Identification des facteurs associés à la qualité des soins et développement d'un outil de repérage des ressources d'hébergement dispensant des soins inadéquats à leur clientèle âgée en perte d'autonomie

La présente étude avait comme objectifs principaux l'identification des facteurs associés à la qualité des soins et l'élaboration d'un outil de repérage des ressources d'hébergement dispensant des soins inadéquats à leur clientèle âgée en perte d'autonomie. Des soins inadéquats correspondent ici à des soins de qualité inférieure à ce qu'un résidant est en droit de recevoir étant donné ses besoins. Des données recueillies auprès de 88 ressources d'hébergement ont permis d'identifier les éléments à inclure dans l'outil. Il s'agit des caractéristiques des résidences ayant un effet spécifique sur l'inadéquation des soins. L'outil proposé est un questionnaire de deux pages, non menaçant, facile, rapide et peu dispendieux à administrer. L'utilisateur le complète par le biais d'un entretien téléphonique avec le responsable de la résidence étudiée. Huit équations prédictives permettent alors, à partir des informations recueillies, d'estimer la qualité des soins dispensés par le milieu globalement ainsi que pour chacune des sept sous-dimensions de la qualité des soins. Pour chaque équation, deux seuils permettent de classer l'établissement comme étant potentiellement de bonne qualité, problématique ou négligent. Ces seuils ont été sélectionnés de façon à assurer la meilleure sensibilité tout en conservant un niveau acceptable de spécificité. Les résultats suggèrent une bonne validité prédictive de l'outil. Globalement, l'instrument identifie comme potentiellement problématiques 48% des milieux avec une sensibilité de 85% et une spécificité de 65%. De plus, il juge potentiellement négligents 12% des établissements avec une sensibilité de 75% et une excellente spécificité de 93%. En ce qui concerne les sept sous-dimensions de la qualité des soins, les résidences problématiques sont ciblées avec une sensibilité d'au moins 77% pour six d'entre elles. Les indices de spécificité sont pour leur part supérieurs à 60% dans presque tous les cas. Les milieux négligents sont repérés avec une sensibilité de plus de 85% pour six des sept sous-dimensions de la qualité des soins. La spécificité est ici supérieure à 65% dans la majorité des cas. Lorsque l'identification des milieux problématiques est recherchée et que la cote globale excède le seuil de positivité associé, il est recommandé d'entreprendre une évaluation globale du milieu. Cependant, lorsque la cote globale prédite est sous le seuil de positivité, il est avantageux de procéder à l'évaluation spécifique des seules sous-dimensions, s'il y en a, pour lesquelles la cote prédite dépasse le seuil de positivité associé. Pour un utilisateur uniquement concerné par les milieux négligents, cette approche d'évaluation spécifique est conseillée quelle que soit la cote globale prédite."--Résumé abrégé par UM

Benzodiazepines and group transdiagnostic cognitive-behaviour therapy for anxiety disorders : a mixed methods study

Abstract : Background: Cognitive behavioural therapy (CBT) is an evidence-based treatment for anxiety disorders. Patients engaging in CBT often have an ongoing pharmacological treatment, generally antidepressants. Benzodiazepines are also commonly used, although they are recommended as short-term adjunctive treatment due to side effects. Aims: Exploring the influence of benzodiazepine use prior to group transdiagnostic CBT (tCBT) and the participants’ experience of their use before, during and after therapy. Method: Mixed methods study embedded in a randomized controlled trial of group tCBT. The experimental arm received tCBT and treatment-as-usual (TAU) (n = 117) for 12 weeks while the control arm received TAU (n = 114). Anxiety symptoms were assessed with the Beck Anxiety Inventory (BAI). Multiple linear regression analysis examined BAI pre-post differences with benzodiazepine use in the past 12 months, tCBT and their interaction. Semi-structured interviews were conducted with 13 participants reporting the use of benzodiazepines at baseline and analyzed using an interpretive descriptive method. Results: tCBT had a significant effect on anxiety symptoms change, but this effect was non- differential according to benzodiazepine use in the past 12 months. Qualitative results provided nuances about the perceived helpfulness of benzodiazepines. Participants reported that benzodiazepines facilitated the experience of sharing in group therapy and conducting exposure exercises. Despite some benefits, participants perceived that benzodiazepines may have interfered with the effectiveness of exposure exercises and the acquisition of concepts due to a sedative effect. Conclusions: Results highlight the importance of sensitizing therapists and patients to the potential effects of benzodiazepines on the experience of tCBT

The effectiveness of the PRISMA integrated service delivery network: preliminary report on methods and baseline data

Purpose: The PRISMA study analyzes an innovative coordination-type integrated service delivery (ISD) system developed to improve continuity and increase the effectiveness and efficiency of services, especially for older and disabled populations. The objective of the PRISMA study is to evaluate the effectiveness of this system to improve health, empowerment and satisfaction of frail older people, modify their health and social services utilization, without increasing the burden of informal caregivers. The objective of this paper is to present the methodology and give baseline data on the study participants. <br><br> Methods: A quasi-experimental study with pre-test, multiple post-tests, and a comparison group was used to evaluate the impact of PRISMA ISD. Elders at risk of functional decline (501 experimental, 419 control) participated in the study. <br><br> Results: At entry, the two groups were comparable for most variables. Over the first year, when the implementation rate was low (32%), participants from the control group used fewer services than those from the experimental group. After the first year, no significant statistical difference was observed for functional decline and changes in the other outcome variables. <br><br> Conclusion: This first year must be considered a baseline year, showing the situation without significant implementation of PRISMA ISD systems. Results for the following years will have to be examined with consideration of these baseline results

Are Improvements Maintained After In-home Pulmonary Telerehabilitation for Patients with Chronic Obstructive Pulmonary Disease?

This study investigated if improvements can be maintained over 24 weeks when in-home pulmonary telerehabilitation is combined with asynchronous self-management education for Chronic Obstructive Pulmonary Disease (COPD). Twenty-three community-living elders with moderate to very severe COPD participated in a pre/post-intervention study. Over 8 weeks, they had access to self-learning capsules on self-management, received 15 in-home teletreatment sessions and were encouraged to gradually engage in unsupervised sessions. Participants were assessed before the intervention (T1), immediately after the intervention (T2), and 6 months later (T3). Outcome measures were 1) exercise tolerance (6-minute walk test [6MWT]), Cycle Endurance Test [CET]), and 2) quality of life (Chronic Respiratory Questionnaire [CRQ]). Although there were significant improvements after 8 weeks of pulmonary telerehabilitation on the 6MWT, CET and three of four CRQ domains, none of these improvements were maintained after 6 months and scores returned to their baseline values (all p values &gt; 0.05 when comparing T3 with T1).  While pulmonary telerehabilitation is possible and has a positive impact on patients with moderate to very severe COPD, improvements were not maintained in the long-term even when physical therapy was accompanied by self-management education.

Comorbidity and glycemia control among patients with type 2 diabetes in primary care

Reports on the relationship between comorbidity and glycemia control in diabetic patients are conflicting and the method of measuring comorbidity varies widely among studies. The aim of the present study was to evaluate the relationship between diabetes control and comorbidity, taking into account all comorbidities and their severity, in a primary care setting. We performed a retrospective descriptive study based on chart review of 96 randomly selected type 2 diabetic patients. Comorbidity was measured with the cumulative illness rating scale (CIRS), an exhaustive comorbidity index. Diabetes was considered as controlled if the mean value of two measurements of glycosylated hemoglobin A (HbA1c) was less than 7%. Taking diabetes control as the dependent variable, its relationship with the CIRS score, age, sex, diabetes duration, and diabetes-related complications was explored. Diabetes control was not significantly related with the CIRS score, age, sex or diabetes severity. Diabetes duration was the only variable significantly related to diabetes control. Our study suggests that comorbidity measured with the CIRS in patients with type 2 diabetes is not a factor that prevents the achievement of a good glycemia control

Exploring support needed by home health aides in choosing bathing equipment: New challenges for occupational therapy collaboration

Abstract : In Quebec (Canada), home health aides aregradually being involved in choosing bathing equipment forcommunity-dwelling clients with bathing difficulties, a task traditionally performed by occupational therapists. OBJECTIVE:This article explores the support home health aides want in assuming this clinical task. PARTICIPANTS:Three home health aides having previously intervened with clients with bathing difficulties. METHODS:Home health aides werefirst observed while performing an assessment, followed by an in-depth individual interview. RESULTS:Results indicate that participants wish to be trained to acquire further knowledge about bathing equipment and learn to use a tool that would guide and document their observations. They sought partnership with a designated occupational therapist, who would be available to answer questions and assess clients with a complex clinical situation. CONCLUSIONS:These results suggest that needs of home health aides are not currently met and highlight clinical as well as organizational implications

Multimorbidity and quality of life: a closer look

© 2007 Fortin et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens

Evaluating the integration of chronic disease prevention and management services into primary health care

Background The increasing number of patients with chronic diseases represents a challenge for health care systems. The Chronic Care Model suggests a multi-component remodelling of chronic disease services to improve patient outcomes. To meet the complex and ongoing needs of patients, chronic disease prevention and management (CDPM) has been advocated as a key feature of primary care producing better outcomes, greater effectiveness and improved access to services compared to other sectors. The objective of this study is to evaluate the adaptation and implementation of an intervention involving the integration of chronic disease prevention and management (CDPM) services into primary health care. Methods/Design The implementation of the intervention will be evaluated using descriptive qualitative methods to collect data from various stakeholders (decision-makers, primary care professionals, CDPM professionals and patients) before, during and after the implementation. The evaluation of the effects will be based on a combination of experimental designs: a randomized trial using a delayed intervention arm (n = 326), a before-and-after design with repeated measures (n = 163), and a quasi-experimental design using a comparative cohort (n = 326). This evaluation will utilize self-report questionnaires measuring self-efficacy, empowerment, comorbidity, health behaviour, functional health status, quality of life, psychological well-being, patient characteristics and co-interventions. The study will take place in eight primary care practices of the Saguenay region of Quebec (Canada). To be included, patients will have to be referred by their primary care provider and present at least one of the following conditions (or their risk factors): diabetes, cardiovascular diseases, chronic obstructive pulmonary disease, asthma. Patients presenting serious cognitive problems will be excluded. Discussion In the short-term, improved patient self-efficacy and empowerment are expected. In the mid-term, we expect to observe an improvement in health behaviour, functional health status, quality of life and psychological well-being. At the organizational level, the project should lead to coordinated service delivery, improved patient follow-up mechanisms and enhanced interprofessional collaboration. Integration of CDPM services at the point of care in primary care practices is a promising innovation in care delivery that needs to be thoroughly evaluated