BASES TEÓRICAS ESPECIALIZADAS SOBRE EL TEMA

6.3.1 Measuring health outcomes

Patients, the public, health care providers and politicians are all interested in evaluating care interventions, health care programmes and the benefits of health care (154-156). Evaluations are often difficult as the magnitude of changes and/or reasons for changes in health outcomes can be challenging to interpret. Most interventions yield small changes in the health of a population despite sometimes rather dramatic changes in health for some patients. If research has a narrow analysis e.g. on adverse events such as deaths and diseases, it may also be difficult to make an assumption that the benefits apparent from one perspective will extend to other perspectives (155).

Older people often suffer from conditions where diagnosis and care reduce the impact of a particular disease without necessarily extending life expectancy or quality of life. In some

circumstances, successful diagnoses and treatment may actually reduce life expectancy or overall life quality (157).

6.3.2 Measures of physiological functionality - ADL

In study II ADL status was tested using Gerix in accordance with the study protocol. There are four main reasons for using Gerix to measure ADL in study II:

o All health professionals (except physicians) in the municipality are quite

familiar with Gerix, as it has been used as a registration tool since 1993.

o There are only two specially trained nurses in each municipality care unit

certified to register and/or change the scores.

o When a patient’s situation changes; socially or because of disease, the scores

are continuously re-evaluated.

o Everybody receiving any kind of community health services has their Gerix

scores recorded in the EHRs.

To evaluate the nurses’ ability to measure ADL correctly a last year medical student was trained to use Gerix. He then tested 72 of the patients included in study II during a three month period in autumn 2004 (158). He assessed better ADL scores in most of the fields and found a significant difference between his assessments and those of the nurses for the

indicators ”dressing”, ”cooking”, ”shopping”, ”motivation”, self sufficiency (cognitive)”, ”outdoor mobility”, ”insight of own situation”, ”indoor mobility” and ”feeling safe”. The differences were particularly large for the first five indicators. However, there were no differences between the assessment of the patients in the community hospital and the general hospital groups.

Instead of using Gerix, there are other commonly used tests that could have been used in study II:

Resident Assessment Instrument (RAI) was developed in the USA and is in use in 30 countries. In USA, Iceland and Japan RAI is the most common functionality measurement instrument in use (135,159).

RAI is a system of several measurement instruments for e.g. home (community) care, sheltered housing, residential and nursing homes, palliative care, mental health and persons with disabilities. It gives scores for medical data, physical, emotional, cognitive and social

internationally validated both for individual use and for planning of health services for groups of patients (2).

RAI is probably a rather more precise instrument and suitable both for individual and group planning. One major problem with RAI is that it is not widely used in Norway and is

generally unknown to health professionals in Trondheim (160).

Barthel Index (BI) measures patient performances in ten activities of daily living (161). BI has an ordinal scale with a maximum score of 100, and has good validity and reliability. However, BI is the insensitivity to small changes in functional status (161).

When study II was planned, using the Barthel Index was considered as BI has been used earlier in studies performed in Trondheim (10,16,99). BI is probably most suitable for individual purposes and is not very (well) known in the community health care service. In addition, the use of BI requires especially trained health personnel familiar with BI to perform the tests.

6.3.3 Measures of mental status

Mental status was not recorded in study II as severe dementia and severe psychological disturbances were reasons for exclusion. Some of the patients admitted to the intermediate care department had a degree of dementia. The physicians at Søbstad tested their mental status and the results were recorded in their EHRs. However, the mental status of patients treated at the general hospital was probably not tested, as there were no scores recorded in the patient journals at the general hospital for any of the patients randomised to care at the general hospital.

6.3.4 Disease-specific outcomes

Study II was designed to use available data from health records and patient administrative systems at the general hospital and in the municipality as described on pages 31-32. Length of inpatient stay, readmissions to general hospital, mortality, ADL, usage of home care services and admissions to long-term nursing homes have been used in several studies assessing the appropriateness of admissions to general hospitals (43-45,79-81,83-86,95-96,162-163) and multicomponent interventions for older people (10,162-163).

Some studies have also used self-reported general health status, for example SF-36 is a validated and widely used questionnaire (164). However, when planning study II it was decided not to collect self-reported health data.