Review articleEffects on quality of care for patients with NIDDM or COPD when the specialised nurse has a central role: a literature review
Introduction
New concepts about the care for chronically ill patients require changes in existing health care systems. The growing number of patients with a chronic disease such as diabetes mellitus or chronic obstructive pulmonary disease (COPD) leads to an increase in the cost of care. The world’s diabetic population will probably have doubled from an estimated 110 million in 1994 to 221 million in 2010 [1] and despite less reliable statistics for COPD across countries, the prevalence rates of COPD are expected to increase as well [2]. This has resulted in pressure on the limited resources available for health care. Moreover, it is recognised that the needs of chronically ill people place specific demands on health care systems. In addition to the treatment of the disease, attention for the total functioning of the sick person has to be assured. Caregivers have to be more initiators and less respondents so that patients receive preventive interventions, systematic assessments, education, psychosocial support and counselling [3]. Patients have to be encouraged to execute self-management tasks [3]. And to achieve compliance with long term care follow-up is required [3].
The way medical care is organised at present in Western countries is to meet the acute and urgent needs of patients. However, chronically ill people need general and specialised care simultaneously. To meet the needs of chronic patients, different caregivers and patients themselves have to be involved in care. Co-ordination and continuity of care are needed so that all these parts of care and the caregivers mesh well to achieve ‘tailor-made’ or ‘high-quality’ care. This means that chronic care has to be organised in a way that care from any one caregiver is linked up to that provided by others so that disturbing gaps, contradictions and overlaps are avoided [4].
These developments have resulted in the introduction of different forms of organising chronic care. Integrated care (USA), shared care (UK) and transmural care (The Netherlands) are models of organising care that pay heed to the pressure on the quality and costs of chronic care [5]. In all these models the kind of relationships between the caregivers involved can be characterised. A distinction can be made between complementary relationships and substitution relationships [6], [7]. In complementary relationships the performance of tasks of care is divided between the caregivers of different categories in accordance with their level of expertise [6]. When the performance of tasks of care is divided between caregivers by transferring tasks, the relationship is substitution-based [6], [7]. Horizontal substitution refers to the transfer of tasks between caregivers within one level of expertise. Tasks can be transferred from specialist to generalist or from inside the hospital to outside the hospital. The transfer of tasks between caregivers of different levels of expertise is referred to as vertical substitution [8].
In the search for the most effective and efficient combination of health professionals to deliver care for chronic patients, the role of specialised nurses has become important. Specialised nurses perform tasks that traditionally belonged to the domain of the physician, and work inside the hospital – specialised care – as well as outside – general care. In their review of the literature, Scheffler et al. [7] expected a major contribution of substitution models of care in terms of productivity. They also mentioned ‘the challenges in measuring variations in patient outcomes associated with specific output measures’.
We looked at models of care for chronic patients where the nurse has a central role in order to answer two questions: (1) which outcomes are identified in publications about the effectiveness and efficiency of these models and (2) are these models of care effective and efficient? After searching for publications about these models in the literature, a comparison of the models on their main features was carried out. The identified or expected effects, as well as the statistically significant effects on quality of care were selected and related to each other and the significant effects were related to the main features of the models. Our interest was generated by the start of a pilot project in Maastricht (The Netherlands) in which the specialised nurse has a central role in the care for patients with non-insulin dependent diabetes mellitus (NIDDM) and chronic obstructive pulmonary disease (COPD).
Section snippets
Methods
A search of Medline Express was made for studies published between 1966 and January 1999, although a review of only published sources may be subject to bias [9]. Medline Express contains all citations published in Index Medicus and also corresponds in a large part to the International Nursing index. ‘Nurse’ was entered as keyword and combined with ‘effect’, ‘outcome(s)’ and ‘effectiveness’. Studies had to meet four criteria. First they had to be published in English or Dutch or have an abstract
Selected publications
Entering the keywords and using the criteria yielded ten publications [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]. Of these studies, eight included patients with one specific disease [10], [11], [12], [13], [14], [15], [17], [19], while two studies included patients with different diseases [16], [18] (Table 1). The biggest numbers of respondents were reported in the studies with different diagnoses. Response rates in these studies were lowest and did not reach 50%.
Organisation of care
All
Discussion
What outcomes are expected in evaluations of health care models for the chronically ill in which the nurse has a central role? Are these models effective and efficient in terms of patient outcomes? Our search for published studies in Medline revealed little evidence to answer these questions: only ten publications met our criteria. This is not surprising, considering the rather young status of the role of the specialised nurse. It is questionable, therefore, whether more publications would be
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