Development of the ASQoL: a quality of life instrument specific to ankylosing spondylitis

Background: Although disease-specific health status measures are available for ankylosing spondylitis (AS), no instrument exists for assessing quality of life (QoL) in the condition. Objective: To produce an AS-specific QoL measure that would be relevant and acceptable to respondents, valid, and reliable. Methods: The ASQoL employs the needs-based model of QoL and was developed in parallel in the UK and the Netherlands (NL). Content was derived from interviews with patients in each country. Face and content validity were assessed through patient field test interviews (UK and NL). A postal survey in the UK produced a more efficient version of the ASQoL, which was tested for scaling properties, reliability, internal consistency, and validity in a further postal survey in each country. Results: A 41 item questionnaire was derived from interview transcripts. Field testing interviews confirmed acceptability. Rasch analysis of data from the first survey (n=121) produced a 26 item questionnaire. Rasch analysis of data from the second survey (UK: n=164; NL: n=154) showed some item misfit, but showed that items formed a hierarchical order and were stable over time. Problematic items were removed giving an 18 item scale. Both language versions had excellent internal consistency (α=0.89–0.91), test-retest reliability (r(s)=0.92 UK and r(s)=0.91 NL), and validity. Conclusions: The ASQoL provides a valuable tool for assessing the impact of interventions for AS and for evaluating models of service delivery. It is well accepted by patients, taking about four minutes to complete, and has excellent scaling and psychometric properties

Self-reported oral health problems and the ability to organize dental care of community-dwelling elderly aged >= 75years

BackgroundIt is unclear how many community-dwelling elderly (>= 75years) experience oral health problems (e.g. pain, dry mouth, chewing problems) and how they manage their dental care needs. This study aimed to assess self-reported oral health problems in elderly who are frail or have complex care needs, and their ability to organize dental care when reporting oral pain.MethodsThree thousand five hundred thirty-three community-dwelling elderly participating in the "Embrace" project were asked to complete questionnaires regarding oral status and oral health problems. Frailty was assessed with the Groningen Frailty Indicator (GFI). Intermed for Elderly Self-Assessment (IM-E-SA) was used to determine complexity of care needs. Next, elderly who reported oral pain were interviewed about their oral pain complaints, their need for dental care, and their ability to organize and receive dental care. For statistical analyses Chi(2)-tests and the one-way ANOVA were used.ResultsOne thousand six hundred twenty-two elderly (45.9%) completed the questionnaires. Dry mouth (11.7%) and oral pain (6.2%) were most frequently reported. Among the elderly reporting oral pain, most were registered at a local dentist and could go there when needed (84.3%). Robust elderly visited the dentist independently (87%), frail (55.6%) and complex (26.9%) elderly more often required assistance from caregivers.ConclusionsDry mouth and oral pain are most reported oral health problems among community-dwelling elderly. Elderly with complex care needs report most oral health problems. In case an elderly seeks dental treatment to alleviate an oral pain complaint, most elderly in this study were able to organize dental care and transport to the dentist. Frail and complex elderly often need assistance from caregivers to visit the dentist. Therefore caretakers should keep in mind that when frailty progresses, visiting a dentist may become more and more difficult and the risk for poor oral health increases

The effect of three years of TNF alpha blocking therapy on markers of bone turnover and their predictive value for treatment discontinuation in patients with ankylosing spondylitis: a prospective longitudinal observational cohort study

INTRODUCTION: The aim of this study was to investigate the effect of three years of tumor necrosis factor-alpha (TNF-alpha) blocking therapy on bone turnover as well as to analyze the predictive value of early changes in bone turnover markers (BTM) for treatment discontinuation in patients with ankylosing spondylitis (AS). METHODS: This is a prospective cohort study of 111 consecutive AS outpatients who started TNF-alpha blocking therapy. Clinical assessments and BTM were assessed at baseline, three and six months, as well as at one, two, and three years. Z-scores of BTM were calculated to correct for age and gender. Bone mineral density (BMD) was assessed yearly. RESULTS: After three years, 72 patients (65%) were still using their first TNF-alpha blocking agent. In these patients, TNF-alpha blocking therapy resulted in significantly increased bone-specific alkaline phosphatase, a marker of bone formation; decreased serum collagen-telopeptide (sCTX), a marker of bone resorption; and increased lumbar spine and hip BMD compared to baseline. Baseline to three months decrease in sCTX Z-score (HR: 0.394, 95% CI: 0.263 to 0.591), AS disease activity score (ASDAS; HR: 0.488, 95% CI: 0.317 to 0.752), and physician's global disease activity (HR: 0.739, 95% CI: 0.600 to 0.909) were independent inversely related predictors of time to treatment discontinuation because of inefficacy or intolerance. Early decrease in sCTX Z-score correlated significantly with good long-term response regarding disease activity, physical function and quality of life. CONCLUSIONS: Three years of TNF-alpha blocking therapy results in a bone turnover balance that favors bone formation, especially mineralization, in combination with continuous improvement of lumbar spine BMD. Early change in sCTX can serve as an objective measure in the evaluation of TNF-alpha blocking therapy in AS, in addition to the currently used more subjective measures

An optimized BSCCO/Ag resonator coil for utility use

AC coils made with BSCCO-2223/Ag tapes and operating in liquid nitrogen have a potential for power related applications, e.g., inductors, transformers and current limiters. High-Tc tapes are available from several producers, while access to the coil building know-help is still rather limited, The relevant knowledge and technology suitable for making HTS coils for 50-60 Hz operation is being developed as a part of the current project. To verify the technology, several test solenoids and a first full-scale sub-coil have been manufactured. Electromagnetic, thermal and mechanical analysis of the coils is performed. The electromagnetic analysis focuses on the reduction of the radial magnetic field component in the windings. Voltage-current characteristics and the AC loss data obtained from relevant short sample measurements are applied. A good agreement between calculated and measured V-I curves and losses of the coils is found. A remarkable increase of the critical current and the reduction of the AC loss at the coil edges are predicted and confirmed experimentally. With the losses defined, thermal analysis and optimization of the coil structure are performed numerically followed by measurements for verification. The paper reports on the series of coils developed and explains the features of the projec

Are edentulousness, oral health problems and poor health-related quality of life associated with malnutrition in community-dwelling elderly (aged 75 years and over)?:a cross-sectional study

As the population ages, the risk of becoming malnourished increases. Research has shown that poor oral health can be a risk factor for malnutrition in institutionalized elderly. However, it remains unclear whether oral health problems, edentulousness and health-related quality of life also pose a risk for malnutrition in community-dwelling older adults. In this cross-sectional observational study, 1325 community-living elderly (75 years) were asked to complete questionnaires regarding nutritional status, oral status (edentulous, remaining teeth, or implant-supported overdentures), oral health problems, health-related quality of life (HRQoL), frailty, activities of daily living (ADL) and complexity of care needs. Univariate and multivariate logistic regression analyses were performed with nutritional status as dependent variable. Of the respondents, 51% (n = 521) were edentulous, 38.8% (n = 397) had remaining teeth and 10.2% (n = 104) had an implant-supported overdenture. Elderly with complex care needs were malnourished most frequently, followed by frail and robust elderly (10%, 4.5% and 2.9%, respectively). Malnourished elderly reported more frequent problems with chewing and speech when compared with well-nourished elderly (univariate analysis). However, multivariate analysis did not show an association between malnutrition and oral health problems and edentulousness, although HRQoL was associated with malnutrition (odds ratio (OR) 0.972, confidence interval (CI) 0.951-0.955). Based on the results of this cross-sectional study, it can be concluded that poor HRQoL is significantly associated with malnutrition; however, edentulousness and oral health problems are not

Development of the GeriatrICS, an ICF-based and person-centred assessment tool for evaluation of health-related problems in community-living older adults

Introduction: Ideally, older adults should receive person-centred care and support that meets their individual needs and wishes, taking all relevant health-related problems into account. The International Classification of Functioning, Disability and Health ICF might offer a basis for identification of these problems as it provides a unified language for evaluation of functioning and disability associated with someone’s health status. ICF Core Sets have been developed to describe the spectrum of disabilities of specific patient populations. Therefore, aim of this study was to develop a valid Geriatric ICF Core Set GeriatrICS reflecting all relevant health-related problems of community-living older adults without dementia. Methods: This study consisted of two sub-studies: 1 a written Delphi study to select ICF categories, and 2 assessing content validity in a cross-sectional study. For the Delphi study, a representative panel of experts older adults and non-medical experts on health-related problems due to ageing was constituted. Panel members had to select second-level categories from the ICF-classification relevant to community-living, non-demented older adults 75+, and had to reach consensus on this selection. For the validation study, older adults frail or with complex care needs were visited by a case manager district nurse or social worker who used the initial GeriatrICS as an assessment tool. Older adults had to rate all categories on a scale ranging from 0 no problem to 10 complete problem. Content validity of a category was guaranteed if ≥10% indicated a problem with that category. Results: 41 Delphi panel members obtained consensus in two rounds on 30 ICF-categories. Next, 267 older adults participated in the validation study. All categories met the criterion for content validity except for d530 Toileting. The final GeriatrICS consists of 29 categories: fourteen Body Functions categories, nine Activities and Participation categories and six Environmental Factors categories. Discussions and conclusions: This study resulted in a valid ICF Core Set GeriatrICS including 29 ICF categories representing the most relevant health-related problems among community-living older adults without the diagnosis of dementia. The GeriatrICS included categories from all ICF components, showing that older people’s health is a multidimensional construct. Compared to commonly used, profession-based tools, the GeriatrICS is unique as it is a population-based, cross-domain tool. Therefore, the GeriatrICS is a good starting point for the delivery of person-centred and integrated care. Lessons learned: The GeriatrICS may be used in person-centred and integrated care practice as an assessment tool, in order to tailor care and support to the needs of older adults. Analysis and interpretation of an older adult’s outcomes, and translation into an appropriate care plan, requires highly competent and experienced professionals. Limitations: Older adults with dementia or cognitive impairments may have been included in the validation study since dementia was not an exclusion criterion. Impact on the results is expected to be trivial as case managers were experienced interviewers and a partner or family member participated in the assessment in case of cognitive problems. Suggestions for future research: Future research should investigate the health-related problems of older adults with dementia and robust older adults

Integrated Care for Older Adults Improves Perceived Quality of Care:Results of a Randomized Controlled Trial of Embrace

BACKGROUND: All community-living older adults might benefit from integrated care, but evidence is lacking on the effectiveness of such services for perceived quality of care. To examine the impact of Embrace, a community-based integrated primary care service, on perceived quality of care. Stratified randomized controlled trial. Integrated care and support according to the "Embrace" model was provided by 15 general practitioners in the Netherlands. Based on self-reported levels of case complexity and frailty, a total of 1456 community-living older adults were stratified into non-disease-specific risk profiles ("Robust," "Frail," and "Complex care needs"), and randomized to Embrace or control groups. Embrace provides integrated, person-centered primary care and support to all older adults living in the community, with intensity of care dependent on risk profile. Primary outcome was quality of care as reported by older adults on the Patient Assessment of Integrated Elderly Care (PAIEC). Effects were assessed using mixed model techniques for the total sample and per risk profile. Professionals' perceived level of implementation of integrated care was evaluated within the Embrace condition using the Assessment of Integrated Elderly Care. Older adults in the Embrace group reported a higher level of perceived quality of care than those in the control group (B = 0.33, 95 % CI = 0.15-0.51, ES d = 0.19). The advantages of Embrace were most evident in the "Frail" and "Complex care needs" risk profiles. We found no significant advantages for the "Robust" risk profile. Participating professionals reported a significant increase in the perceived level of implementation of integrated care (ES r = 0.71). This study shows that providing a population-based integrated care service to community-living older adults improved the quality of care as perceived by older adults and participating professionals

Quality standard for Person-centred and Integrated Care for Older adults

Background: Current healthcare systems are challenged to cope with changing demands of the growing population of older adults, while maintaining quality of care at lower costs. Between 2008 and 2016, the Dutch National Care for the Elderly Program was organized by the ‘Netherlands Organization for Health Research and Development’ ZonMw and financially supported by the Dutch ministry of Health. Aim of the program was to contribute to a solution to these challenges. One of the projects was Embrace1, a person-centered and integrated care service for community-living older adults. Aims of this service are to improve quality of care by reducing the fragmentation in health services, to improve patient outcomes, and to increase sustainability of the healthcare system. Embrace combines two globally recognized models, the Chronic Care Model and a population health management model. Both models were translated to the Dutch situation and specified for older adults. Embrace has been implemented in the Netherlands since 2012. Short- and long-term evaluations, using mixed methods, showed positive results regarding patient outcomes, quality of care, and costs. Before final closing of the national programme, the program committee, with support from the Dutch Care institute and the Dutch ministry of Health, decided to develop a ‘Quality standard Person-centred and Integrated Care for older adults’ based on the characteristics and positive results of Embrace. Aim of this quality standard is to support the transformation in the Dutch health system towards person-centred and integrated care by reaching consensus on values and standards of care for older adults, creating clarity for older adults and professionals, and providing tools for administrative accountability. This network discussion is part of the preparation phase before the actual development of the quality standard. Aim of this phase is to explore the support, scope, and potential bottlenecks for the new standard with future owners of this standard. These owners may include older adults’ representatives, professional organizations and funders for care and welfare. Aims and Objectives: Aim of this network discussion is to use the available expertise among participants of this conference to further explore the support, scope, and potential bottlenecks for the new standard. We have the intention to invite Dutch participants and share the results of the explorations until then, and ask for feedback. Format: The meeting is planned at the end of the six months preparation phase starting January 2018. The preliminary results will be shared with participants, and their reflections and advises will be collected and discussed. Target audience: Dutch experts on person-centred and integrated care. Take away: Results will be included in the final report for the committee of the Dutch National Care for the Elderly Program