nursing home care in The Netherlands.

Criteria are used to prioritise patients on waiting lists for health care services. This is also true for waiting lists for admission to psychogeriatric nursing homes. A patient's position on these latter waiting lists is determined by (changes in) urgency and waiting time. The present article focuses on the process and outcome of an urgency coding system in a fair selection of patients. It discusses the use of urgency codes in the daily practice of waiting list management and the related waiting times. Patients and their informal caregivers were followed from entry on the waiting list to admission to a nursing home. Caregivers were interviewed during the waiting period and after their relative's admission to a nursing home, and the formal urgency codes on the waiting list were monitored. Seventy-eight of the initial 93 patients were admitted to a nursing home. High urgency codes were commonly assigned and the waiting times were shorter for patients with higher urgency codes. Negative consequences of an urgency coding system, e.g. patients with less urgency not being admitted at all and patients not being admitted to the nursing home of their choice, could not be demonstrated. Patients without higher urgency codes were admitted after a mean waiting time of 28 weeks. It may be questioned whether this long waiting time is problematic, because satisfaction of the caregivers with regard to waiting times was not influenced by the actual waiting times. An urgency coding system enables health care professionals to react to changes in the situation of both patients and caregivers by adjusting urgency codes to influence the length of time until nursing home admission.

Burden of delayed admission to psychogeriatric nursing homes on patients and their informal caregivers.

OBJECTIVE: To assess the deleterious effects of waiting for admission to a nursing home on the state of health of patients and their informal caregivers, and on the burden of caring. DESIGN AND PARTICIPANTS: Prospective longitudinal study consisting of interviews with informal caregivers during the period on the waiting list and after admission of the patient to a nursing home. Analysis of patients' files on diagnosis, date of registration on the waiting list, and date of admission to nursing home. SETTING: Ninety three patients registered on waiting lists for admission to a psychogeriatric nursing home in two regions of Amsterdam. RESULTS: Seventy eight of the 93 patients were admitted to a nursing home. The burden on the caregivers declined after admission of the patient but depressive symptoms did not. After 6 months a subgroup of 19 caregivers whose relatives were still waiting to be admitted were interviewed. The health of these patients remained stable during this waiting period and only problems in activities of daily living increased. The burden on these 19 informal caregivers and their state of health remained stable during the waiting period. CONCLUSIONS: A decline in the state of health and a rise in the burden on caregivers during the waiting period did not occur. However, a decrease in the burden and an improvement in mental health could have started earlier if patients had been admitted earlier.

Caring for relatives with dementia--caregiver experiences of relatives of patients on the waiting list for admission to a psychogeriatric nursing home in The Netherlands.

AIMS: Institutionalising a relative is a difficult decision and often relatives have to feel heavily burdened before they take such a step. Then the following delay because of waiting lists can be too much. This paper examines the experiences of caregivers of demented patients at the moment of registration on the waiting list for nursing-home care. METHODS: Interviews were carried out with 93 informal caregivers and analysis was made of the files of patients who were registered on the waiting list for nursing-home admission in Amsterdam in 1997 and 1998. Data collection included the Interview for Deterioration in Daily living activities in Dementia, The Revised Memory and Behaviour Problem Checklist, the Social Support List-Interaction, and three subscales of the Caregiver Reaction Assessment (CRA) scale. RESULTS: At the moment of admission to the waiting list, half of the respondents were rather heavily burdened or worse. Less severe dementia, lower age of the patient and providing more hours of informal care especially accounted for more negative experiences of caregivers. The self-esteem derived from caregiving was higher for caregivers with lower income and for those who perceived the quality of the relationship with the demented person as better. CONCLUSIONS: The high burden levels at the moment the decision to institutionalise the patient is taken put a heavy claim on the energy needed to continue to care during the ensuing waiting period. More social support and formal home care may reduce the level of burden of caregiving.

The meaning of urgency in the allocation of scarce health care resources; a comparison between renal transplantation and psychogeriatric nursing home care.

In the juridical and ethical literature on patient selection criteria it is an unargued premise that those who are most urgently in need of treatment or care will be given priority. The aim of this study is to gain insight into the medical practice of waiting list problems and patient selection at the microlevel, especially with respect to urgency. Thus, the study intends to contribute to the medical ethical discussion on patient selection for scarce resources. The results of qualitative research into the meaning and occurrence of urgency in two health care services, renal transplantation and psychogeriatric nursing home care, are discussed. In the first sector, patients are seldom considered urgent. Criteria for urgency are technical dialysis problems or severe psychological burden due to protracted dialysis treatment. In contrast, psychogeriatric patients are often considered urgent, with the principal criterion being too heavy a care load for informal carers. Both health care services show variation in assigning urgency codes. It appears that the exact meaning of urgency is not self-evident and that admission of urgent patients to nursing homes can be negotiated by professionals or informal carers. This points to the necessity of a discussion within these services as to the actual content matter of urgency. Further, professionals involved in renal transplantation raise several moral and practical arguments against giving patients priority, even if they need treatment urgently. It shows that distributive justice cannot always be applied. Occasionally non-urgent patients are rated urgent as they have been waiting very long due to specific allocation procedures. In these cases urgency is granted in an unexpected way that is ultimately in accordance with the notion of procedural justice.

[Waiting lists for psychogeriatric nursing home admissions: insight into the problematic waiting times]. / Wachtlijsten voor psychogeriatrische verpleeghuisopname: inzicht in problematische wachttijden?

In this article the waiting list for psychogeriatric nursing home care has been described for a large town in the Randstad (Netherlands). A literature study on psychogeriatric waiting lists was conducted; in a qualitative research project the procedure for admission on the waiting list was studied; and in a files study the characteristics of patients on the waiting lists, the waiting times and factors influencing waiting time have been studied. During the research period (1991) 111 patients were admitted to a waiting list, including 8 patients for whom admission was considered to be very urgent. These highly urgent patients were all mildly demented and had a mean waiting time of nine days. Almost half of the patients who were considered 'normally urgent' were moderately demented. The normally urgent patients had a mean waiting time of fourteen weeks. Hospitalized patients waiting for admission to a nursing home, had a lower waiting time than patients with the same urgency who were waiting at home. In comparison to the norms (8 weeks), the mean waiting time was unacceptably long.

Who should decide? Qualitative analysis of panel data from public, patients, healthcare professionals, and insurers on priorities in health care.

OBJECTIVE: To explore the arguments underlying the choices of patients, the public, general practitioners, specialists, and health insurers regarding priorities in health care. DESIGN: A qualitative analysis of data gathered in a series of panels. Members were asked to economise on the publicly funded healthcare budget, exemplified by 10 services. RESULTS: From a medical point of view, both panels of healthcare professionals thought most services were necessary. The general practitioners tried to achieve the budget cuts by limiting access to services to those most in need of them or those who cannot afford to pay for them. The specialists emphasised the possibilities of reducing costs by increasing the efficiency within services and preventing inappropriate utilisation. The patients mainly economised by limiting universal access to preventive and acute services. The "public" panels excluded services that are relatively inexpensive for individual patients. Moreover, they emphasised the individual's own responsibility for health behaviour and the costs of health care, resulting in the choice for copayments. The health insurers emphasised the importance of including services that relate to a risk only, as well as feasibility aspects. CONCLUSIONS: There were substantial differences in the way the different groups approached the issue of what should be included in the basic package. Healthcare professionals seem to be most aware of the importance of maintaining equal access for everyone in need of health care.

[Variation in reporting of available places in the neonatal intensive care units and consequences for efficiency, fairness and quality of care]. / Variatie in aanmelding van vrije plaatsen door neonatale intensive-careafdelingen en consequenties voor doelmatigheid, rechtvaardigheid en kwaliteit van zorg.

OBJECTIVE: To determine whether the national information system on available beds in neonatal intensive care units (NICUs) leads to fair distribution and good efficiency and quality of care. SETTING: Two out of the ten NICUs in the Netherlands. DESIGN: Descriptive. METHODS: Data were gathered through observations and 18 interviews with among others neonatologists, gynaecologists and paediatricians. Another 19 doctors were interviewed by phone after a patient they had referred was refused. Interviews were analysed by means of Kwalitan, a computer programme for analysis of qualitative research. RESULTS: When a patient could not be admitted in his own region, the information system was often used to find out which NICUs had a bed available. Sometimes a NICU was called that, according to the information system, did not have a place available. Reasons were: the information was not up to date and not all available beds were reported. This last reason had to do with the wish to keep a bed free for patients from the NICU's own region. Because most doctors were aware of this, they sometimes negotiated about beds, which was time-consuming. CONCLUSION: The information system was used often, but was working below optimal level, resulting in diminished efficiency. This was primarily caused by the priority given to patients of the own region, which had to do with quality of care considerations. The existing variation in use of the priority policy deserves attention from the viewpoint of procedural justice.

[Hospital admission of nursing home patients considered but not carried out: role of the nursing home physician and the involved parties and various differences with realized hospital admissions]. / Ziekenhuisopname van verpleeghuispatiënten overwogen doch niet gerealiseerd: de rol van de verpleeghuisarts en de overlegpartijen en enkele verschillen met wel gerealiseerde ziekenhuisopnamen.

The objective of the study was to establish in which way nursing home patients, for whom is refrained from hospitalization, differ from hospitalized nursing home patients. The question was also raised of how the decision to refrain from hospitalization is taken: which point of view and method the nursing home physician has, on which arguments decisions are based and which parties are involved and in which way. The design of the study was retrospective and descriptive. Data obtained from semi-structured interviews held in 1987 with 24 nursing home physicians on 45 situations were compared with registration data on 387 hospitalizations of patients from 30 nursing homes. In the non-hospitalized patients malignancies were relatively more frequent than in the hospitalized patients (29% versus 7%). The mean age of hospitalized patients was 78 and of non-hospitalized patients 80 years. The physical condition of non-hospitalized patients was more frequently judged as poor and the life expectancy as more limited. Already at an early stage nursing home physicians appeared to have a point of view, with which they determined the decision making procedure: in favour of (40%), opposing (35%) and in doubt of hospitalization (25%). In 'non-hospitalizations' there was much more involvement in decision making of family members and nurses, and less involvement of patients and medical specialists than in decisions to hospitalization. Non-medical arguments opposing hospitalization had slightly the upper hand above medical arguments. The decisive arguments opposing hospitalization were in the case of psychogeriatric patients more often of medical origin than in the case of somatic patients. The 'quality of live' mentioned arguments were of limited importance. The nursing home physician needs good communicative qualities in such decision making processes. He has to be skilled to judge competency of patients and, if needed, to balance in the right way the information of relatives, nurses, colleagues and specialists.

The use of the waiting list in a fair selection of patients for nursing home care.

When health care resources are scarce, waiting lists may be used as a distribution measure in order to enhance the fair allocation of resources through selection of patients. In this study, the structure and use of a waiting list for a fair selection of patients for nursing home admission was studied. Qualitative research took place in two regions in the Netherlands, where scarcity exists in nursing home care. Selection meetings were attended and 39 health care workers were interviewed. Not only did waiting list criteria like urgency and chronology determine the final selection decision, but also efficiency and quality of care considerations (patients' preferences for particular nursing homes and nursing homes' considerations of matching the unit and work load). These considerations, their relative importance, and the resulting need for enforcement of the decision-making procedures, should be part of the discussion of patient selection. This acknowledges the complexity of the selection of patients.

[Hospital admission of nursing home patients: patient characteristics and purpose of admission]. / Ziekenhuisopnamen van verpleeghuispatiënten: patiëntenkenmerken en doel van opname.

OBJECTIVE: To establish how many hospitalisations of nursing home patients are realised annually, the characteristics of these patients and the diagnoses and the purposes for which they are hospitalised. DESIGN: Retrospective and prospective. METHOD: Analysis of national data for the 5-year period 1986-1990 obtained from the registration of nursing home patients (SIVIS) of the Dutch Centre of Health Care information (SIG) and analysis of 385 separately gathered registration data from 30 nursing homes. RESULTS: More than 9000 hospitalisations of nursing home patients were realised annually, over 10% of those who stay in a nursing home for a shorter or longer time. Somatic patients were hospitalised nearly twice as often as psychogeriatric patients, and men about 1.25 times more often than women. The probability of hospitalisation decreased with advancing age. The most frequent reasons for hospitalisation were cardiovascular diseases, digestive tract diseases and femoral neck fractures. The most important purposes of hospitalisation are: to ward off threat to life (31%), to remedy complaints and burdens (29%), to improve the general condition (16%) and diagnostics (16%). The probability of hospitalisation was 2.5 times as large for the elderly living at home as for older nursing home patients. CONCLUSIONS: Hospitalisations are an important part of medical treatment and care of nursing home patients. There is a variation in hospitalisation rates for different categories of patients. Objectives of hospitalisation are diverse. There is a need for research into the effects of hospitalisation on the quality of life.

[Who decides on hospital admission of nursing home patients?]. / Wie beslist over ziekenhuisopname van verpleeghuispatiënten?

OBJECTIVE: To examine how the decision making to hospitalize nursing home patients proceeds, who takes the initiative, which participants are involved and how much time the consultation and decision making take. DESIGN: Prospective. METHOD: Analysis of registration data about decisions to hospitalize nursing home patients, collected from nursing home physicians in 30 nursing homes. RESULTS: In 76% of the cases the nursing home physician took the initiative to hospitalize. 38% of the patients had been consulted, which influenced the decision. 22% of the patients did not participate in the decision, mostly because of poor mental condition. Consultation of family members and nurses compensated only partly for this limited consultation of patients. With the other patients there had been contact, but without influence on the decision. Medical specialists to nursing home physicians were the most important participants in the decision making. Over 40% of the decisions were taken within 1 h, almost 25% between 1 h and 1 day. The duration of the decision making and the possibilities for consultation were mostly dependent of the urgency of hospitalisation. CONCLUSIONS: Because of the limited possibilities for consultation of nursing home patients when hospitalisation is considered, it is important to anticipate early on such situations by discussing this with patients and family members, and to write down the patients' wishes.

[Hospital admission of nursing home patients: a difficult decision?]. / Ziekenhuisopname van verpleeghuispatiënten: een moeilijke beslissing?

OBJECTIVE: To examine how difficult decisions to hospitalize nursing home patients are considered by the physicians and to what patient characteristics this is related. DESIGN: Prospective and descriptive. METHOD: Analysis of registration data about 387 decisions to hospitalize nursing home patients collected among nursing home physicians in 30 nursing homes. RESULTS: The degree of difficulty of hospitalisation was associated primarily with poor physical condition and much less with the mental condition. It was not related to patient age (apart from physical condition and the reason for hospitalisation). Referrals were difficult for e.g. infections and respiratory tract disorders, which may be further complicated by the short time available for the decision making because of the life threatening nature of the disorders. With malignancies, feeding, urogenital and skin disorders, decisions to hospitalize also proved difficult to make. These disorders usually allowed more time for consultation. CONCLUSION: About half the decisions to hospitalize were considered hard to make. Only when there is better insight into the effects of hospitalisation on patient functioning and quality of life will it be possible to determine correctness and professional obviousness of such decisions.