Setting and design
The current study was conducted in 2010 among older patients who were admitted to a hospital in the context of the Prevention and Reactivation Care Program [
32], which was designed to prevent loss of function in older patients due to hospitalization and targeted older hospital patients (≥65 years of age) who were vulnerable to loss of function after hospital discharge. This research is based on the pilot study of 500 patients (≥65 years old) prior to implementation of the Prevention and Reactivation Care Program. The results of the pilot study have been used to identify possible practical implementation problems in preparation for the main evaluation study and serve as a base for power calculations for the main study.
A total of 1026 patients admitted to the Vlietland hospital in The Netherlands between June and October 2010 were approached to participate in the study. We excluded patients who refused participation, did not understand the Dutch language, were expected to stay in the hospital for less than 48 h, were unable to answer questions or follow instructions due to cognitive problems (MMSE score lower than 12), or had a life expectancy of less than 3 months. Five hundred agreed to participate and signed an informed consent form (response 49 %). Three months after admission, 173 participants had been lost to follow up, 36 participants had died, and 291 people (response rate 58 %) were interviewed.
The study complies with the rules as stated in the Declaration of Helsinki. The medical ethics committee of the Erasmus Medical Centre, Rotterdam, the Netherlands, approved methods for data collection (protocol number MEC2011-041).
Questionnaire
Quality of life was assessed with an adjusted version of Cantril’s Self Anchoring Ladder [
33]. Within 48 h after hospital admission (T0) and 3 months after hospital admission (T1), respondents were asked to rate their lives on a scale of 0–10 by answering the following questing: Which report mark would you give your life at this moment?
Patients’ perceptions of quality of integrated care delivery were assessed with the 10-item Older Patients’ Assessment of Integrated Care (O-PACIC scale, see Additional file
1: Appendix 1) [
34], which was based on the 20-item Patient Assessment of Chronic Illness Care questionnaire (PACIC) [
35]. The PACIC is intended to assess the receipt of integrated care according to the principals of the Chronic Care Model. The Chronic Care Model provides an organized multidisciplinary approach to care delivery. The idea of this model is to transition care delivery from reactive to proactive, planned, integrated, holistic and personalized. Given the complex medical, social, and psychological problems of both chronically-ill and older patients they are both in need of an organised multidisciplinary and integrated approach to care delivery [
34]. Therefore, improvements in integrated care delivery in hospitals according to the principles of the Chronic Care Model are expected to be beneficial for older patients as well. The PACIC has internationally been used as an instrument to evaluate integrated care delivery among patients with various chronic conditions. For a full overview see a recent publication of Iglesias and colleagues [
36] testing all published validation models of the PACIC. With this instrument patients are asked if their care was well organized, if they were given choices about their treatment to think about and if they were helped to make a treatment plan that they could fit in their daily life. Research indeed indicates that these are all important issues to improve outcomes for older patients after hospitalization and reduce poor outcomes such as readmission, functional decline, mortality, nursing home placement, and healthcare costs [
5,
6,
37‐
40]. The O-PACIC was developed and validated as a reliable, feasible instrument to assess older patients’ experiences with integrated care delivery after hospitalization showing strong psychometric properties [
34]. The O-PACIC score represents the sum of the participants’ responses divided by 10. Scores ranged from 1 to 5, with higher scores indicating a greater perception of receipt of integrated care delivery during hospital stay. At T1 (3 months after hospital admission) respondents were asked to give their perception on the quality of integrated care delivery. The Cronbach’s alpha coefficient of the scale in this study was 0.75, indicating reliability.
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS survey, see Additional file
1: Appendix 2) is an 18-item questionnaire which assesses patients’ experiences with hospital care. These 18 items include two global ratings of hospital care delivery and 16 questions that relate to their recent hospital experience. The two global rating items assess patients’ overall rating of the hospital using a 0 (worst hospital possible) to 10 (best hospital possible) rating scale. Willingness to recommend the hospital to friends and family is assessed by using a 4-point scale ranging from
definitely no to
definitely yes. Of the 16 experience questions two items are answered with a simple
yes or
no. These two items assess patients’ experiences regarding cleanliness of hospital environment and quietness of hospital environment. Patients are asked to rate their level of agreement to the remaining 14 items on a 4-point scale ranging from
never to
always. These 14 questions are used to construct the following 6 subscales: communication with nurses (3 questions), communication with doctors (three questions), responsiveness of hospital staff (two questions), pain management (two questions), communication about medicines (two questions), and discharge information (two questions) [
41,
42]. The standardized HCAHPS score was the mean of the participants’ responses on the subscales, individual items and global ratings. Scores ranged from 0 to 2, with higher scores indicating better experiences with the received hospital care. At T1 (3 months after hospital admission) respondents were asked to assess their hospital experience 3 months earlier. The Cronbach’s alpha coefficient for this instrument was 0.87, indicating good reliability.
We further asked participants for age, gender, marital status, education level, length of hospital stay, general health, and cognitive and physical functioning. Education was assessed on seven levels ranging from (1) no school or some primary education (6 years of education or less) to (7) university degree (18 years of education or more). In our analyses, we dichotomized this into (1) low educational level (followed school after primary education, but without a diploma or less), and (0) followed school after primary education with diploma or higher. The length of hospital stay was used as a proxy for severity of the patients’ medical problems for which he/she was admitted. The participants’ general health was assessed on a 5-point scale (1 = excellent, 2 = very good, 3 = good, 4 = reasonable, 5 = bad). We dichotomized this into (1) bad health (scores 4 and 5), and (0) good health (scores 1, 2 and 3). Cognitive functioning was assessed with the Mini Mental State Examination (MMSE), which measures cognitive functioning by asking questions about orientation in time and space, short- and middle-term memory, comprehension, and other cognitive dimensions. Scores ranged from 0 to 30, with higher scores indicating higher levels of cognitive functioning. Any score equal or above 25 points (of 30) represents effective cognitive functioning (intact). Below this, scores can indicate severe (≤9 points), moderate (10–20 points), or mild (21–24 points) cognitive functioning losses [
43,
44]. Physical functioning was assessed using the Katz Index of independence in activities of daily living [
45,
46], which ranks an individuals’ ability to perform six functions: bathe, dress, use the toilet, transfer, remain continent, and feed oneself. Scores of no (1) or yes (0) indicate (in)dependence in each function, with 6 is full physical function, 4 is moderate, and equal or below 2 is severe physical function impairment.
Statistical analysis
Descriptive statistics were used to analyze patients’ age, gender, marital status, education level, length of hospital stay and health. Correlation analysis was used to investigate the relationship between the background characteristics, patients’ general health, cognitive functioning, physical functioning, experiences with hospital care, perceived quality of integrated care delivery, and quality of life. We employed a random-effects multilevel model to investigate the relationship between older patients’ perception of the quality of integrated care delivery, experiences with hospital care and quality of life over time. Background characteristics and significant univariate associations with quality of life at T1 (3 months after hospital admission) were included in the multilevel analyses. A significance level of 0.05 was used for all statistical tests. Data were analyzed using the SPSS software package (ver. 18.0 for Windows; SPSS Inc., Chicago, IL, USA).