Abstract The aim of this thesis was to measure patient reported outcomes, such as health related quality of life and general diabetes knowledge of elderly diabetes mellitus type 2 (DMT2) patients in Slovenia. Patient reported outcomes demonstrate patient perspectives when evaluating the delivery of care. In Slovenia, a new, multidisciplinary model of chronic care was introduced in 2011, which yet needs to demonstrate the efficiency, care improvement and cost reduction. Thus, another aim of the study was to research if multidisciplinary teams in diabetes care are economically viable. To achieve the above, the study was divided into 4 subprojects. Firstly, the general level of diabetes knowledge of elderly DMT2 patients (n=179) was measured. Secondly, the reliability and validity of generic, European Quality of Life- 5 Dimensions (EQ-5D), and disease specific, Audit on Diabetes Dependent Quality of Life (ADDQoL ) instruments were examined. Thirdly, health related quality of life of elderly diabetic patients (n=285) was assessed. Fourthly, the systematic literature review on the cost-effectiveness of multidisciplinary teams was conducted. The data were collected during the period 2011–2012. The main contributions of the current thesis can be summarised as follows: This was the first study to measure general diabetes knowledge of elderly DMT2 patients in Slovenia. The results showed that the place of living does not have an impact neither on diabetes knowledge nor the health related quality of life of these patients. Secondly, a pioneering example of measuring health related quality of life (HRQoL) in elderly diabetic patients in Slovenia, using a validated and reliable instrument (ADDQoL) was provided. A study to evaluate the relationships between diabetic and other co-existing chronic medical conditions on health related quality of life was performed. As part of that study, the reliability and validity of the instruments (EQ-5D and ADDQoL) were measured, and the analysis showed that both instruments are reliable. Thirdly, a systematic way of finding evidence for understanding the cost-effectiveness of multidisciplinary teams was applied. The results of the literature review show weak improvements in the economic outcomes. In general, the thesis contributes to the improved understanding of patient reported outcomes in elderly diabetic patients, which can be a measure in assessing diabetes care program in Slovenia, and offers a basis for a national evaluation of the Model Practices. Furthermore, patient reported outcomes of elderly diabetic patients is important to Slovenian decision makers to identify and implement appropriate interventions for achieving better management of diabetes and ultimately improving the quality of life of diabetes patients. / Tiivistelmä Tutkimuksen tarkoitus oli mitata iäkkäiden tyypin 2 diabetespotilaiden itse ilmoittamia tuloksia, kuten terveyteen liittyvä elämänlaatu ja yleinen diabetekseen liittyvä tietämys Sloveniassa. Tulokset valottavat potilaiden näkökulmaa hoidon arvioinnissa. Sloveniassa otettiin 2011 käyttöön monitieteellinen hoitomalli, jonka tehoa sekä kykyä parantaa hoitoa ja vähentää hoitokustannuksia ei ole osoitettu. Toisena tavoitteena oli selvittää, onko moniammatillisten tiimien käyttö diabeteshoidossa taloudellisesti järkevää. Tutkimus jaettiin neljään osaprojektiin. Ensin mitattiin iäkkäiden tyypin 2 diabetespotilaiden (n=179) yleistä diabetestietämystä. Toiseksi selvitettiin geneerisen European Quality of Life- 5 Dimensions- (EQ-5D) ja diabeteskohtaisen ADDQoL -mittarin luotettavuus ja validiteetti. Kolmanneksi arvioitiin iäkkäiden diabetespotilaiden (n=285) terveyteen liittyvää elämänlaatua. Neljänneksi tehtiin moniammatillisten tiimien kustannus¬tehokkuutta koskeva systemaattinen kirjallisuuskatsaus. Tiedot kerättiin vuosina 2011–2012. Tulokset voidaan tiivistää seuraavasti: Kyseessä oli ensimmäinen tutkimus, jossa mitattiin iäkkäiden tyypin 2 diabetespotilaiden yleistä diabetestietämystä Sloveniassa. Tulosten mukaan asuinpaikka ei vaikuta potilaiden diabetestietämykseen tai terveyteen liittyvään elämänlaatuun. Toiseksi, Sloveniassa toteutettiin pioneerihanke, jossa mitattiin iäkkäiden potilaiden terveyteen liittyvää elämänlaatua (HRQoL) validoidun ja luotettavan instrumentin (ADDQoL) avulla. Tutkimuksessa selvitettiin diabeteksen ja muiden pitkäaikaissairauksien yhteisvaikutusta terveyteen liittyvään elämänlaatuun. Osana tutkimusta selvitettiin instrumenttien (EQ-5D ja ADDQoL) luotettavuus ja validiteetti. Molemmat osoittautuivat luotettaviksi. Kolmanneksi, tutkimuksessa etsittiin systemaattisesti näyttöä moniammatillisten tiimien kustannustehokkuuden arvioimiseksi. Kirjallisuuskatsauksen mukaan taloudellinen tulos paranee vain vähän. Tutkimus lisää tietoa potilaiden ilmoittamista tuloksista iäkkäiden diabetespotilaiden kohdalla, mitä voidaan käyttää diabeteshoito-ohjelman arvioinnissa Sloveniassa sekä mallikäytäntöjen kansallisen arvioinnin perustana. Diabetespotilaiden itse ilmoittava terveystieto on Slovenian päätöksentekijöille tärkeää sopivien interventioiden löytämisessä ja toteuttamisessa, kun halutaan parantaa diabeteshoitoa ja potilaiden elämänlaatua.

Background: In the last two decades Bogota, Colombia has seen a massive influx of internally displaced people (IDP) settling in its periphery where residents face the worst living, social, and economic conditions despite the 2011 passing of The Victims Law entitling IDP victims access to free shelter, food, education, and healthcare. Objective: To understand the circumstances and health care needs of Colombian IDPs, determine trends of health perceptions among IDPs and assess and quality of health services among IDPs in Bogota. Methods: Semi-structured, in-depth interviews were conducted with 12 professionals who work with IDPs and 36 IDPs. Interviews explored opinions of common health conditions and barriers to access health services in IDP communities. The EQ-5D survey about perceptions of health was administered measuring mobility, self-care, daily activities, pain, and depression/anxiety. All interviews were recorded, transcribed, coded for analysis. Results: Most IDPs did not indicate suffering with mobility, self-care, and ability to conduct daily activities. Seventy-five percent of participants indicated moderate to severe pain and 86.85% expressed feeling some form of depression or anxiety. Environmental factors are common contributors to poor health conditions. Individual and societal factors surfaced as detriments to accessing health services. The process to be included in The Victims Law registry is arduous. Although the Victims Law allows IDPs to access health services, many missing links in the system thwart quality health care delivery and discourage IDPs to utilize the health care system. Conclusion: Despite efforts to mitigate the struggles IPDs suffer there remain much needed health services and organizational improvements for the IDP community in Bogota.

A common cause of profound deafness is hair cell dysfunction in the cochlea. Cochlear implants (CI) bypass the hair cells via an electrode and stimulate the cochlear nerve directly. Nowadays, it is possible to preserve residual hair cell function and hearing through flexible electrodes and a-traumatic CI surgery techniques; called hearing preservation CI surgery. This may suit partially deaf patients who can use natural low frequency hearing in combination with electric high frequency hearing; so-called hybrid hearing. The aim of this thesis was to elucidate the effectiveness of hearing preservation CI surgery. The thesis demonstrates human cochlear anatomy in relation to CI and evaluates hearing and patient satisfaction after hearing preservation CI surgery. Analyses of human cochlear moulds belonging to the Uppsala collection showed large variations in dimensions and coiling characteristics of the cochlea. Each cochlea was individually shaped. The size and shape of the cochlea influences the position of the electrode. The diameter of the basal cochlear turn could predict insertion depth of the electrode, which is crucial for hearing preservation. The first 21 patients operated with hearing preservation CI surgery in Uppsala, showed preserved hearing. Nine-teen partially deaf patients receiving implants intended for hybrid hearing, were evaluated concerning pure tone audiometry, monosyllables (MS) and hearing in noise test (HINT). They also responded to a questionnaire, consisting of the IOI-HA, EQ-5D VAS and nine questions about residual hearing. The questionnaire results indicated a high degree of patient satisfaction with improved speech perception in silence and noise. This was also reflected by improved results in MS and HINT. Hearing was preserved in all patients, but there was an on-going deterioration of the residual hearing in the operated ear which surpassed the contralateral ear. There were no correlations between the amount of residual hearing and patient satisfaction or speech perception results. Electric stimulation provides a major contribution to speech comprehension in partially deaf patients. All the patients showed a high degree of satisfaction with their CI, regardless of varying hearing preservation.

Background: Open and closed fractures can be associated with posttraumatic or postoperative soft tissue defects caused by initial trauma, operative procedures, or infections. This study evaluated the postoperative outcomes in patients with open or closed lower leg fractures, related soft tissue defects, and subsequent flap coverage. Methods: We performed a retrospective single-center cohort study in a level 1 trauma center. We analyzed the patients treated from January 2012 through December 2017 and recorded demographics, treatment, and outcome data. The outcome data were measured via patient-reported Foot and Ankle Outcomes Scores (FAOS) and EQ-5D-5L scores. Results: We included 22 patients with complicated fractures (11 open and 11 closed) and subsequent soft tissue defects and flap coverages. The mean follow-up time was 41.2 months. Twenty-one patients developed infections, and necrosis at the site of surgery manifested in all closed fractures. Therefore, all patients needed soft tissue reconstructions. Preoperatively, 16 patients underwent arterial examinations via angiography and six underwent ultrasound examinations of the venous system. Ten patients had complications involving the flaps due to ischemia and consequent necrosis. The mean EQ-5D index was 0.62 ± 0.27, and EQ-5D VAS score was 57.7 ± 20.2. The mean FAOS was 60.7 ± 22.2; in particular, quality of life was 32.3 ± 28.8. The rate of returning to work in our patient group was 37.5% after 1 year. Conclusions: Distal tibial fractures often require revisions and soft tissue reconstruction. The evaluated patient population had poor outcomes in terms of function, quality of life, and return to work. Furthermore, patients suffering from flap ischemia have worse outcomes than those without flap ischemia.

Background: Data regarding both drug-related and non-drug-related costs in patients with Parkinson's disease (PD) are scarce, mainly due to the difficulties in data acquisition in experimental designs. Likewise, the reported impact of drug costs on total direct costs varies across different studies. In addition, the influence of comorbidities on both treatment costs and health-related quality of life has not been adequately evaluated. Methods: A sample of office-based neurologists (n = 315) in Germany was asked to examine up to five consecutive patients with PD (n = 1449) on a specified day during the study period. Patients of all ages were eligible and their evaluation was performed using standardized questionnaires. Results: PD-specific therapy costs increased with the stage of the disease, early onset of the disease and disease duration. The major costs were due to PD-related therapy, whereas other medications only resulted in minor costs. Disease stage mainly influenced direct therapy costs, with an observed increase of total daily costs from €7.3 to €11.3/day. In addition, disease onset at age < 65 years resulted in total daily costs of €11.2 compared to late onset of disease (> 75 years) with daily therapy costs of €5.3. In this patient group neuropsychiatric comorbidities such as dementia and depression were only insufficiently treated. In addition, these comorbidities severely affected health-related quality of life. Conclusion: Therapy costs were influenced by disease stage, disease onset as well as present comorbidities. Furthermore, comorbidities such as depression and dementia were diagnosed but were not adequately treated.

The overall aim of the thesis was to add some pieces to the etiological puzzle of LCPD with special focus on vascular origin and hyperactivity. Furthermore we wanted to evaluate some consequences of LCPD in adulthood. Swedish registry data were used to identify a cohort of patients with the diagnosis of LCPD. This cohort was compared with a general population– based cohort without LCPD to assess the relative risk of cardiovascular diseases, blood or coagulation defects, injury, ADHD, depression and mortality. In a clinical study we assessed health-related quality of life (EQ-5D-3L), physical activity level (IPAQ) and screened for ADHD (ASRSv1.1) in 116 patients with a history of LCPD who were diagnosed or treated in Uppsala University Hospital between 1978 and 1995. The results confirmed our hypothesis: Patients with a history of LCPD had a 1.7-fold higher risk of cardiovascular diseases, and a 1.4-fold higher risk for blood or coagulation defects compared with gender- and age-matched individuals without LCPD. We found a 1.2-fold higher risk for injuries requiring hospital admission than in gender- and age-matched individuals without LCPD. The risk was more pronounced among females. Furthermore, we found a 1.5-fold higher risk for ADHD. Stratified analysis revealed a 2.1-fold higher risk for ADHD among females with LCPD than among females without LCPD. The risk for depression was 1.3-fold higher, and more pronounced among females with LCPD. Patients with LCPD had a slightly higher mortality risk with higher risk for death from suicide and cardiovascular causes. Patients with a history of LCPD reported a lower health-related quality of life and were more physically active than the Swedish population norm. 28% of 116 patients were likely to have ADHD or had already been diagnosed with ADHD. Both vascular and blood diseases could be present even in childhood and could, in combination with hyperactive behavior pattern and a high physical activity level, contribute to the etiology of LCPD. The lower health-related quality of life and higher risk for depression might reflect the mental burden of LCPD. Patients with LCPD have a higher mortality risk with higher risk for death from suicide and cardiovascular causes.

Theoretical foundation Arterial disease which gradually leads to narrowing of artery, up to complete vascular closure and to subsequent manifestation of ischaemia is called ischaemic disease of the lower extremities (IDLE). We need to understand ischaemic disease of the lower extremities not only as a disease causing patients a range of difficulties and significantly impacting their life quality, but also as a very important indicator of overall cardiovascular condition of whole organism. Ischaemic disease of the lower extremities becomes more and more accepted as a chronic disease associated with a substantial cardiovascular risk. This disease causes primarily walking limitation by which it impacts daily activities and significantly decrease the life quality. Goal of the thesis: A goal was set for the thesis: Finding out in which areas the ischaemic disease of the lower extremities impacts the life quality. Hypotheses: 6 hypotheses were set for the thesis: H1: Patients with IDLE feel pain H2: Patients with IDLE are limited in moving H3: Patients with IDLE are limited socially H4: Patients with IDLE feel concern for their future H5: Patients with IDLE perceive their life quality as a low one. H6: Patients with IDLE are limited in the area of basic daily activities. Methodology: The research part of the thesis was implemented based on quantitative inquiry within the grant Project No. 120/2012/S ?Reflection of life quality in nursing?. For the empirical part of the thesis the quantitative method was used, the survey was carried out in form of questionnaires, more precisely a standardized questionnaire EQ-5D-5L, selected questions from a questionnaire WHOQOL 100 and specific non-standardized complementary questions for patients with ischaemic disease of the lower extremities. The survey was carried out by addressing practising physicians , doctors from specialized outpatient departments and inpatient wards. Nurses who were, along with the doctors, responsible for explaining the significance of the survey to the patients were an integral part to the data gathering process. The respondents were selected intentionally, the basic factor of selection was presence of the ischaemic disease of the lower extremities. The selection sample was designed using selective quota, the only quota being the age of respondent. Results: All results obtained were statistically processed in the SASD (Statistical Analysis of Social Data) software. The results were divided into three areas. Firstly results describing the structure of selection sample, secondly results depicted graphically and thirdly results processed using a descriptive statistics. The last two areas were then arranged according to the used questionnaire. The results provided us with information regarding patients' perceiving of pain, the difficulties in moving, the social area, the basic daily activities, the concerns for the future and subjective perceiving ot the life quality. Based on the results, the set hypotheses were evaluated as follows: H1: Patients with IDLE feel pain ? confirmed, H2: Patients with IDLE are limited in moving - confirmed, H3: Patients with IDLE are limited socially - confirmed, H4: Patients with IDLE feel concern for their future - confirmed, H5: Patients with IDLE perceive their life quality as a low one ? not confirmed, H6: Patients with IDLE are limited in the area of basic daily activities - confirmed. Conclusion: The thesis provides a comprehensive view on the areas impacting the life quality of patients with ischaemic disease of the lower extremities. In practice the results can facilitate the choice of effective intervention and improve communication with patients, especially due to the gained knowledge. The results will be published in journals and presented at conferences. The results could also be used as a foundation for another survey and as a studying material for students of nursing.

Background: Data regarding both drug-related and non-drug-related costs in patients with Parkinson's disease (PD) are scarce, mainly due to the difficulties in data acquisition in experimental designs. Likewise, the reported impact of drug costs on total direct costs varies across different studies. In addition, the influence of comorbidities on both treatment costs and health-related quality of life has not been adequately evaluated. Methods: A sample of office-based neurologists (n = 315) in Germany was asked to examine up to five consecutive patients with PD (n = 1449) on a specified day during the study period. Patients of all ages were eligible and their evaluation was performed using standardized questionnaires. Results: PD-specific therapy costs increased with the stage of the disease, early onset of the disease and disease duration. The major costs were due to PD-related therapy, whereas other medications only resulted in minor costs. Disease stage mainly influenced direct therapy costs, with an observed increase of total daily costs from €7.3 to €11.3/day. In addition, disease onset at age < 65 years resulted in total daily costs of €11.2 compared to late onset of disease (> 75 years) with daily therapy costs of €5.3. In this patient group neuropsychiatric comorbidities such as dementia and depression were only insufficiently treated. In addition, these comorbidities severely affected health-related quality of life. Conclusion: Therapy costs were influenced by disease stage, disease onset as well as present comorbidities. Furthermore, comorbidities such as depression and dementia were diagnosed but were not adequately treated.

During recent decades, lumbar spinal stenosis (LSS) has become the most common indication for spine surgery, a change that coincides with a higher worldwide prevalence of overweight and obesity. Thus, surgical treatment of LSS in the overweight and obese population is common and increasing in scope. The overall aim of this thesis was to investigate whether body mass index (BMI) is related to the development of LSS, and whether BMI is linked to outcome after surgery for LSS. We further evaluated whether there are specific experiences of LSS from a patient perspective. Data were obtained for all patients registered in the Swedish Spine Register who had undergone surgery for LSS between January 1, 2006 and June 30, 2008. After adjusting for differences in baseline characteristics, patients with obesity showed both poorer results after surgery and a higher rate of dissatisfaction than patients with normal weight (odds ratio 1.73; 95% confidence interval, CI, 1.36-2.19). Furthermore, patients with obesity in the cohort reported modest weight loss at follow-up (2.0 kg; 95% CI, 1.5-2.4), and only 8% reported a clinical important weight loss 2 years after surgery. Our analysis of 389,132 construction workers, showed that overweight (incidence rate ratio, IRR 1.68; 95% CI, 1.54-1.83) and obesity (IRR 2.18; 95% CI, 1.87-2.53) were associated with an increased future risk in developing LSS when compared with patients with normal weight. To gain insight into the patients' perspective of LSS, we performed interviews with 18 patients who were on a waiting list for LSS surgery. The transcripts, analyzed with content analysis, revealed that living with LSS is a physical, mental and social challenge in which resources to cope with the condition are of major importance. In summary, obesity is associated with poorer results after surgery, and patients with obesity report modest weight loss during follow-up. In addition, obesity is associated with an increased risk to develop LSS. Our findings revealed that being a patient with LSS, naturally involves considerable suffering and pain, but it also implies being a person with his or her own resources who is able to cope with these adverse conditions.

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