Does enhanced information exchange between social insurance physicians and occupational physicians improve patient work resumption? A controlled intervention study.

BACKGROUND: Patient work resumption after sickness absence varies even among patients with similar pathologies and characteristics. Explanations remain uncertain. One newly investigated field is "information asymmetry", a situation in which critical information is not appropriately exchanged between stakeholders in disability management. It is hypothesised that information asymmetry between social insurance physicians and occupational physicians prolongs sickness absence. OBJECTIVES: To assess the influence of enhanced information exchange between these physicians on patient outcome. METHODS: Non-randomised controlled intervention study. The setting was the work inability assessment consultation of social insurance physicians in Belgium. Inclusion criteria were: employee, age 18-50, and subacute (more than one month) sickness absence. The intervention was a structured information exchange (through the use of a communication form) between the patient's social insurance physician and occupational physician. The intervention started when the patient's sickness absence reached the subacute stage, and ended when the sickness absence benefit was ceased or the duration exceeded one year. The primary outcome measure was the sickness absence benefit status of the patient assessed one year after benefit onset. RESULTS: Of the 1883 patients asked to enroll in the study, 1564 (84%) participated; 505 (32%) of 1564 patients were assigned to the intervention group and 1059 (68%) to the control group; 1553 (99%) of 1564 patients completed the study. In the intervention group, 86% received no sickness absence benefit at the end of the study, versus 84% in the control group (95% CI 0.91-1.15). No significant differences in other outcome parameters were obtained. CONCLUSIONS: Information exchange between physicians may not be enough to influence work resumption among patients on sickness absence. Further research on stakeholders' information asymmetry and its effect on the outcome of patients are necessary. The complexity of information asymmetry in disability management cannot be underestimated.

Intradialytic parenteral nutrition in malnourished hemodialysis patients: a prospective long-term study.

BACKGROUND: Malnutrition is a frequent problem of patients on intermittent hemodialysis and substantially contributes to their morbidity and mortality. METHODS: In 26 hemodialysis patients who, despite dietary advice and oral nutritional supplements, still had malnutrition, the feasibility and effects of a specific intradialytic parenteral nutritional (IPN) regimen were evaluated during a 9-month study period. An IPN solution consisting of 250 mL glucose 50%, 250 mL lipids 20%, and 250 mL amino acids 7% was infused i.v. three times a week during the dialysis session. At the end of each dialysis session an additional volume of 250 mL amino acids was infused as a rinsing fluid. Insulin was administered i.v. before dialysis. RESULTS: Of the 26 enrolled patients, 16 completed the study. The remaining 10 patients withdrew mainly because of muscle cramps and nausea during the initiation phase of the treatment, when sodium was not present in the IPN fluid but was supplemented intermittently. In the 16 treated patients, body weight, which had decreased in the pretreatment period from 58.2+/-1.3 kg (-6 months) to 54.8+/-10.1 kg at the start of the study, increased again up to 57.1+/-10.7 kg after 9 months IPN (p < .05). Serum transferrin and prealbumin rose from 1.7+/-0.4 to 2.0+/-0.4 g/L and from 0.23+/-0.05 to 0.27+/-0.10 g/L, respectively. Bone densitometry showed an increase of tissue mass, mostly related to a rise in fat tissue. Triceps skinfold (p < .05) and arm muscle compartment of the midarm (p = .07) increased as well. No such changes were observed in the patients who withdrew from treatment. CONCLUSIONS: An i.v. hyperalimentation regimen applied to malnourished hemodialysis patients results in a rise of body weight and in a limited, but significant, change of some parameters of nutritional status. The rise in body weight is at least in part attributable to an increase of body fat, without changes in plasma lipid levels.

Intradialytic parenteral nutrition in malnourished hemodialysis patients. Review of the literature.

Malnutrition is a frequent problem of patients on intermittent hemodialysis and is associated with increased morbidity and mortality. Intradialytic parenteral nutrition (IDPN), i.e. intravenous supplementation of mixtures of glucose, amino acids and/or lipids during the hemodialysis session, is one of the therapeutic measures that are applied to correct this malnutrition. To our knowledge only few long-term clinical studies have been undertaken, evaluating the effect of intravenous calorie administration in hemodialysis. Most studies were carried out over a relatively short observation period in small study populations; in several of these studies, no measures were taken to prevent losses of nutrients in the dialysate; adequate control groups are often missing. The authors review the current available literature and conclude that IDPN might have a significant beneficial effect on the nutritional status in malnourished hemodialysis populations.