Indicatoren voor kwaliteit van zorg. Wie worden er wijzer van, de patiënten of de managers?

In the Netherlands and abroad detailed indicators are developed to measure quality of care for a variety of treatments and care systems. These days the development of quality indicators is a profession and business in itself. The significance of these indicators is often not related to the primary care process, but based on (administrative) data for 'quality management'. The consequence is a gap between 'real' and 'measured' quality of care. Improvement in quality of care is therefore problematic. There is a need to return to the essence of care, i.e. the patient and the care professional, to develop appropriate indicators for quality of care.     

Radiofrequente ablatiebehandeling van de oudere patiënte met een mammacarcinoom

Breast cancer is an important health care problem, especially in the increasing elderly generation. Treatment of these fragile patients is a challenge for the clinician. Undertreatment has been linked to a higher percentage of recurrence and cancer related morbidity, while overtreatment leads to treatment related morbidity and mortality. Minimally invasive techniques do offer new opportunities for patients, who are no candidates for conventional surgery. The tumor lesion is treated locally and selective with minimal damage to surrounding tissue, yielding an adequate local tumor control. Radio frequency ablation technique seems an effective and safe method for treatment of the elderly patient with small (< 3 cm) breast cancer.     

Gezamenlijke besluitvorming zorgt voor een betere toepassing van evidence-based medicine in de geriatrische patiënt

Evidence based medicine (EBM) is the integration of the best research evidence, clinical expertise and patient values in the decision making process for patient care. However, elderly people are often excluded from participating in scientific studies and they often have multiple morbidities, which complicates the application of EBM. Shared decision making (SDM), a process where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve appropriate treatment can help to shape EBM for this group of patients.In this article, we provide tools for finding relevant literature for the geriatric patient population and for shaping the SDM process to achieve personalized care.     

Bespreken van het reanimatiebeleid op een afdeling geriatrie: de ervaring van patiënt en familie

Discussing the resuscitation policy at a geriatric ward: the experience of patients or their representatives Aim To identify geriatric patients’ and their surrogate decision makers’ experience with regard to discussing cardio pulmonary resuscitation (CPR) policy.Methods This is a prospective, observational, explorative survey. During 10 weeks, all patients admitted to a geriatric ward of a general Dutch hospital or their representatives were asked for their experience regarding discussion of the resuscitation policy with the physician in attendance. Discussing this policy is a standard procedure at the first day of admission. We also asked on several factors which could influence their experience and on factors to improve discussing resuscitation policies. The primary outcome was the participant’s satisfaction expressed on a scale of 1 to 10 regarding satisfaction with the CPR discussion.Results Seventy-six participants were included, of which 29 patients and 47 surrogate decision makers . Discussing the resuscitation policy took an average of 4,5 minutes (SD 3.2) to complete. In 70% (n=53) of cases a do-not-resuscitate decision was made. Discussing the resuscitation policy was experienced positive, with an average rate of 7,8 (SD 1.5). A total of 121 positive comments were made, as opposed to 70 negative comments. When they talked about their resuscitation policy, most patients expressed positive emotional responses. As most important improvements were mentioned: a better introduction to discussing this subject (17%), a better explanation of resuscitation and chances of survival (17%) and providing information prior to admission to the ward, so that patient and surrogate decision maker have been informed that the resuscitation policy will be discussed (12%).Conclusion Most patients and relatives in this study wished to discuss their resuscitation policy with physicians. Still, there is room for improvement in several respects. Patients and surrogate decision makers are in favour of discussing the standard resuscitation policy with the doctor, and evaluate this conversation with a 7.8 / 10. In order to improve both discussing the CPR policy preparing the patient and his representatives and communicating more extensively during the interview are recommended. Tijdschr Gerontol Geriatr 2011; 42: 256-262     

Het gesprek met de patiënt is essentieel voor goede farmacotherapeutische zorg

Frail elderly with polypharmacy are at greater risk of preventable medication-related health damage. To improve medication safety, the healthcare field prepared, in consultation with the Dutch Health Care Inspectorate, a number of guidelines and standards containing conditions for safe prescribing. According to these standards the active involvement of patients by health care professionals is essential for good pharmacotherapeutic care. However, two studies with patients show that there is still room for improvement. According to patients, they can be (even) better informed about changes in their medication. Also the caregivers could communicate more clearly who is the central contact point and who is ultimately responsible for the medication. Patients are not sufficiently informed on this. Furthermore, there is uncertainty about how and why medication reviews are performed. More explanation to patients about this is desirable. In addition, patients experience that keeping their medication list up to date and transferring medication data between health care providers could be improved. Finally, a group of patients welcomes the opportunity to co-decide on changes in their medication. In order to prescribe safely, it is crucial that caregivers actively involve patients in pharmacotherapeutic care and really enter into conversation with them about their medication.     

Veranderingen in de kwaliteit van leven van thuiswonende ouderen: speelt de vorm van zorg een rol?

Changes in the quality of life of older people living at home: does type of care play a role? Purpose: To determine whether a change in physical, psychological and social dimensions of quality of life of older people living at home is associated with receiving formal care, compared to informal care and no care. Method: Data from the observation cycles in 1998 and 2001 of the Longitudinal Aging Study Amsterdam (LASA) were used. Older people receiving formal homecare in 1998 were compared to older people receiving informal care and to older people receiving no care at all in 1998 on subjective scores on 3-year changes in self-perceived health, loneliness, positive affect and satisfaction with life. The data were analysed using linear regression analysis and ANOVA. Results: In all groups there is a change for the worse between 1998 and 2001 in the four aspects of quality of life. Self-perceived health declines significantly more in the group receiving formal care compared to the group without care, but this is explained by a higher score on functional limitations in 1998. Loneliness increases significantly more in the group receiving formal care, even after correction for confounders. In the group receiving formal care the satisfaction with life decreases significantly more compared to the group receiving no care and the group with informal care. An interaction effect with gender was found, showing that after correction for confounders this difference is maintained for the women but not for the men. There is no significant difference between the three care groups regarding changes in positive affect. Conclusion: Older men and women who receive formal home care experience an increase in loneliness, and older women who receive formal care experience less satisfaction with life, compared to women who receive informal care or no care. Future research should confirm these results and investigate the mechanisms underlying these changes. Tijdschr Gerontol Geriatr 2011; 42: 170-183