| 1. |
- Ekdahl, Anne Wissendorff, et al.
(författare)
-
Is care based on comprehensive geriatric assessment with mobile teams better than usual care? : A study protocol of a randomised controlled trial (The GerMoT study)
- 2018
-
Ingår i: BMJ Open. - : BMJ. - 2044-6055. ; 8:10
-
Tidskriftsartikel (refereegranskat)abstract
- INTRODUCTION: Comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process used to determine the medical, psychological and functional capabilities of frail older people. The primary aim of our current study is to confirm whether CGA-based outpatient care is superior than usual care in terms of health-related outcomes, resource use and costs.METHODS AND ANALYSIS: The Geriatric Mobile Team trial is designed as a single-centre randomised, controlled, assessor-blinded (at baseline) trial. All participants will be identified via local healthcare registries with the following inclusion criteria: age ≥75 years, ≥3 different diagnoses and ≥3 visits to the emergency care unit (with or without admittance to hospital) during the past 18 months. Nursing home residency will be an exclusion criterion. Baseline assessments will be done before the 1:1 randomisation. Participants in the intervention group will, after an initial CGA, have access to care given by a geriatric team in addition to usual care. The control group receives usual care only. The primary outcome is the total number of inpatient days during the follow-up period. Assessments of the outcomes: mortality, quality of life, health care use, physical functional level, frailty, dependence and cognition will be performed 12 and 24 months after inclusion. Both descriptive and analytical statistics will be used, in order to compare groups and for analyses of outcomes over time including changes therein. The primary outcome will be analysed using analysis of variance, including in-transformed values if needed to achieve normal distribution of the residuals.ETHICS AND DISSEMINATION: Ethical approval has been obtained and the results will be disseminated in national and international journals and to health care leaders and stakeholders. Protocol amendments will be published in ClinicalTrials.gov as amendments to the initial registration NCT02923843. In case of success, the study will promote the implementation of CGA in outpatient care settings and thereby contribute to an improved care of older people with multimorbidity through dissemination of the results through scientific articles, information to politicians and to the public.TRIAL REGISTRATION NUMBER: NCT02923843; Pre-results.
|
|
| 2. |
- Ekdahl, Anne Wissendorff, et al.
(författare)
-
Primary and Community Care
- 2018
-
Ingår i: Learning geriatric medicine : A study guide for medical students - A study guide for medical students. - Cham : Springer International Publishing. - 2509-6079 .- 2509-6060. - 9783319619972 - 9783319619965 ; , s. 305-311
-
Bokkapitel (refereegranskat)abstract
- Care of older persons in community and primary care differs substantially between European countries, but most countries pursue the concept of “ageing in place”, meaning that most older people do not live in institutions. More and more older people are living alone. Relatives still play an important role in the care of older people, but it differs substantially within Europe, and will probably remain the case even in the future. Care of older people with complex needs requires corresponding complex teams to be able to provide adequate and good quality of care, which means that there must be geriatric skills to diagnose, treat, and comprehensively follow up people with common geriatric diseases, including dementia, within primary and community care. Specially designed structures within primary and community care should work proactively to take care of older people as many do not and cannot seek care appropriately. One of the reasons for this is cognitive decline.
|
|
| 3. |
- Wissendorff Ekdahl, Anne, et al.
(författare)
-
‘Are decisions about dischargeof elderly hospital patients mainlyabout freeing blocked beds?’ : A qualitative observational study
- 2012
-
Ingår i: The BMJ. - : BMJ. - 1756-1833. ; 2:6, s. 1-9
-
Tidskriftsartikel (refereegranskat)abstract
- Objective: To explore the interactions concerning thefrail and elderly patients having to do with dischargefrom acute hospital wards and their participation inmedical decision-making. The views of the patients andthe medical staff were both investigated.Design: A qualitative observational and interviewstudy using the grounded theory.Setting and participants: The setting was threehospitals in rural and urban areas of two counties inSweden of which one was a teaching hospital. The datacomprised observations, healthcare staff interviews andpatient interviews. The selected patients were all aboutto be informed that they were going to be discharged.Results: The patients were seldom invited toparticipate in the decision-making regarding discharge.Generally, most communications regarding dischargewere between the doctor and the nurse, after which thepatient was simply informed about the decision. It wasobserved that the discharge information was oftengiven in an indirect way as if other, albeit absent,people were responsible for the decision. Interviewswith the healthcare staff revealed their preoccupationwith the need to free up beds: ‘thinking aboutdischarge planning all the time’ was the core category.This focus not only failed to fulfil the complex needs ofelderly patients, it also generated feelings of frustrationand guilt in the staff, and made the patients feelunwelcome.Conclusions: Frail elderly patients often did notparticipate in the medical decision-making regardingtheir discharge from hospital. The staff was highlyfocused on patients getting rapidly discharged, whichmade it difficult to fulfil the complex needs of thesepatients.
|
|
| 4. |
- Wissendorff Ekdahl, Anne
(författare)
-
Frail and Elderly Hospital Patients : The Challenge of Participation in Medical Decision Making
- 2012
-
Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: In research, patient participation in medical decision-making has been shown to be associated with higher patient satisfaction and improvement of treatment outcomes. But when it comes to patient participation when being old and frail there are pitfalls and the research in this area is sparse.The aim of this thesis is to explore participation in medical decision making of the frail elderly patient in hospital from the perspectives of patients themselves and the health care staff. In this thesis frail, elderly patients is defined as individuals 75 years old or older, who during the past 12 months have received inpatient hospital care three or more times and who have three or more diagnoses in three or more diagnostic groups according to the classification system ICD-10.The participants were frail patients’ in hospital or newly discharged and it was health care personnel working with frail elderly patients. In three of the studies the method was mainly qualitative (Paper I, III, IV) and in one (Paper II) quantitative. The qualitative methods were one-to-one tape-recorded interviews of 25 patients (Paper I and IV), 18 personnel (III and IV), 5 focus group interviews of physicians (Paper III) and 26 days of observations in hospital wards (IV). Chosen methodologies of analysis were content analysis and Grounded Theory. The quantitative study (II) was a cross-sectional survey using telephone interviews with patients (n= 156). This material was descriptively analysed and examined using weighted kappa statistics.Results: The results reported in Paper II show that elderly patients generally want to participate more in medical decision making than they do, though preferences for degree of participation are highly individualized – both findings important to consider in clinical practice.According to the patients important key concepts of patient participation in medical decision making are to be listened to and to be informed (Paper I). The main reasons for not being able to participate included having many illnesses and generally, overall bad medical condition (Paper II). Also, cited as a problem was difficulty in understanding medical information, for example when given by a foreign-speaking physician (Paper I, II and IV). Frail, elderly patients complained that they were less informed than was their preference (Paper I, II and IV).Moderate agreement was obtained between patient’s preferred and actual roles in medical decision making. Patients often expressed gratitude and confidence in their health care (Paper I and IV), but also, sympathy for stressed health care personnel who had so much to do.The frail elderly patients do sometimes feel like a burden to the health care (Paper I and IV). The professionals gave expressions of trying to avoid taking care of frail elderly patients and at the same time expressions of frustration and bad conscience not being able to take good care of them due to lack of time and lack of beds (Paper III, IV). Especially the physicians felt they were trapped between the needs of the patients’ and the remunerations system rewarding time-constricted health care production (number of investigations, operations, easy accessibility) – not a time-consuming holistic view on all illnesses and medications including communication with the patients and all caregivers involved (Paper III).Both patients and the professionals perceive the hospital as some kind of “institution of power”, difficult to challenge, and the decisions of which one has to accept.Conclusion: In this thesis there are shown a number of challenges to participation in medical decision making by frail, elderly patients, which thus limits quality of care for this patient group. Health care is revealed as not well adapted to meet these patients’ complex needs. A model is presented that explains how the organisation of health care, and the reimbursement system, does not facilitate a holistic view. The health care professionals appear to adapt to the organisation and the remuneration system, which leads to practices, such as, rapid discharges and a tendency to examine the patient for only one or a few problems. Finally a suggestion for a model to improve care of frail elderly patients is presented. This model includes the need of more hospital wards being able to work with a holistic view, better skills in gerontology and geriatrics and a more adapted remuneration system for the frail, elderly patients.
|
|
| 5. |
- Wissendorff Ekdahl, Anne, et al.
(författare)
-
Too complex and time-consuming to fit in! Physicians' experiences of elderly patients and their participation in medical decision making : a grounded theory study
- 2012
-
Ingår i: BMJ Open. - : B M J Group. - 2044-6055. ; 2:3
-
Tidskriftsartikel (refereegranskat)abstract
- Objective To explore physicians' thoughts and considerations of participation in medical decision making by hospitalised elderly patients.Design A qualitative study using focus group interviews with physicians interpreted with grounded theory and completed with a questionnaire.Setting and participants The setting was three different hospitals in two counties in Sweden. Five focus groups were conducted with physicians (n=30) in medical departments, with experience of care of elderly patients.Results Physicians expressed frustration at not being able to give good care to elderly patients with multimorbidity, including letting them participate in medical decision making. Two main categories were found: ‘being challenged’ by this patient group and ‘being a small part of the healthcare production machine’. Both categories were explained by the core category ‘lacking in time’. The reasons for the feeling of ‘being challenged’ were explained by the subcategories ‘having a feeling of incompetence’, ‘having to take relatives into consideration’ and ‘having to take cognitive decline into account’. The reasons for the feeling of ‘being a small part of the healthcare production machine’ were explained by the subcategories ‘at the mercy of routines' and ‘inadequate remuneration system’, both of which do not favour elderly patients with multimorbidity.Conclusions Physicians find that elderly patients with multimorbidity lead to frustration by giving them a feeling of professional inadequacy, as they are unable to prioritise this common and rapidly growing patient group and enable them to participate in medical decision making. The reason for this feeling is explained by lack of time, competence, holistic view, appropriate routines and proper remuneration systems for treating these patients.
|
|
