Introdução: Com o aumento da população idosa e das condições crônicas de saúde, a Atenção Primária à Saúde (APS) é preciso reorganizar esse nível do Sistema Único de Saúde (SUS) para atender às necessidades de saúde decorrentes do novo perfil epidemiológico. Por serem progressivas e incuráveis, as doenças crônico-degenerativas geram crescente demanda por cuidados paliativos (CP). Os CP são indicados desde o diagnóstico de uma doença crônica até o estágio final de vida. Dado o cenário da necessidade de incluir os CP na APS, quais seriam as questões éticas relativas a essa inclusão? Objetivo: Identificar as questões éticas relativas aos Cuidados Paliativos na Atenção Primária à Saúde. Método: Revisão Sistematizada do tipo Scoping Review. As buscas foram nas bases de dados: LILACS, PubMed, CINAHL e EMBASE. Utilizou-se duas estratégias de busca. A primeira cruzou os descritores ética e bioética com atenção primária à saúde. A segunda fez o cruzamento dos dois descritores com cuidados paliativos. Além das buscas nas bases, incluiu-se o acervo de buscas anteriores. Resultados: Foram encontrados 3923 artigos e, após análise, mantiveram-se 16 artigos, referentes a 15 estudos. Os problemas encontrados foram: escassez de recursos; falta de conhecimento dos profissionais de saúde sobre a prática de CP; falta de habilidades comunicacionais; dificuldade em estabelecer limites na relação clínica; sobrecarga de trabalho; falta de apoio de serviços de referência; e falta de comunicação entre os serviços da Rede de Atenção à Saúde (RAS). Esses problemas assemelham-se aos vividos no cotidiano da APS, distinguindo-se pelas especificidades de algumas situações como as de fim de vida. Conclusões: A oferta dos CP na APS tem desafios éticos, além de técnicos e operacionais, como: ultrapassar a assistência oncológica; modificar a visão dos profissionais para iniciar os CP o mais precocemente na vigência das condições crônicas de saúde; fomentar a cultura do cuidado compartilhado e da corresponsabilização pela saúde; e desenvolver continuamente as habilidades e atividades dos profissionais para a comunicação como instrumento do processo de trabalho na APS / Introduction: The increase in the elderly population and chronic health conditions require a new organization of Primary Health Care (PHC) in the Unified Health System (SUS) to meet the health needs from the new epidemiological profile. As these diseases are progressive and incurable, they generate an increasing demand for palliative care (PC). The PC are indicated since the diagnosis of a chronic disease till the end of life. What are the ethical issues related to the inclusion of PC in PHC? Objective: To identify ethical issues related to Palliative Care in Primary Health Care. Method: Scoping Review. Data collection was made in the databases LILACS, PubMed, CINAHL and EMBASE, using two different linkage strategies: ethics and bioethics with primary health care, and ethics and bioethics with palliative care. Besides searching databases, we included articles located by previous searches. Results: We found 3923 articles. After the analysis, remained 16 articles, related to 15 studies. We found the following problems: lack of resources; lack of knowledge of health professionals on the PC practice; lack of communication skills; difficulty in establishing limits in clinical relationship; work overload; lack of referral support; and lack of communication between health services. These ethical issues are similar to those experienced daily in the PHC, except for the specificities of some situations, such as end of life. Conclusion: The offer of PC in the PHC arises ethical and technical challenges: Overcome the treatment of cancer; modify the professional vision to start the PC since the diagnosis of a chronic health condition; foster shared care and co-responsibility for health; and continued development of professionals communication skills as an important tool for the work process in PHC

Darbo tikslas. Įvertinti šeimos gydytojų požiūrį į akušerinės – ginekologinės pagalbos paslaugas, teikiamas pirminėje sveikatos priežiūros grandyje. Uždaviniai. 1. Įvertinti šeimos gydytojų požiūrį į akušerinės – ginekologinės pagalbos organizavimo pokyčius. 2. Nustatyti šeimos gydytojų teikiamų akušerinės – ginekologinės pagalbos paslaugų apimtį pirminėje sveikatos priežiūros grandyje. 3. Nustatyti problemas, su kuriomis susiduria šeimos gydytojai, teikdami akušerinės – ginekologinės pagalbos paslaugas savo bendruomenės moterims. Tyrimo metodika. Tyrimo objektas: Kauno mieste dirbančių šeimos gydytojų požiūris į jų teikiamas akušerinės – ginekologinės pagalbos paslaugas. Tyrimo metodai: Anoniminė anketinė šeimos gydytojų apklausa. Anketa išplatinta visiems Kauno miesto šeimos gydytojams (n = 220). Atsakas – 90,9 proc. Statistinė duomenų analizė atlikta SPSS – 13 programa. Rezultatai. Moterų piktybinių navikų prevencijos vykdymo ir moterų raštingumo lytinės higienos ir šeimos planavimo klausimais priskyrimą šeimos medicinos institucijai teigiamai vertino 96 proc. visų respondentų, nėščiųjų stebėsenos - 58 proc., ginekologinių paslaugų - 64 proc. Privačiose pirminės sveikatos priežiūros įstaigose ( PSPĮ) dirbančių šeimos gydytojų teikiamų akušerinių – ginekologinių paslaugų apimtis (išskyrus klimakterinių simptomų diagnostiką) yra didesnė nei VŠĮ dirbančių šeimos gydytojų. Statistiškai reikšmingi skirtumai nustatyti teikiant šias paslaugas: tepinėlio iš gimdos kaklelio... [toliau žr. visą tekstą] / Aim of the study. To evaluate family physicians’ attitudes towards obstetric-gynecological services provided in primary health care settings. Objectives. 1. To evaluate family physicians’ attitudes towards changes in the organization of obstetric-gynecological servises. 2. To determine the extent of obstetric-gynecological services provided by family physicians in primary health care level. 3. To identify the problems family physicians encounter when providing obstetric-gynecological services . Methods. Anonymous questionnaire-based survey of family physicians was carried out in Kaunas city (n = 220). The response rate was 90.9%. Statistical data analysis was performed using SPSS v.13 software package. Results. The attribution of cancer prevention among women and women’s literacy in sexual hygiene- and family planning-related issues to the institution of family medicine was positively evaluated by 96% of respondents, the attribution of the monitoring of pregnant women – by 58% and the attribution of gynecological services – by 64% of respondents. The extent of obstetric-gynecological services (except for the diagnostics of menopausal symptoms) provided by family physicians working in private primary health care institutions (PHCI) exceeded that provided by family physicians working in public PHCI. Statistically significant differences were detected in the provision of the following services: cervical smear (a service provided by 82.2% of family physicians in private... [to full text]

Introdução: Com o aumento da população idosa e das condições crônicas de saúde, a Atenção Primária à Saúde (APS) é preciso reorganizar esse nível do Sistema Único de Saúde (SUS) para atender às necessidades de saúde decorrentes do novo perfil epidemiológico. Por serem progressivas e incuráveis, as doenças crônico-degenerativas geram crescente demanda por cuidados paliativos (CP). Os CP são indicados desde o diagnóstico de uma doença crônica até o estágio final de vida. Dado o cenário da necessidade de incluir os CP na APS, quais seriam as questões éticas relativas a essa inclusão? Objetivo: Identificar as questões éticas relativas aos Cuidados Paliativos na Atenção Primária à Saúde. Método: Revisão Sistematizada do tipo Scoping Review. As buscas foram nas bases de dados: LILACS, PubMed, CINAHL e EMBASE. Utilizou-se duas estratégias de busca. A primeira cruzou os descritores ética e bioética com atenção primária à saúde. A segunda fez o cruzamento dos dois descritores com cuidados paliativos. Além das buscas nas bases, incluiu-se o acervo de buscas anteriores. Resultados: Foram encontrados 3923 artigos e, após análise, mantiveram-se 16 artigos, referentes a 15 estudos. Os problemas encontrados foram: escassez de recursos; falta de conhecimento dos profissionais de saúde sobre a prática de CP; falta de habilidades comunicacionais; dificuldade em estabelecer limites na relação clínica; sobrecarga de trabalho; falta de apoio de serviços de referência; e falta de comunicação entre os serviços da Rede de Atenção à Saúde (RAS). Esses problemas assemelham-se aos vividos no cotidiano da APS, distinguindo-se pelas especificidades de algumas situações como as de fim de vida. Conclusões: A oferta dos CP na APS tem desafios éticos, além de técnicos e operacionais, como: ultrapassar a assistência oncológica; modificar a visão dos profissionais para iniciar os CP o mais precocemente na vigência das condições crônicas de saúde; fomentar a cultura do cuidado compartilhado e da corresponsabilização pela saúde; e desenvolver continuamente as habilidades e atividades dos profissionais para a comunicação como instrumento do processo de trabalho na APS / Introduction: The increase in the elderly population and chronic health conditions require a new organization of Primary Health Care (PHC) in the Unified Health System (SUS) to meet the health needs from the new epidemiological profile. As these diseases are progressive and incurable, they generate an increasing demand for palliative care (PC). The PC are indicated since the diagnosis of a chronic disease till the end of life. What are the ethical issues related to the inclusion of PC in PHC? Objective: To identify ethical issues related to Palliative Care in Primary Health Care. Method: Scoping Review. Data collection was made in the databases LILACS, PubMed, CINAHL and EMBASE, using two different linkage strategies: ethics and bioethics with primary health care, and ethics and bioethics with palliative care. Besides searching databases, we included articles located by previous searches. Results: We found 3923 articles. After the analysis, remained 16 articles, related to 15 studies. We found the following problems: lack of resources; lack of knowledge of health professionals on the PC practice; lack of communication skills; difficulty in establishing limits in clinical relationship; work overload; lack of referral support; and lack of communication between health services. These ethical issues are similar to those experienced daily in the PHC, except for the specificities of some situations, such as end of life. Conclusion: The offer of PC in the PHC arises ethical and technical challenges: Overcome the treatment of cancer; modify the professional vision to start the PC since the diagnosis of a chronic health condition; foster shared care and co-responsibility for health; and continued development of professionals communication skills as an important tool for the work process in PHC

L’exercici físic provoca efectes beneficiosos per a la salut en persones sanes però també amb certes patologies cròniques. L’objectiu d’aquesta tesi fou valorar els efectes i l’aplicabilitat d’un programa de prescripció i planificació d’exercici físic per a la salut a dos centres d’atenció primària per a pacients amb patologia crònica reclutats durant visites rutinàries al seu equip d’atenció primària. El disseny de l’estudi fou d’una intervenció pragmàtica de 18 mesos avaluada seguint les dimensions RE-AIM. Els protocols establerts per a la intervenció, emmarcada en el Programa CAMINEM, han demostrat ser aplicables en els dos centres i els efectes de l’exercici físic pels participants adherits mostraren una tendència favorable, tot i que els resultats no són estadísticament significatius. Aquesta intervenció en prescripció d’exercici físic per a la salut possiblement hagi estat la primera basada en els principis de l’entrenament esportiu i en promoció de salut pública on un professional no sanitari treballà conjuntament amb professionals sanitaris d’atenció primària. / El ejercicio físico provoca efectos beneficiosos para la salud en personas sanas pero también con ciertas patologías crónicas. El objetivo de esta tesis fue valorar los efectos y la aplicabilidad de un programa de prescripción y planificación de ejercicio físico para la salud en dos centros de atención primaria para pacientes con patología crónica reclutados durante visitas rutinarias a su equipo de atención primaria. El estudio fue diseñado como una intervención pragmática de 18 meses evaluada siguiendo las dimensiones RE-AIM. Los protocolos establecidos para la intervención, basada en el Programa CAMINEM, han demostrado ser aplicables en los dos centros y los efectos del ejercicio físico para los participantes adheridos reflejaron una tendencia favorable, a pesar de que los resultados no sean estadísticamente significativos. Esta intervención en prescripción de ejercicio físico para la salud posiblemente haya sido la primera basada en los principios de entrenamiento deportivo y de promoción de salud pública en el cual un profesional no sanitario trabajó conjuntamente con profesionales sanitarios de atención primaria. / Regular exercise has many health benefits for apparently healthy people and also for people suffering determinant chronic diseases. The main aim of this thesis was to assess the effects and feasibility of a health-enhancing exercise prescription and exercise planning in two primary health-care settings for regular patients suffering from chronic conditions attending their health practitioner. The study was developed as a pragmatic-driven trial for 18 months. It was evaluated following the dimensions of the RE-AIM framework. Health-enhancing physical activity (HEPA) intervention procedures, designed within the framework of the Let’s Walk Programme, have been found to be feasible in both centres. Positive trends may be found in health indicators for adhered participants even though results were not statistically significant. This intervention has probably been the first based on exercise training principles and public health promotion in which exercise specialists were working alongside primary care practitioners.

El presente estudio tiene como objetivo analizar las representaciones sociales acerca el proceso suicida en gatekeepers de atención primaria de la salud en la ciudad de Lima, Perú. Para la presente investigación se utilizó el método cualitativo con diseño fenomenológico, y se analizó la información haciendo uso del análisis de contenido temático. Para tal fin se realizaron entrevistas semiestructuradas a once trabajadores de atención primaria de la salud. Se encontró que las representaciones sociales con respecto al suicidio que tenían los participantes tendían a ser negativas, con presencia de estereotipos y, mitos o creencias falsas. Los temas encontrados están relacionados a la percepción del suicidio, a las características de las personas que deciden suicidarse, factores que influyen en el suicidio y a los sentimientos frente a situaciones suicidas. Se discuten los resultados a la luz del marco teórico y estudios empíricos. / The present study aims to analyze the social representations about the suicide process in primary health care gatekeepers in the city of Lima, Peru. For the present investigation, a qualitative method with phenomenological design was used, and the information was analyzed using the thematic content analysis. To this end, semi-structured interviews were conducted with eleven primary health care workers. It was found that the social representations regarding suicide that the participants had tended to be negative, with the presence of stereotypes and, myths or false beliefs. The themes found are related to the perception of suicide, the characteristics of people who decide to commit suicide, factors that influence suicide and feelings about suicidal situations. The results are discussed in light of the theoretical framework and empirical studies. / Tesis

<p><b>Studie I</b></p><p><i>Bakgrunn</i></p><p>Formålet med studie I var å evaluere kvaliteten på den skriftlige kommunikasjonen mellom kommune- og spesialisthelsetjenesten ved innleggelse i og utskriving fra sykehus med et spesielt fokus på hvem som hadde oppfølgingsansvaret. I tillegg skulle det estimeres hvor mange pasienter som eventuelt kunne blitt behandlet utenfor sykehus i stedet for innleggelse i sykehus.</p><p><i>Materiale og metode</i></p><p>I studie 1 bestod pasientutvalget av 100 innleggelsesskriv og epikriser for pasienter på over 75 år fortløpende innlagt ved ortopedisk, lunge- og kardiologisk avdeling ved St. Olavs Hospital fra Trondheim og Malvik kommuner vinteren 2002. Vurderingene ble gjort ved hjelp av en Delfi-teknikk med to forskjellige ekspertpanel bestående en erfaren spesialist i allmennmedisin, en sykepleier fra kommunen med erfaring fra omsorgstjenester og en sykehusspesialist. Panelene vurderte kvaliteten på beskrivelsen av sykehistorie, aktuelt, funn, medisiner, ADL, sosialt nettverk, behov for omsorgstjenester, og foretok en vurdering av nytte av sykehusopphold og om pasientene kunne ha blitt behandlet i allmennpraksis, på en akuttpoliklinikk eller på et sykehjem.</p><p><i>Resultater</i></p><p>I henvisningsbrevene var sykehistorie, funn og medikamenter svært godt beskrevet i henholdsvis 39 %, 56 % og 39 % av tilfellene. I epikrisene var tilsvarende områder beskrevet svært godt i 92 %, 55 % og 82 % av tilfellene. Bare halvpartene av epikrisene hadde tilfredsstillende beskrivelse av ADL. Ca 2/3 av pasientene ble vurdert til å ha svært god nytte av sykehusoppholdet, og en av seks pasientene kunne ha blitt behandlet uten innleggelse i sykehuset. Mens sykehusspesialistene vurderte at 77 % av pasientene hadde stor nytte av innleggelsen, vurderte allmennlegene at bare 59 % hadde stor nytte av oppholdet. En av fire epikriser beskrev ikke hvem som hadde oppfølgingsansvaret, </p><p><i>Konklusjon studie I</i></p><p>Både innleggesskrivene og epikrisene manglet viktig medisinsk informasjon. Innleggeselsskrivene manglet så mye informasjon at i mange tilfeller kunne dette representere en helserisiko for pasientene. Det var også dårlig samsvar mellom på første- og andrelinjenivå om hva som ble forstått som god kvalitet på innleggelsesskriv og epikriser. Det var heller ikke enighet om hvilke pasienter som hadde god nytte av sykehusoppholdet.</p><p><b>Studie II</b></p><p><i>Bakgrunn</i></p><p>Formålet med studien var å sammenlikne bruk av helse- og omsorgstjenester, kostnader og død under seks og 12 måneders oppfølging av pasienter sluttbehandlet på en intermediæravdeling i sykehjem med tradisjonell behandling i sykehus.</p><p><i>Materiale og metode</i></p><p>I en randomisert kontrollert studie ble 142 pasienter over 60 år innlagt St. Olavs Hospital for akutt sykdom eller forverring av kronisk sykdom slutt- og etterbehandlet på en intermediæravdeling i et sykehjem eller på sykehuset. Intervensjonsgruppen, 72 pasienter, ble mens de var innlagt på sykehuset, randomisert til sluttbehandling på sykehjemmet, mens sykehusgruppen, 70 pasienter, ble randomisert til standard viderebehandling på sykehuset. Resultatene er basert på intention-to-treat analyser og justert for alder, kjønn, ADL og diagnoser.</p><p><i>Resultater</i></p><p>Reinnleggelser </p><p>I intervensjonsgruppen ble 14 pasienter (19,4 %) reinnlagt sammenlignet med 25 pasienter (35,7 %) i sykehusgruppen (p=0,03).</p><p><i>Resultater etter seks måneder</i></p><p>Etter seks måneder var det 18 (25,0 %) klarte seg selv i intervensjonsgruppen sammenlignet med syv (10,0 %) (p=0,02) i sykehusgruppen. Det var en ikke signifikant reduksjon av antall døde i intervensjonsgruppen med en ikke signifikant økning i dager innlagt i institusjon for den initiale behandlingsperioden. Samlede gjennomsnittlige behandlings- og omsorgskostnader per pasient var for de første seks månedene NOK 78632 (95 % CI 59168-98096) i intervensjonsgruppen sammenlignet med NOK 112568 (95 % CI 85736-139392) i sykehusgruppen (p=0,003). Gjennomsnittlige forskjell behandlings- og omsorgskostnader per pasient og observasjonsdag var NOK 296 (95 % CI 8-568) (p=0,003).</p><p><i>Resultater etter 12 måneder</i></p><p>Etter 12 måneder var 13 (18,1 %) døde i intervensjonsgruppens og 22 døde (31,4 %) i sykehusgruppen (p=0,03). Pasientene i intervensjonsgruppen var under observasjon i en lengre tidsperiode enn sykehusgruppen: 335,7 (95 % CI 312,0-359,4) sammenlignet med 12 292,8 (95 % CI 264,1-321,5) dager (p=0,01). Det var ingen statistiske forskjeller i behovet for kommunal langtidsomsorg, antall sykehusinnleggelse eller dager i sykehus mellom gruppene.</p><p>Gjennomsnittlige behandlings- og omsorgskostnader per pasient og observasjonsdag var NOK 606 (95 % CI 450-761) i intervensjonsgruppen sammenlignet med NOK 802 (95 % CI 641-962) i sykehusgruppen (p=0,03).</p><p><i>Konklusjon studie II</i></p><p>Sluttbehandling på intermediært nivå i et sykehjem medførte færre reinnleggelser, at flere pasienter klarte seg selv uten kommunale omsorgstjenester og lavere mortalitet. Samtidig var behandlingstilbudet kostnadseffektivt.</p> / <p><b>Study I</b></p><p><i>Background</i></p><p>Optimal care of patients is dependent on good professional interaction between general practitioners and general hospital doctors, and this collaboration is mainly based upon the quality of the written communication. The main objectives of study I were to evaluate the quality of the written communication between physicians, the description of follow-up responsibility and to estimate the number of patients that could have been treated at primary level instead of in a general hospital.</p><p><i>Methods</i></p><p>The sample of study I comprised referral and discharge letters for 100 patients above 75 years of age hospitalised at the orthopaedic, pulmonary and cardiological departments at the city general hospital in Trondheim. The assessments were done using a Delphi survey with two expert panels each with one general hospital specialist, one general practitioner and one public health nurse using a standardised evaluation protocol with a visual analogue scale (VAS) from one to eight. The panels assessed the quality of the description of medical history, signs, medication, ADL, network, need for care and the level of benefit gained from general hospital care.</p><p><i>Results</i></p><p>In study I information in referral letters on medical history, signs and medications were assessed to be of high quality in 39 %, in 56 % and in 39 %, respectively. The corresponding information assessed to be of high quality in discharge letters were for medical history 92 %, signs 55 % and medications 82 %. Only half of the discharge letters had satisfactory information on ADL. Some two-thirds of the patients were assessed to have had large health benefits from the general hospital stay in question. One of six patients could have been treated without a general hospital admission. The specialists assessed that 77 % of the patients had had a large benefit from the general hospital admission; however the general practitioners assessment was only 59 %. One of four of the discharge letters did not define who was responsible for follow-up care.</p><p><i>Conclusions Study I</i></p><p>Both referral and discharge letters lack vital medical information, and referral letters to such an extent that it might represent a health hazard for the patients. Health professionals at primary and secondary level do not agree as to the definition of good quality as far as referral and discharge letters are concerned. Furthermore they do not agree as to the benefits of admission to a general hospital.</p><p><b>Study II</b></p><p><i>Background</i></p><p>Demographic changes combined with increasing pressure on general hospital beds and other health services by the elderly make allocation of resources to the most efficient care level a vital issue. The aim of study II was to study the efficacy of intermediate care at a community hospital compared to standard prolonged care at a general hospital over a period, with six and 12 months follow-up.</p><p><i>Methods</i></p><p>In a randomised controlled trial, study II, of 142 patients, aged 60 or more admitted to a general hospital due to acute illness or exacerbation of a chronic disease, 72 (intervention group) were randomised to intermediate care at a community hospital and 70 (general hospital group) to prolonged general hospital care. The results are based on intention-to-treat analyses and are adjusted for age, gender, ADL and diagnosis.</p><p><i>Results</i></p><p>Readmissions to general hospital</p><p>In the intervention group 14 patients (19.4 %) were readmitted compared to 25 patients (35.7 %) in the general hospital group (p=0.03).</p><p><i>Results after six months</i></p><p>After 26 weeks 18 (25.0 %) patients in the intervention group were independent of community care compared to seven (10.0 %) in the general hospital group (p=0.02). There was an insignificant reduction in the number of deaths and an insignificant increase in the number of days of inpatient care in the intervention group. The number of patients admitted to long-term nursing homes from the intervention group was insignificantly higher than from the general hospital group. Mean total health services costs per patient in the intervention group for the first six months were EUR 9829 (95 % CI 7396-12262) compared to EUR 14071 (95 % CI 10717-17424) in the general hospital group. The mean difference in costs was EUR 4242 (95 % CI 152-8331) 9</p><p>(p=0.003), and mean difference in cost per day at risk per patient was EUR 37 (95 % CI 1-71) (p=0.003).</p><p><i>Results after 12 months</i></p><p>Thirty-five patients, 13 (18.1 %) of all patients included in the intervention group and 22 (31.4 %) in the general hospital group, died within 12 months (p= 0.03). Patients in the intervention group were observed during a longer period of time than in the general hospital group; 335.7 (95 % CI 312.0-359.4) versus 292.8 (95 % CI 264.1-321.5) days (p=0.01). There were statistically no differences in the need for long-term primary level care or in the number of admissions or days spent in general hospital beds.</p><p>Average total health services costs per patient per observed day were EUR 76 (95 % CI 56- 95) for the intervention group and EUR 100 (95 % CI 80-120) for the general hospital group (p=0.03).</p><p><i>Trial registration</i></p><p>ClinicalTrials.gov NCT00235404</p><p><b>Conclusions Study II</b></p><p>Intermediate care in a community hospital significantly decreased the number of readmissions for the same disease to general hospital and a significantly higher number of patients were independent of community care after 26 weeks of follow-up. There was no increase in mortality and number of days in institutions. Care at intermediate level in a community hospital was cost effective from a health service perspective and contributes to better patient outcome as more patients had better functional status and significantly fewer patients were dead after 12 months follow-up.</p>

<b>Studie I</b> Bakgrunn Formålet med studie I var å evaluere kvaliteten på den skriftlige kommunikasjonen mellom kommune- og spesialisthelsetjenesten ved innleggelse i og utskriving fra sykehus med et spesielt fokus på hvem som hadde oppfølgingsansvaret. I tillegg skulle det estimeres hvor mange pasienter som eventuelt kunne blitt behandlet utenfor sykehus i stedet for innleggelse i sykehus. Materiale og metode I studie 1 bestod pasientutvalget av 100 innleggelsesskriv og epikriser for pasienter på over 75 år fortløpende innlagt ved ortopedisk, lunge- og kardiologisk avdeling ved St. Olavs Hospital fra Trondheim og Malvik kommuner vinteren 2002. Vurderingene ble gjort ved hjelp av en Delfi-teknikk med to forskjellige ekspertpanel bestående en erfaren spesialist i allmennmedisin, en sykepleier fra kommunen med erfaring fra omsorgstjenester og en sykehusspesialist. Panelene vurderte kvaliteten på beskrivelsen av sykehistorie, aktuelt, funn, medisiner, ADL, sosialt nettverk, behov for omsorgstjenester, og foretok en vurdering av nytte av sykehusopphold og om pasientene kunne ha blitt behandlet i allmennpraksis, på en akuttpoliklinikk eller på et sykehjem. Resultater I henvisningsbrevene var sykehistorie, funn og medikamenter svært godt beskrevet i henholdsvis 39 %, 56 % og 39 % av tilfellene. I epikrisene var tilsvarende områder beskrevet svært godt i 92 %, 55 % og 82 % av tilfellene. Bare halvpartene av epikrisene hadde tilfredsstillende beskrivelse av ADL. Ca 2/3 av pasientene ble vurdert til å ha svært god nytte av sykehusoppholdet, og en av seks pasientene kunne ha blitt behandlet uten innleggelse i sykehuset. Mens sykehusspesialistene vurderte at 77 % av pasientene hadde stor nytte av innleggelsen, vurderte allmennlegene at bare 59 % hadde stor nytte av oppholdet. En av fire epikriser beskrev ikke hvem som hadde oppfølgingsansvaret, Konklusjon studie I Både innleggesskrivene og epikrisene manglet viktig medisinsk informasjon. Innleggeselsskrivene manglet så mye informasjon at i mange tilfeller kunne dette representere en helserisiko for pasientene. Det var også dårlig samsvar mellom på første- og andrelinjenivå om hva som ble forstått som god kvalitet på innleggelsesskriv og epikriser. Det var heller ikke enighet om hvilke pasienter som hadde god nytte av sykehusoppholdet. <b>Studie II</b> Bakgrunn Formålet med studien var å sammenlikne bruk av helse- og omsorgstjenester, kostnader og død under seks og 12 måneders oppfølging av pasienter sluttbehandlet på en intermediæravdeling i sykehjem med tradisjonell behandling i sykehus. Materiale og metode I en randomisert kontrollert studie ble 142 pasienter over 60 år innlagt St. Olavs Hospital for akutt sykdom eller forverring av kronisk sykdom slutt- og etterbehandlet på en intermediæravdeling i et sykehjem eller på sykehuset. Intervensjonsgruppen, 72 pasienter, ble mens de var innlagt på sykehuset, randomisert til sluttbehandling på sykehjemmet, mens sykehusgruppen, 70 pasienter, ble randomisert til standard viderebehandling på sykehuset. Resultatene er basert på intention-to-treat analyser og justert for alder, kjønn, ADL og diagnoser. Resultater Reinnleggelser I intervensjonsgruppen ble 14 pasienter (19,4 %) reinnlagt sammenlignet med 25 pasienter (35,7 %) i sykehusgruppen (p=0,03). Resultater etter seks måneder Etter seks måneder var det 18 (25,0 %) klarte seg selv i intervensjonsgruppen sammenlignet med syv (10,0 %) (p=0,02) i sykehusgruppen. Det var en ikke signifikant reduksjon av antall døde i intervensjonsgruppen med en ikke signifikant økning i dager innlagt i institusjon for den initiale behandlingsperioden. Samlede gjennomsnittlige behandlings- og omsorgskostnader per pasient var for de første seks månedene NOK 78632 (95 % CI 59168-98096) i intervensjonsgruppen sammenlignet med NOK 112568 (95 % CI 85736-139392) i sykehusgruppen (p=0,003). Gjennomsnittlige forskjell behandlings- og omsorgskostnader per pasient og observasjonsdag var NOK 296 (95 % CI 8-568) (p=0,003). Resultater etter 12 måneder Etter 12 måneder var 13 (18,1 %) døde i intervensjonsgruppens og 22 døde (31,4 %) i sykehusgruppen (p=0,03). Pasientene i intervensjonsgruppen var under observasjon i en lengre tidsperiode enn sykehusgruppen: 335,7 (95 % CI 312,0-359,4) sammenlignet med 12 292,8 (95 % CI 264,1-321,5) dager (p=0,01). Det var ingen statistiske forskjeller i behovet for kommunal langtidsomsorg, antall sykehusinnleggelse eller dager i sykehus mellom gruppene. Gjennomsnittlige behandlings- og omsorgskostnader per pasient og observasjonsdag var NOK 606 (95 % CI 450-761) i intervensjonsgruppen sammenlignet med NOK 802 (95 % CI 641-962) i sykehusgruppen (p=0,03). Konklusjon studie II Sluttbehandling på intermediært nivå i et sykehjem medførte færre reinnleggelser, at flere pasienter klarte seg selv uten kommunale omsorgstjenester og lavere mortalitet. Samtidig var behandlingstilbudet kostnadseffektivt. / <b>Study I</b> Background Optimal care of patients is dependent on good professional interaction between general practitioners and general hospital doctors, and this collaboration is mainly based upon the quality of the written communication. The main objectives of study I were to evaluate the quality of the written communication between physicians, the description of follow-up responsibility and to estimate the number of patients that could have been treated at primary level instead of in a general hospital. Methods The sample of study I comprised referral and discharge letters for 100 patients above 75 years of age hospitalised at the orthopaedic, pulmonary and cardiological departments at the city general hospital in Trondheim. The assessments were done using a Delphi survey with two expert panels each with one general hospital specialist, one general practitioner and one public health nurse using a standardised evaluation protocol with a visual analogue scale (VAS) from one to eight. The panels assessed the quality of the description of medical history, signs, medication, ADL, network, need for care and the level of benefit gained from general hospital care. Results In study I information in referral letters on medical history, signs and medications were assessed to be of high quality in 39 %, in 56 % and in 39 %, respectively. The corresponding information assessed to be of high quality in discharge letters were for medical history 92 %, signs 55 % and medications 82 %. Only half of the discharge letters had satisfactory information on ADL. Some two-thirds of the patients were assessed to have had large health benefits from the general hospital stay in question. One of six patients could have been treated without a general hospital admission. The specialists assessed that 77 % of the patients had had a large benefit from the general hospital admission; however the general practitioners assessment was only 59 %. One of four of the discharge letters did not define who was responsible for follow-up care. Conclusions Study I Both referral and discharge letters lack vital medical information, and referral letters to such an extent that it might represent a health hazard for the patients. Health professionals at primary and secondary level do not agree as to the definition of good quality as far as referral and discharge letters are concerned. Furthermore they do not agree as to the benefits of admission to a general hospital. <b>Study II</b> Background Demographic changes combined with increasing pressure on general hospital beds and other health services by the elderly make allocation of resources to the most efficient care level a vital issue. The aim of study II was to study the efficacy of intermediate care at a community hospital compared to standard prolonged care at a general hospital over a period, with six and 12 months follow-up. Methods In a randomised controlled trial, study II, of 142 patients, aged 60 or more admitted to a general hospital due to acute illness or exacerbation of a chronic disease, 72 (intervention group) were randomised to intermediate care at a community hospital and 70 (general hospital group) to prolonged general hospital care. The results are based on intention-to-treat analyses and are adjusted for age, gender, ADL and diagnosis. Results Readmissions to general hospital In the intervention group 14 patients (19.4 %) were readmitted compared to 25 patients (35.7 %) in the general hospital group (p=0.03). Results after six months After 26 weeks 18 (25.0 %) patients in the intervention group were independent of community care compared to seven (10.0 %) in the general hospital group (p=0.02). There was an insignificant reduction in the number of deaths and an insignificant increase in the number of days of inpatient care in the intervention group. The number of patients admitted to long-term nursing homes from the intervention group was insignificantly higher than from the general hospital group. Mean total health services costs per patient in the intervention group for the first six months were EUR 9829 (95 % CI 7396-12262) compared to EUR 14071 (95 % CI 10717-17424) in the general hospital group. The mean difference in costs was EUR 4242 (95 % CI 152-8331) 9 (p=0.003), and mean difference in cost per day at risk per patient was EUR 37 (95 % CI 1-71) (p=0.003). Results after 12 months Thirty-five patients, 13 (18.1 %) of all patients included in the intervention group and 22 (31.4 %) in the general hospital group, died within 12 months (p= 0.03). Patients in the intervention group were observed during a longer period of time than in the general hospital group; 335.7 (95 % CI 312.0-359.4) versus 292.8 (95 % CI 264.1-321.5) days (p=0.01). There were statistically no differences in the need for long-term primary level care or in the number of admissions or days spent in general hospital beds. Average total health services costs per patient per observed day were EUR 76 (95 % CI 56- 95) for the intervention group and EUR 100 (95 % CI 80-120) for the general hospital group (p=0.03). Trial registration ClinicalTrials.gov NCT00235404 <b>Conclusions Study II</b> Intermediate care in a community hospital significantly decreased the number of readmissions for the same disease to general hospital and a significantly higher number of patients were independent of community care after 26 weeks of follow-up. There was no increase in mortality and number of days in institutions. Care at intermediate level in a community hospital was cost effective from a health service perspective and contributes to better patient outcome as more patients had better functional status and significantly fewer patients were dead after 12 months follow-up.

Proefschrift Maastricht. / Hiervan verscheen ook een handelsuitgave. Samenvatting in het Nederlands. Met lit. opg. - Met een samenvatting in het Nederlands.

Proefschrift Universiteit Maastricht. / Auteursnaam op omslag: Paul A. Stalenhoef. Met lit. opg. - Met samenvatting in het Nederlands.

Darbo tikslas - įvertinti pacientų, besilankančių pirminės sveikatos priežiūros įstaigose, elektroninių sveikatos paslaugų ir sveikatos informacijos poreikius. Metodika. Tyrimo metu buvo apklausti 307 pacientai, tyrimo vykdymo laikotarpiu lankęsi Kauno miesto pirminėse sveikatos priežiūros įstaigose. Tyrimo apklausai buvo sukurta originali anketa. Duomenų analizė buvo atlikta naudojant statistinį programinį paketą SPSS (15.0 versija). Hipotezėms tikrinti skaičiuotas chi kvadrato (χ2), z kriterijai. Tikrinant statistines hipotezes, naudoti šie statistinių išvadų reikšmingumo lygiai: p<0,001 (itin reikšminga), p<0,01 (labai reikšminga), p<0,05 (reikšminga). Logistinės regresijos metodas buvo taikomas siekiant išsiaiškinti vieno kintamojo priklausomybę nuo kitų kintamųjų. Rezultatai. 65,1 proc. iš visų apklaustųjų naudojasi internetu. Tačiau tik 28,0 proc. respondentų, besinaudojančių internetu, jau yra pasinaudoję galimybe gauti elektronines sveikatos paslaugas internetu. 91,0 proc. iš jų registravosi pas gydytoją internetu. Labiausiai pacientai norėtų registruotis pas gydytoją internetu (59,6 proc.), gauti siuntimą ar konsultaciją internetu (56,0 proc.), išsirašyti receptą nuotoliniu būdu (55,3 proc.), turėti elektroninį sveikatos įrašą (53,4 proc.). Elektronines sveikatos paslaugas internetu statistiškai reikšmingai dažniau norėtų gauti interneto vartotojai nei nesinaudojantys internetu tyrimo dalyviai (p<0,001). 84,4 proc. interneto vartotojų yra ieškoję internete sveikatos... [toliau žr. visą tekstą] / Aim of the study – to assess the patients‘from Primary Health Care Institutions needs of electronical health care service and health – related information. Methods. 307 patients, visiting Kaunas Primary Health Care Institutions during the period of reaseach, were interviewed. An original questionaire was created for the reaseach. The statistic analysis was performed using the SPSS (15.0 version) package. The hypothesis were checked by chi squared (χ2), z criteria. The statistic hypothesis was analysed using these levels of statistical importance: p<0.001 (etra- important), p<0.01 (very important), p<0.05 (important). Method of logistical regression was used to ascertain dependance of one variable from the others. Results. 65.1% of all interviewed use the Internet, but only 28.0% respondents, using the Internet, have already used the possibility to get electronical health care service on the Internet. 91.0% made the appointment by the Internet. Mostly patiens would want to make appointments by the Internet (59.6%), to get consultation or assigment to a doctor- specialist (56.0%), to get a prescription by remote way (55.3%), to get electronical health inscription (53.4%). Electronical health care service on line statistically more often would be significant to the users of the Internet (p<0.001). 84.4% of the internet users have already searched for information about health care services. One user has searched for information about aproximatelly 7.54 topics, concerning... [to full text]