자연주의적 탐구조사(Naturalistic Inquiry)

OBJECTIVE — To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS — We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS — Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower (10% in most studies) than it was 3 decades ago. The type of immunosuppression explained 74% of the variability in incidence (P 0.0004). Risk factors were patient age, nonwhite ethnicity, glucocorticoid treatment for rejection, and immunosuppression with high-dose cyclosporine and tacrolimus. PTD was associated with decreased graft and patient survival in earlier studies; later studies showed improved outcomes. Randomized trials of treatment regimens have not been conducted. CONCLUSIONS — Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs. Diabetes Care 25:583–592, 2002

A systematic review of the literature

Organizational learning II: Theory, method and practice

background A substantial number of patients with rheumatoid arthritis have an inadequate or unsustained response to tumor necrosis factor a (TNF- a ) inhibitors. We conducted a randomized, double-blind, phase 3 trial to evaluate the efficacy and safety of abatacept, a selective costimulation modulator, in patients with active rheumatoid arthritis and an inadequate response to at least three months of anti–TNF- a therapy. methods Patients with active rheumatoid arthritis and an inadequate response to anti–TNF- a therapy were randomly assigned in a 2:1 ratio to receive abatacept or placebo on days 1, 15, and 29 and every 28 days thereafter for 6 months, in addition to at least one disease-modifying antirheumatic drug. Patients discontinued anti–TNF- a therapy before randomization. The rates of American College of Rheumatology (ACR) 20 responses (indicating a clinical improvement of 20 percent or greater) and improvement in functional disability, as reflected by scores for the Health Assessment Questionnaire (HAQ) disability index, were assessed. results After six months, the rates of ACR 20 responses were 50.4 percent in the abatacept group and 19.5 percent in the placebo group (P<0.001); the respective rates of ACR 50 and ACR 70 responses were also significantly higher in the abatacept group than in the placebo group (20.3 percent vs. 3.8 percent, P<0.001; and 10.2 percent vs. 1.5 percent, P=0.003). At six months, significantly more patients in the abatacept group than in the placebo group had a clinically meaningful improvement in physical function, as reflected by an improvement from baseline of at least 0.3 in the HAQ disability index (47.3 percent vs. 23.3 percent, P<0.001). The incidence of adverse events and peri-infusional adverse events was 79.5 percent and 5.0 percent, respectively, in the abatacept group and 71.4 percent and 3.0 percent, respectively, in the placebo group. The incidence of serious infections was 2.3 percent in each group.

https://www.nejm.org/doi/pdf/10.1056/NEJMoa050524

Abatacept for rheumatoid arthritis refractory to tumor necrosis factor alpha inhibition.

This article presents a review of the book “Organizations: Rational, Natural and Open Systems,” by W.R. Scott.

Organizations: Rational, Natural and Open Systems

Integrated care is a burgeoning field. As is often the case in new areas of inquiry and action, conceptual clarification is demanded. Without such attention, it would be difficult to advance theory and practice in this increasingly important professional arena. In the following discussion paper, the authors explore the intellectual territory of integrated care, and underscore the need for a patient-centric imperative and meaning. They also examine the practical applications and implications arising from their views. The intention is to stimulate fruitful dialogue and debate about what ‘integrated care’ could and should be.

/pdf/integrated-care-meaning-logic-applications-and-implications-4wgwua33q4.pdf

Integrated care: meaning, logic, applications, and implications – a discussion paper

Title. Nurse practitioners substituting for general practitioners: randomized controlled trial. Aim. This paper is a report of a study conducted to evaluate process and outcomes of care provided to patients with common complaints by general practitioners or specially trained nurse practitioners as first point of contact. Background. Studies in the United States of America and Great Britain show that substituting nurse practitioners for general practitioners results in higher patient satisfaction and higher quality of care. As the American and British healthcare system and settings differ from that in the Netherlands, a Dutch trial was conducted. Methods. A total of 1501 patients in 15 general practices were randomized to consultation by a general practitioner or a nurse practitioner. Data were collected over a 6-month period in 2006 by means of questionnaires, extracting medical records from practice computer systems and recording the length of consultations. Findings. In both groups, the patients highly appreciated the quality of care. No statistically significant differences were found in health status, medical resource consumption and compliance of practical guidelines in primary care in the Netherlands. Patients in the NP intervention group were more often invited to re-attend, had more follow-up consultations and their consultations took statistically significantly longer. Conclusion. Nurse practitioners and general practitioners provide comparable care. Our findings support an increased involvement of specially trained nurse practitioners in the Dutch primary care and contribute to knowledge of the effectiveness of care provision by nurse practitioners from a national and international perspective.

/pdf/nurse-practitioners-substituting-for-general-practitioners-3bvjg7sefs.pdf

Nurse practitioners substituting for general practitioners: randomized controlled trial

What is a good death? Terminally ill patients dealing with normative expectations around death and dying.

The nurse specialist as main care-provider for patients with type 2 diabetes in a primary care setting: effects on patient outcomes

Chronic diseases and associated conditions will always pose a challenge to healthcare systems. New healthcare models are being introduced in Western countries in response to a set of problems that are evident to some degree in all health services—for example, uncoordinated arrangements for delivering care, bias towards acute treatment, neglect of preventive care, and inappropriate treatment.1 These models take account of the pressure on quality and costs of chronic care and originate from the overlapping approaches of integrated care (United States) and shared care (western Europe). 2 3 In the Netherlands, shared care models have acted as a precursor of the recently introduced concept of disease management. Although several disease management initiatives are emerging, the model is not being adopted as fast as might be expected from the benefits that are claimed to result from it.4 In this article we describe the process of moving from a shared care model to a disease management model by considering recent developments in diabetes care in the region of Maastricht. We also describe the use of health technology assessment to evaluate the model.

#### Summary points

The concepts of integrated care and shared care can be regarded, in the Netherlands at least, as the precursor of disease management

Implementation of a shared care model for diabetes in the region of Maastricht ensured that necessary conditions were met for a disease management model

Widespread use of disease management models is hampered by lack of evidence

Evidence from health technology assessment is necessary to justify large scale use of disease management models but will not be sufficient by itself

Shared care for patients with stable diabetes mellitus type 2 who were receiving care from an endocrinologist in an outpatient clinic was implemented in the region of Maastricht in 1997. Two changes were made from usual care: …

https://www.bmj.com/content/bmj/323/7319/983.full.pdf

Cor Spreeuwenberg

Papers

Integrated care: meaning, logic, applications, and implications – a discussion paper

Nurse practitioners substituting for general practitioners: randomized controlled trial

What is a good death? Terminally ill patients dealing with normative expectations around death and dying.

The nurse specialist as main care-provider for patients with type 2 diabetes in a primary care setting: effects on patient outcomes

Adoption of disease management model for diabetes in region of Maastricht