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Objective: To describe the course of social support (everyday support, support in problem situations and esteem support) from initial inpatient rehabilitation until 3 years post-stroke and to examine the cross-sectional and longitudinal relationships of social support with depressive symptoms. Design: Prospective cohort study. Subjects: A total of 249 stroke patients. Methods: Depressive symptoms were measured with the Center of Epidemiologic Studies Depression Scale. Perceived social support was assessed with the Social Support List-Interaction. Pearson correlations and multilevel analysis were performed. Results: More than one-third of participants had depressive symptoms. Social support and its 3 subtypes declined significantly over time. Divergent relationships were found between subtypes of social support and depressive symptoms. Everyday support and esteem support had negative associations with depressive symptoms, whereas support in problem situations had a positive association. Social support in problem situations was a predictor of depressive symptoms over time. No effect-modification by participants with physical or cognitive limitations was found. Conclusion: Stroke survivors experience a decline in social support over time. Various subtypes of support show distinct relationships with depressive symptoms. Healthcare professionals should focus on the various subtypes of support when supporting patients to improve and maintain an adequate social support network.

Objective: To assess quality of life of adults with Duchenne muscular dystrophy in the Netherlands and to identify domains and major problems influencing quality of life. Design: Cross-sectional. Subjects: Seventy-nine men aged >= 20 years with Duchenne muscular dystrophy. Methods: The Medical Outcome Study Short Form-36 (SF-36), World Health Organization Quality of Life - BREF (WHOQOL-BREF) and an interview were used to assess quality of life and problems. Results: Compared with Dutch general population reference values, the SF-36 domains scores were lower on all domains except mental health and role limitations due to emotional problems. On the WHOQOL-BREF the social relationships domain score was lower. Main problems were intimate relationships, work, leisure, transport and meaningfulness of life. Seventy-three percent stated overall quality of life as "(very) good". The SF-36 domains mental health (r(s) 0.53, p

Objectives: (a) To determine levels of and factors explaining partners' burden, anxiety and depressive symptoms at two months post-stroke, (b) to predict partners' burden, anxiety and depressive symptoms at one year post-stroke based on patient and partner characteristics available at two months post-stroke.Methods: Prospective cohort study. Partners of stroke patients (N = 183) were included. Main outcome measures were the Caregiver Strain Index and the Hospital Anxiety and Depression Scale.Results: Many partners experienced high burden, anxiety and depressive symptoms. At two months post-stroke, these outcomes were associated with the partner variables: age, relationship satisfaction, proactive coping, self-efficacy, everyday social support, burden, anxiety and depressive symptoms; and the patient variables: stroke severity and depressive symptoms.Partner outcomes at one year post-stroke were mainly predicted by the level of these outcomes at two months post-stroke.Conclusions: Partner outcomes at two months post-stroke predict to a large degree partner outcomes at one year post-stroke.Practice implications: Measuring partners' burden and anxiety and depressive symptoms in the post-acute phase is recommended to trace partners at risk of long-term burden and emotional problems. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Purpose: To describe subjective caregiver burden of parents of adults with Duchenne muscular dystrophy (DMD) and to identify factors associated with the level of subjective burden. Methods: In a cross-sectional study in 80 parents of 57 adult, severely disabled DMD patients' level of subjective caregiver burden was measured with the Caregiver Strain Index (CSI) and the Self Rated Burden Scale. A visual analogue scale was used to measure happiness. The expanded CSI version, the CarerQoL and open questions were used to analyse caregiving in more depth. In uni and multivariate analyses, associations of objective care characteristics, patient characteristics and caregiver characteristics with burden were explored. Results: Parents indicated substantial burden, but valued giving care as being important and rewarding. Subjective burden was associated with received support, tracheotomy, active coping by the patient and anxiety in patient and parents, together explaining 34%-36% of variance. Living situation was not associated with experienced burden. Conclusions: Caring for an adult son with DMD is burdensome, but rewarding. Subjective caregiver burden of parents may be alleviated by adequate support and respite care, by avoiding tracheotomy and by intervention programs targeting anxiety and promoting active coping by the patient from childhood.

OBJECTIVE: To quantify the long-term use of various types of healthcare services in patients with traumatic brain injury and to estimate the relative contribution of predisposing characteristics, enabling factors and health-related needs to determine whether there is equity in healthcare utilization. DESIGN: Cross-sectional study. PATIENTS: Seventy-nine non-institutionalized moderate to severe patients with traumatic brain injury (age range 16-67 years). METHODS: Healthcare use was measured at 3-5 years post-injury. The relative contribution of predisposing characteristics, enabling factors, and health-related needs to the utilization of various types of care was analysed using logistic regression to determine whether there was equity in healthcare utilization. RESULTS: At least one healthcare service was used by 68% of the patients. Health-related needs explained most of the utilization. However, predisposing characteristics were also related to the use of other medical care and supportive care. Patients with a high internal locus of control were more likely to be users of supportive care, and patients with a high locus of control with the physician were more likely to visit medical specialists. CONCLUSION: The results suggest that most of our patients who needed care, received care. However, inequity could not be ruled out completely as predisposing characteristics also contributed to some types of healthcare utilization. Language: en

BACKGROUND: This general practice-based case-control study tested the association between cerebrovascular risk factors (CVRFs) and the development of later-life depression by focusing on the impact of exposure duration to CVRFs and the modifying influence of age at depression onset. METHODS: Cases were 286 patients aged > or = 50 years with a first diagnosis of depression at age > or = 50 years. Nondepressed controls (N=832) were individually matched for age, gender and practice. CVRF diagnoses (hypertension, diabetes mellitus, cardiovascular conditions) prior to depression were determined. Analyses controlled for education, somatic and nondepressive psychiatric disease. RESULTS: No CVRF variable examined was significantly associated with subsequent depression in the total sample. An unexpected impact of age at onset of depression was observed: the odds ratio associated with having any CVRF was smaller for patients with age at onset > or = 70 years than for patients with onset between ages 50-59 years (p=.002) and 60-69 years (p=.067). Subsequent analyses excluding patients with onset at age > or = 70 years revealed that CVRF variables, including long-term exposure to CVRFs, significantly increased the odds of subsequent depression with onset between ages 50 and 69 years. LIMITATIONS: Reliance on GPs' records of morbidity may have resulted in bias towards underestimation in patients with depression onset at age > or = 70 years. CONCLUSIONS: Our findings suggest that CVRFs play a relevant role in the development of depression with onset between ages 50 and 69 years, but no evidence was found that they contribute to the occurrence of depression with onset at age > or = 70 years. Replication is warranted to exclude the possibility of bias

Objective.To investigate the longterm association of a wide range of comorbidities with physical and mental functioning in patients with rheumatoid arthritis (RA).Methods.Longitudinal data over a period of 11 years were collected from 882 patients with RA. Somatic comorbidity and comorbid depression were measured at baseline, with a questionnaire including 20 chronic diseases and with the Center for Epidemiologic Depression Scale, respectively. Physical functioning was measured at 5 timepoints with a disease-specific measure [Health Assessment Questionnaire (HAQ)] and a generic measure [physical scales of the Medical Outcomes Study Short Form-36 (SF-36)]. Mental functioning was measured with the mental scales of the SF-36. To determine the association of baseline-specific comorbidities with functioning over time, we performed longitudinal analyses.Results.At baseline, 72% percent of the patients were women, mean age ± SD was 59.3 ± 14.8 years, median RA disease duration was 5.0 years, and 68% had ≥ 1 comorbid condition. The effect of comorbid conditions was more apparent when physical functioning was measured with SF-36, a disease-generic measure, compared with the HAQ, a disease-specific measure. Circulatory conditions and depression were associated (p < 0.05) with worse physical functioning according to the HAQ. Respiratory conditions, musculoskeletal conditions, cancer, and depression were associated (p < 0.05) with worse physical functioning according to the SF-36. Respiratory conditions and depression were associated with worse mental functioning.Conclusion.Patients with specific comorbid conditions have an increased risk of low functioning in the long term. Targeted attention for these specific comorbid conditions by clinicians is recommended.

Background and Objective: To comprehensively examine comorbidity in unselected cohorts of patients with depression, stroke, multiple sclerosis (MS), Parkinson's disease/parkinsonism (PD/PKM), dementia, migraine, and epilepsy. Methods: This cross-sectional study used morbidity data recorded by Dutch general practitioners. Index disease cohort sizes ranged from 241 patients with MS to 6,641 patients with lifetime depression. Thirty somatic and seven psychiatric disease categories were examined to determine whether they were comorbid with the index diseases by performing comparisons with age- and gender-matched control cohorts. Identified comorbidities were classified as either "possible" or "highly probable" comorbidity. Results: An extensive range of 26 disease categories was found to be comorbid with lifetime depression. The comorbidity profile of stroke was also wide, including 21 disease categories. The comorbidity patterns of migraine and epilepsy comprised each 11 disease categories. Those concerning MS, PD/PKM, and dementia included a small number of disease categories. Conclusion: This study provides comprehensive knowledge of the occurrence of somatic and psychiatric comorbidity in general populations of patients with depression, stroke, MS, PD/PKM, dementia, migraine, and epilepsy. The implications of the findings for clinical practice and research are discussed.

This paper reports the results of the application of the opportunity costs and proxy good methods to determine a monetary value of informal care. We developed a survey in which we asked informal caregivers in The Netherlands to indicate the different types of time forgone (paid work, unpaid work and leisure) in order to be able to provide care. Moreover, we asked informal caregivers how much time they spent on a list of 16 informal care tasks during the week before the interview. Data were obtained from surveys in two different populations: informal caregivers and their care recipients with stroke and with rheumatoid arthritis (RA). A total of 218 care recipients with stroke and their primary informal caregivers completed a survey as well as 147 caregivers and their care recipients with RA. The measurement of care according to both methods is more problematic compared to the valuation. This is especially the case for the opportunity costs method and for the housework part in the proxy good method. More precise guidelines are necessary for the consistent application of both methods in order to ensure comparability of results and of economic evaluations of health care.

Background. Depression is highly co-morbid with both psychiatric and chronic somatic disease. These types of co-morbidity have been shown to exert opposite effects on underdiagnosis of depression by general practitioners (GPs). However, past research has not addressed their combined effect on underdiagnosis of depression.Method. Co-morbidity data on 191 depressed primary-care patients selected by a two-stage sampling procedure were analysed. Diagnoses of major depression and/or dysthymia in the last 12 months were assessed using a standardized psychiatric interview (CIDI) and compared with depression diagnoses registered by GPs in patient contacts during the same period. Presence of psychiatric and chronic somatic co-morbidity was determined using the CIDI and contact registration, respectively.Results. Regression analysis showed a significant interaction effect between psychiatric and chronic somatic co-morbidity on GPs’ diagnosis of depression, while taking into account the effects of sociodemographic variables, depression severity and number of GP contacts. Subsequent stratified analysis revealed that in patients without chronic somatic co-morbidity, a lower educational level, a less severe depression, and fewer GP contacts all significantly increased the likelihood of not being diagnosed as depressed. In contrast, in patients with chronic somatic co-morbidity, only having no psychiatric co-morbidity significantly decreased the likelihood of receiving a depression diagnosis.Conclusions. Our results indicate that the effects of psychiatric co-morbidity and other factors on underdiagnosis of depression by GPs differ between depressed patients with and without chronic somatic co-morbidity. Efforts to improve depression diagnosis by GPs seem to require different strategies for depressed patients with and without chronic somatic co-morbidity.

Background and Purpose— In the near future, the number of stroke patients and their related healthcare costs are expected to rise. The purpose of this study was to estimate this expected increase in stroke patients in the Netherlands. We sought to determine what the future developments in the number of stroke patients due to demographic changes and trends in the prevalence of smoking and hypertension in terms of the prevalence, incidence, and potential years of life lost might be. Methods— A dynamic, multistate life table was used, which combined demographic projections and existing stroke morbidity and mortality data. It projected future changes in the number of stroke patients in several scenarios for the Dutch population for the period 2000 to 2020. The model calculated the annual number of new patients by age and sex by using incidence rates, defined by age, sex, and major risk factors. The change in the annual number of stroke patients is the result of incident cases minus mortality numbers. Results— Demographic changes in the population suggest an increase of 27% in number of stroke patients per 1000 in 2020 compared with 2000. Extrapolating past trends in the prevalence of smoking behavior, hypertension, and stroke incidence resulted in an increase of 4%. Conclusions— The number of stroke patients in the Netherlands will rise continuously until the year 2020. Our study demonstrates that a large part of this increase in the number of patients is an inevitable consequence of the aging of the population.

Objective To multidimensionally assess fatigue in rheumatoid arthritis (RA) and to evaluate the impact of fatigue on health-related quality of life (HRQOL). Methods The study was conducted in 1999 among 490 RA patients with varying disease duration. Fatigue was measured with the Multidimensional Fatigue Inventory (MFI-20) and HRQOL with a validated Dutch version of the RAND 36-Item Health Survey. We evaluated the impact of fatigue on HRQOL by multiple linear regression analyses taking into account RA-related pain and depressive symptoms. Results Different aspects of fatigue selectively explained different dimensions of HRQOL. The MFI-20 was entered last to the linear regression models, resulting in an additional increase of explained variance of 1% (mental health) to 14% (vitality). Conclusion The multidimensional portrayal of RA-related fatigue can be used to develop intervention strategies targeted to specific aspects of fatigue. Fatigue, supplementary to RA-related pain and depressive symptoms, appears to be a feasible and treatable target in the clinical management of RA to increase HRQOL.

Objective To improve understanding of the nature and magnitude of the burden of informal care and also to indicate important areas for improving the current ways in which informal care is investigated. Methods Information on objective burden (such as care tasks performed and time investment), subjective burden (using the Caregiver Reaction Assessment instrument and a self-rated burden score), and quality of life (using the EuroQoL instrument) were collected in a postal questionnaire of 153 informal caregivers who provide care for rheumatoid arthritis (RA) patients. Results Caregivers had been caring for the RA patients on average for >11 years, reflecting the chronic nature of RA. They provide a substantial amount of care (27.4 hours per week) and are moderately strained (24.6 on the self-rated burden scale). Caregivers are relatively healthy on average but caregivers of more severe RA patients are relatively unhealthy, which may indicate health losses due to caregiving. Conclusion Informal care can be burdensome in the context of RA. More information may help assist informal caregivers in caring for RA patients and help to avoid health problems and high subjective burden.

Objective To assess the prevalence of unmet health care demands among rheumatoid arthritis (RA) patients, and to determine if these unmet demands indicate underuse. Methods A total of 679 patients with RA participated in a questionnaire survey and clinical examination. Unmet health care demands and health care use were assessed for orthopedic care, allied health care, home care, and psychosocial care. Indications for underuse were determined by comparing health outcomes of patients with unmet health care demands and of health care users. Results Of the 679 patients, 28.7% had an unmet demand for 1 of the 4 services: 13.4% for allied health care, 9.7% for orthopedic care, 9.4% for home care, and 6.2% for psychosocial care. Underuse of allied health care, home care and psychosocial care was observed. Conclusion Unmet demands for health care are frequent among RA patients. Most unmet demands indicate underuse. Health care professionals should therefore be more responsive to the demands of patients.

Purpose— With the rapid international spread of interventions, there is a need to understand the economic implications of these changes and to interpret these economic implications on the international level. The purpose of this study is to systematically compare total health care expenditures on stroke, the costs of stroke per capita, and the distribution of stroke costs within different countries, with special attention to the allocation of resources among different health care facilities. Methods— Studies for this literature review were selected by conducting a literature search from January 1966 to July 2003. Key methodological, country-related, and monetary issues of the selected stroke cost studies were evaluated using a checklist. Results— After selection, 25 stroke cost studies were reviewed. Although the selected cost of illness studies used different methodologies, the estimated expenditures for stroke are approximately similar. The proportion of national health care in the 8 countries studied is unequivocal for the more recent studies, ie, ≈3% of total health care expenditures. A shift is observed from the inpatient treatment costs (in the first year) toward outpatient treatment and long-term care costs (in the latter years). Furthermore, it is remarkable that in the studies, little attention is paid to costs borne by the patient and family or to the costs of comorbidity. Conclusions— This study highlights the importance of studying the economic consequences of stroke and of interpreting the results on the international level. The results of stroke cost studies provide insight into the distribution of the costs of stroke and the impact of stroke on the national expenditure on health care.

Objective: To compare the feasibility, convergent and clinical validity of three commonly used burden scales: Caregiver Strain Index (CSI), Caregiver Reaction Assessment (CRA) and Sense of Competence Questionnaire (SCQ), with a self-developed single question on self-rated burden (SRB). Subjects: Stroke patients receiving support from an informal caregiver ( n=148) and their caregivers were followed up to six months after stroke. Intervention: Feasibility was assessed with several measures of missing values. Convergent validity was assessed on the basis of the correlation patterns between the burden scales, and clinical validity through evaluation of expected associations between levels of burden and explanatory patients' and caregivers' characteristics. Results: Missing values were less often observed on CSI and SRB than SCQ and CRA. Significant correlation coefficients ( p Conclusions: A concise and simple measure would facilitate early detection of caregivers at risk in clinical practice and research. CSI and SRB are more feasible and at least as valid instruments for assessment of caregiver burden in stroke than the longer and more complex SCQ and CRA. SRB could be used for quick screening of caregivers at risk. CSI is indicated for further diagnosis of the burden of informal caregivers.

Objective. To identify health care aspects of inadequate quality in rheumatoid arthritis (RA) care from the perspective of patients, and to study to what extent patients' perspectives on quality of care are associated with patient characteristics. Design. Cross-sectional questionnaire survey performed in 1999. Setting. Secondary and tertiary rheumatology outpatient clinics. Study participants. A random sample (n=683) of patients diagnosed with rheumatoid arthritis according to the 1987 revised American College of Rheumatology criteria. Patients varied widely with respect to age (mean 61.5 years) and disease duration (mean 10.7 years). Main outcome measures. Using the method of the Quote-questionnaire, patients' were asked to rate the importance to them of 29 aspects of care, and to rate the performance of five different health care providers [i.e. rheumatologist, general practitioner (GP), physiotherapist, home nurse, and formal home help] relating to these aspects. To identify aspects of inadequate quality, patients' performance ratings were weighted by importance ratings within each health care service. Inadequate performance on an extremely important aspect was found to be a more serious quality problem than an inadequate performance on an aspect that was less important to patients. Using regression analyses, the association between patients' quality ratings and patient characteristics was assessed. Results. Several aspects of inadequate quality were identified, namely in the field of knowledge of rheumatism and particularly for GPs, physiotherapists, home nurses, and formal home help, and in the field of information on medication and treatment for rheumatologists and GPs. Furthermore, for the majority of the importance and performance ratings, we found no association with patient-related characteristics. Conclusions. Our study demonstrated that the quality of care could be improved further from the perspective of patients. These findings may be used for making health care more responsive to patients' needs

OBJECTIVES: To compare self-reported disability and performance-based limitation and their association in elderly men from three European countries. DESIGN: Cross-sectional data from a cohort study collected around 1990. SETTING: Three cohorts from Finland, the Netherlands, and Italy. PARTICIPANTS: One thousand one hundred sixty-one men aged 70 and older. MEASUREMENTS: Disability and functional limitation were measured in a standardized way in three countries. Self-reported disability was estimated by questionnaire, assessing three domains of activities of daily living: instrumental activities of daily living, mobility, and activities of daily living (score 0-3). Functional limitation was measured by performance tests (score 0-16), with 0 indicated the healthiest score. RESULTS: Self-reported disability and performance-based limitation scores differed between countries. Mean self-reported disability score was worse in Italy (0.72) and the Netherlands (0.70) than in Finland (0.54). Italian men scored worst on the performance-based tests (mean 4.80 vs 4.04 for Finland and 3.74 for the Netherlands). Differences in self-reported disability remained after adjusting for performance scores: Dutch men reported more disabilities (odds ratio (OR) = 1.66, 95% confidence interval (CI) = 1.23-2.25) than men in Finland (reference group) and Italy (OR = 1.08, 95% CI = 0.77-1.53). Self-reported disability was positively associated with performance-based score (OR = 1.28, 95% CI = 1.21-1.35) and did not differ between countries. CONCLUSION: Cross-cultural variation was noted in self-reported disability adjusted for performance score. These differences may be due to sociocultural and physical environmental factors. Self-reported disability was consistently associated with performance-based limitation in Finland, the Netherlands, and Italy.

Objective: To evaluate the responsiveness of a newly developed generic questionnaire, the Impact on Participation and Autonomy (IPA), which focuses on 2 aspects of participation: perceived participation and the experience of problems. Design: Preliminary study of questionnaire responsiveness compared with transition indices. Participants completed 2 assessments, 3 months apart. To measure change, they completed 9 transition indices at the second assessment. One transition index assessed perceived change in general, the other 8 addressed 1 of the specific problem experience items in the IPA. Setting: Outpatient clinic of the rehabilitation department of an academic hospital. Participants: Fifty-seven consecutive persons admitted for multidisciplinary rehabilitation treatment, with various diagnoses, were enrolled in the study; 49 persons completed both assessments. Interventions: Not applicable. Main Outcome Measures: Standardized response mean (SRM) and area under the receiver operating characteristic curve (AUC) for participation domain scores and problem scores. Results: SRMs and AUCs for the participation domains ranged from 0.1 to 1.3 and from 50% to 92%, respectively. The SRMs of the items on the experience of problems ranged from 0.4 to 1.5, whereas their AUCs ranged from 56% to 74%. Conclusions: The IPA detected within-person improvement over time, but its responsiveness must be confirmed in a larger study sample.

Objective: To describe the impact of a chronic disabling condition on participation and to identify variables that may explain perceived restrictions in participation. Study design: Cross-sectional. Setting: People were recruited from the outpatient clinics of two rehabilitation centres and the rehabilitation department of an academic hospital. Subjects: One hundred and twenty-six people from five diagnostic groups (neuromuscular disease, rheumatoid arthritis, spinal cord injury, stroke, fibromyalgia) participated in the study. Method: The IPA (Impact on Participation and Autonomy) questionnaire was used to describe perceived participation. Explanatory variables were studied in terms of sociodemographic factors and health status variables. Results: Some restrictions in participation seem comparable among diagnostic groups, others are specific to one or two groups. People with stroke, rheumatoid arthritis or fibromyalgia perceived more restrictions in participation than people with spinal cord injury or neuromuscular disorders. Emotional distress was the most important factor contributing to restrictions in participation. Conclusions: Perceived participation remains a complex concept in which many factors are involved. To make a contribution to meaningful participation of people with a chronic disabling condition, rehabilitation treatment should address physical, social, emotional and environmental aspects.

Background: Non-response may lead to bias in health(care)outcomes. Methods: We compared respondents (n=334) to a questionnaire survey among patients with rheumatoid arthritis with non-respondents (n=68) and determined predictors of (non-)response. The bias in prevalence estimates of health characteristics and health care use was quantified. Results: Self-reported pain and health care utilization were the most important predictors of (non-)response with respondents experiencing pain more often and more often using specific health care services. Bias concerned especially an underestimation of ‘never having pain’ (60%) and ‘no contact with health care services’ (51%). Conclusion: More insight into the phenomenon of non-response is important to assess disease burden and health care burden more precisely.

Objectives: To assess the prevalence of fatigue, pain, anxiety, and depression in adults with Duchenne muscular dystrophy (DMD), and to analyze their relationship with health-related quality of life. Design: Cross-sectional study. Setting: Home of participants. Participants: Adults (N=80) with DMD. Interventions: Not applicable. Main Outcome Measures: Fatigue was assessed with the Fatigue Severity Scale; pain with 1 item of the Medical Outcomes Study 36-Item Short-Form Health Survey and by interview; and anxiety and depression by using the Hospital Anxiety and Depression Scale. Health-related quality of life was assessed using the World Health Organization Quality of Life Scale Brief Version. Associations between these conditions and quality of life were assessed by means of univariate and multivariate logistic regression analyses. Results: Symptoms of fatigue (40.5%), pain (73.4%), anxiety (24%), and depression (19%) were frequently found. Individuals often had multiple conditions. Fatigue was related to overall quality of life and to the quality-of-life domains of physical health and environment; anxiety was related to the psychological domain. Conclusions: Fatigue, pain, anxiety, and depression, potentially treatable symptoms, occur frequently in adults with DMD and significantly influence health-related quality of life. (C) 2015 by the American Congress of Rehabilitation Medicine

This study examined patterns and determinants of three dimensions of caregiver's health of newly diagnosed colorectal cancer patients, i.e. physical, mental and social functioning (N = 148). Physical functioning declined within a 6-month period in female caregivers, while no change was observed in male caregivers. For mental and social functioning, an improvement was observed in male and female caregivers. Change in physical functioning was associated with gender, age, income and initial level. Change in mental functioning was predicted by initial status and positive as well as negative caregiver experiences, Change in social functioning was mainly predicted by initial level and change in patient's dependency. Physical and mental functioning showed the least favorable patterns in female caregivers. The study shows that caregiving may lead to positive health consequences, and underlines the importance of making a distinction between male and female caregivers and of studying caregiver outcomes by using multidimensional assessments.

A literature search was carried out to identify and summarize the existing information on causes and consequences of comorbidity of chronic somatic diseases. A selection of 82 articles met our inclusion criteria. Very little work has been done on the causes of comorbidity. On the other hand, much work has been done on consequences of comorbidity, although comorbidity is seldom the main subject of study. We found comorbidity in general to be associated with mortality, quality of life, and health care. The consequences of specific disease combinations, however, depended on many factors. We recommend more etiological studies on shared risk factors, especially for those comorbidities that occur at a higher rate than expected. New insights in this field can lead to better prevention strategies. Health care workers need to take comorbid diseases into account in monitoring and treating patients. Future studies on consequences of comorbidity should investigate specific disease combinations.

Objective. To quantify the utilization of health care by rheumatoid arthritis (RA) patients and to estimate the contribution of patient characteristics to the explanation of the use of care, in order to evaluate whether those in need of care actually receive care. Methods. A questionnaire survey and a clinical examination were conducted among patients with RA referred to a rheumatology center. Health care utilization was assessed for medical care, allied health care, psychosocial care, and home care. The influence of sociodemographic variables and clinical and health characteristics on health care utilization was assessed by means of logistic regression. Results. Multivariate analyses showed that, for all types of services, disease-related factors explained most of the utilization. However, some sociodemographic variables (age, sex, and living situation) were also related to the utilization of care. Conclusion. Most patients received the care they needed. However, for the elderly with RA, problems in access to allied health care and psychosocial care exist.

fBACKGROUND, The role of social support and personality within the cancer caregiving process has remained a relatively unexplored area. The current longitudinal study examines the main and moderating effects on caregiver experiences and caregiver's depression over time of various social and psychologic resources.METHODS. Newly diagnosed colorectal carcinoma patients and their partners (N = 148) were included and data were obtained at three measurement points: 2 weeks prior to hospital admission and 3 months and 6 months after discharge. The initial and change scores of the caregiver's negative and positive social interactions and personality attributes (mastery, neuroticism, and extraversion) were included to assess their impact on caregiver experiences and depression over time.RESULTS, The main effects of social and psychologic resources on caregiver experiences were found to be small to absent. With respect to caregiver depression, both initial scores and changes in neuroticism, mastery, and negative social interactions were shown to have substantial main effects over time. Moreover, daily emotional support and mastery modified the relations between caregiver experiences and caregiver depression. Caregivers wit a low level of daily emotional support, as well as those with a low score on mastery and who also perceived caregiving in a more negative way were identified as more depressed over time.CONCLUSIONS. The results of the current study demonstrate the importance of including various social and psychologic resources in studying the cancer caregiving process. It illustrates the distinctive impact of these resources on the depression of caregivers of patients with cancer, and therefore helps healthcare providers understand why some persons adapt better than others to their caregiving role. (C) 2001 American Cancer Society.

The Caregiver Reaction Assessment Scale (CRA) is an instrument designed to assess specific aspects of the caregiving situation, including both negative and positive dimensions of caregiving reactions. This paper addresses the psychometric qualities of the CRA in a multicenter study among partners of colorectal cancer patients (n = 181). No problems in feasibility were observed. Five dimensions of caregiver reactions were identified through exploratory factor analysis: the impact of caregiving on disrupted schedule, financial problems, lack of family support, health problems and the impact of caregiving on caregiver's self-esteem. Reliability analyses showed that standardized Cronbach's alpha's varied between 0.62 and 0.83 for the separate subscales, indicating sufficient internal consistencies. Construct validity was supported. The CRA proves to be a feasible, reliable and valid instrument for assessing both negative and positive reactions to caregiving among partners of patients with cancer.

The aim of this paper is to explore the differential impact of chronic conditions on disability, use of health care and healthy life expectancies. The condition-specific impact is described by comparing persons with a variety of chronic diseases. The classification of the 19 selected chronic conditions in terms of the burden for disability and use of health care showed 8 major conditions with a high illness burden: lung disease, heart disease, stroke, cancer, diabetes mellitus, rheumatism and arthritis complaints, neurological disorders and accident traumas. Co-morbidity has an additional impact on disability as well as on the use of medical care and long-term care. The general impact of chronic conditions is described by calculating healthy life expectancies and assessing the loss of healthy life resulting from chronic morbidity, disability and long-term care. Healthy life expectancies show marked gender differences in the burden of chronic diseases. The advantage to females in terms of life expectancy is a disadvantage In terms of healthy life expectancy. The discussion focuses on disease specificity, co-morbidity and population heterogeneity.

Objective: To describe the course of social support in spouses of patients with stroke, and to examine direct and indirect relationships between social support and life satisfaction over time. Methods: Prospective cohort study (N = 180) with measurements at 2 months after discharge from inpatient rehabilitation, 1 year, and 3 years after stroke. Social support was assessed using the Social Support List-12, Life satisfaction with the Life Satisfaction Questionnaire (LiSat-9) and Caregiver strain with the Caregiver Strain Index. Random coefficient analyses was used. Results: Total social support and the 3 subtypes of social support decreased significantly over time. In all models, caregiver strain was associated with lower life satisfaction and social support was associated with higher life satisfaction, but there were no interaction effects between caregiver strain and social support on life satisfaction. Conclusion: Spouses of patients with stroke experienced a decline of social support over time. Social support was positively associated with life satisfaction, regardless of the amount of caregiver strain experienced by the spouses. Practice implications: It is important to discuss with caregivers of stroke patients the importance of maintaining their own social contacts and to facilitate this by arranging support if appropriate. (C) 2010 Elsevier Ireland Ltd. All rights reserved

Background and Purpose— There exists limited knowledge regarding the relation between depression and healthcare utilization in stroke patients. The objective of this register-based study was to examine the impact of having preexisting depression at the time of hospital admission for acute stroke on length of hospital stay and discharge destination. Methods— Data from a general-practice database were linked to those of a hospital database to identify patients hospitalized for stroke and were used to categorize these patients into 3 groups based on preexisting mental health (MH) status at admission, ie, those with preexisting depression, those with another preexisting MH condition, and those without any preexisting MH condition. Multilevel analyses controlling for several potentially important covariates were performed to estimate the associations under study. Results— Both patients with preexisting depression (n=41) and those with another preexisting MH condition (n=62) did not differ significantly from patients without any preexisting MH condition (n=211) regarding length of hospital stay for acute stroke. Among patients who survived hospitalization, those with preexisting depression had significantly higher odds of being discharged to an institution instead of their home than did patients without any preexisting MH condition. Having another preexisting MH condition had no significant effect on discharge destination. Conclusions— Having preexisting depression at admission seems to be a relevant factor in determining discharge to institutional care after acute stroke hospitalization. Further research is needed to determine the mechanism(s) through which preexisting depression decreases the chances of being discharged to home.

Objectives: In the next decades, the number of stroke patients is expected to increase. Furthermore, organizational changes, such as stroke services, are expected to be implemented on a large scale. The purpose of this study is to estimate the future healthcare costs by taking into account the expected increase of stroke patients and a nationwide implementation of stroke services.Methods: By means of a dynamic multistate life table, the total number of stroke patients can be projected. The model calculates the annual number of patients by age and gender. The total healthcare costs are calculated by multiplying the average healthcare costs specified by age, gender, and healthcare sector with the total number of stroke patients specified by age and gender.Results: In the year 2000, the healthcare costs for stroke amounted to €1.62 billion. This amount is approximately 4.4 percent of the total national healthcare budget. Projections of the total costs of stroke based on current practice result in an increase of 28 percent (€2.08 billion) in the year 2020. A nationwide implementation of stroke services in 2020 would result in a substantial reduction of the costs of stroke (€1.81 billion: 13 percent cost reduction) compared with the regular care scenario.Conclusions: A nationwide implementation of stroke services is a strong policy tool for cost containment of health care in an aging population like that in the Netherlands. Policy makers should optimize the organization of stroke care.

Objectives: The objectives were to investigate the predictive value of hierarchy levels and sum score of disability and change in disability on depressive symptoms. Method: Longitudinal data of 723 men age 70 and older from the Finland, Italy, and the Netherlands Elderly Study were collected in 1990 and 1995. Self-reported disability was based on three disability domains (instrumental activities, mobility, and basic activities) and depressive symptoms on the Zung questionnaire. Results: Severity levels of disability were positively associated with depressive symptoms. Men with no disability scored 5 to 17 points lower (p < .01) on depressive symptoms than did those with disability in all domains. Among men with mild disability, those who had worsening of disability status in the preceding 5 years scored 5 points higher (p = .004) on depressive symptoms than did men who improved. Discussion: Hierarchic severity levels, sum score of disability, and preceding changes in disability status are risk factors for depressive symptoms

Objectives. To investigate the effect of disability severity and the contribution of self-rated health and depressive symptoms to 10-year mortality. Methods. Longitudinal data were collected from 1141 men aged 70 to 89 years from the Finland, Italy, and the Netherlands Elderly Study from 1990 to 2000. Disability severity was classified into 4 categories: no disability, instrumental activities, mobility, and basic activities of daily living. Self-rated health and depressive symptoms were classified into 2 and 3 categories, respectively. Multivariate Cox proportional hazard models were used to calculate mortality risks. Results. Men with severe disability had a risk of mortality that was more than 2-fold higher (hazard ratio [HR]=2.41; 95% confidence interval [CI]=1.84, 3.16) than that of men without disability. Men who had severe disability and did not feel healthy had the highest mortality risk (HR = 3.30; 95% CI = 2.52, 4.33). This risk was lower at lower levels of disability and higher levels of self-rated health. The same trend was observed for depressive symptoms. Conclusions. For adequate prognoses on mortality or for developing intervention strategies, not only physical aspects of health but also other health outcomes should be taken into account.

Purpose. To investigate the relationship between duration and intensity of physical activity and disability 10 years later, and to investigate the possible effect of selective mortality. Method. Longitudinal data of 560 men aged 70 - 89 years, without disability at baseline from the Finland, Italy and The Netherlands Elderly ( FINE) Study was used. Physical activity in 1990 was based on activities like walking, bicycling and gardening. Disability severity ( three categories) in 1990 and 2000 was based on instrumental activities, mobility and basic activities of daily living. Results. Men in the highest tertile of total physical activity had a lower risk of disability than men in the lowest tertile ( odds ratio ( OR) 0.46; 95% confidence interval (CI): 0.26 - 0.84). This was due to duration of physical activity ( OR highest tertile 0.42; 95% CI: 0.23 - 0.78 compared to the lowest tertile). Intensity of physical activity was not associated with disability. Addition of deceased men as fourth category leaded to weaker associations between physical activity and disability ( OR highest tertile 0.67; 95% CI: 0.44 - 1.02). Conclusions. Even in old age among relatively healthy men, a physically active lifestyle was inversely related to disability. To prevent disability duration of physical activity seems to be more important than intensity

Objective To quantify the impact of socioeconomic status (SES) among patients with rheumatoid arthritis on 1) health outcomes and related health care utilization in relation to disease duration and 2) changes in health outcomes and related health care utilization over a 2-year period. Methods A questionnaire survey was conducted among 878 patients with rheumatoid arthritis (RA), varying in disease duration from 0 to more than 15 years. To determine the impact of SES on the health outcomes and health care use, patients were compared within and between 3 disease duration groups. Additionally, longitudinal changes in health outcomes and health care use were assessed with a followup questionnaire sent out 2 years later. Results Patients with low SES have worse disease activity, physical health, mental health, and quality of life than patients with high SES. These differences, however, decreased over time. Regarding health care use, we found that patients with low SES made considerably less use of allied health care than patients with high SES. Conclusion Efforts should be undertaken in health care to alleviate the health disadvantages of RA patients in lower socioeconomic groups. In particular, the access to allied health care could be improved.

Background: The study objective was to examine the relation between combinations of chronic conditions in the same person and the volume and variety of health care utilization. Methods: Analysis of continuous Netherlands Health Interview Survey data (1990–1997). The study population consisted of adults (16 years and older) reporting at least one chronic condition from the following six disease clusters: musculoskeletal diseases, lung diseases, neurological disorders, heart diseases, diabetes, and cancer (n=13, 806). Health care utilization is categorized in terms of contacts in the preceding year with a general practitioner (GP), medical specialist, physiotherapist, home help and/or home nursing, and hospital admission. Utilization was adjusted for age, gender and year of interview. Statistical methods used are contingency table analysis and (logistic) multiple regression. Results: Almost one-fifth of the study population reported more than one chronic condition. Musculoskeletal disease, in addition to being the most common single condition, was found to be the condition most likely to occur with one of the remaining five disease clusters. Seven per cent reported not having used any services at all. Two-thirds of the study population used at least two different services in the previous year. In contrast, 26% of the study population reported comprehensive utilization patterns (GP and/or home care and/or physiotherapist and/or medical specialist and/or hospitalization: minimum of three types). Persons with more than one chronic condition reported having used more services, in terms of volume and variety, than those with only one condition. Conclusions: There is a strong association between comorbidity and the volume and variety of health care services that are used. Since many people have comorbid conditions, their use of health services is more complex than would be suggested by a one-disease approach. New disease management systems need to be developed to reflect the multiplicity of health care needs of the growing number patients with more than one chronic condition.

This study describes patterns of caregiving experiences in partners of patients with cancer (N=148) over a 6-month period. Caregiving experiences were assessed by means of the Caregiver Reaction Assessment Scale (CRA), which consists of four negative dimensions and one positive subscale: Disrupted Schedule, Financial Problems, Lack of Family Support, Loss of Physical Strength, and Self-Esteem. Subgroup analyses were performed according to gender, age, and socioeconomic status (SES). Type, size, and direction of changes in caregiving experiences over time were analyzed both at a group level and at an individual level. Patterns of caregiver experiences appeared to vary between the subgroups; women, younger caregivers, and caregivers with a higher SES experienced caregiving more negatively or less positively. The findings illustrate the value of studying inter- and intraindividual patterns across different subgroups, and stress that caregiver experiences should be regarded as a multidimensional concept that includes both negative and positive experiences of caregiving.

SUMMARY A diagnosis of cancer affects not only the patient but also their significant others, especially when a lot of care tasks are involved. Some caregivers perceive the care as a burden, while others consider it a challenge. In this article, findings concerning the impact of cancer caregiving on informal caregivers will be described. No consistent results are reported, and little is known about patterns of caregiving changes in relation to the course of the patient’s illness. Attention will be given to factors which have been identified as influencing the course and consequences of caregiving. These factors form the basis of a conceptual research model for caregivers of cancer patients. As cancer progresses, care tasks are generated, which can be perceived by the caregiver as either negative (i.e. burden) or positive. Furthermore, these caregiver experiences may lead to negative as well as positive effects on the caregiver’s health and these relationships can be assumed to be bidirectional. © 1998 John Wiley & Sons, Ltd.

Background Comorbidity has been shown to intensify health care utilization and to increase medical care costs for patients with diabetes. However, most studies have been focused on one health care service, mainly hospital care, or limited their analyses to one additional comorbid disease, or the data were based on self-reported questionnaires instead of health care registration data. The purpose of this study is to estimate the effects a broad spectrum of of comorbidities on the type and volume of medical health care utilization of patients with diabetes. Methods By linking general practice and hospital based registrations in the Netherlands, data on comorbidity and health care utilization of patients with diabetes (n = 7,499) were obtained. Comorbidity was defined as diabetes-related comorbiiabetes-related comorbidity. Multilevel regression analyses were applied to estimate the effects of comorbidity on health care utilization. Results Our results show that both diabetes-related and non diabetes-related comorbidity increase the use of medical care substantially in patients with diabetes. Having both diabeterelated and non diabetes-related comorbidity incrases the demand for health care even more. Differences in health care utilization patterns were observed between the comorbidities. Conclusion Non diabetes-related comorbidity increases the health care demand as much as diabetes-related comorbidity. Current single-disease approach of integrated diabetes care should be extended with additional care modules, which must be generic and include multiple diseases in order to meet the complex health care demands of patients with diabetes in the future.