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Leyden Academy publishes in The Netherlands Journal of Medicine

In the July/August issue of The Netherlands Journal of Medicine an article on gerontology and geriatrics in Dutch medical education was published by Ward Tersmette, David van Bodegom, Diana van Heemst, David Stott and Rudi Westendorp. Ward is a former Master Vitality and Ageing student, and we congratulate him with this publication.

Background
The world population is ageing and healthcare services require trained staff who can address the needs of older patients. In this study we determined how current medical education prepares Dutch students of medicine in the field of Gerontology and Geriatrics (G&G).

Methods
Using a checklist of the essentials of G&G, we assessed Dutch medical education on three levels. On the national level we analysed the latest National Blueprint for higher medical education (Raamplan artsopleiding 2009). On the faculty level we reviewed medical curricula on the basis of interviews with program directors and inspection of course materials. On the student level we assessed the topics addressed in the questions of the cross-institutional progress test (CIPT).

Results
The National Blueprint contains few specific G&G objectives. Obligatory G&G courses in medical schools on average amount to 2.2% of the total curriculum measured as European Credit Transfer System units (ECTS). Only two out of eight medical schools have practical training during the Master phase in the form of a clerkship in G&G. In the CIPT, on average 1.5% of questions cover G&G.

Conclusion
Geriatric education in the Netherlands does not seem to be in line with current demographic trends. The National Blueprint falls short of providing sufficiently detailed objectives for education on the care of older people. The geriatric content offered by medical schools is varied and incomplete, and students are only marginally tested on their knowledge of G&G in the CIPT.

Click here for the full article.

In this report we delve into the coordination issues in the Dutch health care system. Coordination is considered to relate to two concepts: information-sharing, and definition of roles and responsibilities. Through good coordination of care, the client is guided through the many difficult pathways in health care in an effective and timely manner, ensuring that the patient is kept informed and satisfied. Effective information-sharing and a good division of roles and responsibilities can save lives, keep patients satisfied, and decrease spending levels. The main bottlenecks in the Dutch health care system are discussed and an oversight of all information streams is given.

Click here for the report.

The report is written upon request of the Institute of Future Welfare Japan.

Although the Dutch health care system has a complex structure with many drawbacks, many countries are interested in its features. This is not suprising. The medical care market has a novel semi-free market system, and the medical care system is one of the most qualitative and efficient systems in the world. The Dutch long-term care system is the most expensive in the world, reason why the Dutch government is drastically changing long-term care legislation and pioneering with a ‘social support system’. In 2013, health care is arranged through three major laws: the Health Insurance Act (ZVW); the Exceptional Medical Expenses Act (AWBZ); and the Social Support Act (WMO). In this report, we provide an overview of the workings and finances of the Dutch health care system by giving structured information on these three laws. Future plans are presented in the last part.

Click here for the report.

This report was written on the request of the Institute of Future Welfare Japan and presented at Waseda University in Tokyo.

Higher variability in visit-to-visit blood pressure readings, independent of average blood pressure, could be related to impaired cognitive function in old age in those already at high risk of cardiovascular disease, suggests a paper published on bmj.com.

There is increasing evidence that vascular factors contribute in development and progression of dementia. This is of special interest as cardiovascular factors may be amendable and thus potential targets to reduce cognitive decline and the incidence of dementia. Visit-to-visit blood pressure variability has been linked to cerebrovascular damage (relating to the brain and its blood vessels). It has also been shown that this variability can increase the risk of stroke.

It has been suggested that higher blood pressure variability might potentially lead to cognitive impairment through changes in the brain structures.

Researchers from the Leiden University Medical Center (Netherlands), University College Cork (Ireland) and the Glasgow University (UK) therefore investigated the association of visit-to-visit blood pressure variability (independent of average blood pressure) with cognitive function in older subjects at high risk of cardiovascular disease.

Both systolic (peak pressure) and diastolic (minimum pressure) blood pressures were measured every three months in the same clinical setting. The variability between these measurements were calculated and used in the analyses.

The study used data on cognitive function where the following was tested: selective attention and reaction time; general cognitive speed; immediate and delayed memory performance.

Results showed that visit-to-visit blood pressure variability was associated with worse performance on all cognitive tests. The results were consistent after adjusting for cardiovascular disease and other risk factors.

Association of visit-to-visit variability in blood pressure with cognitive function in old age: prospective cohort study
Sabayan B*, Wijsman LW, Foster-Dingley JC, Stott DJ, Ford J, Buckley BM, Sattar N, Jukema JW, Osch MJP van, Grond J van der, Buchem MA van, Westendorp RGJ, Craen AJM de, Mooijaart SP
BMJ 2013;347:f4600

*Behnam Sabayan succesfully completed the master Vitality and Ageing at Leyden Academy in 2011.

A quarter of all older people have four or more chronic health conditions, resulting in a need for complex health care that is very expensive. Recent research has suggested that enhancing primary health care in several ways could improve the quality of such chronic care and reduce its costs.
Guided Care is a nursing-enhanced model of comprehensive primary care for this population, which was recently tested. The results showed that it improved the quality of chronic care and physicians’ satisfaction with the care they provided. In integrated systems of care, guided care also reduced the use of hospitals and nursing homes.
On Tuesday 9 April Dr. Chad Boult gave a comprehensive lecture about caring for older persons with multiple chronic conditions. Dr. Boult outlined that persons with 4 or more chronic conditions, about 20 to 25% of the population, use approximately 80% of health care budget nowadays. This is related to many issues, but mainly, he argued, associated with numerous factors of mismatch in the organization and structure of health care. For instance, this chronically ill population is characterized by a high number of hospitalizations, caused by a frequent relapse after hospitalizations. Some, he described, are at the hospital more than 50 times a year, partly because the current system is not responsive to their needs.
Dr. Boult argued that our current health care is fragmented, discontinuous, difficult to access, inefficient, unsafe and expensive. In an illustrative quotation, he cited the American health care analyst Donald Berwick “Every system is designed perfectly to produce the results it gets”: The current system does not fit our chronically ill population and is mainly targeted at curing and not at caring. This produces a mismatch that increases costs. In an attempt to find alternative models, Dr. Boult and his team developed the guided care model.

In this model, guided care nurses work in a team with a physician to care for the 50-60 high risk patients with chronic conditions and complex health care needs. Nurses start by assessing needs and more importantly also patients’ preferences and priorities. From this they develop a care plan that is converted in an action plan in lay language for the patient. Instead of awaiting calls by the patient they proactively monitor the patient and create a close connection with the patient. They involve them in their own care, make them responsible for their own health, but also support and motivate them. Especially important in this regard are the transitions between different care institutions, such as from the hospital to the home and vice versa and the access to community services. The nurses also communicate with all the providers and caregivers involved.
The guided care model was researched in a trial involving more than 900 patients (485 in guided care and 419 in usual care). Results were positive, especially in regard to patient satisfaction, reductions of hospitalisations and reductions in caregiver strain. Physician satisfaction in the intervention group was also larger than in the usual care. Finally, after calculation of cost differences guided care proved to be 75.000 dollars cheaper per caseload than usual care.

Despite these promising results, it has not yet been further rolled out in the USA. Kaiser Permanente, a large insurance company owning its own health care facilities intends to further use the model. Dr. Boult related the slow furthering of this to one of the main problems of the structure of financing: savings are made on the side of the hospital, whereas the cost for this guided care model is paid by the primary care. As these two systems do not transfer money from one to another, the model is hard to implement.

In the discussion that followed, the application of the guided care model for the Netherlands was debated. Overall, many similarities were seen in the Dutch system, for instance with guided care nurses were compared to nurse practitioners or the role of neighborhood nurses. Moreover, in many instances general practitioners tend to take on the role of the guided care nurses as the point of reference for the patient. In the Netherlands, furthermore, similar financing problems would be the case.

Finally, Prof. Rudi Westendorp commented that in a discussion with one of the biggest health care insurers in the Netherlands exactly this point was raised and it was felt that the time has come to make a step towards changing this system.
All in all, the guided care model was seen as a promising model. The systematic barriers that currently still exist however, pose a large challenge for the actual implementation of these kinds of models. A change must be made to be responsive to the needs and wishes of our changing health care population.

Lecturer
Dr. Chad Boult is a teacher, researcher and board-certified physician in Family Medicine and Geriatrics. Dr. Boult has extensive experience in developing, testing, evaluating and diffusing new models of health care for older persons with chronic conditions. He has published two books and more than 80 articles in biomedical scientific journals. In 2009 and 2010 dr. Boult served as a ‘Health and Aging Policy Fellow’ at the Centers for Medicare & Medicaid Services (CMS).

February… Days are getting longer and a little bit less cold. Snow days are scarcer every week that passes by. Winter is almost over. I was afraid I might have found it a tough experience, but the truth is I loved every day of it, every day of snow, every bit of hail and every freezing evening with temperatures under zero. The best of the winter, however, were the Christmas holidays.

For as long as I can remember, Christmas has been my favorite time of the year. These last holidays were particularly special because I got to experience them from a completely different cultural context. I learned about Sinterklaas and I actually had him visit me and my fellow students at the Leyden Academy – it was a great surprise and we had quite a merry time while one of my classmates sat on his lap and sang a sinterklaasliedje. I got to experience first-hand the Christmas markets, and drank my share of hot wine, hot chocolate and all sorts of delicious seasonal treats. No wonder I put on a couple of kilo’s which I am now struggling to get rid of!

Special Christmas
One thing that made this Christmas even more special was having part of my family visiting over the holidays and travelling around with them. We went to Paris, where we spent Christmas, then Luxembourg, Brussels and finally Amsterdam for New Year. In the picture you see my grandfather and me in Versailles, France. Later on in January I received yet another visit – a very special one – and had the loveliest time in the last few months.

Current practices of geriatric medicine
Still, all things come to an end, and now it’s back to reality and hard working at the Leyden Academy. Not that I complain, though. I am still enjoying it as much as ever, even when it can be quite challenging. For example in our last course, Multimorbidity and Geriatric Giants, we learned some revolutionary concepts that bring into question some of the current practices of geriatric medicine. For a trained geriatrician like me, this can be shocking to say the least, but I am fully convinced that the only way to make progress and improve our practices is to constantly question and rethink what we hold as true and valid. After all, science is about a continuous and renewed search for answers that allow us to pose new questions. I find this quite stimulating.

Chinese New Year
Getting along with people comes rather easily to me, and this has been a very useful skill. I have made good friends with my classmates from the Master, but also with other international students outside the master. I am not that much of an all-night-party guy anymore, but I always take pleasure in an evening out or a nice dinner and I do enjoy the occasional party. For example, just last weekend a friend from the Master who is from China invited us to celebrate Chinese New Year at her place. We had a great time! In the picture you see fellow student Tianyi Bu leading the celebration of the Year of the Snake.

Orientation meeting for students
I remember that shortly before departing from Mexico I attended an orientation meeting for students who were going to live in The Netherlands. One of the speakers told us about a process of adaptation that most students go through, which consists of three phases: a honeymoon, when everything is new and exciting, followed by a blue phase, where homesickness is the main feature, and finally a phase during which students adjust to their life abroad. At that moment, I thought this was a very useful bit of information, and I was prepared to go through these phases. I don’t know what happened, though, because I am now well adjusted but still living my honeymoon with The Netherlands and I don’t see the end of it coming at all. I have only half a year left here and I intend to make the most of it. No time for homesickness, no time for longing. Every single day that passes is beautiful, unique and will never come back. This only happens once in a lifetime and I won’t miss the chance to live it!

They say that home is where the heart is. I say that home is where one makes it. And come to that, I am pretty sure I have made myself at home in this wonderful place, the memories of which I shall treasure forever.

Public health in the 21^st century: the prevention of diseases at old age

Dr. Luc Bonneux will set out his vision on public health in the 21st century. He will review Geoffrey Rose’s strategies of prevention and will critically appraise current public health policies, including screening, vaccination and cardiovascular risk management. Furthermore, he will review the role of the government, pharmaceutical companies and individuals themselves in this domain.

Dr. Luc Bonneux is a medical doctor, epidemiologist and publicist. He started his career as a doctor in tropical medicine, studied epidemiology in London and wrote his dissertation on health economic models of diseases of old age. He is well-known for his critical columns in, amongst others, ‘Medisch Contact’. In 2012 his latest book was published: ‘En ze leefden nog lang en gezond’. He currently works as a physician in elderly care. Dr. Luc Bonneux also lectures at the Master Vitality and Ageing of Leyden Academy.

Programme
16.00 – Introduction by Dr. David van Bodegom, Leyden Academy
16.10 – Lecture by Dr. Luc Bonneux
17.15 – Discussion
17.30 – Drinks

Location
Leyden Academy on Vitality and Ageing
Poortgebouw Leiden
South Entrance, room 0.15
Please click here for the directions.

Registration
Send an e-mail by 12 February to register for this free academic lecture: ageing@leydenacademy.nl.

Every month a question on ageing is answered by an expert from Leyden Academy on Vitality and Ageing. This months question is ‘Do health care costs increase with ageing?’
Do you have a question about aging? Please send an email.

In news releases and reports the rise of care costs is mainly explained by the growing number of elderly. At first glance, this seems very logical. Step 1: Older people are more likely to get sick and have a higher chance of a chronic disease. Step 2: The care cost thus increase when people grow older. Step 3: If in the Netherlands the number of older people continues to increase, so will the healthcare costs. This reasoning seems to be confirmed by the figures. The number of people older than 65 in the Netherlands increases from 15% in 2009 to 24% in 2040.[1] Of the lifetime health care costs of Dutch people, 72% is made after the age of 65.[2]

1 + 1 + 1 = 3, right?
 

Not quite, if we look at the calculations of two former Dutch politicians: Roger van Boxtel and Willem Vermeend.[3] According to them, the care costs increased 6.4% annually between 2008 and 2011. Of this percentage, only 0.7% can be contributed to ageing. The other 5.7% is due to legitimate economic changes (such as inflation and the Baumol effect) and volume growth (more people are seen and treated by the doctor or therapist, or hospitalised). Patients have become more demanding and medical innovations have increased the possibilities. Of course, this is a blessing. Economic growth must be in the service of our health, health care cannot serve economic growth.

Nevertheless, we do not want our premiums to increase. If, in the upcoming years, we can achieve economic growth and we maintain the volume growth, then health care costs do not have to rise, despite of the ageing population. In the Netherlands, two major changes can reduce the average cost of elderly care in the long term. Firstly, the Dutch government want to set priorities in the field of care. Elderly care will have to deal with huge cutbacks. More is expected from the elderly themselves, as well as from the citizens, who must support the elderly more actively. More important than cutbacks is ending bureaucracy, which causes inefficiency and breaks down the quality of health care. Experiments with district nurses, cooperatives and abolition of rules and regulations are current examples.
Secondly, the elderly community itself is changing. It is very likely that the elderly of the future will be more independent. Also the life expectance of men is increasing, reducing the number of care-dependent widows. In addition, research shows that a large part of health care costs is made just before death. Sometimes treatments at very high ages is unnecessary and not in the best interest of the patient. More insight into the effectiveness of treatments in older age, and associated improvements in protocols, are needed.

Improving healthcare and reducing costs at the same time is within reach!

Herbert Rolden
Economist and PhD student Leyden Academy on Vitality and Ageing

[1] Central Bureau of Statistics
[2] National Institute for Public Health and the Environment
[3] Willem Vermeend & Roger van Boxtel. Uitdagingen voor een Gezonde Zorg. Amsterdam: Lebowski, 2010.