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PubMed1994

An integrated health care model in medical education: interviews with faculty and administrators.

PURPOSE: To broaden the understanding of how medical schools can help students learn an approach to health care that reflects the integration of psychosocial and biomedical factors in health and illness. METHOD: A qualitative research design was used, with data collected through document review and semi-structured interviews conducted in the spring and summer of 1992 with 22 faculty and administrators from 17 U.S. and Canadian medical schools. The interviewees represented the following disciplines: internal medicine, family medicine, pediatrics, psychiatry, and preventive/behavioral medicine. An analytic framework was developed, within which the constant comparative method was used on a continuous basis during and after data collection. Category development focused on (1) defining the scope and character of an integrated perspective, (2) delineating various ways to incorporate such a perspective in medical education, and (3) identifying barriers to and facilitative factors for incorporating such a perspective in medical education. Validity was assessed by having the interviewees and three other faculty members review the analyses and preliminary results. RESULTS: The interviewees' conceptions of an integrated perspective on health care focused on the theoretical need for a broader scientific model and on the practical need for more inclusive approaches to medical practice. The interviewees described patient-level and community-level approaches as equally important. The ideal curricula envisioned by the interviewees were patient-centered, integrated, developmental, and population-based. In addition to naming many barriers to integration (e.g., negative attitudes of faculty and administrators, diffuse organization of medical schools, ignorance of appropriate curriculum design and implementation), the interviewees identified certain facilitative factors (e.g., strong leaders, faculty development programs, and reform of the faculty reward system). CONCLUSION: The interviewees envisioned an integrated model of health care that suggests that medical curricula should address the development of physicians' knowledge, attitudes, and skills regarding physicians' relationships with both patients and community.

Administrative Personnel↗
PubMed1996

The development of diagnostic competence: comparison of a problem-based, an integrated, and a conventional medical curriculum.

PURPOSE: To compare the diagnostic performances of students in five curriculum years educated at schools with problem-based, integrative, or conventional medical curricula. METHOD: Data were analyzed in 1994 for 612 students in their second, third, or fourth (preclinical) or fifth or sixth (clinical) years at three Dutch medical schools with problem-based, integrative, or conventional curricula. The students gave differential diagnoses for 30 case histories that were epidemiologically representative of Dutch society and covered all organ systems. The numbers of accurate diagnostic hypotheses were tallied for each of the groups involved. The data were analyzed using analysis of variance and post-hoc Newman-Keuls tests. RESULTS: Overall, the students trained within the problem-based framework and the students trained within the integrated curriculum made more accurate diagnoses than the students trained within the conventional curriculum. No overall differences were found between the students in the problem-based and integrated curricula, although the second- and third-year students from the latter performed better than the second- and third-year students from both other schools. CONCLUSION: Integration between basic and clinical sciences and an emphasis on patient problems may be the critical factors that determine superior diagnostic performance rather than whether a curriculum is self- or teacher-directed. Problem-based learning seems to live up to its expectations, but so does the integrated approach to medical education. In addition, the procedure for measuring diagnostic performance appears to be valid and to provide a simple means of measuring curriculum effects. It remains to be seen whether the findings would be replicated when students are allowed to freely gather data in open interaction with patients rather than respond to written presentations of cases.

Aged↗
PubMed2000

Breaking down the walls: thoughts on the scholarship of integration.

The scholarship of integration is concerned with making connections across scientific disciplines, placing the work of individual investigators and their specialty fields into a larger context, and educating nonspecialists. The authors focus their comments on the biomedical sciences, but observe that closer integration of the biomedical and behavioral sciences will be particularly crucial to advance understanding of the human brain. They observe that as biomedical sciences become more technologically sophisticated, progress is increasingly dependent on sciences such as physics, chemistry, engineering, and related fields. However, the scholarship of integration has been slower than other forms of scholarship to gain acceptance as an integral activity of the professoriate. The isolation of disciplines from one another, particularly at large universities, and the perception of interdisciplinary work as risky and professionally unrewarding are among the forces that may discourage integrative scholarship. In addition, a troubling disconnect exists between the scientific community and the larger public in the understanding of science. Leaders in academic medicine and science must develop strategies to move interdisciplinary work from the margins into the mainstream of academia. Solutions that have been proposed include creating new research entities and funding mechanisms dedicated to interdisciplinary work; reinvigorating the integrative role of the physician-scientist; and training specialists in translational research. The scientific community must also work to develop more effective means of communicating the importance of its work to the public.

Academic Medical Centers↗
PubMed2002

Assessment of an integrated curriculum in radiology.

OBJECTIVE: To describe an interdisciplinary team's experience using a six-stage curriculum-development model to assess an integrated curriculum in radiology. DESCRIPTION: In 1996 the University of Maryland School of Medicine implemented reforms of its undergraduate curriculum. A third-year required clerkship in radiology was eliminated, but an integrated curriculum was developed for first- and second-year students and for third-year students during their core clinical clerkships. A fourth-year elective was retained. In 2000 the school's Curriculum Coordinating Committee found that it lacked data regarding program performance or learner competencies in radiology since the reforms were implemented. The Committee designated an interdisciplinary team including a radiologist, an anatomist, and an internist with medical education expertise to conduct a rapid review of the adequacy of the curriculum as it is currently integrated. The team mapped the curriculum, identifying where radiology was taught, and analyzed each sub-curriculum according to a six-stage curriculum-development model. This method permitted nearly concurrent assessment of the national literature, local needs assessment, presence and adequacy of educational objectives and methods, adequacy of resources to support curriculum implementation, and the availability and adequacy of learner and program outcome measures. The team identified changes in the clinical classrooms that have been unanticipated four years earlier, including implementation of PACS systems for digital film storage and retrieval, rapid advances in clinical imaging capabilities, and diminished faculty teaching time due to increased clinical volumes. The team concluded its work in four months and issued a report recommending revisions to third-year curricula. The Curriculum Committee, the Dean's Office, and the Department of Radiology accepted the analysis and have dedicated personnel, technical, and financial resources to effect the recommended revisions, which include (1) revision of clinical clerkship objectives for competencies in radiology, (2) development of Web-based modules for self-directed learning, (3) faculty development to enhance teaching skills, and (4) competency-based assessment measures based on learning objectives. DISCUSSION: Schools and faculty are often faced with the need to develop and implement innovative curricula rapidly. Periodic assessments by oversight groups such as curriculum committees identify where additional information is required to assess the performances of learners and curricula in rapidly-changing clinical contexts. In this study a three-member team with focused expertise in radiology, anatomy, and medicine/medical education conducted a rapid in-depth review of an integrated radiology curriculum "hosted" by several departments. A curriculum-development model provided a template for analysis of needs, objectives, methods, resources, and assessment measures for all curricula, and guided the team's recommendations for targeted revision. Each team member brought expertise in some element of the integrated curriculum or in curriculum design. The team identified what integrated curricular elements had not been designed adequately, what could no longer be supported with current resources, and how curricular revisions could be assessed for adequacy.

Curriculum↗
PubMed1999

Quantification of integrated and total HIV-1 DNA after long-term highly active antiretroviral therapy in HIV-1-infected patients.

OBJECTIVE: To assess the impact of long-term virus suppression on the peripheral blood CD4 T cells integrated and total HIV-1 DNA loads in patients receiving highly active antiretroviral therapy (HAART). METHODS: A total of 10 HIV-1-infected patients receiving a triple combination therapy (two nucleoside analogues and one protease inhibitor) were longitudinally studied to compare integrated and total HIV-1 DNA loads. HIV-1 DNA quantification was performed using a quantitative nested polymerase chain reaction (PCR) on genomic peripheral blood mononuclear cell (PBMC) DNA obtained at baseline and at 48 weeks of HAART. RESULTS: All the study patients showed an early and sustained decrease in plasma HIV-1 RNA to below the limit of detection (200 copies/ml). Concordant with the plasma viral decline, a significant increase in the CD4 T cell count was observed (P = 0.007). A statistically significant fivefold decrease in total HIV-1 DNA was detected after 48 weeks of HAART (P = 0.005). However, no statistically significant change was noted after the therapy when the integrated HIV-1 DNA copy number was compared (P = 0.333). Taken together, these results suggest that in the patients analysed the integrated HIV-1 DNA does not decay rapidly after HAART. CONCLUSION: Within the study cohort the total amount of PBMC HIV-1 DNA decreased drastically after 48 weeks of HAART. Nevertheless, the integrated HIV-1 DNA did not significantly decay during this period. Although the data presented here are limited by the number of patients analysed, our findings suggest that 48 weeks of HAART does not significantly reduce the integrated HIV-1 proviral DNA load in the latently infected CD4 T cell reservoir.

Anti-HIV Agents↗
PubMedDate not supplied

Self-reported integration as a proxy for acculturation: a qualitative study.

BACKGROUND: It is essential to account for acculturation in any research conducted in multicultural populations. Both unidimensional and bidimensional approaches are used to measure the extent of acculturation; however, neither one of them is optimal. OBJECTIVE: To explore the immigrants' rating of the extent of their acculturation (self-reported integration) in contrast to an external (researchers') measurement. METHODS: Fifteen in-depth interviews with strategically sampled Russian-speaking men and women aged 25-70 years, with varying marital and employment status and living permanently in Stockholm, Sweden, were analyzed using a content analysis technique. The results were validated by means of a series of additional mini-interviews by telephone. RESULTS: The immigrants' self-reported integration corresponded with the researchers' bidimensional measurement of the extent of acculturation of these immigrants. Self-reported integration accounted for the mastering of the formal criteria of integration, resolving of grief concerning the homeland, and fulfilling the internal criteria of integration. DISCUSSION: Self-reported integration may be used as a proxy for acculturation but its application should be tested primarily in other settings and in a quantitative analysis.

Acculturation↗
PubMed2002

In vitro stability of FRA spacers with integrated crossed screws for anterior lumbar interbody fusion.

STUDY DESIGN: Mechanical testing of human lumbar functional spine units was carried out after instrumenting the disc space with femoral ring allografts (FRAs) with and without integrated crossed anterior screws applied into the adjacent bodies. OBJECTIVES: To assess the stability of FRA construct with and without the integrated crossed anterior screws and to compare that with the intact specimen. SUMMARY OF BACKGROUND DATA: Most modern methods of achieving anterior lumbar intervertebral fusion rely on the use of interbody spacers to restore and maintain intervertebral height, overall alignment, and stability while facilitating arthrodesis. The FRAs have the advantage of biologic compatibility but may not have enough stability when used as stand-alone devices. FRA spacers alone are less stiff in torsion and extension compared with other instrumented constructs. Increased motion could lead to higher failure rates because of graft migration and pseudarthrosis. This makes the use of supplementary anterior or posterior fixation necessary. The current authors hypothesized that the addition of anterior integrated crossed screws applied through the FRA spacer into the adjacent vertebral bodies would increase the stability of the FRA spacer in extension and torsion in the absence of further posterior instrumentation. METHODS: Seven fresh-frozen human cadaveric lumbar spine functional spine units were tested applying cantilever bending moments in flexion, lateral bending, torsion, and extension. The specimens were tested in the following sequence: intact, with FRA spacer alone and with FRA spacer and integrated crossed screws. The stiffness of each construct was then compared with the intact specimen. Specimens with obvious deformity on radiographs or dual-energy radiograph absorptiometry t score values <-1.2 were excluded. RESULTS: The addition of the integrated crossed metal screw system improved the stiffness of the construct by 53% over the intact (P = 0.02) and by 31% over the FRA alone in extension (P = 0.01), whereas it improved the stiffness by 40% over the intact (P = 0.03) and by 18% over the FRA alone in torsion (P = 0.21). The crossed screw system did not improve the stiffness compared with intact in either flexion or lateral bending modes. CONCLUSIONS: Although there is a trend toward improved stability of the FRA spacers in torsion with the addition of the metal screws, this is not statistically significant. The integrated crossed anterior metal screw system significantly improves the stability of the FRA spacers in extension when used for anterior lumbar interbody fusion.

Adult↗
PubMed2006

The integrative family medicine program: an innovation in residency education.

The Integrative Family Medicine (IFM) Program is a four-year combined family medicine residency program and integrative medicine fellowship. It was created in 2003 to address the needs of four constituencies: patients who desire care from well trained integrative physicians, physicians who seek such training, the health care system which lacks a conventional integrative medicine training route, and educational leaders in family medicine who are seeking new strategies to reverse the declining interest in family medicine amongst U.S. graduates. The program was designed jointly by the University of Arizona Program in Integrative Medicine (PIM) and family medicine residency programs at Beth Israel/Albert Einstein College of Medicine (AECOM), Maine Medical Center, Middlesex Hospital, Oregon Health & Science University, and the Universities of Arizona and Wisconsin. One or two residents from each of these institutions may apply, and when selected, commit to extending their training by a fourth year. They complete their family medicine residencies at their home sites, enroll in the distributed learning associate fellowship at PIM, and are mentored by local faculty members who have training in integrative medicine. To date three classes totaling twenty residents have entered the program. Evaluation is performed jointly: PIM evaluates the residents during residential weeks and through online modules and residency faculty members perform direct observation of care and review treatment plans. Preliminary data suggest that the program enhances interest amongst graduating medical students in family medicine training. The Accreditation Council of Graduate Medical Education Family Medicine residency review committee has awarded the pilot experimental status.

Complementary Therapies↗
PubMed1993

Recombination at the coagulase locus in Staphylococcus aureus: plasmid integration and amplification.

The integrating plasmid pCOA18, comprising pUC18 linked to a mutated coagulase (coa) gene from Staphylococcus aureus, and constructed by substituting coa sequences with a tetracycline (Tc)-resistance marker (delta coa::Tcr), was transformed into Staphylococcus aureus RN4220, where it underwent recombination with the chromosomal coa locus. Allele-replacement mutants were recovered at a low frequency directly after transformation. The majority of transformants carried pCOA18 integrated in the chromosome by a single Campbell-type recombination event. The majority of integrants contained tandem repeats of pCOA18 and expressed high levels of resistance to Tc (> 30 micrograms ml-1) compared to the single-copy integrants and allele-replacement mutants (15 micrograms ml-1). Transduction of a single-copy integrant to a Coa+ recipient allowed the cointegrant to be resolved and allele-replacement recombinants to be selected. In addition, growth of a single-copy integrant on high concentrations of Tc (> 30 micrograms ml-1) selected for amplified derivatives at a frequency of 10(-5). It was estimated that up to 19 copies of pCOA18 could occur in a tandem array in the chromosome.

Alleles↗
PubMed1997

Targets for pSAM2 integrase-mediated site-specific integration in the Mycobacterium smegmatis chromosome.

An improved integrative cassette from plasmid pSAM2 has been constructed containing plasmid int and attP genes but excluding the xis gene, which should results in increased stability by suppression of the excision reaction. This cassette was included in both suicide and thermosensitive plasmids and used for integration in Mycobacterium smegmatis. Suicide plasmids containing this cassette integrated at a single site (attB1) in the M. smegmatis chromosome. The sequence of the attB1 site has been determined and was identified as a putative tRNA(Pro) gene. Thermosensitive plasmids containing the cassette integrated both at the same attB1 site and at other different sites, often giving rise to simultaneous integration at two sites. A second integration site (attB2) has been sequenced, which was located in the region encoding 16S rRNA of one of the two rrn operons of M. smegmatis.

Base Sequence↗
PubMed1989

A nucleoprotein complex mediates the integration of retroviral DNA.

The integration of viral DNA into the host genome is an essential step in the retrovirus life cycle. To understand this process better, we have examined the native state of viral DNA in cells acutely infected by murine leukemia virus (MLV), using both a physical assay for viral DNA and a functional assay for integration activity (Brown et al. 1987). The viral DNA and integration activity copurify during velocity sedimentation, gel filtration, and density equilibrium centrifugation, indicating that viral DNA is in a large (approximately 160S) nucleoprotein complex that includes all functions required for integration activity in vitro. Analysis by immunoprecipitation shows that the viral capsid protein is part of the active nucleoprotein complex, but recognition of the complex by only a subset of anti-capsid sera implies that the protein is constrained conformationally. The viral DNA within this structure is accessible to nucleases; the effects of nucleases on the integrity of the complex suggest that the integration-competent particle is derived from and similar to the core of extracellular virions.

Animals↗
PubMed2000

A fast and scalable radiation hybrid map construction and integration strategy.

This paper describes a fast and scalable strategy for constructing a radiation hybrid (RH) map from data on different RH panels. The maps on each panel are then integrated to produce a single RH map for the genome. Recurring problems in using maps from several sources are that the maps use different markers, the maps do not place the overlapping markers in same order, and the objective functions for map quality are incomparable. We use methods from combinatorial optimization to develop a strategy that addresses these issues. We show that by the standard objective functions of obligate chromosome breaks and maximum likelihood, software for the traveling salesman problem produces RH maps with better quality much more quickly than using software specifically tailored for RH mapping. We use known algorithms for the longest common subsequence problem as part of our map integration strategy. We demonstrate our methods by reconstructing and integrating maps for markers typed on the Genebridge 4 (GB4) and the Stanford G3 panels publicly available from the RH database. We compare map quality of our integrated map with published maps for GB4 panel and G3 panel by considering whether markers occur in the same order on a map and in DNA sequence contigs submitted to GenBank. We find that all of the maps are inconsistent with the sequence data for at least 50% of the contigs, but our integrated maps are more consistent. The map integration strategy not only scales to multiple RH maps but also to any maps that have comparable criteria for measuring map quality. Our software improves on current technology for doing RH mapping in areas of computation time and algorithms for considering a large number of markers for mapping. The essential impediments to producing dense high-quality RH maps are data quality and panel size, not computation.

Algorithms↗
PubMed2004

Integrative genomics: in silico coupling of rat physiology and complex traits with mouse and human data.

Integration of the large variety of genome maps from several organisms provides the mechanism by which physiological knowledge obtained in model systems such as the rat can be projected onto the human genome to further the research on human disease. The release of the rat genome sequence provides new information for studies using the rat model and is a key reference against which existing and new rat physiological results can be aligned. Previously, we described comparative maps of the rat, mouse, and human based on EST sequence comparisons combined with radiation hybrid maps. Here, we use new data and introduce the Integrated Genomics Environment, an extensive database of curated and integrated maps, markers, and physiological results. These results are integrated by using VCMapview, a java-based map integration and visualization tool. This unique environment allows researchers to relate results from cytogenetic, genetic, and radiation hybrid studies to the genome sequence and compare regions of interest between human, mouse, and rat. Integrating rat physiology with mouse genetics and clinical results from human by using the respective genomes provides a novel route to capitalize on comparative genomics and the strengths of model organism biology.

Animals↗
PubMed2005

Assessing the limits of genomic data integration for predicting protein networks.

Genomic data integration--the process of statistically combining diverse sources of information from functional genomics experiments to make large-scale predictions--is becoming increasingly prevalent. One might expect that this process should become progressively more powerful with the integration of more evidence. Here, we explore the limits of genomic data integration, assessing the degree to which predictive power increases with the addition of more features. We focus on a predictive context that has been extensively investigated and benchmarked in the past-the prediction of protein-protein interactions in yeast. We start by using a simple Naive Bayes classifier for integrating diverse sources of genomic evidence, ranging from coexpression relationships to similar phylogenetic profiles. We expand the number of features considered for prediction to 16, significantly more than previous studies. Overall, we observe a small, but measurable improvement in prediction performance over previous benchmarks, based on four strong features. This allows us to identify new yeast interactions with high confidence. It also allows us to quantitatively assess the inter-relations amongst different genomic features. It is known that subtle correlations and dependencies between features can confound the strength of interaction predictions. We investigate this issue in detail through calculating mutual information. To our surprise, we find no appreciable statistical dependence between the many possible pairs of features. We further explore feature dependencies by comparing the performance of our simple Naive Bayes classifier with a boosted version of the same classifier, which is fairly resistant to feature dependence. We find that boosting does not improve performance, indicating that, at least for prediction purposes, our genomic features are essentially independent. In summary, by integrating a few (i.e., four) good features, we approach the maximal predictive power of current genomic data integration; moreover, this limitation does not reflect (potentially removable) inter-relationships between the features.

Algorithms↗
PubMed2005

L1 integration in a transgenic mouse model.

To study integration of the human LINE-1 retrotransposon (L1) in vivo, we developed a transgenic mouse model of L1 retrotransposition that displays de novo somatic L1 insertions at a high frequency, occasionally several insertions per mouse. We mapped 3' integration sites of 51 insertions by Thermal Asymmetric Interlaced PCR (TAIL-PCR). Analysis of integration locations revealed a broad genomic distribution with a modest preference for intergenic regions. We characterized the complete structures of 33 de novo retrotransposition events. Our results highlight the large number of highly truncated L1s, as over 52% (27/51) of total integrants were <1/3 the length of a full-length element. New integrants carry all structural characteristics typical of genomic L1s, including a number with inversions, deletions, and 5'-end microhomologies to the target DNA sequence. Notably, at least 13% (7/51) of all insertions contain a short stretch of extra nucleotides at their 5' end, which we postulate result from template-jumping by the L1-encoded reverse transcriptase. We propose a unified model of L1 integration that explains all of the characteristic features of L1 retrotransposition, such as 5' truncations, inversions, extra nucleotide additions, and 5' boundary and inversion point microhomologies.

Animals↗
PubMed2000

Signatures of quantum integrability and nonintegrability in the spectral properties of finite hamiltonian matrices

For a two-spin model which is (classically) integrable on a five-dimensional hypersurface in six-dimensional parameter space and for which level degeneracies occur exclusively (with one known exception) on four-dimensional manifolds embedded in the integrability hypersurface, we investigate the relations between symmetry, integrability, and the assignment of quantum numbers to eigenstates. We calculate quantum invariants in the form of expectation values for selected operators and monitor their dependence on the Hamiltonian parameters along loops within, without, and across the integrability hypersurface in parameter space. We find clear-cut signatures of integrability and nonintegrability in the observed traces of quantum invariants evaluated in finite-dimensional invariant Hilbert subspaces. The results support the notion that quantum integrability depends on the existence of action operators as constituent elements of the Hamiltonian.

Journal Article↗
PubMed2001

Authenticity and integrity of digital mammography images.

Data security becomes more and more important in telemammography which uses a public high-speed wide area network connecting the examination site with the mammography expert center. Generally, security is characterized in terms of privacy, authenticity and integrity of digital data. Privacy is a network access issue and is not considered in this paper. We present a method, authenticity and integrity of digital mammography, here which can meet the requirements of authenticity and integrity for mammography image (IM) transmission. The authenticity and integrity for mammography (AIDM) consists of the following four modules. 1) Image preprocessing: To segment breast pixels from background and extract patient information from digital imaging and communication in medicine (DICOM) image header. 2) Image hashing: To compute an image hash value of the mammogram using the MD5 hash algorithm. 3) Data encryption: To produce a digital envelope containing the encrypted image hash value (digital signature) and corresponding patient information. 4) Data embedding: To embed the digital envelope into the image. This is done by replacing the least significant bit of a random pixel of the mammogram by one bit of the digital envelope bit stream and repeating for all bits in the bit stream. Experiments with digital IMs demonstrate the following. 1) In the expert center, only the user who knows the private key can open the digital envelope and read the patient information data and the digital signature of the mammogram transmitted from the examination site. 2) Data integrity can be verified by matching the image hash value decrypted from the digital signature with that computed from the transmitted image. 3) No visual quality degradation is detected in the embedded image compared with the original. Our preliminary results demonstrate that AIDM is an effective method for image authenticity and integrity in telemammography application.

Computer Security↗
PubMed2005

Informal and formal caregivers' involvement in nursing home care activities: impact of integrated care.

AIMS: This paper reports a study to investigate the relationships between informal and formal care, changing relationships over time, impact of integrated care, and theoretical and methodological lessons that can be drawn from research on this topic. BACKGROUND: The ratio of informal to formal care provided in nursing homes varies. In many countries the predominance of traditional, formal care is being challenged by the emergence of integrated care models in which formal and informal caregivers co-operate and co-ordinate their activities to deliver tailor-made care. This move towards integrated care is likely to result in changes in the degree and nature of involvement of formal and informal caregivers in care activities. However, very little research has investigated this. Previous research is restricted to one point in time, as opposed to focussing on the changing relationships between formal and informal caregivers over time. METHODS: The quasi-experimental design encompassed a traditional care comparison setting and an experimental setting with an integrated care intervention. At three measurement points, one before the intervention in May/June 2000 and two at 6 and 14 months after the intervention, informal and formal caregivers recorded their care activities. Informal care relationships were determined by calculating contribution rates and informal/formal care ratios for 14 activities. RESULTS: Integrated care did not bring about the expected major changes. There was a limited amount of substitution of formal care with informal care. There were limited changes in the extent of dual specialization, in which informal and formal caregivers perform separate activities. There was little supplementation of formal care with informal care. Furthermore, relationships changed over time, resulting in a complex pattern of linkages at the level of separate activities. CONCLUSIONS: Informal caregivers contribute to many activities. The impact of integrated care on the degree and nature of involvement, however, was moderate. A possible explanation is the contextual situation for nursing home care. These findings point to the need for further research into the (changing) relationship between formal and informal carers in residential care activities and the evolution of this relationship over time.

Caregivers↗