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Influenza Other Respi Viruses. 2019;13:233–239. | 233wileyonlinelibrary.com/journal/irv

Received: 29 August 2018 | Revised: 19 December 2018 | Accepted: 31 December 2018
DOI: 10.1111/irv.12633

O R I G I N A L A R T I C L E

Impact of influenza on hospitalization rates in children with a
range of chronic lung diseases

1Faculty of Medicine, Discipline of Pediatrics, School of Women’s and Children’s Health, UNSW Sydney, Sydney, New South Wales, Australia
2Respiratory Department, Sydney Children’s Hospital, Sydney, New South Wales, Australia
3Stats Central, Mark Wainwright Analytical Centre, UNSW Sydney, Sydney, New South Wales, Australia
4Department of Newborn Care, Royal Hospital for Women, Sydney, New South Wales, Australia
5Centre for Big Data Research in Health UNSW Sydney, Sydney, New South Wales, Australia
6NSW Pregnancy and Newborn Services Network, Sydney Children’s Hospitals Network, Sydney, New South Wales, Australia
7Princess Margaret Hospital, Perth, Western Australia, Australia
8Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
9Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
10School of Public Health, Curtin University, Bentley, Western Australia, Australia
11National Perinatal Epidemiology and Statistics Unit (NPESU), Kensington, New South Wales, Australia

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2019 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.

Correspondence
Nusrat Homaira, Discipline of Pediatrics,
School of Women’s and Children’s Health,
UNSW Medicine, Level-8, Centre for Child
Health Research and Innovation (ChERI), The
Bright Alliance, Randwick, NSW, Australia.
Email: n.homaira@unsw.edu.au

Funding information
This work was supported by The Rotary Club
of Sydney Cove. The funding organization
had no role in the study design, analyses or
drafting of the manuscript.

Background: Data on burden of severe influenza in children with a range of chronic
lung diseases (CLDs) remain limited.
Method: We performed a cohort study to estimate burden of influenza-associated
hospitalization in children with CLDs using population- based linked data. The cohort
comprised all children in New South Wales, Australia, born between 2001 and 2010
and was divided into five groups, children with: (a) severe asthma; (b) bronchopulmo-
nary dysplasia (BPD); (c) cystic fibrosis (CF); (d) other congenital/chronic lung condi-
tions; and (e) children without CLDs. Incidence rates and rate ratios for
influenza- associated hospitalization were calculated for 2001- 2011. Average cost/
episode of hospitalization was estimated using public hospital cost weights.
Results: Our cohort comprised 888 157 children; 11 058 (1.2%) had one of the CLDs.
The adjusted incidence/1000 child- years of influenza- associated hospitalization in
children with CLDs was 3.9 (95% CI: 2.6- 5.2) and 0.7 (95% CI: 0.5- 0.9) for children
without. The rate ratio was 5.4 in children with CLDs compared to children without.
The adjusted incidence/1000 child- years (95% CI) in children with severe asthma was
1.1 (0.6- 1.6), with BPD was 6.0 (3.7- 8.3), with CF was 7.4 (2.6- 12.1), and with other
congenital/chronic lung conditions was 6.9 (4.9- 8.9). The cost/episode (95% CI) of
influenza- associated hospitalization was AUD 19 704 (95% CI: 11 715- 27 693) for
children with CLDs compared to 4557 (95% CI: 4129- 4984) for children without.

www.wileyonlinelibrary.com/journal/irv

https://orcid.org/0000-0003-3341-7964

http://creativecommons.org/licenses/by/4.0/

mailto:n.homaira@unsw.edu.au

234 | HOMAIRA et Al.

1 | INTRODUCTION

Globally, influenza is a major public health problem. Every year
during seasonal epidemics, 3- 5 million people develop severe in-
fluenza requiring hospitalization.1 Young children, especially those
aged <5 years, are particularly vulnerable to infection; around 10%- 30% of children are infected with the virus during each influenza season.2 Children also play an important role in transmission by shedding large quantities of virus for 7- 10 days and introducing the virus into households.3

Influenza virus infection may be especially problematic in chil-
dren with chronic lung diseases (CLDs). It can exacerbate the re-
spiratory symptoms of the underlying lung condition resulting in
unscheduled medical presentations and contributing to the total
burden of CLDs on the health system. Children with CLDs such as
asthma have been reported to be at double the risk of hospitalization
with influenza compared to children with other chronic conditions.4
Data on the burden of influenza among children with other CLDs are
more limited, and largely limited to the burden in children with cystic
fibrosis (CF).5 Such data are crucial for informing policy makers, clini-
cians, and public health professionals of the magnitude of the prob-
lem and for monitoring burden of disease over time and evaluate
vaccine effectiveness thus influencing influenza vaccine policy. We
therefore conducted a retrospective population- based cohort study
designed to measure the incidence rates and direct healthcare cost
related to influenza- associated hospitalization in children with CLDs.

2 | PATIENTS AND METHODS

2.1 | Study population

The study was conducted in New South Wales (NSW), Australia,
comprising all children born and residing in NSW during 2001- 2010
with follow- up until the end of 2011 (31 December 2011).

2.2 | Study design

The retrospective cohort study used linked population- based admin-
istrative data sets. In NSW, The Centre for Health Record Linkage
(CHeReL) (www.cherel.org.au) conducts linkage of administrative
health data sets for research purposes and provides each child with
a unique Patient Project Number (PPN). The de- identified data sets
with the unique PPNs were provided to the study investigators.
Records of the same child in the different data sets were combined
using the unique identifier key.6

The NSW Perinatal Data Collection (PDC) which records all births
in NSW was used as the primary data source for identifying the
study cohort. Information relating to maternal and child factors such
as maternal smoking during pregnancy, number of previous pregnan-
cies, Indigenous status of the mother, postcode of area of residence,
birth weight, gestational age at birth, and sex of the baby was as-
certained from PDC. Data relating to diagnosis of CLDs and influ-
enza-associated hospitalization were ascertained from the Admitted
Patient Data Collection (APDC) and Neonatal Intensive Care Unit
Data (NICU). The data sets have been described previously.6

2.3 | Exposure assessment

The birth cohort was divided into five mutually exclusive sub- groups.
We used the International Classification of Diseases, 10th edition
(ICD-10), primary diagnostic codes to identify children in each sub-
group, which was introduced in Australian hospitals in July 1998.7

1. Children with severe asthma: Children aged >2 years who had
≥2 asthma hospitalization after the age of 2 years with ICD-10
diagnostic codes associated with asthma (J45), predominantly
allergic asthma (J45.0), non-allergic asthma (J45.1), mixed asthma
(J45.8), asthma unspecified (J45.9), and status asthmaticus (J46).
As diagnosis of asthma is difficult in children aged <2 years 8 and as the national immunization guidelines recommend seasonal influenza vaccine for children with severe asthma (requiring frequent hospitalization),9 only these children were included in the analysis. Additionally, we excluded ICD codes associated with recurrent wheeze as many of these could have been due to respiratory viral infection and not due to asthma.

2. Children with bronchopulmonary dysplasia (BPD): Children who
were born at gestational age (GA) ≤32 weeks and required oxygen
and/or any type of respiratory support at 36 weeks’ GA 10 or had
any history of hospitalization with ICD-10 diagnostic code associ-
ated with bronchopulmonary dysplasia originating in the perinatal
period (P27.1). The NICU data set and the APDC data sets were
used to identify children with BPD.

3. Children with CF: Children with any history of hospitalization with
ICD-10 diagnostic codes associated with CF (E84), CF with pulmo-
nary manifestations (E84.0), CF with intestinal manifestations
(E84.1), CF with other manifestations (E84.8), CF unspecified (E84.9).

4. Children with other congenital and chronic lung conditions:
Children with any hospitalization code associated with congeni-
tal/chronic lung conditions for which there was an available ICD
code including congenital diaphragmatic hernia (Q79.0-Q79.4),

Discussion: This large population- based study suggests a significant healthcare bur-
den associated with influenza in children with a range of CLDs.

KEY WORDS

chronic lung diseases, influenza burden, pediatrics

http://www.cherel.org.au

| 235HOMAIRA et Al.

congenital tracheo-esophageal fistula (Q39.2-Q39.8), congenital
tracheomalacia (Q32.0-32.4), congenital malformation of lung
and respiratory system (Q33-Q34), bronchiectasis (Q33.4), de-
pendence on ventilators (Z99.1), interstitial emphysema (J98.2),
other specified and unspecified interstitial lung diseases (J84.8
and J84.9), and Kartegener’s syndrome (Q89.3).

5. All other children without chronic lung diseases.

2.4 | Primary outcome

Influenza- associated hospitalization: The ICD-10, primary diagnos-
tic codes associated with influenza-associated hospitalizations were
used to identify all influenza- associated hospitalizations from APDC.
Any ICD- 10 diagnostic codes listed as influenza and pneumonia (J09,
J10, J10.0, J10.1, and J10.8) where influenza virus was identified
were considered to be associated with influenza. All other hospi-
talizations associated with influenza and pneumonia code but where
a virus was not identified (J11.0, J11.1, and J11.8) and where the
hospitalization occurred during influenza season (usually between
May- September in Australia) were also considered to be associated
with influenza.

2.5 | Other co- variates

Data on maternal and child factors considered to be independent risk
factors for acute lower respiratory infections 11 including multipar-
ity of the mother (previous pregnancy lasting >20 weeks), maternal
smoking during pregnancy, Indigenous status of the mother, residen-
tial postcode of the mother at birth, small for gestational age, and sex
of the cohort child were ascertained from the PDC. Frequency of all-
cause- associated hospitalizations in the cohort child was retrieved
from the APDC. Socioeconomic disadvantage was inferred from the
maternal postcode using the Socioeconomic Index of Areas (SEIFA)
and Index of Relative Socioeconomic Advantage and Disadvantage
(IRSAD) compiled by the Australian Bureau of Statistics.12

2.6 | Bias

This was a large population- based cohort study with minimum selec-
tion bias.

2.7 | Study size

This was a whole- of- population study including all children born in
NSW between 2001 and 2010.

2.8 | Analyses

The overall and year- specific incidence rates for influenza- associated
hospitalizations were calculated for years 2001- 2011. We calculated
incidence as the number of new influenza-associated hospitaliza-
tions divided by the child- years at risk in each of the disease groups.
A lag of 14 days between two successive influenza- associated

hospitalizations was considered to be a new hospitalization. We used
Poisson estimation to calculate incidences and incidence rate ratios
(including 95% confidence interval around the estimates) of influenza-
associated hospitalizations. The incidence rates and rate ratios were
adjusted for parity of the mother, maternal smoking during pregnancy,
Indigenous status, IRSAD, sex of the child, small for gestational age,
and frequency of previous hospitalizations in the cohort child. There
were 0.5% missing data for variables including Indigenous status of
the mother, socioeconomic disadvantage of the area of residence,
and maternal smoking during pregnancy. Observations with one or
more variables missing were dropped from the analyses.

Inpatient hospital costs associated with influenza was estimated
using NSW Cost of Care Standards 2009/10.13 These standards
specify costs and cost weights based on Australian Refined Diagnosis
Related Group Version (AR- DRG) for each episode of acute admitted
hospital services. The cost weights provide a measure of resource
consumption relative to a reference value of one in NSW represent-
ing the average inpatient hospital (public and private) admission in a
given year. At discharge, each episode of acute hospital care is as-
signed an AR- DRGs and associated cost weight which represents its
relative resource consumption relative to the reference value. The
cost weights account for admission through emergency department
presentation and admission in to the intensive care unit. Further
adjustments are made to the cost weights to account for same- day
admissions, extended length of stay, transfer episodes, Indigenous
status, private hospital stays, neonates, and death.

To estimate hospital costs for influenza admissions, we assigned
the weighted “total standard NSW public hospital cost” to the cost
weights assigned to each episode of acute hospital care in the APDC
using the NSW Costs of Care Standards 2009/10.13 The average
costs for acute admitted care were 4280 Australian dollars (AUD) for
2009/10 which was indexed for each study year (average annual dis-
count rate of 3.5%) using the deflators specified in the NSW Costs of
Care Standards to reflect constant 2009/10 Australian dollars. For
hospitalizations that resulted in transfer to other facilities, the cost
was equivalent to the sum of total cost incurred at each of facility. We
divided the total cost of all influenza- associated hospitalization iden-
tified over the 11- year period by 11 to estimate the annual direct cost
of influenza- associated hospitalizations. All analyses were done using
STATA (STATA release 13; StataCorp LP, College Station, TX, USA).

2.9 | Ethics approval

The project was approved by the NSW Population and Health
Service Research (HREC/09/CIPHS/33; 2009/05/155) and the
Aboriginal Health and Medical Research Council Ethics (726/10).

3 | RESULTS

3.1 | Profile of the Cohort

The cohort comprised 888 157 children born between 2001 and
2010. Of these, 11 058 (1.2%) had one of the CLDs, and 6724

236 | HOMAIRA et Al.

(61.0%) were male. Around 4.0% of all children with CLDs were of
Indigenous origin (Table 1).

3.2 | Incidence of influenza-associated
hospitalization

During 2001- 2011, there were 3.101 influenza- associated hospi-
talizations, and 2.4% of the children with CLDs compared to 0.3%
children without CLDs had one or more influenza- associated hospi-
talizations. The unadjusted and adjusted incidence/1000 child- years
of influenza- associated hospitalization in children with CLDs was 3.7
(95% CI: 3.0- 4.3) and 3.9 (95% CI: 2.6- 5.2) and for all other children
without CLDs was 0.5 (95% CI: 0.4- 0.5) and 0.7 (95% CI: 0.5- 0.9),
respectively. During 2001- 2011, the annual incidence of influenza-
associated hospitalization in children with CLDs ranged between 0.0
and 25.4/1000 child- years (Figure 1). The adjusted incidence rate
ratio for influenza- associated hospitalization in children with CLDs
compared to children without CLDs was 5.4.

The unadjusted incidence/1000 child- years of influenza-
associated hospitalization in each CLD group was 1.1 (0.7- 1.4) for
children with severe asthma, 5.4 (3.6- 7.2) for BPD, 6.9 (2.5- 11.4) for
CF, and 7.7 (5.9- 9.4) for children with other congenital and chronic
lung conditions. The adjusted age- specific incidence rates and rate
ratios are presented in Table 2.

3.3 | Inpatient resource consumption of
influenza illness

The length of stay (days) for each episode of influenza- associated
hospitalization in children with and without CLDs is presented in
Figure 2. The longest median length of stay was for children with

BPD (7.0 days; IQR 1.7- 27.3). A total of 13% of the episodes of in-
fluenza-associated hospitalization in children with CLDs required
referral to another hospital for continuity of care compared to 7%
in children without CLDs. The average cost/episode of influenza-
associated hospitalization for children with CLDs was AUD 19 704
(95% CI: 11 715- 27 693) equating to an average annual cost to the
NSW hospital system of AUD 428 132 (equivalent to approximately
US$ 314 902) and for children without CLDs was 4557 (95% CI:
4129- 4984) which was equivalent to AUD 867 033 annually (ap-
proximately US$ 637 808).

4 | DISCUSSION

This large population- based study has demonstrated that children
with CLDs are at least five times more likely than children with-
out CLDs to be hospitalized with influenza. A previous study from
the USA has also demonstrated that children with acute cardio-
pulmonary diseases were 2- 4 times more likely to be hospitalized
with influenza- associated illness than other children.4 The direct
medical cost of AUD 19 704/episode of influenza- associated hospi-
talization in children with CLDs was also four times higher compared
to children without, representing a high economic burden on the
healthcare system. Furthermore, the hospitalization rates in our co-
hort were highest in the youngest children and decreased with age,
a finding that is consistent with the USA study.4 Younger children
especially those aged <2 years are at higher risk than older children of severe influenza,14 which is increased in the presence of an under- lying CLD. Vaccination against influenza is the primary strategy to control seasonal outbreaks. Influenza vaccination has been proven to be a safe and effective in people with CLDs.15 The Australian

TABLE 1 Descriptive profile of the cohort children born between 2001 and 2010 in NSW, Australia

N = 888 157

Exposures

Children with
severe asthma Children with BPD Children with CF

Children with other
congenital and chronic
lung conditions

All other children
without chronic
lung diseases

n = 7736 n = 1055 n = 260 n = 2007 n = 877 099

n (%)

Multiparity of the mother 4446 (57.5) 510 (48.3) 137 (52.7) 1161 (58.0) 510 288 (58.2)

Maternal smoking during pregnancy 1315 (17.0) 253 (24.0) 41 (15.8) 330 (16.4) 120 397 (13.7)

Indigenous status of the mother 291 (3.8) 68 (6.5) 13 (5.1) 91 (4.6) 29 228 (3.4)

IRSAD

1 (most disadvantaged) 1990 (25.7) 268 (25.5) 56 (21.5) 469 (23.4) 195 668 (22.3)

2 1893 (24.5) 229 (22.0) 64 (24.6) 486 (24.2) 202 308 (23.1)

3 1979 (25.6) 263 (25.0) 74 (28.5) 495 (24.7) 223 744 (25.5)

4 (most advantaged) 1873 (24.2) 290 (27.6) 66 (25.4) 553 (27.6) 254 923 (29.1)

Male sex of the baby 4839 (62.5) 595 (56.4) 126 (48.5) 1164 (58.0) 449 943 (51.3)

Small for gestational age at birth 320 (4.1) 56 (5.3) 14 (5.4) 147 (7.4) 28 080 (3.2)

BPD, Bronchopulmonary dysplasia; CF, Cystic fibrosis; IRSAD, Index of Relative Socioeconomic Advantage and Disadvantage.

| 237HOMAIRA et Al.

immunization guidelines emphasize the need for seasonal influenza
vaccine for people aged ≥6 months with chronic medical conditions.9
Maternal immunization to protect infants in their first 6 months of
life 16 followed by active immunization annually may help lower the
exceptionally high burden on the health system associated with in-
fluenza illness in young children with CLDs.

The rate of influenza- associated hospitalization in children aged
2- 5 years with asthma in our cohort was much higher than the re-
ported annual rate of 0.6/1000 person- years in children with asthma
in the USA.17 This could be due to differences between the study
populations; the study from USA only included children who were
hospitalized with acute respiratory infection or fever whereas we
considered any hospitalization with ICD- 10 codes associated with
influenza. Additionally, Australia has a universal healthcare system
where most inpatient care for children is covered by federal state
governments. Australia’s immunization guidelines emphasize the
need for seasonal influenza vaccination for children with severe
asthma requiring frequent hospitalizations.9 Although the national
vaccine uptake data for asthmatic children are limited, a survey con-
ducted by Asthma Australia in 2016 demonstrated that 41% of peo-
ple with asthma (mostly children) were not likely to be vaccinated
against influenza clearly indicating very low uptake which is unac-
ceptable for any other pediatric vaccine.

Children with CF in our cohort were at least 11 times more likely
to be hospitalized with influenza- associated illness compared to chil-
dren without CLDs. While much attention is given to bacterial infec-
tions in children with CF, respiratory viral infections have also been
associated with pulmonary deterioration and disease progression.18
Studies from the USA have associated increases in influenza trans-
mission with increased frequency of pulmonary exacerbations 19 and
found comparable high rates of influenza-associated hospitalization
(12.97/1000 person- year) among children aged 0- 17 years with CF.5
Influenza vaccine is widely recommended for people with CF, and
the vaccine has been shown to be safe in these patients 20 and, in
contrast to children with asthma, the uptake of seasonal influenza
vaccine has been reported to be high (≥80%).21, 22 There is a need for
further research into the impact of regular seasonal influenza vaccine
on pulmonary function in patients with CF.23, 24 Additionally, there is
a need to examine the benefit of timely use of antivirals in these chil-
dren with proven or suspected influenza infection in reducing lung
damage.20

In our study, children with BPD also had very high rates of hos-
pitalizations associated with influenza. The median length of hospi-
talization was also very long for children with BPD. Studies suggest
that although symptoms of BPD improve with age, children with
BPD continue to have abnormal lung function and are at elevated

FIGURE 1 Annual incidence/1000
child- years of influenza- associated
hospitalization in children with and
without chronic lung diseases, 2001- 2011,
NSW, Australia

0
2
4
6
8

10
12
14
16
18
20
22
24
26
28
30

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

In
ci

de
nc

e
of

in
lfu

en
za

-a
ss

oc
ia

te
d

ho
sp

ita
lis

at
io

n/
10

ch
ild

-y
ea

Children with chronic lung diseases All other children without chronic lung diseases

TABLE 2 Adjusted incidence/1000 child- years and incidence rate ratios of influenza- associated hospitalization in children with chronic
lung diseases, 2001- 2011, NSW, Australia

Incidence/1000 child- years (95% CI)
Incidence rate
ratio (95% CI)a0- 24 mo 2- 5 y 5- 10 y Overall incidence

Severe asthma N/A 5.4 (1.4- 9.4) 1.2 (0.3- 2.0) 1.1 (0.6- 1.6) 1.8 (1.2- 2.6)

BPD 41.6 (15.7- 67.5) 1.7 (−0.8 to 4.2) 1.0 (−0.8 to 4.4) 6.0 (3.7- 8.3) 9.0 (6.4- 12.7)

CF 44.5 (6.0- 83.0) 4.6 (−2.15 to 11.4) 0 (0- 0) 7.4 (2.6- 12.1) 11.12 (6.0- 20.9)

Other congenital and
chronic lung conditions

42.9 (18.1- 67.8) 6.0 (1.4- 10.6) 1.1 (0.2- 2.1) 6.9 (4.9- 8.9) 10.4 (7.9- 13.5)

All other children without
chronic lung diseases

9.3 (4.4- 14.2) 0.6 (0.3- 1.0) 0.1 (0.0- 0.1) 0.6 (0.4- 0.9) Reference group

BPD, Bronchopulmonary dysplasia; CF, Cystic fibrosis; IRSAD, Index of Relative Socioeconomic Advantage and Disadvantage; 95% CI, 95% Confidence
interval.
aThe rate of influenza-associated hospitalization in each of the groups of children with chronic lung diseases was significantly higher (P < 0.05) com- pared to rate in all other children without chronic lung diseases.

238 | HOMAIRA et Al.

risk of being hospitalized with respiratory illness compared to other
children.25-27 While several studies have shown the significant bur-
den of respiratory syncytial virus among children with BPD,6, 28 the
impact of influenza illness remains less clearly defined.

Our study also showed that the rate of influenza-associated hos-
pitalization was 10 times higher in children with other congenital and
chronic lung diseases than all children without CLDs, yet there are
almost no available data on the burden of influenza in these children.

Our study has several important limitations. There are no na-
tional disease registries for children with CLDs (with the excep-
tion of CF) so our cohort was constructed from a comprehensive
hospitalization dataset based on ICD codes. Ascertainment of
influenza- associated hospitalization was also based on ICD codes.
Even though not all influenza- associated hospitalizations are labo-
ratory confirmed but as influenza is a notifiable condition in NSW,
it is likely that most hospitalizations receiving an influenza- specific
code were laboratory confirmed; however, we were not able to
substantiate this. Not all children hospitalized with acute lower
respiratory illness are routinely tested for influenza so it is likely
that the true burden of influenza- associated hospitalization in chil-
dren with CLDs is even higher than our estimates. We considered
all influenza- coded hospitalizations where an influenza virus was
not identified to be associated with influenza which may have in-
flated our estimates; however, none of the influenza-associated
hospitalization in our cohort was associated with an ICD code for
influenza where an influenza virus was not identified. We did not
have access to data on primary care or emergency presentations
and therefore we could not assess the rate of ambulatory influ-
enza infection in children with CLDs, where the burden is likely to
be higher. Although we adjusted our estimated rates for a num-
ber of known potential confounders, we did not have access to
direct information on other potential confounders such as house-
hold exposure to tobacco smoke or presence of siblings at home.

Instead, we used maternal smoking during pregnancy as a proxy
for household smoke exposure and previous pregnancy/parity
(lasting at least 20 weeks) as a proxy for having older siblings at
home. We used the IRSAD score of the mother’s postcode at the
time of delivery, a measure of average socioeconomic disadvan-
tage in that postcode, as a proxy for family level socioeconomic
disadvantage.29 We estimated incidence rate ratio for influenza-
associated hospitalization in children with CLDs compared to all
other children which included children with other chronic condi-
tions and may have led to lower rate ratios. Influenza vaccination
status is not routinely recorded in the national immunization data
base, and we did not have access to antiviral use in these children.

In summary, although only around 1.4% of the total pediatric
population in our cohort had one of the chronic lung diseases, these
children form a special group because of their ongoing need for
healthcare services. Our data clearly show that influenza illness in
these children add to the existing burden of chronic diseases on the
health system. While there are no effective vaccines or antivirals for
most childhood respiratory viral infections, fortunately we do have
a vaccine against influenza. There are also effective antivirals which,
if administered in a timely manner, may reduce disease severity.30-32
However, such high burden of hospitalizations indicates that cur-
rent efforts at influenza prevention are inadequate among children
with CLDs. Further studies investigating the effectiveness of newer
vaccines, treatment, or chemoprophylaxis in these children will help
lower the burden of disease.

ACKNOWLEDGEMENTS

The authors would like to thank Sydney Children’s Hospital Foundation
and Rotary Club of Sydney Cove for their continued support in our
research endeavors. We also thank all the Directors, the NICUs mem-
bers and the audit officers of all the tertiary units in supporting this

FIGURE 2 Length of stay for
influenza- associated hospitalization in
the cohort children, 2001- 2011, NSW,
Australia

| 239HOMAIRA et Al.

collaborative study. We are grateful to the Respiratory Department
of Sydney Children’s Hospital, Randwick, Sydney for their coopera-
tion. We thank the Aboriginal Health and Medical Research Council
and Ministry of Health, NSW. We also thank the babies and their fam-
ilies, the nursing and midwifery, obstetric and medical records staff of
the obstetric and children’s hospitals in NSW and the ACT.

CONFLICT OF INTEREST

The authors have no conflicts of interest relevant to this article to
disclose.

ORCID

Nusrat Homaira https://orcid.org/0000-0003-3341-7964

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How to cite this article: Homaira N, Briggs N, Oei J-L, et al.
Impact of influenza on hospitalization rates in children with a
range of chronic lung diseases. Influenza Other Respi Viruses.
2019;13:233–239. https://doi.org/10.1111/irv.12633

https://orcid.org/0000-0003-3341-7964

http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/7B28E87511E08905CA257D4D001DB1F8/$File/Aus-Imm-Handbook

http://www1.health.nsw.gov.au/pds/ArchivePDSDocuments/GL2011_007

https://doi.org/10.1111/irv.12633

Copyright of Influenza & Other Respiratory Viruses is the property of Wiley-Blackwell and
its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.

56 JCN 2019, Vol 33, No 4

H
ealth promotion is an

important part of a
community nurse’s job role

(Lundberg et al, 2017). As a concept,
health promotion has become more
popular since the 1970s following
a Canadian health report (Lalonde,
1974). Recent publications have
shaped nurses understanding of
health promotion (Polan and Taylor,
2019), defining this role as being able
to empower patients to take control
of their own health needs while
enabling them to identify which
aspects of their health are most
important to them (Naidoo and
Wills, 2016).

The prevalence of smoking means
that almost every health and social
care practitioner, including those in
the community, will be involved in
the treatment or management of
conditions exacerbated by smoking.
Smoking cessation continues to be

Smoking cessation and the health
promotion role of community nurses

a goal for patients as they begin to
understand the effects that smoking
has on their overall health and
wellbeing. It is likely that, previously,
many patients were unaware of the
future detrimental effects smoking
would have on their health. However,
there is now a movement towards
preventing conditions before they
develop or worsen.

BENEFITS OF
STOPPING SMOKING

The benefits of smoking cessation
are significant (Blomster et al, 2016;
Baker et al, 2018; Barengo et al,
2019). Due to the high prevalence of
smoking, community nurses care for
many patients on a journey towards
cessation. In the authors’ clinical
opinion, they have one of the most
important health promoting roles
and are often involved in working
in partnership with patients,
highlighting how smoking cessation
will be able to positively change
their health. Tobacco smoking has
many detrimental effects, causing
it to be one of the main causes of
mortality worldwide (Golechha,
2016). Smoking cessation benefits
both physical and mental health.
Taylor et al (2014) suggested that
smoking cessation helps to relieve

symptoms of depression and
anxiety, as well as improving overall
psychological wellbeing.

ROLE OF COMMUNITY NURSES
IN HEALTH PROMOTION

Health promotion applies to all
nurses and healthcare professionals,
regardless of which arena they
specialise in (Raingruber, 2014).
However, community nurses are
often the first point of contact for
many patients, so it could be argued
that their health promotion role
is one of the most crucial. Zandee
et al (2010) studied the unique
relationship between community
practitioners and nursing students
in promoting public health in urban
areas. The research highlighted the
positive health promoting outcomes
of this relationship, which could
be directly applied to the patient
scenario included here (Mr Wilson’s
care), whereby the first author
was able to act independently as a
health promoter under the guidance
of a qualified and knowledgeable
community nurse.

The Ottawa charter (World
Health Organization [WHO],
1986), a founding health promotion
document, identified three key roles
that health promoters, including
community nurses, could use
to further advance their health
promoting skills, namely:
 Advocating
 Enabling
 Mediating.

Advocating is standing up for
the needs of the individual and
attempting to provide a healthy
environment, such as a strong social
background or economic conditions
(Choi, 2015). Enabling is about
striving to give people what they
require to be successful and aims at

Tara Bright, second year adult nursing student;
Teresa Burdett, senior lecturer in integrated
health care, both at Bournemouth University

Community nurses are well placed to initiate health promotion,
including the goal of smoking cessation. Changing health
behaviours, including smoking, may be directly addressed by working
collaboratively with patients to better understand their personal
situation, with the hope of enabling them to engage in a productive
manner in health promotion now and in the future (Lau-Walker,
2014). This paper critically discusses the first author’s health promotion
role during her time as a community student nurse working in a
community nursing team.

KEYWORDS:
 Smoking cessation  Health promotion  Make every contact
count (MECC)

Tara Bright, Teresa Burdett

SMOKING CESSATION

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ensuring people have equal access
to the resources which allow them
to pursue their best health (Hubley
and Coperman, 2018). Finally,
mediating concerns the idea that for
health promotion to be successful
it requires the cooperation of many
groups, including the government,
the healthcare sector and the media
(WHO, 1986).

The Ottawa charter (WHO, 1986)
has since been used to increase the
population’s health potential (WHO,
2007). However, the question now
is whether the charter remains as
significant today (Vinko et al, 2016).
Vinko et al (2016) identified that
there are still many challenges to
health promotion, including the
obstacle of ensuring that there
are enough sufficiently trained
professionals. Thompson et al (2018)
also concluded that there is still a
way to go and that health promotion
should be continually focusing on
reducing the inequalities faced by
the population, such as inadequate
housing and poverty. These two
factors clearly impacted on Mr Wilson
in the patient scenario here.

Naidoo and Wills (2016) have
highlighted three principles to help
guide clinicians, such as community
nurses, in their health promotion
role to gain the best outcomes for
patients, namely:
 Participation
 Collaboration
 Equity.

Participation means the public
playing a part in developing policies
surrounding health promotion. A
goal of partnership is ensuring that
patients feel that they are able to
contribute their own opinions. As
a principle, partnership remains
prevalent in recent literature (Gregory
et al, 2018). This applies directly to
Mr Wilson because the first author
regularly enabled him to express his
own wishes and ideas surrounding
his goals around smoking cessation,
thereby enhancing his own locus
of control.

Collaboration is similar to the
concept of participation, in that
it is the process of healthcare
professionals working together on

Patient scenario — Mr Wilson

As a student nurse, I had the privileged opportunity to experience
community nursing first hand. The patients I met had health issues, which
meant that they were unable to live independently and rarely left their own
homes. For confidentiality, in accordance with the Nursing and Midwifery
Council’s ‘Code of Conduct’ (NMC, 2018), the patient will be referred to as
Mr Wilson to protect his identity and any personal data (Royal College of
Nursing [RCN], 2016).

Mr Wilson, was visited twice a week so that the community nurses,
including the first author, could advise him on self-management of his
chronic obstructive pulmonary disease (COPD). Mr Wilson had always
been a heavy smoker and said that he had tried unsuccessfully to stop
multiple times. However, he believed that with the help of healthcare
professionals he could stop. He was living in a top floor flat, which left him
vulnerable should he ever need to get out. The flat itself was very cluttered
and in a state of disrepair. Mr Wilson said that this was because his pension
could not accommodate the repairs.

The first author recognised that Mr Wilson already had some motivation
to change, but knew that she had not only to acknowledge the effects of
smoking on his physical health concerning his COPD, but also to identify
how his smoking was affecting his emotional, social and mental health
and wellbeing. Conversations were initiated with Mr Wilson to gauge
his understanding of the effects of smoking on his long-term health. By
looking at all aspects of his situation, it became clear that smoking was also
negatively affecting his family life. His daughter had recently given birth to
a baby, Mr Wilson’s first granddaughter. However, due to his smoking, she
was refusing to let him spend time with her.

Rather than being dependent on the community nurse, Mr Wilson
would have loved spending more time going out with his family. The first
author explained to Mr Wilson that with her mentor she would work in
partnership with him towards enabling this goal to happen. Subsequently,
short conversations were had with Mr Wilson at each visit about the
positive effects that smoking cessation would have on his health. This
also meant that he had time to think about the information he was being
provided and could make his own informed decisions, and be the advocate
for his own health. However, despite attempting to promote Mr Wilson’s
health and wellbeing, due to the nature of the first author’s role, i.e. being
a student, meant that her time in placement ended before being able to
follow up on Mr Wilson’s progress. However, the community nursing team
continued to work in partnership with Mr Wilson to help him reach
his goals.

projects with the aim of achieving
more large-scale goals, such as
creating the most effective methods
of health promotion (Naidoo and
Wills, 2016). However, Meyer (2018)
highlights that there are challenges
to working in collaboration in
nursing, explaining that with
different stakeholders having diverse
philosophies, mutual respect is
required to provide the best patient
care. By working in collaboration with
Mr Wilson and demonstrating respect
and empathy for his situation, it was

hoped that this would encourage him
to open up about his feelings and
make his own healthcare decisions.

Equity is about having equal
access and parity to services and
health care (Naidoo and Wills 2016).
However, in the authors’ clinical
opinion, more work is required to
make this is a reality. Socio-economic
factors need to be tackled to have a
positive impact on the population’s
health (Commission on Social
Determinants of Health [CSDH],

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▼ Practice point
The role of community nurses can
often be the most central to health
promotion because they are the
professionals who have built up a
rapport with patients and may be
their first point of contact.

2008). While this report is useful for
addressing the challenges of health
equity, limitations have been noted.
However, its validity is still relevant
as Green et al (2019) identified
that health care needs to tackle the
effects of economic inequalities on
a person’s health. For example, poor
housing is likely to have a negative
impact on a patient’s health and
they will ultimately need more
healthcare treatment, i.e. the various
determinants of health, including
social or economic factors, are
equally influential (Scriven, 2017)
on health as a patient’s behavioural
choices. Thus, community nurses
need to consider the individual
situation and background of their
patients before approaching
health promotion.

A further principal,
empowerment, has been defined by
many experts throughout the years
as giving patients control over their
own behavioural change (Rogers,
1961; Yeh et al, 2018). The use of
empowerment has been encouraged
in health promotion to give people
autonomy. By allowing them to take
some responsibility, they develop
an increase in skills and knowledge
relating to their health (Powers et al,
2012). Despite this, there have been
criticisms of using empowerment
in health promotion. Tengland
(2012) argued that the approach of
empowerment in health promotion
is time-consuming and therefore
could cost the health service more
overall. While government money
may be saved if additional time is
not spent with patients and they
are not empowered, this will have
little positive impact for the patients,
directly contradicting the aims of
health promotion. It is likely that
patients who are not empowered
to improve their health behaviours
will develop more lifestyle-related

complications, increasing the burden
on community nurses.

These ideas are directly relatable
to Mr Wilson’s care because the
community nursing team were
striving to help him take control of
his own health. Although the first
author spent a considerable amount
of time with Mr Wilson and provided
him with research-based information
about the effects of smoking on his
health based on her training and
knowledge, she did not go further
and signpost him to other relevant
information, but rather attempted to
encourage him to be the advocate
for his own health. If Mr Wilson had
been readily provided with additional
information, he would perhaps have
been more likely to make his own
decisions about what was right
for him.

Todres et al (2009) said that nurses
should be working to increase the
autonomy of their patients, allowing
them to have a greater choice and
to share responsibility for decisions
made. However, there will always be
situations where this is not possible.
For example, although receptive to
health promotion advice and support,
Mr Wilson had a long history of
repeatedly trying to stop smoking
without success.

Varley and Murfin (2014) also
explained that a patient should only
be approached at a time when they
are ready and receptive to change,
and that health promotors should
not inflict their own suggestions of
change onto patients (PHE, 2015b).

MAKE EVERY CONTACT COUNT

Recent guidelines known as ‘Making
Every Contact Count’ (MECC)
are regarded as a fundamental
framework for staff to follow (Public
Health England [PHE], 2016a).
MECC is linked to the principle of
empowerment and is defined as
health and social care practitioners
being confident to encourage people
to change their health behaviours by
delivering healthy lifestyle messages
(PHE, 2016b). For a community
nurse to provide the most effective
health promotion, a set of skills are
necessary. These include the use of

open discovery questions to allow
the patient to further explore the
topic, as well as spending more time
listening to the patient, so they are
able to make their own suggestions
(PHE, 2015b).

Although MECC has been
developed as the ideal standard for
health promotion, in the authors’
clinical opinion, it is not easy for all
community practitioners to adopt
on top of their busy workloads.
There are some limitations to the
use of MECC. Nelson et al (2013)
identified that one of the barriers
to its success is practitioners’ view
that adopting this method would
increase workload. However, despite
its challenges, MECC as a means of
health promotion has been praised
as being a valuable and flexible
approach (Chisholm et al, 2018). That
said, awareness of MECC still needs
to increase. Keyworth et al (2018)
found that only 41% of nurses and
health visitors recognised the MECC
consensus statement.

▼ MECC…
The very nature of MECC means
that the knowledge can be passed
between practitioners to improve
practice. The MECC programme
is set up so that nurses or other
healthcare professionals are able
to attend the training and therefore
become a trainer themselves to help
reduce the number of people that
have to be trained to implement
MECC health promotion.
 Have you ever considered

becoming MECC trained?
 Have you or any of your

colleagues been MECC trained in
the past?

 Do you know what training is
available in and around your
local area?

Further information about
MECC training can be found on
the ‘Training in MECC’ webpage at:
www.makingeverycontactcount.
co.uk/training/. This page has
additional resources, including
easily accessible e-learning and
workbooks (Health Education
England, 2019).

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REFLECTIONS ON PRACTICE —
MR WILSON

When caring for Mr Wilson, it was
important to consider the outside
influences on his health, looking at
his whole situation in depth, rather
than just examining the effects of
smoking as an individual behaviour.

The first author built up a
positive professional relationship
with Mr Wilson, which enabled her
to understand him as an individual.
This meant that he felt more open
to sharing information. Indeed,
DeVille-Almond (2013) found that
forging a relationship with patients
is one of the most effective ways
for community nurses to facilitate
behaviour change.

However, health promotion
was a challenging new role for
the first author to adopt, despite
working under the supervision of
her mentor and being helped with
health promoting ideas beneficial
to Mr Wilson. At a later visit with
her mentor, it was decided to give
Mr Wilson more information about
services because he had chosen not
to do so independently. This included
the local stop smoking service, which
aims to provide equal support to all
patients using a variety of different
methods, such as apps and websites
which track progress and offer
specialist advice (National Health
Service [NHS] England, 2016; PHE,
2016b).

The educational approach to
health promotion is when the
practitioner provides knowledge
and information which allows the
patient to make informed choices
about their care (Naidoo and Wills,
2016). It is likely that using such
an approach motivated Mr Wilson
further with wanting to change his
behaviour. Hinchliff (2009) suggested
that putting a patient in a positive

learning environment, builds a
trusting relationship with the health
promoter. In Mr Wilson’s case, this
meant that he would have felt more
able to express himself because he
felt psychologically safe.

CONCLUSION

The promotion of a patient’s health
and wellbeing is a vital aspect of
health care. However, there are many
challenges to this which are not
within the healthcare arena, i.e. social
determinants including poverty,
unequal access to housing, food
and health. Health promotion has
emerged to tackle these inequalities.
There is now a considerable amount
of research to support both nurses
and other healthcare professionals
with providing the most effective
health promoting care.

It is recognised that nurses should
be trained in health promotion,
but there is a conflict between
putting limited funding into health
promotion when funding challenges
exist in other areas. However, change
in health behaviours will benefit the
patient and potentially save money
for the National Health Service
overall. Continual work within the
health promotion arena can also
significantly enhance integrated,
person-centred care and help to ease
pressures on community nurses and
their teams.

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▼ Remember
Further training will improve
community nurse’s understanding of
the facets of health promotion.

JCN

▼ Practice point
The nature of community nursing
means practitioners working
towards building partnerships with
their patients.

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KEY POINTS
 Patients’ health may be

improved if they access
additional services
independently following
information given by
community nurses.

 Patients will be less reliant on
the care of community nurses
and primary practitioners and
may seek out other care options
which fit with their lifestyle.

 Not all community nurses need
to undertake the additional
training in health promotion,
but can share their knowledge
between themselves and
thereby reduce their workload.
This is relevant because NHS
staffing pressures mean that
community nurses are already
limited with their time.

 Health promotion could save
the NHS money by reducing the
behavioural factors worsening
long-term conditions,
potentially reducing their need
for treatment. For example, in
2015, smoking cost the NHS
£2.6 billion (PHE, 2015a).

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Thyroid Diseases and Conditions; Researchers at
National Cancer Institute Have Reported New
Data on Thyroid Diseases (PBDE flame
retardants, thyroid disease, and menopausal
status in US women)

Publication info: Women’s Health Weekly ; Atlanta [Atlanta]23 June 2016: 4357.

ProQuest document link

ABSTRACT

According to the news reporters, the research concluded: “Exposure to BDEs 47, 99, and 100 is associated with

thyroid disease in a national sample of U.S. women, with greater effects observed post-menopause, suggesting

that the disruption of thyroid signaling by PBDEs may be enhanced by the altered estrogen levels during

menopause.”

FULL TEXT

2016 JUN 23 (NewsRx) — By a News Reporter-Staff News Editor at Women’s Health Weekly — Fresh data on Thyroid

Diseases and Conditions are presented in a new report. According to news reporting from Research Triangle Park,

North Carolina, by NewsRx journalists, research stated, “Women have elevated rates of thyroid disease compared

to men. Environmental toxicants have been implicated as contributors to this dimorphism, including

polybrominated diphenyl ethers (PBDEs), flame retardant chemicals that disrupt thyroid hormone action.”

The news correspondents obtained a quote from the research from National Cancer Institute, “PBDEs have also

been implicated in the disruption of estrogenic activity, and estrogen levels regulate thyroid hormones. Post-

menopausal women may therefore be particularly vulnerable to PBDE induced thyroid effects, given low estrogen

reserves. The objective of this study was to test for an association between serum PBDE concentrations and

thyroid disease in women from the United States (U.S.), stratified by menopause status. Serum PBDE

concentrations (BDEs 47, 99, 100 and 153) from the National Health and Examination Survey (NHANES) and

reports on thyroid problems were available in the NHANES 2003-2004 cycle. Odds ratios (ORs) were calculated

using multivariate logistic regression models accounting for population-weighted survey techniques and

controlling for age, body mass index (BMI), education, smoking, alcohol consumption and thyroid medication.

Menopause status was obtained by self-reported absence of menstruation in the previous 12 months and declared

menopause. Women in the highest quartile of serum concentrations for BDEs 47, 99, and 100 had increased odds

of currently having thyroid disease (ORs: 1.5, 1.8, 1.5, respectively) compared to the reference group (1st and 2nd

quartiles combined); stronger associations were observed when the analysis was restricted to postmenopausal

women (ORs: 2.2, 3.6, 2.0, respectively).”

According to the news reporters, the research concluded: “Exposure to BDEs 47, 99, and 100 is associated with
thyroid disease in a national sample of U.S. women, with greater effects observed post-menopause, suggesting

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that the disruption of thyroid signaling by PBDEs may be enhanced by the altered estrogen levels during
menopause.”

For more information on this research see: PBDE flame retardants, thyroid disease, and menopausal status in US

women. Environmental Health, 2016;15():1-9. Environmental Health can be contacted at: Biomed Central Ltd, 236

Grays Inn Rd, Floor 6, London WC1X 8HL, England. (BioMed Central – www.biomedcentral.com/; Environmental

Health – www.ehjournal.net)

Our news journalists report that additional information may be obtained by contacting J.G. Allen, Natl Canc Inst

NIEHS, Res Triangle Pk, NC, United States. Additional authors for this research include S. Gale, R.T. Zoeller, J.D.

Spengler, L. Birnbaum and E. McNeely.

Keywords for this news article include: Research Triangle Park, North Carolina, United States, North and Central

America, Thyroid Diseases and Conditions, Endocrine System Diseases, Flame Retardants, Thyroid Diseases,

Women’s Health, Endocrinology, Estrogens, Menopause, Hormones, Genetics, National Cancer Institute.

LLC

DETAILS

Subject: Womens health; Fire resistant materials; Health risk assessment; Estrogen

Location: United States–US

Company / organization: Name: National Cancer Institute; NAICS: 923120

Identifier / keyword: City:Research Triangle Park State:North Carolina Country:United States Region:North

and Central America Thyroid Diseases and Conditions Endocrine System Diseases

Flame Retardants Thyroid Diseases Women’s Health Endocrinology Estrogens

Menopause Hormones Genetics

Publication title: Women’s Health Weekly; Atlanta

First page: 4357

Publication year: 2016

Publication date: Jun 23, 2016

Publisher: NewsRx

Place of publication: Atlanta

Country of publication: United States, Atlanta

Publication subject: Medical Sciences, Women’s Interests

Database copyright  2020 ProQuest LLC. All rights reserved.
Terms and Conditions Contact ProQuest

ISSN: 10787240

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Language of publication: English

Document type: Expanded Reporting

ProQuest document ID: 1797342407

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Thyroid Diseases and Conditions; Researchers at National Cancer Institute Have Reported New Data on Thyroid Diseases (PBDE flame retardants, thyroid disease, and menopausal status in US women)

Pa
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International Journal of Nursing Studies 50 (2013) 1537–1549

A R

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tient preference and satisfaction in hospital-at-home

and

ual hospital care for COPD exacerbations: Results of a
ndomised controlled trial§,§§

cile M.A. Utens a,b,*, Lucas M.A. Goossens c, Onno C.P. van Schayck b,
ureen P.M.H. Rutten-van Mölken c, Walter van Litsenburg a, Annet Janssen a,
ouschka van der Pouw d, Frank W.J.M. Smeenk a

partment of Respiratory Medicine, Catharina Hospital, Eindhoven, The Netherlands

partment of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands

titute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands

partment of Respiratory Medicine, Rijnstate Hospital, Arnhem, The Netherlands

What is already known about the topic?

� Patient satisfaction with hospital-at-home schemes is
high, but most schemes admit patients with various
conditions.
� Effectiveness and cost-effectiveness of hos

pital-at-home

and usual hospital care for COPD patients are not

T I C L E I N F O

le history:

ived 27 September 2012

ived in revised form 15 March 2013

pted 15 March 2013

ords:

pital-at-home

y assisted

discharge

nic Obstructive Pulmonary Disease

ent preference

ent satisfac

tion

A B S T R A C T

Background: In the absence of clear differences in effectiveness and cost-effectiveness

between hospital-at-home schemes and usual hospital care, patient preference plays an

important role. This study investigates patient preference for treatment place, associated

factors and patient satisfaction with a community-based hospital-at-home scheme for

COPD exacerbations.

Methods: The study is part of a larger randomised controlled trial. Patients were

randomised to usual hospital care or early assisted discharge which incorporated

discharge at day 4 and visits by a home care nurse until day 7 of treatment (T + 4 days). The

hospital care group received care as usual and was discharged from hospital at day 7.

Patients were followed for 90 days (T + 90 days). Patient preference for treatment place

and patient satisfaction (overall and per item) were assessed quantitatively and

qualitatively using questionnaires at T + 4 days and T + 90 days. Factors associated with

patient preference were analysed in the early assisted discharge group.

Results: 139 patients were randomised. No difference was found in overall satisfaction. At

T + 4 days, patients in the early assisted discharge group were less satisfied with care at

night and were less able to resume normal daily activities. At T + 90 days there were no

differences for the separate items. Patient preference for home treatment at T + 4 days was

42% in the hospital care group and 86% in the early assisted discharge group and 35% and

59% at T + 90 days. Patients’ mental state was associated with preference.

Conclusion: Results support the wider implementation of early assisted discharge for

COPD exacerbations and this treatment option should be offered to selected patients that

prefer home treatment.

We thank Kitty van der Meer, research assistant, for her work in

the

ribution and management of the questionnaires and data.

Trial registration: NetherlandsTrialRegister NTR 1129.
Corresponding author at: Department of Respiratory Medicine,

arina Hospital, Eindhoven, The Netherlands. Tel.: +31 612796688.

E-mail address: cecileutens@gmail.com (Cecile M.A. Utens).

Contents lists available at SciVerse ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

0-7489/$ – see front matter � 2013 Elsevier Ltd. All rights reserved.
://dx.doi.org/10.1016/j.ijnurstu.2013.03.006

http://crossmark.crossref.org/dialog/?doi=10.1016/j.ijnurstu.2013.03.006&domain=pdf

http://dx.doi.org/10.1016/j.ijnurstu.2013.03.006

mailto:cecileutens@gmail.

com

http://www.sciencedirect.com/science/journal/00207489

http://dx.doi.org/10.1016/j.ijnurstu.2013.03.006

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491538

different, therefore the choice between the two should
be based on patient preference.

What this paper adds

� This paper is the first to demonstrate patient

satisfaction

with hospital-at-home and usual hospital care and
preference for treatment place in only patients with a
COPD exacerbation.
� This paper demonstrates that patients are satisfied with

hospital-at-home.
� The majority of patients prefers home treatment if they

could choose.

1. Introduction

Internationally, there are trends to deliver care in the
community and more closely to the patients’ home.
Combined with a pressure on hospital beds and a
continuous need to constrain health care costs, this has
led to the development of alternatives for hospital care.
Schemes aimed at avoiding hospital admission or reduce
length of stay by treating and supervising patients at home,
instead of the hospital, are called hospital-at-home
schemes (Shepperd et al., 2008, 2009). Studies have proved
that these schemes are safe and have no negative effects on
patient outcomes (Shepperd et al., 2008, 2009; Ram et al.,
2003). Chronic Obstructive Pulmonary Disease (COPD)
exacerbations are responsible for a great number of annual
hospital admissions, and accompanying health care costs
(Toy et al., 2010). To reduce the pressure on hospital beds
hospital-at-home schemes have been designed. Forty-four
percent of British hospitals runs a hospital-at-home
scheme for COPD exacerbations (Quantrill et al., 2007).
Patient satisfaction with hospital-at-home schemes is
high, but results are mainly derived from studies evaluat-
ing general, non-specialised schemes, meaning that they
admit patients with various conditions and treatments
(Montalto, 1996; Dubois and Santos-Eggimann, 2001;
Wilson et al., 2002; Leff et al., 2006). Three British studies
evaluated patient satisfaction with hospital-at-home
schemes admitting only patients with COPD exacerbations
(Ojoo et al., 2002; Schofield et al., 2006; Clarke et al., 2010).
All studies reported high patient satisfaction. However, the
schemes were hospital-based outreach schemes, with
specialised respiratory nurses performing visits at home.
Recently we have reported the results of a randomised
controlled trial studying the effectiveness of community-
based early assisted discharge for patients admitted to the
hospital with a COPD exacerbation (Utens et al., 2012). The
community-based hospital-at-home scheme for COPD
exacerbations, with community nurses performing home
visits, had similar patient outcomes as usual hospital care
(Utens et al., 2012). The economic evaluation, that was
performed as part of this clinical trial, also did not show a
large cost difference between the two treatments. From
the health care perspective savings of early assisted
discharge were s244 and from a societal perspective,
incorporating costs of informal caregiving and productivity
loss in addition to health care costs, savings of early
assisted discharge were s65 (Goosens et al., 2013).

Therefore, the choice between the two treatments should
be largely based on patient preference. Preference is the
desirability of a treatment, process or treatment choice
(Krahn and Naglie, 2008). Little is known about the
preference for treatment place and which factors influence
this preference. Therefore, in this study we investigate
patient preference for treatment place and associated
factors. Preference for treatment and satisfaction with
treatment are associated. Satisfaction reflects the degree to
which a patients’ perceived experience matches prefer-
ences regarding this experience (Brennan, 1995). In this
study we compared satisfaction with the community-
based hospital-at-home scheme and usual hospital care.
Satisfaction is determined by the ratio between patients’
expectations of care and their perceptions of the actual
care received, influenced by previous experiences and
personal values (Carr-Hill, 1992).

2. Methods

2.1. Design and patients

The current study was part of a randomised controlled
trial, investigating the effectiveness of community-based
early assisted discharge for patients admitted to the
hospital with a COPD exacerbation (Utens et al., 2010). The
study was conducted between November 2007 and March
2011 in five hospitals and three home care organisations.
Patients that were considered eligible according to the
inclusion and exclusion criteria at admission (Table 1), and
those meeting the criteria of clinical stability (see Table 1)
on day three of admission, were randomised to usual
hospital care or early assisted discharge. Clinical stability
was assessed by the reviewing physician of the hospital
ward. Randomisation was performed on a 1:1 scale using a
computer-generated allocation list that was placed in
sealed envelopes. Randomisation was performed per
participating hospital location and a block-size of 6. Due
to the nature of the intervention, patients and health care
staff involved could not be blinded to treatment allocation.
Those randomised to early assisted discharge, were
discharged home on the fourth day of admission and
visited at home by community nurses that same day and
the next 3 days. In addition, during the 4 days of home
treatment a 24-h telephone access with the hospital ward
was installed. After a total of 7 days of hospital followed by
home treatment, patients were discharged from the
scheme. Patients randomised to usual hospital care
continued the hospital treatment for another 4 days,
making the total length of hospital treatment 7 days, and
were then discharged home. Patients were followed-up for
three months. A detailed description of the trial and the
early assisted discharge intervention has been published
elsewhere (Utens et al., 2010). The trial was approved by
the Medical Ethics Committee of the Catharina Hospital
Eindhoven, the Netherlands.

2.2. Measurements

Baseline characteristics were collected at admission.
Characteristics that were obtained are age, gender, living

situ
adm
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C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1539

ation, presence of informal care, care at home prior to
ission, number of years diagnosed with COPD,

ome, education, coping style with the Utrecht Coping
(Schreurs et al., 1993), health status with the Clinical

PD Questionnaire (van der Molen et al., 2003),
asuring 3 domains: symptoms, functional state and
ntal state, and comorbidity with the Charlson comor-
ity index (Charlson et al., 1987). Patients’ satisfaction

preference for treatment place was measured with a,
this study translated, questionnaire by Ojoo et al.

02). The questionnaire for both treatment groups
sisted of three parts. The first qualitative part was two
n-end questions asking for three things of the

eived treatment that patients were most satisfied
most dissatisfied about. The second part consisted of
quantitative questions, with five response options
ying from a very positive to a very negative response.

questions discuss topics of medication, concerns
ing treatment and nursing care among others. Each of

answer options of the second part of the satisfaction
stionnaire was assigned as score between 1

mpletely negative answer) and 5 (completely positive
wer) and an overall score was calculated by dividing

total sum score by the total number of valid
stions. Six missing values were allowed. The final
t was a quantitative, dichotomous, hypothetical
stion on where patients would want to be treated
ey could choose: in the hospital and partly at home or

irely in the hospital. The questionnaire was completed
two moments; at the end of the home or hospital
tment (T + 4 days) and after three months follow-up

90 days). At the end of the home treatment, the early
isted discharge group received an additional, separate,
stionnaire with six quantitative questions for the
luation of the home care. This questionnaire covered
rall satisfaction, satisfaction with the total number of

days that home care was provided, the number of visits
each day and the duration of the daily visits. A from
Dutch to English translated version of the questionnaires
can be found in Appendix

The sample size calculation for the randomised
controlled trial was performed for the primary outcome
measure, which was effectiveness expressed in change in
the clinical COPD questionnaire. Patient preference and
satisfaction were secondary outcomes in the randomised
controlled trial. The required sample size for the primary
outcome was 165 patients.

2.3. Analysis

Patient satisfaction with the care they receive has been
the subject of many quantitative and qualitative studies. In
order to be more specific in the evaluation of hospital-at-
home in comparison to usual hospital care we used
deductive content analysis for the responses to the first
part of the questionnaire which contained the two open-end
questions (Graneheim and Lundman, 2004; Elo and Kyngas,
2008). Deductive content analysis is based on previous
theories or models and therefore allows to go beyond general
findings which would have been the focus of an inductive
analysis. Sofaer and Firminger (2005) have identified seven
categories on which patients base the definition of quality of
health care on. These categories are namely patient-centred
care; access; communication and information; courtesy and
emotional support; technical quality; efficiency of care/
organisation; and structure and facilities. Responses to the
two open-end questions were reviewed and then coded
according to these seven categories. CU performed the first
coding and CPvS checked these codings. Discrepancies were
discussed between the two coders. For each of the categories
the most named aspects are described and illustrated with
authentic citations.

le 1

usion and exclusion criteria (applied at admission) and randomisation criteria (applied at day 3 of admission).

clusion criteria (checked on day 1 Exclusion criteria (checked on day 1)

e �40 years Major uncontrolled comorbidity, including pneumonia that
is prominent, heart failure that is prominent, acute changes on

ECG and (suspected) underlying malignancy

mpetent to give written informed consent Mental disability, including dementia, impaired level of consciousness and

acute confusion

agnosed with COPD. COPD was defined

as at least GOLD stage I and 10 pack

years of smoking

Living outside care region of the home care organisation

spitalisation for COPD exacerbation Inability to understand the program

Indication for admission to intensive care unit of for non invasive ventilation

Insufficient availability of informal care at home

ndomisation criteria (checked on day 3)

mpleted informed consent of day 3 of admission

ceptable general health:

– Decrease of physical complaints

– Non-dependency of therapies that cannot be

given at home (intravenous therapy and

newly prescribed oxygen treatment)

– Being able to visit toilet independently,

or as

prior to admission

rmal or moderately increased blood sugar levels, defined as �15 mmol/L of �15 mmol/L but capable to regulate independently
spiratory complaints of dyspnoea, wheezing and rhonchi must have been decreased in comparison with day of admission

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491540

For the second part of the questionnaire differences in
the overall satisfaction score and differences on the
different items were tested using Mann–Whitney tests.

The third part of the questionnaire – the preference of
treatment place – was analysed in two steps. First, the
comparison of the percentage of patients in both groups
preferring home treatment in the hypothetical situation
that they could choose between treatments, was analysed
using Chi-square test. Second, we wanted to study which
factors are associated with treatment place. Therefore, for
early assisted discharge group (N = 70), that experienced
both hospital treatment and home treatment, a two-step
logistic regression was performed. First, bivariate logistic
regression analysis was conducted to determine the factors
associated with patients’ preference for treatment place.
The following factors were investigated for their associa-
tion with preference for treatment place: age, gender,
living situation (alone vs. with someone), presence of
informal caregiver, presence of home care prior to
admission, long term oxygen treatment (yes vs. no), oral
corticosteroid maintenance treatment (yes vs. no) coping
styles (active, avoidant and passive style), income, educa-
tion, number of years diagnosed with COPD, clinical COPD
questionnaire scores (symptoms, functional state and
mental state) at randomisation, and comorbidity (COPD
vs. COPD and one/multiple comorbidities). Next, factors
with p � 0.1 in the bivariate analyses were included in a
multivariate logistic regression. Four factors (long-term
oxygen treatment, income, living situation and clinical
COPD questionnaire – mental state) were included in the
multivariate regression. This requires a sample size of at
least 40 cases, a requirement that was met (Rothman et al.,
2008). Dependent variable in the logistic regressions was
either preference at T + 4 days or T + 90 days.

The additional six questions for the evaluation of the
home care from the early assisted discharge group are
reported as percentage of total responses.

3. Findings

In total 139 patients were randomised, 69 to usual
hospital care and 70 to early assisted discharge care. Table
2 provides an overview of the patient characteristics. Both
groups appeared to be comparable on baseline character-
istics. Immediately after randomisation seven patients in
the usual hospital care group and three patients in the
early assisted discharge group withdrew consent, because
they were not satisfied with the allocated place of
treatment. These seven patients were not different from
the other patients in the usual hospital care group, but the
three patients in the early assisted discharge group that
withdrew consent immediately after randomisation had a
worse comorbidity score than other patients in this
treatment group.

3.1. Findings – first part: qualitative questions on satisfaction

In total, 105 patients (49 of the usual hospital care group
and 56 of the early assisted discharge group) provided 200
comments on aspects they were most satisfied about and 87

Table 2

Patient characteristics. Scores represent number (%), unless stated

otherwise.

Characteristic Usual hospital

care (N = 69)

Early assisted

discharge (N = 70)

Age (years), mean (SD) 67.8 (11.30) 68.31 (10.34)

Sex: male 38 (55.1) 48 (68.6)

Charlson comorbidity scorea

Patients with score = 1 42 (60.0) 38 (54.0)

Patients with score > 1 27 (39.0) 32 (46.0)

Clinical COPD Questionnaireb

Symptoms (range 0–6),

mean (SD)

2.25 (1.05) 2.50 (1.05)

Fnctional state

(range 0–6), mean (SD)

2.61 (1.33) 3.33 (1.42)

Mental state

(range 0–6), mean (SD)

1.38 (1.28) 1.49 (1.45)

Long term oxygen treatment

prior to admission

Yes 4 (5.8) 5 (7.1)

No 65 (94.2) 65 (92.2)

Oral corticosteroid maintenance treatment prior to admission

Yes 5 (7.2) 10 (14.3)

No 64 (92.8) 60 (85.7)

Coping Utrecht coping list�
Active coping style

(range 7–28), mean (SD)

16.72 (3.26) 17.98 (4.14)

Passive coping style

(range 7–28), mean (SD)

12.30 (3.04) 12.25 (3.99)

Avoidant coping style

(range 8–32), mean (SD)

17.24 (3.94) 17.67 (3.62)

Living situation

Living alone 21 (30.4) 22 (31.4)

Living with partner 44 (63.8) 42 (60.0)

Living with child(ren) 1 (1.4) 2 (2.8)

Living with partner

and child(ren)

3 (4.3) 4 (5.7)

Presence of informal care

Yes 62 (89.9) 62 (88.6)

No 7 (10.1) 8 (11.4)

Care at home before admission

None 54 (78.3) 53 (75.7)

Nursing care or help with

activities of daily living

2 (2.9) 7 (10.0)

Domestic help 10 (14.5) 7 (10.0)

Both 3 (4.3) 3 (4.3)

Number of years

diagnosed with

COPD, mean (SD)

8.32 (7.69) 8.16 (7.96)

Incomec

Low 17 (40.5) 18 (40.9)

Medium 12 (28.6) 11 (25.0)

High 13 (31.0) 15 (34.1)

Education leveld

Low 20 (33.9) 21 (35.0)

Medium 26 (44.1) 27 (45.0)

High 15 (22.0) 12 (20.0)
a Score of 1 means COPD only, score >1 means COPD and other

comorbidities.
b 0 represents best possible score and 6 worst possible score; �higher

scores mean higher level of trait.
c Low refers to monthly family income � s1249, medium refers to

monthly family income between s1250 and s1749, high refers to
monthly family income � s1750. Data are missing or patient did not want
to specify in 27 cases.

d Low refers to (parts) of primary school only, medium refers to lower

vocational education or intermediate general education, high refers to

intermediate vocational education or higher general education or higher

vocational training or university.

aspects they were most dissatisfied about.

3.1.

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C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1541

1. Patient-centred care

Most responses in this category were on satisfying
ects. Only 5 comments were on dissatisfying aspects.
ients in both groups were satisfied with the (nursing)
e and counselling they received, which is illustrated by

following comments:

‘‘The care I received, problems were solved and the
assistance of the staff.’’ (Patient in usual hospital care
group)
‘‘The care was personal.’’ (Patient in early assisted
discharge group)

Patients in the early assisted discharge group were
sfied with how they were received at home and the
e at home by the home care nurses.
At the end of the follow-up period, patients from
h groups commented that they were dissatisfied
ut the fact that they saw different nurses and doctors
ry time, or that they did not see their own
monologist.

‘‘I was not treated and seen by my own pulmonologist.’’
(Patient in usual hospital care group)
‘‘I saw different specialists’’ and ‘‘I had to tell the same
story over and over again.’’ (Patient in early assisted
discharge group)
‘‘At home there were different nurses every time.’’
(Patient in early assisted discharge group)

2. Access

The aspect which was satisfying and most mentioned
patients in the early assisted discharge group was

possibility to go home by early assisted discharge
receive follow-up care from nurses of the home

e organisation. The regular check-ups, receiving
nursing care and medication at home were very
ch appreciated. One patient described the advantages

disadvantages of early assisted discharge very
rly:

Advantages were: ‘‘Privacy’’ and ‘‘able to follow own
daily rhythm’’ while disadvantages were: ‘‘being alone
at night when I am breathless’’ and ‘‘it is easier to cross
my own limits [in physical context].’’ (Patient in early
assisted discharge group)

Patients in the usual hospital care group appreciated
hospital care that they received.
Due to bed shortages, several patients in both groups
re not treated at the respiratory nursing ward but the
sing ward of another specialty. This was subject of
atisfying comments:

‘‘The first days I stayed not on the respiratory ward.’’
(Patient in usual hospital care group)
‘‘I was not admitted to the respiratory ward, where
I belong.’’ (Patient in early assisted discharge
group)

3. Communication and information

Patients in both groups were satisfied on the informa-
and clear explanation they received of staff which

focussed on the disease COPD, the treatment and the
project, illustrated by the following comments:

‘‘The good explanation on the project.’’ (Patient in early
assisted discharge group)
‘‘The clear explanation about what they [staff] are going
to do.’’ (Patient in usual hospital care group)

However, some patients, especially in the early assisted
discharge group, experienced that they received little
information on medication, the disease and what the
upcoming days would happen. This is illustrated by the
following comments:

‘‘I am surprised that after 12 years having a lung
disease I get breathing exercises for the first time’’ and
‘‘I am surprised to have learned the diagnosis COPD
now and not earlier.’’ (Patient in early assisted
discharge group)
‘‘They [hospital staff] promised more in the hospital.’’
(Patient in early assisted discharge group)
‘‘Insufficient preparation for going home. I expected
more care at home with regard to medication and
making coffee.’’ (Patient in early assisted discharge
group)

3.1.4. Courtesy and emotional support

Patients from both groups were satisfied with the
contact they had with the medical and nursing staff.
Patients were satisfied with the kindness of the staff, the
attention staff had for them and the understanding. The
following comments illustrate this:

‘‘Kindness, which makes me feel calm.’’ (Patient in usual
hospital care group)
‘‘I really appreciated the attention of the student nurse.’’
(Patient early assisted discharge group)
‘‘The guidance at home gave me confidence.’’ (Patient
early assisted discharge group)

At the end of the follow-up period, several patients in
both groups provided satisfying comments on the respira-
tory nurses in the hospital and at home.

Only 2 patients provided comments on where they
were dissatisfied about. Both comments concerned the
attention staff had for them. For example:

‘‘They [staff] have little time and therefore little
attention.’’ (Patient in usual hospital care)

3.1.5. Efficiency of care and organisation

Patients in both groups commented that treatment
(medication, examination and help) took place on time
and/or fast. However, others commented that they had
to wait long for help, medication and examinations.
Patients also commented on the busy hospital staff.

‘‘There is a shortage for staff. There is no time for the
patient.’’ (Patient in usual hospital care group)
‘‘when you press the nursing alarm, you sometimes
have to wait long for a response.’’ (Patient in usual
hospital care group’’

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491542

Patients in both groups had comments on aspects of
coordination of care and transfer of information, which are
illustrated by the following comments:

‘‘The mutual coordination was lacking. This bothers
me.’’ (Patient in the usual hospital care group)
‘‘On the ward it was unstructured and disorganised.’’
(Patient in the usual hospital care group)

‘‘The nurse of the home care organisation did not come.
This should be better organised, especially during
weekends’’ and ‘‘care should be tuned because of the
medication and inhalations.’’ (Patient in early assisted
discharge group)
‘‘There was no clear information transfer to the
respiratory nurse.’’ (Patient in early assisted dischar-
gegroup)

3.1.6. Technical quality

Patients from both groups reported to be satisfied with
the treatment and observation they received in the
hospital and at home that was performed by medical
and nursing staff. Patients were satisfied with the recovery
of their condition.

‘‘Treatment in the hospital was good and the treatment
at home was good as well.’’ (Patient in early assisted
discharge group)

However, many comments on what patients from both
groups were most dissatisfied about concerned medica-
tion in the hospital: the type of medication, errors that
were made with prescribing, distribution and adminis-
tration of medication. The following comments illustrate
this:

‘‘The distribution of medicines was better last time
[previous admission].’’ (Patient in usual hospital care
group)
‘‘There was indistinctness concerning the medicines.’’
(Patient in usual hospital care group)
‘‘In the hospital the mouth piece of my inhaler was not
cleaned.’’ (Patient in early assisted discharge group)
‘‘Mistakes were made with the medicines.’’ (Patient in
early assisted discharge group)

3.1.7. Structure and facilities

Patients in both groups were most satisfied about
the quality of the food in the hospital. On the other
hand, patients in both groups were most dissatisfied
about the busy, crowded rooms in the hospital that
provided little privacy. In addition, one patient com-
mented that the rooms and toilets were dirty. Two
patients in the early assisted discharge group commen-
ted that at home they appreciated the quiet environment
with privacy.

3.2. Findings – second part: quantitative questions on

satisfaction

Table 3 shows the results on the second, quantitative
part of the questionnaire on patient satisfaction. For 34
(49%) patients in the usual hospital care group and 29

(41%) patients in the early assisted discharge group, an
overall satisfaction score could be calculated. Overall
satisfaction was 70% in the usual hospital care group and
71% in the early assisted discharge group (Table 3). Two
differences in satisfaction items between groups were
found (Table 3). During nights, patients in the early
assisted discharge group felt significantly more unsafe in
comparison to patients that received usual hospital care.
Significantly more patients in the early assisted discharge
group felt unable to resume normal daily activities.

More than 60% of patients in both groups were very or
completely satisfied with the received intravenous and
oral medication treatment, inhaled medication treatment
and oxygen treatment. The majority of patients was (very)
satisfied with the medical and nursing treatment, and care
they received in the hospital and/or at home.

At T + 90 days, overall satisfaction was 72% and 70% for
usual hospital care patients (29 valid scores) and early
assisted discharge patients (33 valid scores), respectively.
No differences between groups were found for the separate
questions (data not shown).

3.3. Findings – third part: preference for place of treatment

Fig. 1a shows that at T + 4 days, 42% (N = 25) of patients
allocated to hospital treatment and 86% (N = 56) of patients
allocated to home treatment preferred to be treated at
home, if they could choose. Table 4 shows the results of the
multivariate logistic regression analysis on associated
factors for preference in the early assisted discharge group.
Only clinical COPD questionnaire – mental state was
significantly associated with preference for home treat-
ment. Patients with worse scores were less likely to choose
home treatment. The trend for income was inconsistent. At
T + 90 days the percentage of patients preferring home
treatment had decreased to 35% (N = 17) and 59% (N = 33)
in the hospital treatment and home treatment group,
respectively (Fig. 1b). At T + 90 days, none of the
investigated variables were associated with preference
in the multivariate logistic regression analysis.

3.4. Findings – additional part: evaluation of early assisted

discharge

Results from the additional questionnaire for patients
that received home care showed that 85% (N = 34) of
patients that received home care was (very) satisfied. The
average number of home visits per day was one. The total
number of days that patients received home visits and the
number of visits per day was valued as sufficient by 83%
(N = 29) and 97% (N = 34) of patients. The far majority
valued the duration of the home visits as sufficient.

4. Discussion

The quantitative and qualitative evaluation among
patients in this study showed that patients are satisfied
with the hospital and home care they received. The overall
satisfaction scores in both groups were 70%. Evaluation on
separate items of the satisfaction questionnaire showed
only differences in feelings of safety at night and ability to

Table 3

Patient satisfaction. Numbers represent number of respondents and percentage, unless stated otherwise.

HC N = 34 EAD N = 29

p-Valuea

Overall satisfaction score,

range 0–100, mean (SD)

70 (12.7) 71 (12.5) 0.863

Completely/very satisfied Satisfied (Very) unsatisfied p-Valuea

Satisfaction with HC EAD HC EAD HC EAD

Administration of intravenous therapy

and tablets

44 (72.1) 37 (56.1) 14 (23) 23 (34.8) 3 (4.9) 6 (9.1) 0.068

Administration of nebulised/metered

dose inhalations

41 (69.5) 39 (60.9) 17 (28.8) 19 (29.7) 1 (1.7) 6 (9.4) 0.133

Oxygen treatmentb 30 (73.2) 34 (73.9) 10 (24.4) 12 (26.1) 1 (2.4) 0 (0) 0.755

Improvement of symptoms 37 (60.7) 30 (49.2) 20 (32.8) 21 (34.4) 4 (6.6) 10 (16.4) 0.089

Nursing care during daytime 44 (72.1) 38 (57.6) 15 (24.6) 24 (36.4) 2 (3.3) 4 (6.1) 0.093

Nursing care at night 40 (65.6) 31 (59.6) 17 (27.9) 18 (34.6) 4 (6.6) 3 (5.8) 0.654

Involvement in treatment 33 (55.0) 33 (50.8) 22 (36.7) 28 (43.1) 5 (8.3) 4 (6.2) 0.855

Amount of time spent by

nurses with patient

31 (52.5) 34 (51.5) 25 (42.4) 25 (37.9) 3 (5.1) 7 (10.6) 0.568

Information received on illness 32 (54.2) 32 (49.2) 18 (30.5) 29 (44.6) 9 (15.3) 4 (6.2) 0.736

Length of treatment 28 (46.7) 31 (47.7) 32 (53.3) 29 (44.6) 0 (0) 5 (7.7) 0.516

Extremely/very worried Worried Little or not worried p-Valuea

How worried were you

during treatment?

13 (21.7) 13 (19.7) 18 (30.0) 13 (19.7) 29 (48.3) 40 (60.6) 0.319

Complete/very well

addressed

Adequately addressed Poorly/not at all

addressed
p-Valuea

How was the attention

for worries?

24 (43.6) 28 (45.9) 21 (38.2) 27 (44.3) 10 (18.2) 6 (9.8) 0.417

Extremely/very safe Safe (Most) unsafe p-Valuea

Feeling safe during daytime 42 (68.9) 35 (53.0) 17 (27.9) 30 (45.5) 2 (3.3) 1 (1.5) 0.143

Feeling safe during nights 35 (58.3) 24 (37.5) 20 (33.3) 31 (48.4) 5 (8.3) 9 (14) 0.029

Completely/

very capable

Capable (Very) incapable p-Value*

At end of hospital or home treatment capable to resume normal daily activities 5 (8.5) 4 (6.3) 36 (61) 25 (39.1) 18 (30.5) 35 (54.7) 0.018

HC, usual hospital care; EAD, early assisted discharge; n.a., not applicable.
a Linear-by-linear association.
b Only for those who had oxygen.

Fig. 1. Number of patients preferring hospital and home treatment (A) T + 4 days and (B) T + 90 days.

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1543

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491544

resume activities. Safety at night and ability to resume
activities was valued significantly worse by patients in the
early assisted discharge group. The separate evaluation in
patients that received home care showed that 85% of
patients was satisfied with early assisted discharge. The
number and duration of home visits was sufficient. Forty-
two percent hospital-treated patients and 86% of home-
treated patients preferred home treatment if they could
have chosen. In home-treated patients, this preference was
influenced by their mental state.

Home-treated patients did not, like hospital-treated
patients, have access to nursing care during nights. This
may have caused them feeling unsafe during nights.
Previous studies showed that help at night is important
and an advantage of hospital treatment (Fried et al., 1998).
When designing and implementing hospital-at-home
schemes, nights should be appropriately addressed. Only
1 study reported to have nursing night cover by district
nurses (Davies et al., 2000). In accordance with Ojoo et al.
(2002) and Diaz et al. (2005) a 24-h telephone access to the
hospital was installed in our study. However, no patient
used this possibility during the nights. Nonetheless, we
believe that patients should be instructed on what
problems they might experience at home at night, how
to avoid these problems and how to act upon.

At the end of the 7-day treatment, patients that
experienced hospital-at-home reported significantly more
often not being capable to resume their normal daily
activities in comparison to patients from the usual hospital
care group. Median time to symptomatic recovery of
exacerbations is 7 days (Seemungal et al., 2000). However,
complete recovery of health status may take up to 90 days
(Seemungal et al., 1998, 2000) and many patients
experience difficulties with their daily activities after
hospital admission (Clarke et al., 2010). At the end of the 7-
day treatment patients from the usual hospital care group
had not been confronted yet with possible difficulties at
home when they completed the questionnaire, whereas
patients in the early assisted discharge group had been
confronted with daily activities since day four of the
treatment. Possibly, at the end of the 7-day treatment,
patients from the usual hospital care group have over-
estimated their capabilities to resume normal daily

activities. At the end of the 90 days follow up, the
difference between the groups regarding this item had
disappeared, supporting this explanation.

Despite feeling unsafe during nights and being less able
to resume activities, most patients in the early assisted
discharge still prefer to be treated at home. It is likely that
the benefits and advantages patients experience from
being treated at home outweigh these disadvantages.

Overall satisfaction with hospital and home care was
high, and not different between groups. Many negative
responses in both groups were related to medication. Most
of these comments could be linked to the hospital, as most
comments concerned the distribution and administration
of medicines which in the hospital is the under the
hospitals’ responsibility (prescribing doctors, hospital
pharmacy, distributing nurses) but at home under the
patients’ own responsibility. The comments did not
concern aspects that were the result of the introduction
of early assisted discharge and most likely have been
present before.

Overall, patients were very satisfied with the early
assisted discharge care. Advantages that patients experi-
enced from being treated at home were that the
environment at home was familiar, quiet, clean and
provided privacy. Furthermore, being at home made
patients able to stick to their own daily routines and
rules. However, patients’ comments revealed aspects that
could be improved. Coordination of the logistics of the
community nursing hampered in several cases. Within the
home care organisation separate teams are responsible for
defined geographic areas. Teams should be timely in-
formed about the patients’ discharge, and visiting arrange-
ments should be confirmed before the patient is
discharged. While some patients commented that care
at home was not necessary and nurses only came to check
upon them, others experienced difficulties at home alone
and expected more care, especially in the domestic field.
This wide difference in opinion was also found in the study
by Taylor et al. (2007). Patients should be explicitly
informed about the purpose and objectives of early
assisted discharge and home treatment and which care
can be expected at home. If this is insufficient, the patient
should not be early assisted discharged or additional

Table 4

Odds ratios and 95% confidence intervals for factors associated with preferred place of treatment at day 7 of treatment.

Preference at day 7a N OR 95% CI p-Value

Long term oxygen treatment

Nob 37 1

Yes 3 0.030 0.001–1.302 0.068

Income

Lowb 17 1

Medium 9 0.032 0.001–0.785 0.035
High 14 3.737 0.057–244.181 0.536

Living situation

With somebodyb 23 1

Alone 17 0.348 0.022–5.411 0.451

Clinical COPD Questionniare – mental state 40 0.349 0.135–0.904 0.030
a Results from multivariate logistic regression performed in early assisted discharge group. Variables from the bivariate logistic regression with p < 0.1

were included in the multivariate logistic regression.
b Reference category.

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C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1545

vices should be arranged. Patients from both groups
mented on the hampering information transfer from

pital to home or between hospital staff. It has been
wn that this is an important issue in transfers from
ondary to primary care (Berendsen et al., 2009; Preston
l., 1999). Health care professionals from secondary and

ary care should pay attention to this topic, in order to
ke flawless transitions from hospital to home possible.
Although patients that were treated in the hospital had
experience with home treatment, over half of all

ients preferred home treatment, if they would have had
opportunity to choose. This confirms previous results
joo et al. (2002) and Schofield et al. (2006). Patients

o were treated at home, and were able to make a true
parison, preferred home treatment significantly more
n. Patients find it difficult to imagine that at home
ilar treatment is possible as in the hospital (Fried et al.,
8), but often adjust their opinion once they have
erienced home treatment (Schofield et al., 2006).
In the group of home-treated patients we found that
ients with worse scores on the mental state domain of
clinical COPD questionnaire were less likely to prefer

e treatment. Home treatment appeals on the ability of
ients to manage with the disease more independently.
ofield et al. (2006) found a correlation between attitude
ards home care and emotional functioning and coping
ls. We found no such association. However, we did find
association between worse emotional functioning and
sive coping style. Patients with more negative or anxious
ughts and feelings are less confident that they will be
e to manage at home when problems occur. Patients who

better able to ration the purpose of early assisted
harge in relation to hospital care and have better insight

heir own role in the scheme, are better able to cope with
culties at home (Schofield et al., 2006).

We found an inconsistent association between income
preference. Medium income was associated with
ference for home treatment, high and low income and
ference were not associated. However, the patient

bers in the three groups were unequal which may
e caused inconsistent association.
Previous studies revealed that patients living alone
re treated more often in the hospital (Schofield et al.,
6) and that patients choose to be treated at home as

g as informal care giving was present (Dubois and
tos-Eggimann, 2001). In our study 30% of patients lived

ne, which did not withhold them from participation to
trial. Fried et al. (1998) stated that in patients that
fer home treatment and live alone, without support
work, strong self-reliance is an important factor. This
ports the conclusion that patients who are better able
anage their symptoms and difficulties will more often

ose home treatment.
This study has some limitations. Firstly, the current
luation was part of a randomised controlled trial.
ients with strong resistance against early assisted
harge and home treatment did not consent to partici-

e, which may have caused selection of patient with
itive attitudes towards home treatment. Furthermore,

design of the study was for the comparison of the
ctiveness, and therefore not optimal for the comparison

of preference. Therefore, the analysis of factors influencing
preference was only performed in patients that experienced
both treatments. Secondly, the number of patients in which
the preference analysis was performed was small, which
might have influenced results. However, this was a
pragmatic study reflecting the real situation enhancing
validity of results. Thirdly, because a validated question-
naire for measuring satisfaction with hospital-at-home was
not available, we had to develop one ourselves. The
questionnaire we developed contained questions on specific
items of the hospital care and hospital-at-home care
patients received, and therefore provided a clear view on
how patients value specific aspects of usual hospital care
hospital-at-home care. However, like in many patient
satisfaction evaluations, we found high satisfaction scores
among patients, which may mask real opinions on certain
subjects (Fitzpatrick, 1991). Finally, the satisfaction and
preference measures were performed at the end of the 7-day
treatment and the end of the 90-day follow-up period. In the
time frame between these time points events and challenges
may have occurred that have not been captured in the study
measurements, but may have influenced patient satisfac-
tion and/or preference. Further research is needed to
evaluate hospital-at-home on specific items and to gain
more insight in what and how patient satisfaction and
preference are influenced.

In conclusion, we found no large differences between
patients’ evaluation of home- and hospital care, but
attention should be paid to ensure patients feel safe at
night whilst receiving home treatment. Forty-two percent
of hospital-treated patients over 86% of home-treated
patients preferred home treatment, suggesting an overall
preference for home treatment. Mental state is associated
with preference for home treatment which is most likely to
be associated with being better able to manage the disease
independently. In the absence of clear differences in
outcomes between hospital-at-home and usual hospital
care, patient preference plays an important role in the
decision to implement hospital-at-home. Results from this
study support the wider implementation of hospital-at-
home for COPD exacerbations and this treatment option
should be offered to selected patients that prefer home
treatment over hospital treatment.

Conflict of interest: No conflict of interest.
Funding: The study was funded by the Netherlands

Organisation for Health Research and Development
(ZonMw), grant application number 945-50-7730. The
funder had no role in the design of the study; the collection
analysis and interpretation of the data; or the writing of the
article and the decision to submit the article for publication.
All researchers were independent from the funder.

Ethical approval: The trial was approved by the Medical
Ethics Committee of the Catharina Hospital Eindhoven, the
Netherlands.

Appendix 1. Patient satisfaction questionnaire

Day 7 of treatment
The questions in this questionnaire apply to the treatment

you received for your lung disease in the past 7 days in the
hospital or partly in the hospital and partly at home.

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491546

For each question we ask you to mark the answer that
applies most to your situation. Some questions require a
written reply from you.

Where would you have preferred to be treated?
& Hospital

& Home

2. What 3 things were you most satisfied with the care
you received?
2.1 ___________________________________________
2.2 ___________________________________________
2.3 ___________________________________________

3. What 3 things were you most dissatisfied with in the
care you received?
3.1 ______________________________________
3.2 ______________________________________
3.3 ______________________________________

4. How satisfied were you with the administration of
your infusion and tablets?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

5. How satisfied were you with your inhalations and
nebulised inhalations?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

6. How satisfied were you with the oxygen treatment?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

7. How satisfied were you with the improvement of your
symptoms?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

8. How worried were you during the treatment period?
& Extremely worried
& Very worried
& Worried
& A little bit worried
& Not at all worried

9. How much attention was there for your worries
addressed by the health care staff?
& Fully attention
& Very good attention
& Adequate attention
& Little attention
& No attention at all

10. How safe did you feel during the days in the treatment
period?
& Extremely safe

& Very safe

& Safe
& Unsafe
& Very unsafe

11. How safe did you feel during the nights in the
treatment period?
& Extremely safe

& Very safe
& Safe
& Unsafe
& Very unsafe

12. How satisfied were you with the nursing care during
the day?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

13. How satisfied were you with the nursing care during
the nights?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

14. How satisfied are you with the amount of time spent to
you by health care staff?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

15. How satisfied were you with the way you were
involved in the treatment?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

16. How satisfied were you with the information you
received concerning your illness?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

17. How satisfied were you with the length of the
treatment period?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

18. To what extent did you feel capable to resume your
usual daily activities?
& Completely capable
& Very capable
& Adequately capable
& Incapable
& Very incapable

Add
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C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1547

This is the end of the questionnaire.
Thank you for completing the questionnaire.

itional questions
early discharge patients only!
The following questions apply to the home visits by the
munity nurses you received.

With these questions we try to optimise the frequency
duration of the home visits.

al number of days with home care

he total number of days of home treatment with home
isits (4 days) is:

Sufficient number of days
Too many days
Too few days

mber of home visits per day

During the home treatment, 3 home visits per day
ere possible. It is possible that you have not used all 3

ome visits.
ow many home visits did you receive each day? Please

ircle the correct number
. Day 1 (day of discharge): 1/2/3 home visits
. Day 2: 1/2/3 home visits
. Day 3: 1/2/3 home visits
. Day 4: 1/2/3 home visits
he number of days that the nurse of the home care
rganisation performed was:

Sufficient number of visits per days
Too many visits per days
Too few visits per days

gth of home visits
he length of the first home visit each day was:

Sufficiently long
Too long
Too short

he length of the second and third home visit each day
as:

Sufficiently long
Too long
Too short
not applicable, I only received 1 home visit per day

ient satisfaction questionnaire
of follow-up

The questions in this questionnaire apply to the treatment
received for your lung disease approximately 3 months

in the hospital or partly in the hospital and partly at
e.

For each question we ask you to mark the answer that
lies most to your situation. Some questions require a
tten reply from you.

Where would you have preferred to be treated?
& Hospital

2. What 3 things were you most satisfied with the care
you received?
2.1 ______________________________________
2.2 ______________________________________
2.3 ______________________________________

3. What 3 things were you most dissatisfied with in the
care you received?
3.1 __________________________________
3.2 __________________________________
3.3 __________________________________

4. How satisfied were you with the administration of
your infusion and tablets?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
5. How satisfied were you with your inhalations and
nebulised inhalations?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
6. How satisfied were you with the oxygen treatment?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
7. How satisfied were you with the improvement of your
symptoms?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
8. How worried were you during the treatment period?
& Extremely worried
& Very worried
& Worried
& A little bit worried
& Not at all worried
9. How much attention was there for your worries
addressed by the health care staff?
& Fully attention
& Very good attention
& Adequate attention
& Little attention
& No attention at all

10. How safe did you feel during the days in the treatment
period?
& Extremely safe
& Very safe
& Safe
& Unsafe
& Very unsafe

11. How safe did you feel during the nights in the
treatment period?
& Extremely safe
& Home
& Very safe

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491548

& Safe
& Unsafe
& Very unsafe

12. How satisfied were you with the nursing care during
the day?
? Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

13. How satisfied were you with the nursing care during
the nights?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
14. How satisfied are you with the amount of time spent to
you by health care staff?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
15. How satisfied were you with the way you were
involved in the treatment?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
16. How satisfied were you with the information you
received concerning your illness?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
17. How satisfied were you with the length of the
treatment period?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

18. To what extent did you feel capable to resume your
usual daily activities?
& Completely capable
& Very capable
& Adequately capable
& Incapable
& Very incapable

This is the end of the questionnaire.
Thank you for completing the questionnaire.

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Patient preference and satisfaction in hospital-at-home and usual hospital care for COPD exacerbations: Results of a randomised controlled trial

Introduction
Methods
Design and patients
Measurements
Analysis
Findings
Findings – first part: qualitative questions on satisfaction
Patient-centred care
Access
Communication and information
Courtesy and emotional support
Efficiency of care and organisation
Technical quality
Structure and facilities
Findings – second part: quantitative questions on satisfaction
Findings – third part: preference for place of treatment
Findings – additional part: evaluation of early assisted discharge
Discussion
Patient satisfaction questionnaire
References

Rubic_Print_Format

N/A

10.0%

N/A

10.0%

N/A

10.0%

Course Code

Class Code

Assignment Title

Total Points

HLT-362V

HLT-362V-O501

Article Analysis 1

120.0

Criteria

Percentage

1: Unsatisfactory (0.00%)

2: Less Than Satisfactory (65.00%)

3: Satisfactory (75.00%)

4: Good (85.00%)

5: Excellent (100.00%)

Comments

Points Earned

Content

100.0%

Three Quantitative Articles

10.0%

Fewer than three articles are presented. None of the articles presented use quantitative research.

N/A

Three articles are presented. Of the articles presented, only two articles are based on quantitative research.

Three articles are presented. All three articles are based on quantitative research.

Article Citation and Permalinka 2

Article citation and permalink are omitted.

Article citation and permalink are presented. There are significant errors. Page numbers are not indicated to cite information, or the page numbers are incorrect.

Article citation and permalink are presented. Article citation is presented in APA format, but there are errors. Page numbers to cite information are missing, or incorrect, in some areas.

Article citation and permalink are presented. Article citation is presented in APA format. Page numbers are used to cite information. There are minor errors.

Article citation and permalink are presented. Article citation is accurately presented in APA format. Page numbers are accurate and used in all areas when citing information.

Broad Topic Area/Title

Broad topic area and title are omitted.

Broad topic area and title are referenced but are incomplete.

Broad topic area and title are summarized. There are some minor inaccuracies.

Broad topic area and title are presented. There are some minor errors, but the content overall is accurate.

Broad topic area and title are fully presented and accurate.

Independent and Dependent Variables and Type of Data for Variables

Variable types and data for variables are omitted.

Variable types and data for variables are presented. There are major inaccuracies or omissions.

Variable types and data for variables are presented. There are inaccuracies.

Variable types and data for variables are presented. Minor detail is needed for accuracy.

Variable types and data for variables are presented and accurate.

Population of Interest for the Study

Population of interest for the study is omitted.

Population of interest for the study is presented. There are major inaccuracies or omissions.

Population of interest for the study is presented. There are inaccuracies.

Population of interest for the study is presented. Minor detail is needed for accuracy.

Population of interest for the study is presented and accurate.

Sample

Sample is omitted.

Sample is presented. There are major inaccuracies or omissions.

Sample is presented. There are inaccuracies.

Sample is presented. Minor detail is needed for accuracy.

Sample is presented and accurate.

Sampling Method

Sampling method is omitted.

Sampling is presented. There are major inaccuracies or omissions.

Sampling is presented. There are inaccuracies.

Sampling is presented. Minor detail is needed for accuracy.

Sampling method is presented and accurate.

Descriptive Statistics (mean, median, mode; standard deviation) (Identify examples of descriptive statistics in the article.)

Descriptive statistic examples from the article are omitted. There are major inaccuracies or omissions.

Descriptive statistic examples from the article are presented. There are some very minor inaccuracies or omissions.

Descriptive statistic examples from the article are presented and accurate.

Inferential Statistics (Identify examples of inferential statistics in the article.)

Inferential statistic examples from the article are omitted. There are major inaccuracies or omissions.

Inferential statistic examples from the article are presented. There are some very minor inaccuracies or omissions.

Inferential statistic examples from the article are presented and accurate.

Mechanics of Writing (includes spelling, punctuation, grammar, and language use)

Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is employed.

Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied.

Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed.

Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech.

The writer is clearly in command of standard, written, academic English.

Total Weightage

100%

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