© Borgis - New Medicine 1/2013, s. 9-13
*Małgorzata Koziarska-Rościszewska1, Tomasz Kostka2, 3
Improving the care of older people by family physicians in Poland
1Family and Community Medicine Department, Medical University of Łódź, Poland
2Department of Geriatrics, Medical University of Łódz, Poland
3Institute of Rheumatology, Medical University of Warsaw, Poland
Introduction. Polish society has been aging rapidly. The percentage of citizens aged ≥ 65 years will increase to 17.2% in 2025. The current undergraduate and postgraduate training in geriatrics is not sufficient. The project objectives were to provide general practitioners (GPs) with the necessary knowledge.
Material and methods. A group of GPs was trained in important geriatric problems management during a one-year course funded by a grant from the Merck Institute of Aging & Health; The course covered: data concerning community-dwelling and institutionalized elderly, morbidity, mortality, the most important elements of comprehensive geriatric assessment. The program included 5lecture (general knowledge)-, 8seminar (problem-based approach to the topic)- and 16workshop days (case studies). At the beginning and at the end of the course trainees completed tests regarding geriatrics knowledge.
Results. Evaluation of the educational modules was performed (0-5 scale). Assessment included scientific value (SV), practical value (PV), presentation techniques (PT), global evaluation (GE). SV was highest for seminars (4.98 ± 0.02) (mean ± standard error), lower for workshops (4.62 ± 0.05), the lowest for lectures (4.47 ± 0.04). PV was better for seminars (4.88 ± 0.05) and workshops(4.60 ± 0.06) than for lectures (4.39 ± 0.04). PT were higher for seminars (4.84 ± 0.09) and workshops (4.57 ± 0.05) than lectures (4.25 ± 0.04). GE was highest for seminars (4.92 ± 0.04), the lowest for lectures (4.42 ± 0.04). Mean result of the follow-up test (12.54 ± 0.48 correct answers) was significantly higher (P < 0.001) in comparison with the baseline test (11.0 ± 0.37).
Conclusions. The program was effective in improving the GPs knowledge on essential issues of geriatrics. Providing interactive methods is crucial for an efficacious GPs education in geriatrics.
Poland, with over 38 million inhabitants (1), is one of the largest countries in the Central-Eastern Europe. Polish society has been aging rapidly during recent years. Since 1990, the average life span has increased by nearly 4 years (ys) for men and 3.4 ys for women. Although the average life expectancy was 70.5 ys for men and 78.9 ys for women in 2003, it is predicted to increase to 77.6 ys for men and 80 ys for women by 2030. The percentage of citizens aged ≥ 65 ys was 10.2% in 1990, 12% in 1999, and is predicted to increase further to 17.2% by 2025 (1). This aging population is confronted by a medical education system completely unprepared to deal with such a situation. The number of geriatricians in Poland is about 150, only 80 actually work within this specialization, making an average of 0.16 geriatricians/10,000 citizens > 65 ys old, which is far lower than what is needed and much lower than in the other EU countries. In Great Britain for example, the number of geriatricians is about 800; however, the target level is 1200 (1.2 geriatricians/10 000 subjects over 65 ys) (2). In Poland, undergraduate training in gerontology and geriatrics does not exist in the majority of medical universities, postgraduate training for geriatricians is very scarce, and for GPs, it is virtually absent. A growing number of older people require adequate medical treatment and care. Primary care physicians consult the majority (> 65%) of patients from their lists at least one time each year and 90% at least once in 5 years, so they are in an excellent position within the health care system to provide the proper care (3).
As GPs lack knowledge of gerontology and geriatrics, the project objectives were to provide Polish family physicians with this knowledge.
material and METHODS
A group of GPs was trained in the management of important geriatric problems, such as data concerning the community-dwelling and institutionalized elderly in Poland, morbidity and mortality, and the most important elements of comprehensive geriatric assessment, on a one-academic year course funded by a grant from the Merck Institute of Aging & Health. Particular emphasis was paid to the following information and skills:
1. Biology of aging; demographic and epidemiological data concerning the community-dwelling and institutionalized elderly in Poland. Prevalence of diseases, morbidity and mortality.
2. The most important elements of comprehensive geriatric assessment:
– evaluation of the nutritional state by measuring the percentage of body fat tissue, using the 4-skinfolds method, measuring calf circumference, the waist-hip-ratio (WHR), calculating the body mass index (BMI) and using the Mini Nutritional Assessment questionnaire (MNA),
– evaluation of physical disability by the activities of daily living (ADL) and the instrumental activities of daily living (IADL),
– evaluation of cognitive functions using the mini-mental state examination (MMSE) and the 15-item geriatric depression scale (GDS).
3. Other important elements of geriatric evaluation, such as physical activity questionnaires or quality of life scales.
4. Disease and disability prevention.
The principal intervention included lectures, seminars and workshops throughout the whole academic year. Five general lectures -4 hours (h) per lecture- presented general knowledge in geriatrics (epidemiology, health promotion, disease prevention, care of older adults). The team of instructors comprised four university professors, and four university lecturers with PhDs: two in geriatrics and two in family medicine. The number of participants was 50-100 at each lecture. Eight seminars (4 h per seminar, 1 seminar per month) included lectures provided by both instructors and participants, working groups and case discussions concerning community and hospitalized patients. Each seminar included an introduction with an overview and a problem-based approach to the topic of the session, focusing on a community setting. The number of participants was 10-25 at each seminar. Sixteen interactive workshops and small group discussions designed to deal with case studies and one selected practical geriatric topic (4 h per session) were provided. Five expert geriatricians, two university family medicine lecturers and one senior nurse lecturer were running the sessions with 5-15 participants at a time. Workshops included case presentations and practical training methods including fitness measurements (aerobic exercise testing, musculoskeletal fitness, flexibility), anthropometry, and nutritional assessment. Interactive discussions in small groups enabled GPs to analyze their own practice, discuss current approaches and share opinions among the work-groups about an assigned topic. Implementation of EBM standards of care at homes for the elderly was especially stressed.
The unique feature of the educational program was the cooperation with the WHO Countrywide Integrated Noncommunicable Diseases Intervention Programme (CINDI) in Poland4. The course coincided with an important event, the national WHO CINDI Poland Meeting with disease prevention and health promotion in the elderly being the leading topic, with one day of the congress being devoted to GP training in geriatric medicine.
The educational grant financed also two TV programs and two general newspaper articles on health problems affecting the older population in Poland. All these activities substantially contributed to the development of a policy of non-communicable disease prevention in the elderly. A special website “Improving the care of older people in Poland”, targeting practising GPs in particular, was created (5). A special issue of Lekarz Rodzinny (Family Physician), one of the well-known journals for GPs in Poland, was published (6).
Data were verified for normality of distribution and equality of variances. The one way analysis of variance (ANOVA) with LSD post hoc testing and the Kruskal-Wallis test were used for comparisons between educational modules and lecturers” evaluation. Paired t-test was used to compare final to the baseline test performed by the same 59 GPs. The results are presented as the mean ± standard error (SE). The level of significance was set at p ≤ 0.05 for all the analyses.
An evaluation of each module (lectures, seminars, workshops) was performed. Assessment included scientific value (SV), practical value (PV), techniques of presentation (PT) and global evaluation (GE). The scale of the assessment was 0 (minimal) to 5 (maximal).
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