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Contains fulltext : 296204.pdf (Publisher’s version ) (Open Access), BACKGROUND: To evaluate the effects of a shared decision making (SDM) intervention for older adults with multiple chronic conditions (MCCs). METHODS: A pragmatic trial evaluated the effects of the SDM(MCC) intervention, existing of SDM training for nine geriatricians in two hospitals and a preparatory tool for patients. A prospective pre-intervention post-intervention multi-center clinical study was conducted in which an usual care group of older patients with MCC and their informal caregivers was included before the implementation of the intervention and a new cohort of patients and informal caregivers after the implementation of the intervention. SDM was observed using the OPTION(MCC) during video-recorded consultations. Patient- and caregivers reported outcomes regarding their role in SDM, involvement, perceived SDM and decisional conflict were measured. The differences between groups regarding the level of observed SDM (OPTION(MCC)) were analyzed with a mixed model analysis. Dichotomous patient-reported outcomes were analyzed with a logistic mixed model. RESULTS: From two outpatient geriatric clinics 216 patients with MCCs participated. The mean age was 77.3 years, and 56.3% of patients were female. No significant difference was found in the overall level of SDM as measured with the OPTION(MCC) or in patient-reported outcomes. However, at item level the items discussing 'goals', 'options', and 'decision making' significantly improved after the intervention. The items discussing 'partnership' and 'evaluating the decision-making process' showed a significant decrease. Fifty-two percent of the patients completed the preparatory tool, but the results were only discussed in 12% of the consultations. CONCLUSION: This study provides scope for improvement of SDM in geriatrics. Engaging older adults with MCCs and informal caregivers in the decision making process should be an essential part of SDM training for geriatricians, beyond the SDM steps of explaining options, be

Objective: The current waiting times for intermediate care in the Netherlands prohibit timely access, leading to unwanted and costly hospital admissions. We propose alternative policies for improvement of intermediate care and estimate the effects on the waiting times, hospitalization, and the number of patient replacements. Design: Simulation study. Setting and Participants: For our case study, data were used of older adults who received intermediate care in Amsterdam, the Netherlands, in 2019. For this target group, in- and outflows and patient characteristics were identified. Methods: A process map of the main pathways into and out of the intermediate care was obtained and a discrete event simulation (DES) was built. We demonstrate the use of our DES for intermediate care by evaluating possible policy changes for a real-life case study in Amsterdam. Results: By means of a sensitivity analysis with the DES, we show that in Amsterdam the waiting times are not a result of a lack in bed capacity but are due to an inefficient triage and application process. Older adults have to wait a median of 1.8 days for admission, leading to hospitalization. If the application process becomes more efficient and evening and weekend admissions are allowed, we find that unwanted hospitalization can be decreased substantially. Conclusion and Implications: In this study, a simulation model is developed for intermediate care that can serve as a basis for policy decisions. Our case study shows that the waiting times for health care facilities are not always solved by increasing bed capacity. This underlines the necessity for a data-driven approach to identify logistic bottlenecks and find the best ways to solve them.

Objectives: The long waiting times for nursing homes can be reduced by applying advanced waiting-line management. In this article, we implement a preference-based allocation model for older adults to nursing homes, evaluate the performance in a simulation setting for 2 case studies, and discuss the implementation in practice.Design: Simulation study.Setting and Participants: Older adults requiring somatic nursing home care, from an urban region (Rotterdam) and a rural region (Twente) in the Netherlands.Methods: Data about nursing homes and capacities for the 2 case studies were identified. A set of preference profiles was defined with aims regarding waiting time preferences and flexibility. Guidelines for implementation of the model in practice were obtained by addressing the tasks of all stakeholders. Thereafter, the simulation was run to compare the current practice with the allocation model based on specified outcome measures about waiting times and preferences.Results: We found that the allocation model decreased the waiting times in both case studies. Compared with the current practice policy, the allocation model reduced the waiting times until placement by at least a factor of 2 (from 166 to 80 days in Rotterdam and 178 to 82 days in Twente). Moreover, more of the older adults ended up in their preferred nursing home and the aims of the distinct preference profiles were satisfied.Conclusions and Implications: The results show that the allocation model outperforms commonly used waiting-line policies for nursing homes, while meeting individual preferences to a larger extent. Moreover, the model is easy to implement and of a generic nature and can, therefore, be extended to other settings as well (eg, to allocate older adults to home care or daycare). Finally, this research shows the potential of mathematical models in the care domain for older adults to face the increasing need for cost-effective solutions.

Contains fulltext : 251825.pdf (Publisher’s version ) (Open Access)

Contains fulltext : 234429.pdf (Publisher’s version ) (Open Access), PURPOSE: Geriatric Emergency Medicine (GEM) focuses on delivering optimal care to (sub)acutely ill older people. This involves a multidisciplinary approach throughout the whole healthcare chain. However, the underpinning evidence base is weak and it is unclear which research questions have the highest priority. The aim of this study was to provide an inventory and prioritisation of research questions among GEM professionals throughout Europe. METHODS: A two-stage modified Delphi approach was used. In stage 1, an online survey was administered to various professionals working in GEM both in the Emergency Department (ED) and other healthcare settings throughout Europe to make an inventory of potential research questions. In the processing phase, research questions were screened, categorised, and validated by an expert panel. Subsequently, in stage 2, remaining research questions were ranked based on relevance using a second online survey administered to the same target population, to identify the top 10 prioritised research questions. RESULTS: In response to the first survey, 145 respondents submitted 233 potential research questions. A total of 61 research questions were included in the second stage, which was completed by 176 respondents. The question with the highest priority was: Is implementation of elements of CGA (comprehensive geriatric assessment), such as screening for frailty and geriatric interventions, effective in improving outcomes for older patients in the ED? CONCLUSION: This study presents a top 10 of high-priority research questions for a European Research Agenda for Geriatric Emergency Medicine. The list of research questions may serve as guidance for researchers, policymakers and funding bodies in prioritising future research projects.

Contains fulltext : 235781.pdf (Publisher’s version ) (Closed access), Background Medication management is jeopardized during a patient's transition from hospital to home. Insight is required from both hospital and primary healthcare providers on how care should be organised to achieve continuity of medication management. Objective This study aimed to identify perspectives of hospital and primary healthcare providers on barriers to the continuity of medication management during a patient's transition from hospital to home and facilitators to overcome these. Setting A qualitative descriptive study was conducted within hospital and primary healthcare settings in the Netherlands. Method Two focus groups were performed with two community care registered nurses, two community pharmacists, four general practitioners, two hospital nurses, two hospital pharmacists, four outpatient pharmacists, two pharmacy technicians, and one physician. A semi-structured interview guide was used to identify perspectives of participants on barriers to continuity of medication management and facilitators to overcome these. Data were analysed following thematic content analysis. Main outcome measure Barriers to the continuity of medication management during a patient's transition from hospital to home would be enumerated, along with facilitators to overcome these barriers. Results Three main themes of barriers and facilitators were identified: (1) healthcare provider collaboration, including the transfer of medication information and effective collaboration; (2) patient's medication use, including information about medication, personalised care, and supervision after discharge; and (3) organisation of healthcare, including the connection between information systems and the supply of medication. Conclusion Barriers and facilitators to continuity of medication management during the transition from hospital to home occur at the provider, patient, and healthcare-system levels. Future interventions should focus on all levels through interprofessional healthcare teams

Contains fulltext : 219491.pdf (publisher's version ) (Open Access)

Contains fulltext : 202278.pdf (publisher's version ) (Open Access), BACKGROUND: During transitions from hospital to home, up to half of all patients experience medication-related problems, such as adverse drug events. To reduce these problems, knowledge of patient experiences with medication use during this transition is needed. This study aims to identify the perspectives of patients on barriers and facilitators with medication use, during the transition from hospital to home. METHODS: A qualitative study was conducted in 2017 among patients discharged from two hospitals using a semi-structured interview guide. Patients were asked to identify all barriers they experienced with medication use during transitions from hospital to home, and facilitators needed to overcome those barriers. Data were analyzed following thematic content analysis and visualized using an "Ishikawa" diagram. RESULTS: In total, three focus groups were conducted with 19 patients (mean age: 70.8 (SD 9.3) years, 63% female). Three barriers were identified; lack of personalized care in the care continuum, insufficient information transfer (e.g. regarding changes in pharmacotherapy), and problems in care organization (e.g. medication substitution). Facilitators to overcome these barriers included a personal medication-counselor in the care continuum to guide patients with medication use and overcome communication barriers, and post-discharge follow-up care (e.g. home visits from healthcare providers). CONCLUSIONS: During transitions from hospital to home patients experience individual-, healthcare provider- and organization level barriers. Future research should focus on personal-medication counselors in the care continuum and post-discharge follow-up care as it may overcome communication, emotional, information and organization barriers with medication use.

Title: Experiences of older cardiac patients with the Cardiac Care Bridge transitional care program: A qualitative study. Background: The Cardiac Care Bridge (CCB) transitional care program is a randomized controlled trial aiming to reduce hospital readmissions and mortality for high-risk cardiac patients of 70 years and older. A qualitative study has been conducted as part of the process evaluation of the CCB-program, evaluating patients’ experiences on the care they received. Aim: The aim was to explore older cardiac patients’ experiences with the CCB-program during the hospital-, discharge- and post-clinical phase. Methods: An explorative research with a generic qualitative approach has been performed. Semi-structured interviews were conducted with twelve older cardiac patients at their homes. All interviews were audio-recorded, transcribed, and analysed using The Framework Method and six themes from the ‘Six Senses Framework’. Results: Few patients had a clear memory about the hospital- and transitional phase of the CCB-program. The six senses were particularly prominent in experiences with the care received during the post-clinical phase. The feeling that there was someone there helping them with recovery and maintain independence, ensured a great sense of security. The sense of purpose and fulfilment particularly came forward in experiences with exercises received from the PT. However, patients did not always recognise the aim of the home-visits received from the CCRN. Conclusion and recommendation: Results indicate that patients experienced a helping hand during their first period of recovery. During further implementation of the CCB-program, attention should be given to tailored information for this target group about the received care and to goalsetting with active involvement of the patient. This may contribute to the sense of continuity of care, insight in the goals to work on, and contribution to recovery and may keep patients motivated for participation

Background. The Cardiac Care Bridge (CCB) intervention was designed to reduce unplanned readmission and mortality within six months after hospital admission, for frail cardiac patients of ≥70 years. The Medical Research Council Process Evaluation framework (MRCPE) provides guidance to assess contextual factors, implementation success and mechanisms of impact. Aims. The first aim was to assess the level of treatment delivery, by fidelity, dose, and reach. The second aim was to gain insights in the caregivers’ experience with the delivery of the CCB intervention. By gaining insight in the contextual factors, implementation success and mechanisms of impact from the MRCPE. Methods. A mixed-method concurrent qualitative dominant design was conducted, with a retrospective descriptive design for the quantitative part, using self-reported logbooks. An interpretive descriptive design, using semi-structured interviews with the caregivers (nurses and physiotherapists) for the qualitative part. Results. Delivery rates ranged from 13.7% to 91.9% per key-element. One patient received all key-elements. Caregivers expressed strong beliefs in the effectiveness of the CCB intervention but experience some barriers in providing the key-elements. Expressed barriers were related to lack of insights in the added value of key-elements, time limitations and planning issues. The motivation of the patients had a large influence on providing care during home-visits. Conclusion. The CCB intervention is currently not completely provided as intended, but caregivers strongly believe in the intervention. They are confident that this intervention can contribute to the patients’ wellbeing and prevents adverse events like readmissions. Recommendations. The research-team should apply targeted implementation strategies during the study period to increase the level of adherence to the protocol by the caregivers. A secondary qualitative analysis guided by the Normalization Process Theory could contribute

Contains fulltext : 174198.pdf (publisher's version ) (Open Access), BACKGROUND: Preference-weighted multi-faceted endpoints have the potential to facilitate comparative effectiveness research that incorporates patient preferences. The Older Persons and Informal Caregivers Survey-Composite endpoint (TOPICS-CEP) is potentially a valuable outcome measure for evaluating interventions in geriatric care as it combines multiple outcomes relevant to older persons in a single metric. The objective of this study was to validate TOPICS-CEP across different study settings (general population, primary care and hospital). METHODS: Data were extracted from TOPICS Minimum Dataset (MDS), a pooled public-access national database with information on older persons throughout the Netherlands. Data of 17,603 older persons were used. Meta-correlations were performed between TOPICS-CEP indexed scores, EuroQol5-D utility scores and Cantril's ladder life satisfaction scores. Mixed linear regression analyses were performed to compare TOPICS-CEP indexed scores between known groups, e.g. persons with versus without depression. RESULTS: In the complete sample and when stratified by study setting TOPICS-CEP and Cantril's ladder were moderately correlated, whereas TOPICS-CEP and EQ-5D were highly correlated. Higher mean TOPICS-CEP scores were found in persons who were: married, lived independently and had an education at university level. Moreover, higher mean TOPICS-CEP scores were found in persons without dementia, depression, and dizziness with falls, respectively. Similar results were found when stratified by subgroup. CONCLUSION: This study supports that TOPICS-CEP is a robust measure which can potentially be used in broad settings to identify the effect of intervention or of prevention in elderly care.

Background: As populations age, chronic geriatric conditions linked to progressive organ failure jeopardize health-related quality of life (HRQoL). Thus, this research assessed the validity and applicability of the EQ-5D (a common HRQoL instrument) across four major chronic

Background Preference-weighted multi-faceted endpoints have the potential to facilitate comparative effectiveness research that incorporates patient preferences. The Older Persons and Informal Caregivers Survey Composite endpoint (TOPICS-CEP) is potentially a valuable outcome measure for evaluating interventions in geriatric care as it combines multiple outcomes relevant to older persons in a single metric. The objective of this study was to validate TOPICS-CEP across different study settings (general population, primary care and hospital). Methods Data were extracted from TOPICS Minimum Dataset (MDS), a pooled public-access national database with information on older persons throughout the Netherlands. Data of 1

Item does not contain fulltext, OBJECTIVE: To develop, implement and evaluate a personalized patient discharge letter (PPDL) to improve the quality of handoff communication from hospital to home. DESIGN: From the end of 2006-09 we conducted a quality improvement project; consisting of a before-after evaluation design, and a process evaluation. SETTING: Four general internal medicine wards, in a 1024-bed teaching hospital in Amsterdam, the Netherlands. PARTICIPANTS: All consecutive patients of 18 years and older, admitted for at least 48 h. INTERVENTIONS: A PPDL, a plain language handoff communication tool provided to the patient at hospital discharge. MAIN OUTCOME MEASURES: Verbal and written information provision at discharge, feasibility of integrating the PPDL into daily practice, pass rates of PPDLs provided at discharge. RESULTS: A total of 141 patients participated in the before-after evaluation study. The results from the first phase of quality improvement showed that providing patient with a PPDL increased the number of patients receiving verbal and written information at discharge. Patient satisfaction with the PPDL was 7.3. The level of implementation was low (30%). In the second phase, the level of implementation improved because of incorporating the PPDL into the electronic patient record (EPR) and professional education. An average of 57% of the discharged patients received the PPDL upon discharge. The number of discharge conversations also increased. CONCLUSION: Patients and professionals rated the PPDL positively. Key success factors for implementation were: education of interns, residents and staff, standardization of the content of the PPDL, integrating the PPDL into the electronic medical record and hospital-wide policy.

Contains fulltext : 154203.pdf (publisher's version ) (Open Access), BACKGROUND: To assess the effectiveness of geriatric interventions, The Older Persons and Informal Caregivers Survey - Composite Endpoint (TOPICS-CEP) has been developed based on health valuations of older persons and informal caregivers. This study explored the influence of the raters' age on the preference weights of TOPICS-CEP's components. METHODS: A vignette study was conducted with 200 raters (mean age +/- standard deviation: 72.5+/-11.8 years; 66.5% female). Profiles of older persons were used to obtain the preference weights for all TOPICS-CEP components: morbidity, functional limitations, emotional well-being, pain experience, cognitive functioning, social functioning, self-perceived health, and self-perceived quality of life. The raters assessed the general wellbeing of these vignettes on a 0-10 scale. Mixed linear regression analysis with interaction terms was used to explore the effects of raters' age on the preference weights. RESULTS: Interaction effects between age and the TOPICS-CEP components showed that older raters gave significantly (P<0.05) more weight to functional limitations and social functioning and less to morbidities and pain experience, compared to younger raters. CONCLUSION: Researchers examining effectiveness in elderly care need to consider the discrepancies between health valuations of younger olds and older olds when selecting or establishing outcome measures. In clinical decision making, health care professionals need to be aware of this discrepancy as well. For this reason we highly recommend shared decision making in geriatric care.

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Background: Hospitalization in older people is associated with disability, mortality and entry to long-term care (LTC, care in care institutions or home care). Aim and research question(s): To describe (predictors of) LTC and mortality in six months post-hospitalization in older patients with stroke, pneumonia, myocardial infarction (MI), hip fracture, chronic obstructive pulmonary disease (COPD) and chronic heart failure. 1) What percentage of patients use LTC or die in the six months post-hospitalization? 2) What percentage of patients discharged to LTC still require LTC at three and six months? 3) Which variables predict LTC and mortality? Methods: Quantitative retrospective longitudinal observational cohort study with data from 3,154 patients >65, hospitalized because of one of six diagnoses. Dependent variables: LTC and mortality. Independent variables: age, gender, ethnicity, urbanization and diagnosis. Percentages of LTC use and mortality were calculated and multinomial logistic regression was performed. Results: Institutionalization at one month was highest in hip fracture (31.1%) and lowest in MI (3.1%). Home care use was highest in COPD (over 12%). Between 16.7% and 26.6% died. At three months >48% discharged to a care institution were institutionalized, at six months >60% were still institutionalized. More than 55% discharged with home care still required this at three months, and 45%-72% at six months. High age and living in strongly urbanized areas predicted LTC and mortality. Pneumonia, stroke and hip fracture predicted institutionalization and COPD both home care and institutionalization. Pneumonia and stroke predicted mortality. Conclusion: LTC utilization and mortality are high after hospitalization in older people and vary between diagnosis groups. LTC is often required for a long duration. Age, urbanization and diagnosis predict LTC and mortality. Recommendations: Health care workers should distinguish patients with poor prognosis from those who b

Contains fulltext : 154840.pdf (publisher's version ) (Open Access)

Introduction: In 2008, the Ministry of Health, Welfare and Sport commissioned the National Care for the Elderly Programme. While numerous research projects in older persons' health care were to be conducted under this national agenda, the Programme further advocated the development of The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS) which would be integrated into all funded research protocols. In this context, we describe TOPICS data sharing initiative (www.topics-mds.eu). Materials and Methods: A working group drafted TOPICS-MDS prototype, which was subsequently approved by a multidisciplinary panel. Using instruments validated for older populations, information was collected on demographics, morbidity, quality of life, functional limitations, mental health, social functioning and health service utilisation. For informal caregivers, information was collected on demographics, hours of informal care and quality of life (including subjective care-related burden). Results: Between 2010 and 2013, a total of 41 research projects contributed data to TOPICS-MDS, resulting in preliminary data available for 32,310 older persons and 3,940 informal caregivers. The majority of studies sampled were from primary care settings and inclusion criteria differed across studies. Discussion: TOPICS-MDS is a public data repository which contains essential data to better understand health challenges experienced by older persons and informal caregivers. Such findings are relevant for countries where increasing health-related expenditure has necessitated the evaluation of contemporary health care delivery. Although open sharing of data can be difficult to achieve in practice, proactively addressing issues of data protection, conflicting data analysis requests and funding limitations during TOPICS-MDS developmental phase has fostered a data sharing culture. To date, TOPICS-MDS has been successfully incorporated into 41 research projects, thus supporting the feasi

Background: In previous studies there were 30-day readmission rates of around 20%. It is not clear whether these readmissions are preventable and which factors contribute to it. Better understanding of patient and process factors related to preventable readmissions would enable us to improve the discharge procedure and reorganize care pathways to prevent these readmissions. Aim and research question: To find patient-, process-, and medication-related factors which lead to unplanned hospital readmissions. The research question of this study was: Which patient-, process- and medication-related factors are associated with unplanned hospital readmission in patients 18 years and older discharge from a general internal medicine ward? Method: A case control study is done with 35 cases and 35 controls. Using a self made case report form all the medical records a searched. Also earlier collected prospective data is included in this study. The included factors are divided in three levels. Patient-, process- and medication-related factors. Results: From the patient-related factors only chronic illness is a factor who can be associated with hospital readmissions. From the process-related factors mean length of stay in days, wanted to receive care after discharge and timely informed about discharge are significantly proven. The factors medication change and use prednisone are from the medication-related level and can be associated with unplanned hospital readmission. Conclusion: There are a lot factors investigated, but only a couple of them are significantly different. Normally it is common to include more controls against the cases into such a ratio of 1:3. Recommendations: It is a recommendation to extend this study with more controls and more depth in some factors. Now, it is still too wide examine. In the prospective data there were a lot of missing values, this should be less next time.