ENTRAR            

CONSENSUS

Research on the Implementation of Nursing Services for Chronic & Dependent patients*

José Miguel Morales Asencio (Speaker)
Head of the Effectiveness and Research Division, Malaga Primary Care Healthcare District, Spain. Associate Lecturer, Andalusian Public Health School, Spain

Manuscript received by 23.12.2007
Manuscript accepted by 27.8.2008

Index de Enfermería [Index Enferm] 2009; 18(4): 249-252
*Contents of the Round Table developed in the International Simposium on Comunitary Nursing Research, moderated by Prof. Rosamund Bryar. PhD. City University. London, UK. Granada, Spain, Andalusian School of Public Health, October 4^th and 5^th, 2007

How to cite this document

What we know and "appear" to ignore

    According to the WHO, chronic diseases, such as heart failure, stroke, COPD or diabetes, are the major conditions responsible for almost 60% of all deaths. These diseases are like a "silent epidemic", which has not yet managed to raise the necessary awareness among politicians, managers and many professionals. In addition, they are burdened by a series of mistaken beliefs which further perpetuate this lack of awareness, such as the idea that these are conditions typical of developed countries, or that they only affect older people. Just note that 80% of chronic processes occur in developing countries,¹ with cardiovascular disease ranking as the leading cause of death.² In 2020, mortality rates for ischaemic disease in these countries will have increased by 120% in men and 137% in women.³ Furthermore, projections indicate that the 171 million diabetic patients estimated in 2000 will rocket to 366 million in 2030, of which 298 million will live in developing countries.⁴
    Ageing of the population, disease chronicity, heightened disability, lesser informal support networks, increase in available healthcare technology... all these issues will trigger fresh problems or will shed light on new dimensions in traditional issues. Currently, almost 50% of hospital stays involve patients over 65 years of age,⁵ Elders are the primary users of healthcare services⁶ and they display dependency and disability-related features to a greater extent than the remainder of patients. This is the scenario currently governing the demand of healthcare services. The expectations held by the public regarding what healthcare services can and should do for them also needs to be factored in.^7,8

"When faced with new challenges, let's keep the status quo"

    Although these data are well-known, it appears that little progress is being made in terms of re-orienting healthcare services. For instance, only 29% of countries assessed by the WHO allocate funding to address chronic diseases.⁹ In general, this new scenario is tackled by healthcare services using old ways and approaches, despite the fact that we all know that when chronic conditions take centre-stage, models based on healthcare for acute patients are useless.¹⁰ This is exemplified by studies on avoidable hospitalisation; roughly 15% of hospital admissions can be avoided by delivering effective, timely primary care either by applying preventive measures to avoid onset of the disease, by monitoring the onset of an acute episode, or by treating a chronic condition.¹¹
    Conversely, in the US around 15% of chronic patients report that they received differing diagnoses for the same symptoms, depending on the doctor they consulted, as well as contradictory information, procedures and duplication of tests.¹² So the healthcare system "transfers" on to patients the way its services are organised, with fragmented, separate care -as if each intervention for the same user were applied to different patients.¹³
    veryone seems to agree on the need to re-direct assistance towards a more integrated model in order to guarantee more effective continuity of care, combined with diversification of services and tailoring these to each individual.¹⁴

Are care, nursing and the community related with what needs to be done?

    A priori, many of the requirements needed to address the issue appear to be on the nursing side. As Corbin remarked, delivering care to chronic patients requires a flexible, case-by-case approach, adapting healthcare to the various stages in the disease, the individual's needs, his or her interests and loved ones, and the cultural setting where healthcare is to be provided.¹⁵ Nurses are naturally disposed to guaranteeing most of the above premises, given their deep-rooted humanistic approach, in which understanding the life-experience of the disease and experiencing dependency, along with the human responses that arise under these circumstances, steer decision-making regardless of the underlying medical process in question.¹⁶
    A number of models have been proposed in which nurses are of greater or lesser relevance, though often conditioned by the local context or by organisational factors -case and disease management, tele-care, multi-disciplinary teams, outpatient clinics for specific diseases, etc.

What has been researched to date?

    There is a long list of research studies that broach these issues, although they do not necessarily entail a community or primary care approach. It is possible that in settings where the footprint of primary care is scarce, or where the supply of specialised services is hypertrophied (as is the case in the US¹⁷), models are designed "from the hospital outwards", where the starting point is a debut episode or recurrence event. Other options have been designed within the primary care setting, improving decision-making ability, continuity and co-ordination with Specialised Care. These models seek "permanence in the community" and they begin by identifying the population at risk -which was most probably already known to the healthcare team.
    In a very vague way, both approaches share common -and not so common- interventions, so it is fairly difficult to clearly elucidate this extremely critical aspect. The table 1 shows the primary features characterising the various alternatives.
    Although research outcomes are beyond the scope of this presentation, and the issue is the subject of a plethora of systematic reviews and meta-analyses, below is a summary of a number of outcomes intended to briefly illustrate the outcomes of implementing nursing interventions targeting dependent individuals and/or chronic patients [Table 2].

What is required to increase our knowledge and solve more problems?

    There is a series of methodological issues running through this myriad of research projects which need to be resolved if we are to avoid further systematic reviews that conclude with the well-known statement: "broader studies are required, based on more robust designs in order to assess the effectiveness of...".

Conceptual framwork. Many intervention models are based on shaky conceptual foundations and seem to be governed more by local approaches which intend to address the demands of the moment by applying rapid and sustainable solutions. Are we capitalising fully on the potential of the nursing conceptual framework, implemented over the last fifty years? Are we applying trans-disciplinary knowledge appropriately which would trigger optimal synergy with care?

Patients. Perhaps we are still not fully aware of the criteria adopted for selecting the target populations for different interventions. Sometimes studies and trials are grouped according to age criteria or on the basis of profiles in service use; others, on the type of chronic process under scrutiny or according to functionality criteria... We need to improve the quality of studies to gain a better understanding of the scope and characteristics of the population benefiting from care interventions. The example put forward in the study published by Pearson et al. illustrates how chronic population groups quite possibly require different approaches. Initially no outcomes were obtained from the intervention. After conducting a post-hoc analysis which excluded COPD patients, however, the authors observed considerable benefits in terms of re-admissions and long-term mortality -almost eight years.²¹ This result is consistent with the outcomes reported by Coultas et al.²² Perhaps we should be devoting greater efforts to devising more sensitive and specific risk indicators, or screening and classification mechanisms with greater predictive value.
    However, are we perhaps identifying more complex cases now which we missed before? Or were they so "scattered" throughout the healthcare system that they were inconspicuous to all?

Interventions. Interventions always entail multiple components and hence they invariably raise methodological difficulties that cannot always be successfully overcome. Currently we have conceptual approaches available which enable us to undertake complex interventions with a fairly good degree of reliability, but to do so, these must first be implemented.^23,24
    A good example is the complexity of interventions in the field of heart failure.^25,26 The broad range of models available hinders accurate determination of an intervention that can be reproduced simultaneously in a number of contexts.^27,28 Do all case managers adopt the same approach? Do we all understand case-management in the same terms? Here, the context of professional practice plays a key, determining role in Nursing. While English-speaking countries advocate and implement advanced practice models, with great autonomy along with academic and social recognition for nurses, access to PhDs and maximum dedication to research, in other countries governments do not even recognise that nursing is a university graduate course -as is sadly the case in France.

Outcomes. Are we applying the appropriate outcome criteria according to patient indication and the designs implemented? A good example is institutionalisation as a primary endpoint; it does not always unequivocally point to a patient's functional decline or failure, but may also reflect the family's difficulty to cope.²⁹ Are the outcomes used sufficiently sensitive to nursing practice? Do short-term studies allow us to assess outcomes in population groups in which subjects have spent most of their lives suffering the disease?

Designs. Are we only adopting experimental and randomised models? Should we not assess certain areas using qualitative methods, for instance? Strictly speaking, classical randomised, controlled trials can not always be conducted - sometimes for ethical or operational reasons, or as a result of conceptual unfeasibility.^30,31 We should not dismiss other methodological approaches which are making major contributions to our understanding, such as large observational studies using data-bases and information systems.
    We also require long-term cohort studies to gain insight into the sustainability of interventions, durability of effects, and acceptability of models.
    If we opt for experimental designs, we must demand greater rigour in the design and setting of units of analysis. We find that some studies are based on randomised designs by clusters, in which analysis is conducted at subject level, without taking into account design effects or outcomes by clusters.³²
    By way of example to support the above statements, we can compare two interventions, implemented in different settings, where case-management is conducted by community nurses, with similar implementation and interventions, but with disparate outcome criteria and aims: the ENMAD study in Spain³³ and the EVERCARE study in the United Kingdom.³⁴

Will we see it?

    In closing, I would like to ask the audience if we will ever get to read the following paper: "Increased life expectancy and quality of life for chronically-ill patients, through a community-based case management intervention. International, Multi-centre Randomized Controlled Trial, in 11 countries. Journal of Impossible Nursing. 2025; 23(5): 236-42."

Referemces

1. World Health Organization. Preventing chronic diseases: a vital investment. WHO global report. Ginebra, 2005.
2. World Health Organization. The World Health Report 2003-Shaping the Future. Geneva, Switzerland: World Health Organization; 2003.
3. Leeder S, Raymond S, Greenberg H, Liu H, Esson K. A Race Against Time: The Challenge of Cardiovascular Disease in Developing Economies. New York, NY: Columbia University; 2004.
4. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for 2000 and projections for 2030. Diabetes Care. 2004; 27: 1047-1053.
5. INE. Encuesta de morbilidad hospitalaria. Madrid, INE, 1998.
6. Suárez F, Oterino de la Fuente D, Peiró S et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp de Salud Pública, 2001; 75: 237-248.
7. Gornemann I, Zunzunegui MV. Incremento en la utilización de servicios hospitalarios por las personas mayores de 55 años: envejecimiento poblacional y respuesta del sistema de servicios de salud. Gac Sanitaria, 2002; 16(2): 156-159.
8. Castells X, Mercadé Ll, Riu M. Envejecimiento y utilización hospitalaria. Informe SESPAS. Escuela Valenciana de Estudios para la Salud. Valencia, 2002.
9. Alwan A, MacLean D, Mandil A. Assessment of National Capacity for Noncommunicable Disease Prevention and Control. Geneva, Switzerland: World Health Organization; 2001.
10. World Health Organization. Innovative Care for Chronic Conditions. Geneva, Switzerland: World Health Organization; 2002.
11. Alfonso Sánchez JL, Sentís Vilalta J, Blasco Perepérez S, Martínez Martínez I. Hospitalización evitable en España. Med Clin (Barc) 2004; 122(17): 653-8.
12. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action; interventions that encourage people to acquire self-management skills are essential in chronic illness care. Health Aff. 2001; 20(6): 64-78.
13. Guía de diseño y mejora continua de procesos asistenciales: calidad por sistema. Sevilla: Consejería de Salud, 2001.
14. Morilla Herrera JC, Martín Santos FJ, Morales Asencio JM, Gonzalo Jiménez E. Oportunidades para la Atención Integral. Enferm Comunit. 2005, 1(2): 37-42.
15. Corbin JM. The Corbin and Strauss chronic illness trajectory model: an update. Sch Inq Nurs Pract. 1998; 12(1): 33-41.
16. Cumbie S, Conley V, Burman M. Advanced Practice Nursing Model for Comprehensive Care With Chronic Illness: Model for Promoting Process Engagement. Adv Nurs Sci. 2004; 27(1): 70-80.
17. Bindman AB, Majeed A. Primary care in the United Status. BMJ 2003; 326: 631-634.
18. Weingarten SR, Henning JM, Badamgarav E, et al. Interventions used in disease management programmes for patients with chronic illness which ones work? Meta-analysis of published reports. BMJ. 2002; 325: 925.
19. Piette JD, Weinberger M, McPhee SJ, Mah CA, Kraemer FB, Crapo LM. Do automated calls with nurse follow-up improve self-care and glycemic control among vulnerable patients with diabetes? Am J Med 2000; 108: 20-27.
20. Morales Asencio JM, Morilla Herrera JC, Martín Santos FJ, Terol Fernández FJ, Gonzalo Jiménez E. Telecuidados: posibilidades de una alternativa asistencial en Enfermería Comunitaria. Index Enferm. 2003; AÑO XII(42): 44-48.
21. Pearson S, Inglis SC, McLennan SN et al. Prolonged Effects of a Home-Based Intervention in Patients With Chronic Illness. Arch Intern Med. 2006; 166: 645-650.
22. Coultas D, Frederick J, Barnett B, Singh G, Wludyka P. A randomized trial of two types of nurse-assisted home care for patients with COPD. Chest. 2005; 128(4): 2017-24.
23. Campbell M, Fitzpatrick R, Haines A, Kinmonth A, Sandercock P, Spiegelhalter D, et al. Framework for design and evaluation of complex interventions to improve health. BMJ. 2000; 321: 694-6.
24. Campbell NC, Murray E, Darbyshire J et al. Designing and evaluating complex interventions to improve health care. BMJ, 2007; 334: 455-459.
25. Morales Asencio JM, Sarria Santamera A. Modelos alternativos de atención para pacientes con insuficiencia cardiaca: revisión sistemática. Rev. Calidad Asistencial. 2006; 21(1): 51-59.
26. Yu DS, Thompson DR, Lee DT. Disease management programmes for older people with heart failure: crucial characteristics which improve post-discharge outcomes. Eur Heart J. 2006; 27(5): 596-612.
27. Whellan DJ, Hasselblad V, Peterson E, O'Connor CM, Schulman KA. Metaanalysis and review of heart failure disease management randomized controlled clinical trials. Am Heart J. 2005; 149(4): 722-9.
28. Taylor S. Bestall J. Cotter S. Falshaw M. Hood S. Parsons S. Wood L. Underwood M. Clinical service organisation for heart failure. Cochrane Database of Systematic Reviews. 2005; (2): CD002752.
29. Godfrey M, Randall T, Long A, Grant M: Review of effectiveness and outcomes of home care. Centre for Evidence-Based Social Services. University of Exeter. Exeter, 2000.
30. Thomson H, Hoskins R, Petticrew M, Ogilvie D, Craig N, Ouinn T, et al. Evaluating the health effects of social interventions. BMJ. 2004; 328: 282-5.
31. Vera Hernández M. Evaluar intervenciones sanitarias sin experimentos. Gac Sanit 2003; 17(3): 238-48.
32. Thompson DA, Estabrooks CA, Scott-Findlay S, Moore K, Wallin L. Interventions aimed at increasing research use in nursing: a systematic review. Implementation Science 2007, 2: 15.
33. Morales Asencio JM, Gonzalo Jiménez E, Martín Santos FJ, Morilla Herrera JC, Toral Fernández I, Rivas García A, García Arrabal JJ, Tobías Manzano A, Contreras Fernández E, Millán Carrasco A. Efectividad de un nuevo modelo de atención domiciliaria en Andalucía. Proyecto financiado por la Consejería de Salud de la Junta de Andalucía (Exp 134/02) y el Fondo de Investigaciones Sanitarias. Ministerio de Sanidad y Consumo (PI031161).
34. Gravelle H, Dusheiko M, Sheaff R, Sargent P, Boaden R, Pickard S, Parker S, Roland M. Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data. BMJ. 2007; 334: 31.