535
Original Article
Rev. Latino-Am. Enfermagem 2015 May.-June;23(3):535-42 DOI: 10.1590/0104-1169.0338.2585
www.eerp.usp.br/rlae
Programmed home visits by nursing professionals to older adults: prevention or treatment?1 Caridad Dios-Guerra2 Juan Manuel Carmona-Torres3 África Ruíz-Gándara4 Adoración Muñoz-Alonso5 María-Aurora Rodríguez-Borrego6
Objetivos: conocer la repercusión de la visita domiciliaria de los profesionales en enfermería a personas de 65 años o más, pluripatológicas, en morbimortalidad. Método: estudio retrospectivo caso-control por auditoria de historias clínicas. Muestreo aleatorio. Variables principales morbilidad, mortalidad; descriptivas: visitas de la enfermera, filiación, datos clínicos y socio sanitarios. Análisis por medidas de tendencia central, dispersión, posición, tabulación, frecuencias relativas, absolutas; no paramétricas, contrastes χ2; Wilcoxon-Mann-Whitney. Resultados: se estudiaron a 1743 pacientes, de ellos 199 recibieron visita domiciliaria; la edad media de quien recibe visita es de 81,99 años; estos presentan mayor número de patologías de media 3,76; habitan en domicilio particular, si bien en conjunto presentan más institucionalización que los controles; el 50% no tiene identificado el Cuidador Principal; es mayor el número de visitas de las enfermeras a los pacientes que viven en residencias (p < 0,001). El 50% de casos no tiene plan de cuidados, con relación significativa (p < 0,001). No existen diferencias significativas en tiempo de vida entre los casos y los controles. Conclusión: la visita domiciliaria del profesional en enfermería no repercute en la morbimortalidad; visita a los pacientes cuando ya ha aparecido el problema de salud, no hay datos de prevención. Descriptors: Home Visit; Disease; Nurse; Morbidity; Mortality.
1
Paper extracted from doctoral dissertation “Estudio del efecto de la visita domiciliaria programada y protocolizada de la enfermera de Atención Primaria en la morbilidad en pacientes de 65 o más años pluripatológicos”, presented to Universidad de Córdoba, Córdoba, Andalucía, Spain.
2
MSc, Associate Professor, Departamento de Enfermería, Facultad de Medicina y Enfermería, Universidad de Córdoba, Córdoba, Andalucía, Spain.
3
MSc, RN, Hospital Infanta Luisa, Sevilla, Andalucía, Spain.
4
PhD, RN, UGC Santa Rosa, Servicio Andaluz de Salud, Córdoba, Andalucía, Spain.
5
MSc, Assistant Professor, Departamento de Estadística, Universidad de Córdoba, Córdoba, Andalucía, Spain.
6
PhD, Full Professor, Departamento de Enfermería, Universidad de Córdoba, Córdoba, Andalucía, Spain.
Corresponding Author: Caridad Dios-Guerra Universidad de Córdoba. Facultad de Medicina y Enfermería Departamento de Enfermería 14004, Córdoba, Andalucía, España E-mail: [email protected]
Copyright © 2015 Revista Latino-Americana de Enfermagem This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC). This license lets others distribute, remix, tweak, and build upon your work non-commercially, and although their new works must also acknowledge you and be non-commercial, they don’t have to license their derivative works on the same terms.
536
Rev. Latino-Am. Enfermagem 2015 May.-June;23(3):535-42.
Introduction
on citizens’ health, envisaging a study with the aim of discovering the impact of planned home visits by health
The population in the 65 and over age group is
care professionals working in Primary/Community Care
increasing significantly and of these, the number of
services to multi-pathological individuals aged 65 and
very elderly (80 and over) is growing, as reflected in
over, in the own home or in nursing homes (in the case
the recently published Global Ageing Index, in-depth
of those who were institutionalized), on the morbi-
report, 2014
mortality of the population cared for.
.
(1)
In Spain, in particular, 16% of the
population is aged over 65 and the very elderly form almost 25% of all older adults; if current mortality
Method
rates continue, by the middle of this century this latter group will account for around 30% of all older adults
This was a retrospective case-control study. The
– those aged over 65 . Among the problems resulting
subjects were patients aged 65 and over who used the
from the ageing population, the difficulties the health
Andalusian Health Care System (SAS), belonging to
care services face in dealing with increased demand
the Córdoba-Guadalquivir Health Care district (formed
from the needs of the ageing population stand out,
of 13 urban health care centers, 6 on the outskirts and
difficulties which affect not only increased care costs
24 rural), serving a total of 76,452 patients. Inclusion
but also organizational capacity at different levels of the
criteria for both groups were: being aged 65 or over
care system. Primary and/or Community Health Care
and diagnosed with 2 or more chronic diseases from 1st
Teams, and especially nursing professionals who form
January 2013, individuals belonging to the health care
part of them, are one of the strengths of the system for
district mentioned and subsidized to receive home care
carrying out interventions to meet the above mentioned
(in the patient’s home or in a nursing home) from a
needs, especially those of dependent citizens in health
nursing professional from their local health care center.
situations that lead to fragility, living in their own homes;
The cases group of patients were those who received
as well as the needs of the families who care for them,
and average of 6 or more programmed visits a year(5)
who need specialists to help them plan and administer
(based on the review study Programmed Nursing home
care
(2)
. A common epidemiological profile among those
visits to over 65s -Visita domiciliaria programada de
who require home care is: multi-pathological (more
enfermería a persona mayores de 65 años, published by
than two chronic illnesses), polymedicated , fragility
the Ministry of Health and Consumo Español in 2002)
or a high degree of invalidity, dependent on formal or
by nursing professionals. The control group was formed
informal carers, requiring health care which, especially
of those who received home care from the professional
because dealing with individuals of an advanced age
when the patient requested it (5 or fewer visit per year).
or with functional and/or cognitive limitations, is
In order to calculate the sample size, the main result
provided at home or in institutions by Primary and/or
variable was used as a reference: percentage of patients
Community nursing staff
(3-4)
of
deceased when followed up after 18 months (mortality
the effectiveness of different care models in patients
. A systematic review
rate); based on the results obtained in a clinical trial
with heart failure concluded that re-hospitalization is
concerning programmed home visits with fragile older
much lower for this population when there is homecare
adults (10). The EPIDAT 3.1 program was used (Calculating
which is well planned and with specific interventions
sample size to estimate relative risk) with the following
both at home and on an outpatient basis by nurses, and
assumptions: exposed (intervention to be tested) at
place emphasis on a new role for nursing professionals,
14% mortality risk; non exposed (normal intervention)
focusing on home and multi-disciplinary care, structured
at 18% mortality risk; expected Relative Risk: 0.778.
telephone monitoring, help, carer support, families and
Control Group to Case Group Ration 1:1. Level of
guaranteed continuity of care through specially created
confidence: 95%, and for relative precision of 80%
clinical pathways. As for emergency service use by
the resulting sample size was 826 subjects per group,
the older adult population
the data vary according
with an estimated non-response rate of 10%. N final=
to different environments, cultures and/or causes,
N previous [1/(1-R)]=826 [1/(1-0.10)]= 918 subjects/
although the figure is considerable, around 30%.
group. Total sample: 1,836. Patients aged over 64 in
Faced with the complexity and variety of facets to the
areas corresponding to the Córdoba-Guadalquivir health
situation, the research team questioned the work of
district number 76,452. In the Córdoba (capital) area:
nursing professionals in the community and its impact
53,898 (70.50% de 76,452) 1,294. In the Guadalquivir
(5-6)
(8-9)
(7)
www.eerp.usp.br/rlae
Dios-Guerra C, Carmona-Torres JM, Ruíz-Gándara A, Muñoz-Alonso A, Rodríguez-Borrego MA.
537
area (province): 22,554 (29.50% of 76,452) 542 older
comparing patients receiving home care from nursing
adults. Later, there were two follow ups of random
professionals and those who are not (199-1544). A
patients who were part of the sample. The sources of
second block, composed of patients who received home
the data were the databases from the Health Districts in
visits from a nursing professional 197 cases and 1564
question and the Electronic Medical History (DIRAYA), it
controls, noting differences. Of the 1,836 patients in the
was from the latter that the usual clinimetric instruments
sample, 93 were excluded as there were no records in the
for the activities of the nursing professional were found:
medical history for the period in question, leaving 1743
questionnaires
and
patients as the final sample (N); of these, 1,546 did not
(Lawton and Brody)(12); cognition (Pfeiffer’s Test)(13); risk
evaluating
function
(Barthel)
receive home visits from a nursing professional, and 199
of pressure sores (Norton)
(11)
, risk of falls (Risk of multiple
did. Of the total (N 1,743), 1,050 were female (60.2%)
falls)(15) and the questionnaire evaluating Basic Needs
and 693 male (39.8%). The mean age of the individuals
according to Virginia Henderson, the model of used in the
visited by nursing staff was 81.99 (SE 0.539) compared
District studied. The main variables were morbidity and
with 74.87 (SE 0.183) for those who did not, with 82.82
mortality; and the descriptive variables were: number
years old (SE 0.611) for the women and 79.91 (SE 1.06)
of home visits by the nursing professional and patients’
for the men. Regarding age, that of the cases exceeded
socio-demographic, medical and socio-health case data.
that of the controls, with a mean 82.89 years old,
Data were collected from auditing the medical histories
compared with 74.76 (SE 0.541-0.179 respectively).
of patients selected through the above mentioned
Differences were observed between men and women,
sampling procedure; the study took place between May
including in home care, with women being older (82.82).
and September 2013; the information collected from the
Table 1 shows morbidity from the most prevalent chronic
medical histories was limited to information from the
diseases. The mean number of pathologies was 2.92
year preceding the audit. The SPSS 15 statistics package
(SD 1.449) with the highest percentage for individuals
was used to analyze the data and descriptive analysis
with 3 or more pathologies (27.8%), followed by 2
was conducted: measuring central trends, dispersion
(24.8%) and 4 (18.5%). On average, women had more
and position of the quantitative variables in question;
pathologies than men; 3.01 and 2.78 respectively (SE
the data were tabulated and relative and absolute
0.0045). Patients who received visits from the Nurse
frequencies were calculated for the qualitative data. For
were those with the highest number of pathologies, with
statistical inference analysis, the following techniques
a mean 3.76 (SE 0.107), compared with 2.81 of those
were used: techniques in the parametrics differed for
who did not receive this service.
(14)
cases and controls and proportions were compared using
As for medicine use, around 90.5% of the patients
χ2 contrasts. As for the quantitative variables, means
were on medication (55.4% of women and 35.2% of
were compared using Wilcoxon-Mann-Whitne contrasts
men). On average, the women took more medicine
for all variables deemed relevant. Analyses of the result
than the men; 6.88 (SE 0.119); and when comparing
variables (mortality and morbidity) were crossed with
pharmaceutical use between patients who received
socio-demographic and other independent variables or
home visits and those who did not, mean consumption
with prognostics of interest, gathered in the study; where
was higher in the former 8.42 (SE 0.269). The cases used
necessary, Pearson’s c2 test and Fisher’s exact test,
more pharmaceuticals (in number) than the controls (p
Original Article
Rev. Latino-Am. Enfermagem 2015 May.-June;23(3):535-42 DOI: 10.1590/0104-1169.0338.2585
www.eerp.usp.br/rlae
Programmed home visits by nursing professionals to older adults: prevention or treatment?1 Caridad Dios-Guerra2 Juan Manuel Carmona-Torres3 África Ruíz-Gándara4 Adoración Muñoz-Alonso5 María-Aurora Rodríguez-Borrego6
Objetivos: conocer la repercusión de la visita domiciliaria de los profesionales en enfermería a personas de 65 años o más, pluripatológicas, en morbimortalidad. Método: estudio retrospectivo caso-control por auditoria de historias clínicas. Muestreo aleatorio. Variables principales morbilidad, mortalidad; descriptivas: visitas de la enfermera, filiación, datos clínicos y socio sanitarios. Análisis por medidas de tendencia central, dispersión, posición, tabulación, frecuencias relativas, absolutas; no paramétricas, contrastes χ2; Wilcoxon-Mann-Whitney. Resultados: se estudiaron a 1743 pacientes, de ellos 199 recibieron visita domiciliaria; la edad media de quien recibe visita es de 81,99 años; estos presentan mayor número de patologías de media 3,76; habitan en domicilio particular, si bien en conjunto presentan más institucionalización que los controles; el 50% no tiene identificado el Cuidador Principal; es mayor el número de visitas de las enfermeras a los pacientes que viven en residencias (p < 0,001). El 50% de casos no tiene plan de cuidados, con relación significativa (p < 0,001). No existen diferencias significativas en tiempo de vida entre los casos y los controles. Conclusión: la visita domiciliaria del profesional en enfermería no repercute en la morbimortalidad; visita a los pacientes cuando ya ha aparecido el problema de salud, no hay datos de prevención. Descriptors: Home Visit; Disease; Nurse; Morbidity; Mortality.
1
Paper extracted from doctoral dissertation “Estudio del efecto de la visita domiciliaria programada y protocolizada de la enfermera de Atención Primaria en la morbilidad en pacientes de 65 o más años pluripatológicos”, presented to Universidad de Córdoba, Córdoba, Andalucía, Spain.
2
MSc, Associate Professor, Departamento de Enfermería, Facultad de Medicina y Enfermería, Universidad de Córdoba, Córdoba, Andalucía, Spain.
3
MSc, RN, Hospital Infanta Luisa, Sevilla, Andalucía, Spain.
4
PhD, RN, UGC Santa Rosa, Servicio Andaluz de Salud, Córdoba, Andalucía, Spain.
5
MSc, Assistant Professor, Departamento de Estadística, Universidad de Córdoba, Córdoba, Andalucía, Spain.
6
PhD, Full Professor, Departamento de Enfermería, Universidad de Córdoba, Córdoba, Andalucía, Spain.
Corresponding Author: Caridad Dios-Guerra Universidad de Córdoba. Facultad de Medicina y Enfermería Departamento de Enfermería 14004, Córdoba, Andalucía, España E-mail: [email protected]
Copyright © 2015 Revista Latino-Americana de Enfermagem This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC). This license lets others distribute, remix, tweak, and build upon your work non-commercially, and although their new works must also acknowledge you and be non-commercial, they don’t have to license their derivative works on the same terms.
536
Rev. Latino-Am. Enfermagem 2015 May.-June;23(3):535-42.
Introduction
on citizens’ health, envisaging a study with the aim of discovering the impact of planned home visits by health
The population in the 65 and over age group is
care professionals working in Primary/Community Care
increasing significantly and of these, the number of
services to multi-pathological individuals aged 65 and
very elderly (80 and over) is growing, as reflected in
over, in the own home or in nursing homes (in the case
the recently published Global Ageing Index, in-depth
of those who were institutionalized), on the morbi-
report, 2014
mortality of the population cared for.
.
(1)
In Spain, in particular, 16% of the
population is aged over 65 and the very elderly form almost 25% of all older adults; if current mortality
Method
rates continue, by the middle of this century this latter group will account for around 30% of all older adults
This was a retrospective case-control study. The
– those aged over 65 . Among the problems resulting
subjects were patients aged 65 and over who used the
from the ageing population, the difficulties the health
Andalusian Health Care System (SAS), belonging to
care services face in dealing with increased demand
the Córdoba-Guadalquivir Health Care district (formed
from the needs of the ageing population stand out,
of 13 urban health care centers, 6 on the outskirts and
difficulties which affect not only increased care costs
24 rural), serving a total of 76,452 patients. Inclusion
but also organizational capacity at different levels of the
criteria for both groups were: being aged 65 or over
care system. Primary and/or Community Health Care
and diagnosed with 2 or more chronic diseases from 1st
Teams, and especially nursing professionals who form
January 2013, individuals belonging to the health care
part of them, are one of the strengths of the system for
district mentioned and subsidized to receive home care
carrying out interventions to meet the above mentioned
(in the patient’s home or in a nursing home) from a
needs, especially those of dependent citizens in health
nursing professional from their local health care center.
situations that lead to fragility, living in their own homes;
The cases group of patients were those who received
as well as the needs of the families who care for them,
and average of 6 or more programmed visits a year(5)
who need specialists to help them plan and administer
(based on the review study Programmed Nursing home
care
(2)
. A common epidemiological profile among those
visits to over 65s -Visita domiciliaria programada de
who require home care is: multi-pathological (more
enfermería a persona mayores de 65 años, published by
than two chronic illnesses), polymedicated , fragility
the Ministry of Health and Consumo Español in 2002)
or a high degree of invalidity, dependent on formal or
by nursing professionals. The control group was formed
informal carers, requiring health care which, especially
of those who received home care from the professional
because dealing with individuals of an advanced age
when the patient requested it (5 or fewer visit per year).
or with functional and/or cognitive limitations, is
In order to calculate the sample size, the main result
provided at home or in institutions by Primary and/or
variable was used as a reference: percentage of patients
Community nursing staff
(3-4)
of
deceased when followed up after 18 months (mortality
the effectiveness of different care models in patients
. A systematic review
rate); based on the results obtained in a clinical trial
with heart failure concluded that re-hospitalization is
concerning programmed home visits with fragile older
much lower for this population when there is homecare
adults (10). The EPIDAT 3.1 program was used (Calculating
which is well planned and with specific interventions
sample size to estimate relative risk) with the following
both at home and on an outpatient basis by nurses, and
assumptions: exposed (intervention to be tested) at
place emphasis on a new role for nursing professionals,
14% mortality risk; non exposed (normal intervention)
focusing on home and multi-disciplinary care, structured
at 18% mortality risk; expected Relative Risk: 0.778.
telephone monitoring, help, carer support, families and
Control Group to Case Group Ration 1:1. Level of
guaranteed continuity of care through specially created
confidence: 95%, and for relative precision of 80%
clinical pathways. As for emergency service use by
the resulting sample size was 826 subjects per group,
the older adult population
the data vary according
with an estimated non-response rate of 10%. N final=
to different environments, cultures and/or causes,
N previous [1/(1-R)]=826 [1/(1-0.10)]= 918 subjects/
although the figure is considerable, around 30%.
group. Total sample: 1,836. Patients aged over 64 in
Faced with the complexity and variety of facets to the
areas corresponding to the Córdoba-Guadalquivir health
situation, the research team questioned the work of
district number 76,452. In the Córdoba (capital) area:
nursing professionals in the community and its impact
53,898 (70.50% de 76,452) 1,294. In the Guadalquivir
(5-6)
(8-9)
(7)
www.eerp.usp.br/rlae
Dios-Guerra C, Carmona-Torres JM, Ruíz-Gándara A, Muñoz-Alonso A, Rodríguez-Borrego MA.
537
area (province): 22,554 (29.50% of 76,452) 542 older
comparing patients receiving home care from nursing
adults. Later, there were two follow ups of random
professionals and those who are not (199-1544). A
patients who were part of the sample. The sources of
second block, composed of patients who received home
the data were the databases from the Health Districts in
visits from a nursing professional 197 cases and 1564
question and the Electronic Medical History (DIRAYA), it
controls, noting differences. Of the 1,836 patients in the
was from the latter that the usual clinimetric instruments
sample, 93 were excluded as there were no records in the
for the activities of the nursing professional were found:
medical history for the period in question, leaving 1743
questionnaires
and
patients as the final sample (N); of these, 1,546 did not
(Lawton and Brody)(12); cognition (Pfeiffer’s Test)(13); risk
evaluating
function
(Barthel)
receive home visits from a nursing professional, and 199
of pressure sores (Norton)
(11)
, risk of falls (Risk of multiple
did. Of the total (N 1,743), 1,050 were female (60.2%)
falls)(15) and the questionnaire evaluating Basic Needs
and 693 male (39.8%). The mean age of the individuals
according to Virginia Henderson, the model of used in the
visited by nursing staff was 81.99 (SE 0.539) compared
District studied. The main variables were morbidity and
with 74.87 (SE 0.183) for those who did not, with 82.82
mortality; and the descriptive variables were: number
years old (SE 0.611) for the women and 79.91 (SE 1.06)
of home visits by the nursing professional and patients’
for the men. Regarding age, that of the cases exceeded
socio-demographic, medical and socio-health case data.
that of the controls, with a mean 82.89 years old,
Data were collected from auditing the medical histories
compared with 74.76 (SE 0.541-0.179 respectively).
of patients selected through the above mentioned
Differences were observed between men and women,
sampling procedure; the study took place between May
including in home care, with women being older (82.82).
and September 2013; the information collected from the
Table 1 shows morbidity from the most prevalent chronic
medical histories was limited to information from the
diseases. The mean number of pathologies was 2.92
year preceding the audit. The SPSS 15 statistics package
(SD 1.449) with the highest percentage for individuals
was used to analyze the data and descriptive analysis
with 3 or more pathologies (27.8%), followed by 2
was conducted: measuring central trends, dispersion
(24.8%) and 4 (18.5%). On average, women had more
and position of the quantitative variables in question;
pathologies than men; 3.01 and 2.78 respectively (SE
the data were tabulated and relative and absolute
0.0045). Patients who received visits from the Nurse
frequencies were calculated for the qualitative data. For
were those with the highest number of pathologies, with
statistical inference analysis, the following techniques
a mean 3.76 (SE 0.107), compared with 2.81 of those
were used: techniques in the parametrics differed for
who did not receive this service.
(14)
cases and controls and proportions were compared using
As for medicine use, around 90.5% of the patients
χ2 contrasts. As for the quantitative variables, means
were on medication (55.4% of women and 35.2% of
were compared using Wilcoxon-Mann-Whitne contrasts
men). On average, the women took more medicine
for all variables deemed relevant. Analyses of the result
than the men; 6.88 (SE 0.119); and when comparing
variables (mortality and morbidity) were crossed with
pharmaceutical use between patients who received
socio-demographic and other independent variables or
home visits and those who did not, mean consumption
with prognostics of interest, gathered in the study; where
was higher in the former 8.42 (SE 0.269). The cases used
necessary, Pearson’s c2 test and Fisher’s exact test,
more pharmaceuticals (in number) than the controls (p
