The impact of primary care organization on avoidable hospital admissions for diabetes in 23 countries

Objective: Diabetes is a so-called ambulatory care sensitive condition. It is assumed that by appropriate and timely primary care, hospital admissions for complications of such conditions can be avoided. This study examines whether differences between countries in diabetes-related hospitalization rates can be attributed to differences in the organization of primary care in these countries. Design: Data on characteristics of primary care systems were obtained from the QUALICOPC study that includes surveys held among general practitioners and their patients in 34 countries. Data on avoidable hospitalizations were obtained from the OECD Health Care Quality Indicator project. Negative binomial regressions were carried out to investigate the association between characteristics of primary care and diabetes-related hospitalizations. Setting: A total of 23 countries. Subjects: General practitioners and patients. Main outcome measures: Diabetes-related avoidable hospitalizations. Results: Continuity of care was associated with lower rates of diabetes-related hospitalization. Broader task profiles for general practitioners and more medical equipment in general practice were associated with higher rates of admissions for uncontrolled diabetes. Countries where patients perceive better access to care had higher rates of hospital admissions for long-term diabetes complications. There was no association between disease management programmes and rates of diabetes-related hospitalization. Hospital bed supply was strongly associated with admission rates for uncontrolled diabetes and long-term complications. Conclusions: Countries with elements of strong primary care do not necessarily have lower rates of diabetes-related hospitalizations. Hospital bed supply appeared to be a very important factor in this relationship. Apparently, it takes more than strong primary care to avoid hospitalizations.

• Key points

• Countries with elements of strong primary care do not necessarily have lower rates of diabetes-related avoidable hospitalization.

• Hospital bed supply is strongly associated with admission rates for uncontrolled diabetes and long-term complications.

• Continuity of care was associated with lower rates of diabetes-related hospitalization.

• Better access to care, broader task profiles for general practitioners, and more medical equipment in general practice was associated with higher rates of admissions for diabetes.

     

Euthanasia and physician-assisted suicide in the Dutch homecare sector: the role of the district nurse

AIM: This paper is a report of the findings of a study into the role of district nurses in euthanasia and physician-assisted suicide in homecare organizations, conducted as part of a study into the role of nurses in medical end-of-life decisions. BACKGROUND: Issues concerning legislation and regulation with respect to the role of nurses in euthanasia and physician-assisted suicide gave the Minister for Health reason to commission a study into the role of nurses in medical end-of-life decisions in hospitals, nursing homes and homecare organizations. This is the first quantitative study from the perspective of nurses. Previous quantitative studies were conducted under physicians and information on the role of nurses was obtained indirectly. METHOD: A questionnaire was sent in 2003 to 500 district nurses employed in 55 homecare organizations. The absolute response rate was 86.0% and 81.6% (408) could be used for analysis. RESULTS: In 22.3% of 278 cases, the district nurse was the first with whom patients discussed their request for euthanasia or physician-assisted suicide. In about half (49.8%) of 267 cases nurses were not involved in the general practitioner's decision-making process, and in only 13.3% of 264 cases, did they attend the administration of the lethal drugs. District nurses had provided some degree of aftercare to the surviving relatives in 80.3% of 264 cases. CONCLUSION: Collaboration between general practitioners and district nurses needs improvement, particularly in relation to decision-making. Our Dutch data could help nurses in other countries to define their (future) role in euthanasia and physician-assisted suicide.     

Two-dimensional echocardiographic appearance of left ventricular thrombi with systemic emboli after myocardial infarction

To test the hypothesis that left ventricular (LV) thrombi that project into the lumen and are mobile are more likely to embolize than those that do not have these characteristics, the 2-dimensional echocardiograms of 16 patients with LV thrombi after myocardial infarction were retrospectively reviewed. Ten had evidence of peripheral embolization and 6 did not. The studies were reviewed in random order by an observer blinded to the clinical data. Each echocardiogram was graded as showing a protruding or nonprotruding thrombus and the presence or absence of increased mobility. The thrombus projected into the lumen on the echocardiograms of 8 of 10 patients who had had emboli and in 0 of 6 who had not. The thrombus had increased mobility in 4 of 10 patients with emboli and 0 of 6 without. Thus, LV thrombi that project into the lumen and have increased mobility are more likely to embolize than those without these characteristics.