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1.  Evaluation of person-centred care after hip replacement-a controlled before and after study on the effects of fear of movement and self-efficacy compared to standard care 
BMC Nursing  2016;15(1):53.
The goal of total hip arthroplasty (THA) is optimal pain relief and a normalized health-related quality of life. Anxious patients describe more pain and more difficulties than non-anxious patients during rehabilitation after THA. The aims of the present study were twofold: (1) to identify vulnerable patients using the general self-efficacy scale (GSES) and the Tampa scale for Kinesiophobia (TSK), and (2) to evaluate if person-centred care including the responses of the instruments made rehabilitation more effective in terms of shortening hospital length of stay.
The design of the study was quasi-experimental. Patients scheduled for THA, a control group (n = 138) and an intervention group (n = 128) were consecutively recruited. The intervention was the provision of person-centred care which was designed to reduce the negative effects of low self-efficacy and high levels of pain-related fear of movement.
Patients with low GSES in the intervention group had shorter length of stay (LoS) by 1.6 days (95 % CI 0.16–3.15) p-value 0.03. Patients with high TSK in the intervention group had shorter LoS by 2.43 days (95 % CI 0.76–4.12) p-value 0.005. For patients who had both, the reduction of LoS was 2.15 days (95 % CI 0.24–4.04) p-value 0.028.
The GSES and the TSK instrument were found useful as tools to provide information to support patients which reduced the LoS by 1.67 days in the whole intervention group (95 % CI 0.72–2.62) p-value 0.001. More importantly, vulnerable patients such as ASA group 3 probably gained the most from the extra support, they had a reduction with 6.78 days (95 % CI 2.94–10.62) p-value 0.001.
PMCID: PMC5017008  PMID: 27616936
Person-centred care; Person-centered care; General self-efficacy; Tampa Scale of Kinesiophobia; ASA classification; Total hip replacement; Rehabilitation; Health plan; Planned surgery management; Nursing care
2.  A cost-effectiveness study of cost of care and health consequences for two modes of treatment for patients with hip fractures 
To perform an economic evaluation of two treatment approaches in participants with an acute hip fracture.
A cost-effectiveness analysis was performed to compare an intervention treatment (treatment A) with standard care (treatment B). The intervention treatment was an integrated care pathway (ICP). Participants were selected consecutively and the treatment study used a before-and-after design.
An orthopaedic ward at a hospital southwest of Sweden.
112 independently living participants, aged 65 years or older and admitted to hospital with a hip fracture, were included. The exclusion criteria were pathological fracture and severe intellectual impairment (Pfeiffer's test <3 points).
The main outcome was hospital's total treatment costs for each participant undergoing surgery for a hip fracture, where effectiveness was measured using the Katz ADL index.
The main result was a 40% reduction for each participant in the average total cost for treatment A € 9,685 vs. € 16,002 for treatment B (p=0.000). Moreover, effectiveness was significantly improved. The cost-effectiveness ratio for treatment A was € 14,840 vs. € 31,908 for treatment B. In addition, 75% of the participants in treatment A were successfully rehabilitated vs. 55% in treatment B.
The use of an ICP was cost-effective, with the greatest reduction in hotel costs. A longer hospital stay was related to more investigation costs, which appeared to be unrelated to the participants' medical condition. The cost of developing the ICP had already been covered after three participants. No 30-day re-admission was recorded in either group and the one-year mortality rate was 16% in both groups.
PMCID: PMC2430299
hospital care; health care cost; integrated care pathway; Sweden
3.  Person-centred care compared with standardized care for patients undergoing total hip arthroplasty—a quasi-experimental study 
A common approach to decrease length of stay has been to standardize patient care, for example, by implementing clinical care pathways or creating fast-track organizations. In a recent national report, it was found that Sweden’s healthcare system often fails to anticipate and respond to patients as individuals with particular needs, values and preferences. We compared a standardized care approach to one of person-centred care for patients undergoing total hip replacement surgery.
A control group (n =138) was consecutively recruited between 20th September 2010 and 1st March 2011 and an intervention group (n =128) between 12th December 2011 and 12th November 2012, both scheduled for total hip replacement. The primary outcome measures were length of stay and physical function at both discharge and 3 months later.
The mean length of stay in the control group was 7 days (SD 5.0) compared to 5.3 days in the intervention group (SD 2.2). Physical functional performance, as assessed using activities of daily living, was similar at baseline for both groups. At discharge, 84% in the control group had regained activities of daily living level A vs. 72% in the intervention group. At 3 months after surgery, 88% in the control group had regained their independence vs. 92.5% in the person-centred care group.
Focusing attention on patients as people and including them as partners in healthcare decision-making can result in shorter length of stay. The present study shows that the patients should be the focus and they should be involved as partners.
PMCID: PMC4222396  PMID: 25359278
Person-centred care; Person-centered care; General self-efficacy; Tampa scale of Kinesiophobia; ASA classification
4.  Experiences of person-centred care - patients’ perceptions: qualitative study 
BMC Nursing  2014;13:28.
Patient care models have been implemented and documented worldwide. Many studies have focused on features that hinder and facilitate the shift to such models, including the implementation process, staff involvement, resistance to new models and cultural dimensions. However, few studies have identified the potential effects of such new care models from a patient perspective. The aim of the present study was to investigate whether patients did in fact perceive the intentions of partnership in the new care model 1 year after its implementation.
Sixteen participants were interviewed, selected from two wards in a medical department where a new care model had been implemented 1 year earlier. A directed deductive content analysis was selected. The aim of the directed approach to content analysis was to investigate to what extent the new care model had been implemented, using patients’ perspectives to describe the level of implementation. A coding framework was developed based on a theoretical paper that described the key features of the new care model.
The implementation of person-centred care had clearly occurred to a large degree, even if some patients appeared not to have been exposed to the model at all. Aspects of the newly implemented care model were obvious; however, it was also clear that implementation was not complete. The analysis showed that patients felt listened to and that their own perception of the situation had been noted. Patients spontaneously expressed that they felt that the staff saw them as persons and did not solely focus on their disease. It was also stated that not every ailment or aspect of a patient’s illness needed to be addressed or resolved for open listening to be perceived as a positive experience.
The findings indicate that even though some patients were not interested in participating and playing an active role in their own care, this might relate to a lack of understanding on how to invite them to do so and to increase their confidence. To change healthcare from a paternalistic system to care where patients are seen as partners may require pedagogical skills.
PMCID: PMC4193911  PMID: 25309128
Deductive content analysis; Health care models; Implementing care; Person-centred care; Patient-centred care; Patients’ experience
5.  Incidence and root causes of cancellations for elective orthopaedic procedures: a single center experience of 17,625 consecutive cases 
The purpose of the Swedish public health-care system is to provide care on equal terms for all citizens. In this, as in most other systems where taxes and/or insurances pay for most of the care, normal market forces are set aside at least in part. At times, this has, for example, resulted in long waiting lists, particularly in terms of elective orthopaedic surgery, with several negative consequences, such as cancellations of planned surgery.
The main purpose of this retrospective observational single center study was to evaluate and describe the number and reasons for cancellations in elective orthopaedic surgery. Studied were all the elective patients scheduled for joint replacement, arthroscopy and foot & ankle surgery, January 1, 2007 to December 31, 2011, whose procedure was cancelled at least once.
Of all 17,625 patients scheduled for elective surgery 6,911 (39%) received at least one, some several cancellations. The most common reason for cancelling a planned surgery was different patient-related factors 3,293 (33%). Cancellations due to treatment guarantee legislation reached 2,885 (29%) and 1,181 (12%) of the cancellations were related to incomplete pre-operative preparation of the patients. Organisational reasons were the cause of approximately 869 (9%) of the cancellations.
In this study of patients waiting for elective orthopaedic surgery 6,911(39%) had their surgical procedure cancelled at least once, some several times. It appears that it should be possible to eliminate many of these cancellations, while others are unavoidable or caused by factors outside the responsibility of the individual clinic or even hospital. One possible way of influencing the high rate of cancellations might be to change the view of the patients and involve them in the overall planning of the care process.
PMCID: PMC4064269  PMID: 24955115
Appointments and schedules; Operating rooms/organisation and administration; Waiting lists; Cancellation; Orthopaedic surgery; Perioperative nursing
6.  Use of the PREPARE (PREhabilitation, Physical Activity and exeRcisE) program to improve outcomes after lumbar fusion surgery for severe low back pain: a study protocol of a person-centred randomised controlled trial 
Following lumbar fusion surgery, a successful outcome is empirically linked to effective rehabilitation. While rehabilitation is typically postoperative, the phase before surgery – termed prehabilitation – is reportedly an ideal time to prepare the patient. There are presently no guidelines for prehabilitation before lumbar fusion surgery. Physical activity has well-known health benefits, and staying physically active despite pain is a major principle in non-pharmacological chronic low back pain treatment. Psychological factors such as fear of movement, pain catastrophizing and low self-efficacy are known to be barriers to staying active. No studies have investigated prehabilitation protocols that promote physical activity and target psychological risk factors before lumbar fusion surgery. The aim of our proposed randomised controlled trial is to investigate whether patients who undergo lumbar fusion surgery for degenerative disc disease experience better functioning with a physiotherapeutic prehabilitation program (PREPARE) based on a cognitive behavioural approach compared to conventional care.
We will recruit 110 patients between 18–70 years of age with degenerative disc disease who are waiting for lumbar fusion surgery. These patients will be randomly assigned to receive either PREPARE or conventional care. PREPARE uses a person-centred perspective and focuses on promoting physical activity and targeting psychological risk factors before surgery. The primary outcome will be disability measured using the Oswestry Disability Index 2.0. Secondary outcomes will include functioning (patient-reported and performance-based), physical activity (accelerometer), health-related quality of life, back and leg pain intensity, pain catastrophizing, kinesiophobia, self-efficacy, depression, anxiety, satisfaction with treatment results and health economic factors. Data will be collected at baseline (preoperatively) after the intervention (preoperatively), 3 and 8 weeks, 3, 6, 12, 24 and 60 months postoperatively.
We hypothesise that the focus on promoting physical activity and targeting psychological risk factors before surgery will decrease disability and help the patients to be more active despite pain both before and after surgery. We will use a combination of outcome measures both patient-reported and performance-based, as well as accelerometer data. This will provide a more comprehensive picture of the patient’s functioning than just patient-reported outcomes alone.
Trial registration
Current Controlled Trials ISCRTN17115599, Retrospectively Registered 18 May 2015.
PMCID: PMC4991107  PMID: 27538757
Prehabilitation; Rehabilitation; Spinal fusion surgery; Physiotherapy; Cognitive behavioural approach; Person-centred; Chronic low back pain; Physical activity
7.  Impacts of patient characteristics on hospital care experience in 34,000 Swedish patients 
BMC Nursing  2012;11:8.
Standardized patient surveys are widely used for assessing quality of healthcare from the patient perspective. An important purpose of such surveys is to identify disparities in care among different patient groups. The purpose of this study was to 1.) evaluate aspects of the validity of the adapted Swedish version of the Picker Patient Care Experience -15 (PPE-15) survey and 2.) examine the explanatory value of various socio-demographic and health characteristics in predicting patients’ care experiences.
A retrospective cross-sectional study design was used. Patients discharged from internal medicine wards at regional and university hospitals in different parts of Sweden during 2010 were invited to participate in the regularly administered national care-experience survey for hospital care. The internal validity of the PPE-15 was assessed with Cronbach’s alpha and item-scale correlations. Pearson product–moment correlation coefficients were used to compare PPE-15 total scores with overall care satisfaction ratings and Spearman correlation coefficients were used to compare PPE-15 total scores with various patient characteristics. Multiple linear regression analysis was performed to examine the influence of various patient characteristics on PPE-15 scores.
The response rate was 66% (n = 34 603). Cronbach’s alpha was 0.87. The correlation between the PPE-15 total score and overall care satisfaction was high (0.62, p < 0.0001). Good self-rated health (SRH) and having Swedish as native language were associated with better care experiences and poorer experiences with greater healthcare utilization, higher age, functional impairment and being female. All examined characteristics, except language, were significant predictors in the regression model and SRH was the strongest predictor; however, the model explained only 7% of the total variance. Vulnerable patients (i.e. poor SRH and functional impairment) reported significantly less positive care experiences than did non-vulnerable patients (mean PPE-15 score 75 vs 85; p < 0.0001).
Our results supported the internal validity of the Swedish adapted version of the PPE-15. The explanatory value of the examined patient socio-demographic and health characteristics was low, suggesting the need for exploring other patient-related determinants of care experiences. Our findings also suggest a care paradox: patients in greatest need of hospital care are least satisfied with the quality of the care they receive.
PMCID: PMC3482554  PMID: 22697398
Patient-reported outcome; Self-rated health; Functional status; Frail; Care experience; Care disparity; Patient-centred care
8.  The integrated care pathway reduced the number of hospital days by half: a prospective comparative study of patients with acute hip fracture 
The incidence of hip fracture is expected to increase during the coming years, demanding greater resources and improved effectiveness on this group of patients. The aim of the present study was to evaluate the effectiveness of an integrated care pathway (ICP) in patients with an acute fracture of the hip.
A nonrandomized prospective study comparing a consecutive series of patients treated by the conventional pathway to a newer intervention. 112 independently living patients aged 65 years or older admitted to the hospital with a hip fracture were consecutively selected. Exclusion criteria were pathological fracture and severe cognitive impairment. An ICP was developed with the intention of creating a care path with rapid pre-operative attention, increased continuity and an accelerated training programme based on the individual patient's prerequisites and was used as a guidance for each patient's tailored care in the intervention group (N = 56) The main outcome measure was the length of hospital stay. Secondary outcomes were the amount of time from the emergency room to the ward, to surgery and to first ambulation, as well as in-hospital complications and 30-day readmission rate.
The intervention group had a significantly shorter length of hospital stay (12.2 vs. 26.3 days; p < 0.000), a shorter time to first ambulation (41 vs. 49 h; p = 0.01), fewer pressure wounds (8 vs. 19; p = 0.02) and medical complications (5 vs. 14; p = 0.003) than the comparison group. No readmissions occurred within 30 days post-intervention in either group.
Implementing an ICP for patients with a hip fracture was found to significantly reduce the length of hospital stay and improve the quality of care.
PMCID: PMC1634996  PMID: 17150123
9.  Effects of person-centred care in patients with chronic heart failure: the PCC-HF study 
European Heart Journal  2011;33(9):1112-1119.
Person-centred care (PCC) emphasizes a partnership in care between patients and healthcare professionals and is advocated by WHO as a key component of quality health care. We evaluated outcomes of PCC in hospitalized patients with chronic heart failure (CHF) with respect to the length of hospital stay (LOS), activities of daily living (ADL), health-related quality of life (HRQL) and 6-month readmission rate.
Methods and results
During 2008–2010, 248 consecutive patients hospitalized for symptoms of worsening CHF were enrolled in a controlled before and after designed study. A Usual care group (n= 123) was recruited according to pre-defined criteria to map usual CHF care and assess outcomes at five designated hospital wards. Based on the mapping, a panel of in-house clinicians and researchers developed measures aimed at aligning usual care with basic PCC principles. These measures were incorporated into a study protocol to guide care procedures at the same five wards. Person-centred care was then implemented at these wards and evaluated in 125 patients. Both length of hospital stay and 6-month readmission were extracted from patient records. Activities of daily living were evaluated at baseline and discharge and HRQL was evaluated at baseline and after 3 months. In the analysis of all patients, the LOS was reduced by 1 day (P= 0.16) while retaining ADL (P= 0.07). When PCC was fully implemented (per protocol analysis), LOS was reduced by 2.5 days (P= 0.01) and the ADL-level better preserved (P= 0.04). Health-related quality of life and time-to-first readmission did not differ.
In this proof-of-concept study, our findings suggest that a fully implemented PCC approach shortens hospital stay and maintains functional performance in patients hospitalized for worsening CHF, without increasing risk for readmission or jeopardizing patients' HRQL.
PMCID: PMC3751966  PMID: 21926072
Patient-centred care; Chronic heart failure; Disease management programmes; Person-centered medicine; Person-centered care

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