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Background: Across the European Union costs for the treatment of oral disease is expected to rise to €93 Billion by 2020 and be higher than those for stroke and dementia combined. A significant proportion of these costs will relate to the provision of care for older people. Dental caries severity and experience is now a major public health issue in older people and periodontal disease disproportionately affects older adults. Poor oral health impacts on older people's quality of life, their self-esteem, general health and diet. Oral health care service provision for older people is often unavailable or poor, as is the standard of knowledge amongst formal and informal carers. The aim of this discussion paper is to explore some of the approaches that could be taken to improve the level of co-production in the design of healthcare services for older people., Main Text: People's emotional and practical response to challenges in health and well-being and the responsiveness of systems to their needs is crucial to improve the quality of service provision. This is a particularly important aspect of care for older people as felt, expressed and normative needs may be fundamentally different and vary as they become increasingly dependent. Co-production shifts the design process away from the traditional 'top-down' medical model, where needs assessments are undertaken by someone external to a community and strategies are devised that encourage these communities to become passive recipients of services. Instead, an inductive paradigm of partnership working and shared leadership is actively encouraged to set priorities and ultimately helps improve the translational gap between research, health policy and health-service provision., Discussion: The four methodological approaches discussed in this paper (Priority Setting Partnerships, Discrete Choice Experiments, Core Outcome Sets and Experience Based Co-Design) represent an approach that seeks to better engage with older people and ensure an inductive, co-produced process to the research and design of healthcare services of the future. These methods facilitate partnerships between researchers, healthcare professionals and patients to produce more responsive and appropriate public services for older people.

Background: Medical students in clerkship are continuously confronted with real and relevant patient problems. To support clinical problem solving skills, students perform a Critical Appraisal of a Topic (CAT) task, often resulting in a paper. Because such a paper may contain errors, students could profit from discussion with peers, leading to paper revision. Active peer discussion by a Computer Supported Collaborative Learning (CSCL) environment show positive medical students perceptions on subjective knowledge improvement. High students' activity during discussions in a CSCL environment demonstrated higher task-focussed discussion reflecting higher levels of knowledge construction. However, it remains unclear whether high discussion activity influences students' decisions revise their CAT paper. The aim of this research is to examine whether students who revise their critical appraisal papers after discussion in a CSCL environment show more task-focussed activity and discuss more intensively on critical appraisal topics than students who do not revise their papers., Methods: Forty-seven medical students, stratified in subgroups, participated in a structured asynchronous online discussion of individual written CAT papers on self-selected clinical problems. The discussion was structured by three critical appraisal topics. After the discussion, the students could revise their paper. For analysis purposes, all students' postings were blinded and analysed by the investigator, unaware of students characteristics and whether or not the paper was revised. Postings were counted and analysed by an independent rater, Postings were assigned into outside activity, non-task-focussed activity or task-focussed activity. Additionally, postings were assigned to one of the three critical appraisal topics. Analysis results were compared by revised and unrevised papers., Results: Twenty-four papers (51.6%) were revised after the online discussion. The discussions of the revised papers showed significantly higher numbers of postings, more task-focussed activities, and more postings about the two critical appraisal topics: "appraisal of the selected article(s)", and "relevant conclusion regarding the clinical problem"., Conclusion: A CSCL environment can support medical students in the execution and critical appraisal of authentic tasks in the clinical workplace. Revision of CAT papers appears to be related to discussions activity, more specifically reflecting high task-focussed activity of critical appraisal topics.

Background: Physical activity surveillance systems are important for public health monitoring but rely mostly on self-report measurement of physical activity. Integration of device-based measurements in such systems can improve population estimates, however this is still relatively uncommon in existing surveillance systems. This systematic review aims to create an overview of the methodology used in existing device-based national PA surveillance systems. Methods: Four literature databases (PubMed, Embase.com, SPORTDiscus and Web of Science) were searched, supplemented with backward tracking. Articles were included if they reported on population-based (inter)national surveillance systems measuring PA, sedentary time and/or adherence to PA guidelines. When available and in English, the methodological reports of the identified surveillance studies were also included for data extraction. Results: This systematic literature search followed the PRISMA guidelines and yielded 34 articles and an additional 18 methodological reports, reporting on 28 studies, which in turn reported on one or multiple waves of 15 different national and 1 international surveillance system. The included studies showed substantial variation between (waves of) systems in number of participants, response rates, population representativeness and recruitment. In contrast, the methods were similar on data reduction definitions (e.g. minimal number of valid days, non-wear time and necessary wear time for a valid day). Conclusions: The results of this review indicate that few countries use device-based PA measurement in their surveillance system. The employed methodology is diverse, which hampers comparability between countries and calls for more standardized methods as well as standardized reporting on these methods. The results from this review can help inform the integration of device-based PA measurement in (inter)national surveillance systems. [ABSTRACT FROM AUTHOR]

Background: BERT models have seen widespread use on unstructured text within the clinical domain. However, little to no research has been conducted into classifying unstructured clinical notes on the basis of patient lifestyle indicators, especially in Dutch. This article aims to test the feasibility of deep BERT models on the task of patient lifestyle classification, as well as introducing an experimental framework that is easily reproducible in future research. Methods: This study makes use of unstructured general patient text data from HagaZiekenhuis, a large hospital in The Netherlands. Over 148 000 notes were provided to us, which were each automatically labelled on the basis of the respective patients' smoking, alcohol usage and drug usage statuses. In this paper we test feasibility of automatically assigning labels, and justify it using hand-labelled input. Ultimately, we compare macro F1-scores of string matching, SGD and several BERT models on the task of classifying smoking, alcohol and drug usage. We test Dutch BERT models and English models with translated input. Results: We find that our further pre-trained MedRoBERTa.nl-HAGA model outperformed every other model on smoking (0.93) and drug usage (0.77). Interestingly, our ClinicalBERT model that was merely fine-tuned on translated text performed best on the alcohol task (0.80). In t-SNE visualisations, we show our MedRoBERTa.nl-HAGA model is the best model to differentiate between classes in the embedding space, explaining its superior classification performance. Conclusions: We suggest MedRoBERTa.nl-HAGA to be used as a baseline in future research on Dutch free text patient lifestyle classification. We furthermore strongly suggest further exploring the application of translation to input text in non-English clinical BERT research, as we only translated a subset of the full set and yet achieved very promising results. [ABSTRACT FROM AUTHOR]

Background: This study takes on the challenge of quantifying a complex causal loop diagram describing how poverty and health affect each other, and does so using longitudinal data from The Netherlands. Furthermore, this paper elaborates on its methodological approach in order to facilitate replication and methodological advancement. Methods: After adapting a causal loop diagram that was built by stakeholders, a longitudinal structural equation modelling approach was used. A cross-lagged panel model with nine endogenous variables, of which two latent variables, and three time-invariant exogenous variables was constructed. With this model, directional effects are estimated in a Granger-causal manner, using data from 2015 to 2019. Both the direct effects (with a one-year lag) and total effects over multiple (up to eight) years were calculated. Five sensitivity analyses were conducted. Two of these focus on lower-income and lower-wealth individuals. The other three each added one exogenous variable: work status, level of education, and home ownership. Results: The effects of income and financial wealth on health are present, but are relatively weak for the overall population. Sensitivity analyses show that these effects are stronger for those with lower incomes or wealth. Physical capability does seem to have strong positive effects on both income and financial wealth. There are a number of other results as well, as the estimated models are extensive. Many of the estimated effects only become substantial after several years. Conclusions: Income and financial wealth appear to have limited effects on the health of the overall population of The Netherlands. However, there are indications that these effects may be stronger for individuals who are closer to the poverty threshold. Since the estimated effects of physical capability on income and financial wealth are more substantial, a broad recommendation would be that including physical capability in efforts that are aimed at improving income and financial wealth could be useful and effective. The methodological approach described in this paper could also be applied to other research settings or topics. [ABSTRACT FROM AUTHOR]

Background: In paediatric palliative care, children with life-threatening and life-limiting conditions, their families, and their health care professionals often face difficult decisions about treatment, goals of care, and delivery of care. Advance care planning and shared decision-making are strategies that can improve quality of care by discussing goals and preferences on future care. In this paper, we provide recommendations that aim to optimise advance care planning and shared decision-making in paediatric palliative care in the Netherlands. Methods: A multidisciplinary guideline panel of 20 experts in paediatric palliative care and nine (bereaved) parents was established to develop recommendations on advance care planning and shared decision-making. We performed systematic literature searches to identify quantitative and qualitative evidence and used the GRADE (CERQual) methodology for appraisal of evidence. Recommendations were formulated based on quantitative and qualitative evidence, clinical expertise, and patient and family experiences. Results: We identified 4 RCTs that reported on the effect of advance care planning interventions in paediatric palliative care and 33 qualitative studies on barriers and facilitators to advance care planning and shared decision-making. We formulated 28 strong recommendations in close collaboration with a multidisciplinary guideline panel that provide guidance to offer advance care planning and shared decision-making, involve children and their family, and communicate information about care and treatment. Conclusion: The identified evidence and recommendations support the use of advance care planning and shared decision-making in paediatric palliative care. However, we found several knowledge gaps that should be addressed. As advance care planning and shared decision-making require specific skills and can be time-consuming, we emphasise the importance of education, adequate staffing and sufficient funding to improve integration in clinical practice. We do believe that our recommendations can be used as a starting point to develop recommendations in other countries. However, country-specific factors should be very carefully considered before applying any recommendations in other countries. [ABSTRACT FROM AUTHOR]

Background: Involvement of young partners by experience in research is on the rise and becoming expected practice. However, literature on how to promote equitable and meaningful involvement of young people is scarce. The purpose of this paper is to describe and reflect on different approaches between researchers and young partners by experience based on six research projects conducted in Canada, Netherlands, and United Kingdom. Methods: From six exemplar research projects, at least one researcher and one young partner by experience were asked to collaboratively (1) describe the project; (2) summarise the values and practicalities of the project; and (3) reflect on their partnership. Thematic analysis was applied to the findings from these reflective exercises, which included meeting summaries, recordings, and notes. Results: All projects shared similar values, including mutual respect between all team members. Young partners were offered a variety of opportunities and approaches to being involved, for example in recruiting participants, co-analysing or (co-)presenting results. Supports were provided to the teams in a variety of ways, including organizing accessible meetings and having dedicated facilitators. Regular and proactive communication was encouraged by using asynchronous modes of communication, establishing reference documents, and a personal approach by facilitators. Facilitators aimed to tailor the needs of all team members by continuously discussing their preferred roles in the project. While most projects did not offer formal research training, various learning and skill development opportunities were provided throughout, including presenting skills or advocacy training. Conclusion: With this paper, we demonstrated the value of reflection, and we invite others to reflect on their partnerships and share their lessons learned. Our recommendations for involvement of young people in research are: (1) Remember that it is okay to not know what the partnership might look like and there is no single recipe of how to partner; (2) Take the time to invest in partnerships; (3) Provide ongoing opportunities to reflect on partnerships; (4) Consider how to balance the power dynamics; and (5) Consider how to incorporate diversity in the background of young partners in research. Plain English summary: In more and more projects, researchers and young people are working together in partnership; but there is little guidance about how to organize this partnership. In this paper, we share what partnerships in six projects from Canada, Netherlands, and United Kingdom looked like, so that others can be inspired. To do so, a researcher and a young partner from each project were asked to together: (1) describe their project, (2) summarize the practical details about the collaboration and (3) think about things that went well or could be improved. We found that all projects had the same beliefs important to partnerships, like having respect for each other. Young people could work on parts of the project they liked in a way that worked for them. They were supported by staff, could join meetings and were appreciated for their work. Clear communication during and in-between meetings was helpful. Youth were often asked about the role they wanted in the project. While there was often no formal training on how to do research, there were many opportunities to learn. We offer six recommendations to researchers and young people who want to partner together: (1) It is okay to not know what the partnership will look like and there is no single recipe of how to partner; (2) Take your time; (3) Discuss how the partnership is going; (4) Think about who is doing what and why; (5) Consider the diversity of young partners. We hope others will share their experiences. [ABSTRACT FROM AUTHOR]

Background: The effects of many treatments in healthcare are determined by factors other than the treatment itself. Patients' expectations and the relationship with their healthcare provider can significantly affect treatment outcomes and thereby play a major role in eliciting placebo and nocebo effects. We aim to develop and evaluate an innovative communication training, consisting of an e-learning and virtual reality (VR) training, for healthcare providers across all disciplines, to optimize placebo and minimize nocebo effects through healthcare provider-patient communication. The current paper describes the development, mid-term evaluation, optimization, and final evaluation of the communication training, conducted in The Netherlands. Methods: The development of both the e-learning and the VR training consisted of four phases: 1) content and technical development, 2) mid-term evaluation by healthcare providers and placebo/communication researchers, 3) optimization of the training, and 4) final evaluation by healthcare providers. To ensure the success, applicability, authenticity, and user-friendliness of the communication training, there was ongoing structural collaboration with healthcare providers as future end users, experts in the field of placebo/communication research, and educational experts in all phases. Results: Placebo/communication researchers and healthcare providers evaluated the e-learning positively (overall 7.9 on 0–10 scale) and the content was perceived as useful, accessible, and interesting. The VR training was assessed with an overall 6.9 (0–10 scale) and was evaluated as user-friendly and a safe method for practicing communication skills. Although there were some concerns regarding the authenticity of the VR training (i.e. to what extent the virtual patient reacts like a real patient), placebo and communication researchers, as well as healthcare providers, recognized the significant potential of the VR training for the future. Conclusions: We have developed an innovative and user-friendly communication training, consisting of an e-learning and VR training (2D and 3D), that can be used to teach healthcare providers how to optimize placebo effects and minimize nocebo effects through healthcare provider-patient communication. Future studies can work on improved authenticity, translate the training into other languages and cultures, expand with additional VR cases, and measure the expected effects on providers communication skills and subsequently patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Intervention planners use logic models to design evidence-based health behavior interventions. Logic models that capture the complexity of health behavior necessitate additional computational techniques to inform decisions with respect to the design of interventions. Objective: Using empirical data from a real intervention, the present paper demonstrates how machine learning can be used together with fuzzy cognitive maps to assist in designing health behavior change interventions. Methods: A modified Real Coded Genetic algorithm was applied on longitudinal data from a real intervention study. The dataset contained information about 15 determinants of fruit intake among 257 adults in the Netherlands. Fuzzy cognitive maps were used to analyze the effect of two hypothetical intervention scenarios designed by domain experts. Results: Simulations showed that the specified hypothetical interventions would have small impact on fruit intake. The results are consistent with the empirical evidence used in this paper. Conclusions: Machine learning together with fuzzy cognitive maps can assist in building health behavior interventions with complex logic models. The testing of hypothetical scenarios may help interventionists finetune the intervention components thus increasing their potential effectiveness. [ABSTRACT FROM AUTHOR]

Background: Despite the great confidence of Western governments in the principles of New Public Management (NPM) and its ability to stimulate "healthcare entrepreneurship", it is unclear how policies seeking to reform healthcare services provoke such entrepreneurship in individual institutions providing long-term healthcare. This study examines such situated responses in a Dutch nursing home for elderly people suffering from dementias such as Alzheimer's disease. Methods: A four-year inductive longitudinal single-case study has been conducted. During this time period, the Dutch government imposed various NPM-based healthcare reforms and this study examines how local responses unfolded in the nursing home. Through interviews conducted with managers, administrators and supporting staff, as well as the examination of a large volume of government instructions and internal documents, the paper documents how these reforms resulted in several types of entrepreneurship, which were not all conducive to the healthcare innovations the government aspired to have. Results: The study records three subsequent strategies deployed at the local level: elimination of healthcare services; non-healthcare related collaboration with neighboring institutions; and specialization in specific healthcare niches. These strategies were brought about by specific types of entrepreneurship – two of which were oriented towards the administrative organization rather than healthcare innovations. The study discusses the implications of having multiple variations of entrepreneurship at the local level. Conclusion: Governmental policies for healthcare reforms may be more effective, if policymakers change output-based funding systems in recognition of the limited control by providers of long-term healthcare over the progression of clients' mental disease and ultimate passing. [ABSTRACT FROM AUTHOR]

Objective: Hospitals and healthcare providers should assess and compare the quality of care given to patients and based on this improve the care. In the Netherlands, hospitals provide data to national quality registries, which in return provide annual quality indicators. However, this process is time-consuming, resource intensive and risks patient privacy and confidentiality. In this paper, we presented a multicentric 'Proof of Principle' study for federated calculation of quality indicators in patients with colorectal cancer. The findings suggest that the proposed approach is highly time-efficient and consume significantly lesser resources. Materials and methods: Two quality indicators are calculated in an efficient and privacy presevering federated manner, by i) applying the Findable Accessible Interoperable and Reusable (FAIR) data principles and ii) using the Personal Health Train (PHT) infrastructure. Instead of sharing data to a centralized registry, PHT enables analysis by sending algorithms and sharing only insights from the data. Results: ETL process extracted data from the Electronic Health Record systems of the hospitals, converted them to FAIR data and hosted in RDF endpoints within each hospital. Finally, quality indicators from each center are calculated using PHT and the mean result along with the individual results plotted. Discussion and conclusion: PHT and FAIR data principles can efficiently calculate quality indicators in a privacy-preserving federated approach and the work can be scaled up both nationally and internationally. Despite this, application of the methodology was largely hampered by ELSI issues. However, the lessons learned from this study can provide other hospitals and researchers to adapt to the process easily and take effective measures in building quality of care infrastructures. [ABSTRACT FROM AUTHOR]

Background: Holistic housing renovations combine physical housing improvements with social and socioeconomic interventions (e.g. referral to social services, debt counselling, involvement in decision-making, promoting social cohesion). In a deprived neighbourhood in Utrecht, the Netherlands, this paper examined residents' and professionals' experiences, ideas, and perceptions regarding holistic housing renovation, its health effects, and underlying mechanisms explaining those effects. Methods: Semi-structured in-depth interviews were conducted with 21 social housing residents exposed to holistic housing renovation, and 12 professionals involved in either the physical renovation or social interventions implemented. Residents were interviewed in various renovation stages (before, during, after renovation). Transcripts were deductively and inductively coded using qualitative software. Results: Residents experienced and professionals acknowledged renovation stress caused by nuisance from construction work (noise, dust), having to move stuff around, and temporary moving; lack of information and control; and perceived violation of privacy. Involvement in design choices was appreciated, and mental health improvement was expected on the long term due to improved housing quality and visual amenity benefits. Social contact between residents increased as the renovation became topic for small talk. Few comments were made regarding physical health effects. The interviews revealed a certain amount of distrust in and dissatisfaction with the housing corporation, construction company, and other authorities. Conclusions: Renovation stress, aggravated by lack of information and poor accessibility of housing corporation and construction company, negatively affects mental health and sense of control. Potential stress relievers are practical help with packing and moving furniture, and increased predictability by good and targeted communication. Social interventions can best be offered after renovation, when residents live in their renovated apartment and the nuisance and stress from the renovation is behind them. Social partners can use the period leading up to the renovation to show their faces, offer practical help to reduce renovation stress, and increase residents' trust in their organization and authorities in general. This might also contribute to residents' willingness to accept help with problems in the social domain after renovation. [ABSTRACT FROM AUTHOR]

Background: Given the developmental vulnerability of justice-involved youth, providing a safe environment in secure facilities is a paramount, yet challenging task. Within this complexity, a sound security framework is key. The security framework exists on three dimensions: physical, procedural and relational security. Existing knowledge points at the importance of a shift in focus on physical and procedural security towards relational security as the core of the security framework. At the same time there is a dearth of knowledge on relational security, particularly in the context of youth justice. This paper explores relational security and its working mechanisms in practice. Methods: This paper draws on findings of a comprehensive three-year evaluation of three small-scale, community-embedded facilities that are grounded in relational security. The approach of the evaluation was derived from action research, involving a cyclic process alternating between action, research and critical reflection, while engaging all stakeholders in the research process. The action research cycle involved qualitative research (a total of 63 semi-structured interviews) incorporating the perspective of staff, youth and parents. Results: Relational security is grounded in three distinct, but interrelated, elements – staff's basic attitude, a constructive alliance between staff and youth, staff presence – and promotes a safe and therapeutic environment through several mechanisms. Conclusions: Relational security can be defined in a practical conceptualization; outlining a way of working that guides staff in how to establish a safe and therapeutic environment in secure facilities. This conceptualization finds support in the well-established literature covering the therapeutic alliance and can be substantiated by two aligning theories concerning youth justice strategies: social-ecological theory and self-determination theory. Relational security is not only a way of working, but also a way of being. It encompasses a vision about security and mentality towards justice-involved youth that sees them not merely as 'risks to be managed', but primarly as 'resources to be developed'. [ABSTRACT FROM AUTHOR]

Background: In the Netherlands most patients are currently seen in an outpatient clinic after an anterior cervical discectomy, which is an effective neurosurgical procedure with relatively low rate of severe complications. In this back sight, the need for patients returning to the post-operative outpatient clinic could be questioned. The aim of the study is to evaluate whether a post-operative outpatient appointment after anterior cervical discectomy could be replaced by an alternative or be omitted without adversely impacting, or increasing, the value of healthcare and patient satisfaction for this procedure.Methods: A narrative review was performed to evaluate the quality of care and patient satisfaction for patients with and without a post-operative outpatient appointment after spinal surgery. A literature search of the previous ten years was performed in Pubmed, CENTRAL and EMBASE.Results: A total of 403 articles were identified. Four studies remained after title and abstract selection by 3 independent reviewers. No papers were selected for further analysis, due to the absence of interventional studies that compared the utility of a post-operative outpatient clinic appointment with an intervention after spinal surgery.Conclusions: Currently, there is a lack of evidence for the need of a post-operative follow-up after anterior cervical discectomy. Nor is there any literature in favor of omitting these appointments. No determinants which patients benefits from these outpatient appointments could be identified. Potential harmful and beneficial effects of omitting these post-operative follow-ups should be investigated to identify possible determinant for patients who might benefit from a post-operative appointment. [ABSTRACT FROM AUTHOR]

System dynamics approaches are increasingly addressing the complexity of public health problems such as childhood overweight and obesity. These approaches often use system mapping methods, such as the construction of causal loop diagrams, to gain an understanding of the system of interest. However, there is limited practical guidance on how such a system understanding can inform the development of an action programme that can facilitate systems changes. The Lifestyle Innovations Based on Youth Knowledge and Experience (LIKE) programme combines system dynamics and participatory action research to improve obesity-related behaviours, including diet, physical activity, sleep and sedentary behaviour, in 10–14-year-old adolescents in Amsterdam, the Netherlands. This paper illustrates how we used a previously obtained understanding of the system of obesity-related behaviours in adolescents to develop an action programme to facilitate systems changes. A team of evaluation researchers guided interdisciplinary action-groups throughout the process of identifying mechanisms, applying the Intervention Level Framework to identify leverage points and arriving at action ideas with aligning theories of change. The LIKE action programme consisted of 8 mechanisms, 9 leverage points and 14 action ideas which targeted the system's structure and function within multiple subsystems. This illustrates the feasibility of developing actions targeting higher system levels within the confines of a research project timeframe when sufficient and dedicated effort in this process is invested. Furthermore, the system dynamics action programme presented in this study contributes towards the development and implementation of public health programmes that aim to facilitate systems changes in practice. [ABSTRACT FROM AUTHOR]

Background: Osteogenesis Imperfecta (OI) is characterised by bone fragility. Among several features, easy bruising and multiple case reports on haemorrhagic events have been reported. This paper describes the diverse manifestations of bleeding and bruising in a large cohort of 328 OI patients. The aim of this study is to provide insight in the diverse aspects and therapeutic considerations of bleedings in OI. Methods: This descriptive cohort study was conducted at the National Expert Center for adults with OI in the Netherlands. Bleeding was assessed by the validated self-bleeding assessment tool (Self-BAT) The tool was distributed among 328 adults with different clinically confirmed types of OI. Results: 195 of 328 invited patients (completion rate 60%) with OI type 1 (n = 144), OI type 3 (n = 17) and OI type 4 (n = 34), aged between 18 and 82 years, completed the tool. Self-BAT scores were above the normal range in 42% of all patients. For males Self-BAT scores were increased in 37% with a mean score of 3.7, ranged between 0 and 18. For females the Self-BAT scores were increased in 44% with a mean of 5.4 and a range of 0–24. No statistical differences in OI subtypes were found. Conclusions: Bleeding tendency appears to be a relevant complication in OI patients as this study confirms the presumption of bleeding tendency. There are specific recommendations to clinicians who treat OI patients to consider an assessment of bleeding tendency and use potential interventions to reduce haemorrhagic complications and improve quality of life. [ABSTRACT FROM AUTHOR]

Background: User involvement and participation in the supervision of the quality of care is an important topic for many healthcare inspectorates. It offers regulators an additional view on quality, increases the legitimacy and accountability of the inspectorate, empowers users and enhancing the public's trust in the inspectorate. To assess the accessibility of the local governmental social domain services the Joint Inspectorate Social Domain in the Netherlands worked together with people with intellectual disabilities performing as 'mystery guests' in an innovative project. This paper describes the findings of the evaluation of this project. Methods: People with intellectual disabilities living at home on their own may need some help with daily activities such as administrative tasks, raising children, household tasks, managing debts or finding work. In the Netherlands they have to arrange this help at their municipality. The goal of this project was to find out how easily people with intellectual disabilities could get help from their municipality. The participants were equal partners with the JISD inspectors from the beginning: in constructing an inspection framework, in acting as mystery guest with a fictive support request, reported back the results by storytelling. Results: The evaluation of the project showed that the JISD succeeded in their key aspect of the project: the goal to involve people with intellectual disabilities in a leading role from the beginning until the end. Their perspectives and preferences were the starting point of supervision. Pain points in accessibility became clear straight away and gave important insights for both inspectors as municipality professionals. Municipalities started to improve their services and evaluated the improvements with the clients. Furthermore, the impact on the participants themselves was also huge: they felt being taken seriously, valued and empowered. Conclusion: Involving people with intellectual disabilities as participants in all phases of supervision processes contributes to more relevant and useful outcomes, creates mutual understanding of perspectives, as affirmed by both municipalities and inspectors, and creates empowerment of the participants. Furthermore, it fits perfectly within the United Nation Convention on the rights of persons with disabilities and the current development of 'value driven regulation'. [ABSTRACT FROM AUTHOR]

Introduction: This study characterized the extent to which (1) financial barriers and (2) abortion care-seeking within a person's country of residence were associated with delays in abortion access among those travelling to England and the Netherlands for abortion care from European countries where abortion is legal on broad grounds in the first trimester but where access past the first trimester is limited to specific circumstances. Methodology: We drew on cross-sectional survey data collected at five abortion clinics in England and the Netherlands from 2017 to 2019 (n = 164). We assessed the relationship between difficulty paying for the abortion/travel, acute financial insecurity, and in-country care seeking on delays to abortion using multivariable discrete-time hazards models. Results: Participants who reported facing both difficulty paying for the abortion procedure and/or travel and difficulty covering basic living costs in the last month reported longer delays in accessing care than those who had no financial difficulty (adjusted hazard odds ratio: 0.39 95% CI 0.21–0.74). This group delayed paying other expenses (39%) or sold something of value (13%) to fund their abortion, resulting in ~ 60% of those with financial difficulty reporting it took them over a week to raise the funds needed for their abortion. Having contacted or visited an abortion provider in the country of residence was associated with delays in presenting abroad for an abortion. Discussion: These findings point to inequities in access to timely abortion care based on socioeconomic status. Legal time limits on abortion may intersect with individuals' interactions with the health care system to delay care. Plain Language Summary: This paper explores delays in accessing abortion care associated with financial and medical system barriers. We focus on residents of countries in Europe where abortion is available on broad grounds in the first trimester seeking abortion care outside of their country of residence. This study demonstrates an association between difficulty covering abortion costs for people facing financial insecurity and in-country care seeking and delays in accessing abortion abroad. Policy barriers, medical system barriers, as well as financial barriers may interact to delay access to care for people in European countries with broad grounds for abortion access in the first trimester but restrictions thereafter, especially for people later in pregnancy. [ABSTRACT FROM AUTHOR]

Background: Before 2012, established national surveillance systems in the Netherlands were not able to provide a timely, comprehensive epidemiological view on nosocomial outbreaks. The Healthcare-associated Infections and AntiMicrobial Resistance Monitoring Group (SO-ZI/AMR) was initiated in 2012 for timely national nosocomial outbreak monitoring and risk assessment. This paper aims to describe the achievements of the SO-ZI/AMR by presenting characteristics of outbreaks reported in 2012–2021. Methods: Hospitals and, since 2015, long-term care facilities (LTCF) were requested to report outbreaks when (1) continuity of care was threatened, or (2) transmission continued despite control measures. A multi-disciplinary expert panel (re-)assessed the public health risk of outbreaks during monthly meetings, using 5 severity phases and based on data collected via standardised questionnaires. We descriptively studied the panel's consensus-based severity classification, distribution of (highly resistant) microorganisms, and duration and size of outbreaks between April 2012 and December 2021. Results: In total, 353 hospital outbreaks and 110 LTCF outbreaks were reported. Most outbreaks (hospitals: n = 309 (88%), LTCF: n = 103 (94%)) did not progress beyond phase 1 (no public health implications, outbreak expected to be controlled within two months), one hospital outbreak reached phase 4 (insufficient/ineffective response: possible public health threat, support offered). Highly resistant microorganisms (HRMO) were involved in 269 (76%) hospital and 103 (94%) LTCF outbreaks. Most outbreaks were caused by methicillin-resistant Staphylococcus aureus (MRSA; n = 93 (26%) in hospitals, n = 80 (72%) in LTCF), vancomycin-resistant Enterococcus faecium (VRE; n = 116 (33%) in hospitals, n = 2 (2%) in LTCF) and highly resistant Enterobacterales (n = 41 (12%) in hospitals, n = 20 (18%) in LTCF). Carbapenemase-producing gram-negative bacteria were involved in 32 (9.1%) hospital and five (4.5%) LTCF outbreaks. In hospitals, VRE outbreaks had the longest duration (median 2.3; range 0.0-22.8 months) and widest range of affected patients (median 9; range 2-483). Conclusions: The SO-ZI/AMR provided national insight into the characteristics of nosocomial outbreaks over the past decade. HRMO outbreaks – mostly caused by MRSA, VRE (in hospitals) and highly resistant Enterobacterales – occurred regularly, but most of them were controlled quickly and did not develop into a public health threat. The SO-ZI/AMR has become a solid monitoring body, essential to assess risks and raise awareness of potential HRMO threats. [ABSTRACT FROM AUTHOR]

Background: Provision of paediatric palliative care for children with life-threatening or life-limiting conditions and their families is often complex. Guidelines can support professionals to deliver high quality care. Stakeholders expressed the need to update the first Dutch paediatric palliative care guideline with new scientific literature and new topics. This paper provides an overview of the methodology that is used for the revision of the Dutch paediatric palliative care guideline and a brief presentation of the identified evidence. Methods: The revised paediatric palliative care guideline was developed with a multidisciplinary guideline panel of 72 experts in paediatric palliative care and nine (bereaved) parents of children with life-threatening or life-limiting conditions. The guideline covered multiple topics related to (refractory) symptom treatment, advance care planning and shared-decision making, organisation of care, psychosocial care, and loss and bereavement. We established six main working groups that formulated 38 clinical questions for which we identified evidence by updating two existing systematic literature searches. The GRADE (CERQual) methodology was used for appraisal of evidence. Furthermore, we searched for additional literature such as existing guidelines and textbooks to deal with lack of evidence. Results: The two systematic literature searches yielded a total of 29 RCTs or systematic reviews of RCTs on paediatric palliative care interventions and 22 qualitative studies on barriers and facilitators of advance care planning and shared decision-making. We identified evidence for 14 out of 38 clinical questions. Furthermore, we were able to select additional literature (29 guidelines, two textbooks, and 10 systematic reviews) to deal with lack of evidence. Conclusions: The revised Dutch paediatric palliative care guideline addresses many topics. However, there is limited evidence to base recommendations upon. Our methodology will combine the existing evidence in scientific literature, additional literature, expert knowledge, and perspectives of patients and their families to provide recommendations. [ABSTRACT FROM AUTHOR]

Background: Unwarranted practice variation refers to regional differences in treatments that are not driven by patients' medical needs or preferences. Although it is the subject of numerous studies, most research focuses on variation at the end stage of treatment, i.e. the stage of the treating specialist, disregarding variation stemming from other sources (e.g. patient preferences, general practitioner referral patterns). In the present paper, we introduce a method that allows us to measure regional variation at different stages of the patient journey leading up to treatment. Methods: A series of logit regressions estimating the probability of (1) initial visit with the physician and (2) treatment correcting for patient needs and patient preferences. Calculating the coefficient of variation (CVU) at each stage of the patient journey. Results: Our findings show large regional variations in the probability of receiving an initial visit, The CVU, or the measure of dispersion, in the regional probability of an initial visit with a specialist was significantly larger (0.87–0.96) than at the point of treatment both conditional (0.14–0.25) and unconditional on an initial visit (0.65–0.74), suggesting that practice variation was present before the patient reached the specialist. Conclusions: We present a new approach to attribute practice variation to different stages in the patient journey. We demonstrate our method using the clinically-relevant segment of varicose veins treatments. Our findings demonstrate that irrespective of the gatekeeping role of general practitioners (GPs), a large share of practice variation in the treatment of varicose veins is attributable to regional variation in primary care referrals. Contrary to expectation, specialists' decisions meaningfully diminish rather than increase the amount of regional variation. [ABSTRACT FROM AUTHOR]

Objective: During the COVID-19 pandemic new collaborative-care initiatives were developed for treating and monitoring COVID-19 patients with oxygen at home. Aim was to provide a structured overview focused on differences and similarities of initiatives of acute home-based management in the Netherlands. Methods: Initiatives were eligible for evaluation if (i) COVID-19 patients received oxygen treatment at home; (ii) patients received structured remote monitoring; (iii) it was not an 'early hospital discharge' program; (iv) at least one patient was included. Protocols were screened, and additional information was obtained from involved physicians. Design choices were categorised into: eligible patient group, organization medical care, remote monitoring, nursing care, and devices used. Results: Nine initiatives were screened for eligibility; five were included. Three initiatives included low-risk patients and two were designed specifically for frail patients. Emergency department (ED) visit for an initial diagnostic work-up and evaluation was mandatory in three initiatives before starting home management. Medical responsibility was either assigned to the general practitioner or hospital specialist, most often pulmonologist or internist. Pulse-oximetry was used in all initiatives, with additional monitoring of heart rate and respiratory rate in three initiatives. Remote monitoring staff's qualification and authority varied, and organization and logistics were covered by persons with various backgrounds. All initiatives offered remote monitoring via an application, two also offered a paper diary option. Conclusions: We observed differences in the organization of interprofessional collaboration for acute home management of hypoxemic COVID-19 patients. All initiatives used pulse-oximetry and an app for remote monitoring. Our overview may be of help to healthcare providers and organizations to set up and implement similar acute home management initiatives for critical episodes of COVID-19 (or other acute disorders) that would otherwise require hospital care. [ABSTRACT FROM AUTHOR]

Background: To develop public health intervention models using micro-simulations, extensive personal information about inhabitants is needed, such as socio-demographic, economic and health figures. Confidentiality is an essential characteristic of such data, while the data should reflect realistic scenarios. Collection of such data is possible only in secured environments and not directly available for open-source micro-simulation models. The aim of this paper is to illustrate a method of construction of synthetic data by predicting individual features through models based on confidential data on health and socio-economic determinants of the entire Dutch population. Methods: Administrative records and health registry data were linked to socio-economic characteristics and self-reported lifestyle factors. For the entire Dutch population (n = 16,778,708), all socio-demographic information except lifestyle factors was available. Lifestyle factors were available from the 2012 Dutch Health Monitor (n = 370,835). Regression model was used to sequentially predict individual features. Results: The synthetic population resembles the original confidential population. Features predicted in the first stages of the sequential procedure are virtually similar to those in the original population, while those predicted in later stages of the sequential procedure carry the accumulation of limitations furthered by data quality and previously modelled features. Conclusions: By combining socio-demographic, economic, health and lifestyle related data at individual level on a large scale, our method provides us with a powerful tool to construct a synthetic population of good quality and with no confidentiality issues. [ABSTRACT FROM AUTHOR]

Background: The introduction and wide application of non-invasive prenatal testing (NIPT) has triggered further evolution of routines in the practice of prenatal diagnosis. 'Routinization' of prenatal diagnosis however has been associated with hampered informed choice and eugenic attitudes or outcomes. It is viewed, at least in some countries, with great suspicion in both bioethics and public discourse. However, it is a heterogeneous phenomenon that needs to be scrutinized in the wider context of social practices of reproductive genetics. In different countries with their different regulatory frameworks, different patterns of routines emerge that have different ethical implications. This paper discusses an ethics of routines informed by the perspectives of organizational sociology and psychology, where a routine is defined as a repetitive, recognizable pattern of interdependent organizational actions that is carried out by multiple performers. We favour a process approach that debunks the view – which gives way to most of the concerns – that routines are always blindly performed. If this is so, routines are therefore not necessarily incompatible with responsible decision-making. Free and informed decision-making can, as we argue, be a key criterion for the ethical evaluation of testing routines. If free and informed decision-making by each pregnant woman is the objective, routines in prenatal testing may not be ethically problematic, but rather are defensible and helpful. We compare recent experiences of NIPT routines in the context of prenatal screening programmes in Germany, Israel and the Netherlands. Notable variation can be observed between these three countries (i) in the levels of routinization around NIPT, (ii) in the scope of routinization, and (iii) in public attitudes toward routinized prenatal testing. Conclusion: An ethics of routines in the field of prenatal diagnostics should incorporate and work with the necessary distinctions between levels and forms of routines, in order to develop sound criteria for their evaluation. [ABSTRACT FROM AUTHOR]

Background: Local policymakers require information about public health, housing and well-being at small geographical areas. A municipality can for example use this information to organize targeted activities with the aim of improving the well-being of their residents. Surveys are often used to gather data, but many neighborhoods can have only few or even zero respondents. In that case, estimating the status of the local population directly from survey responses is prone to be unreliable. Methods: Small Area Estimation (SAE) is a technique to provide estimates at small geographical levels with only few or even zero respondents. In classical individual-level SAE, a complex statistical regression model is fitted to the survey responses by using auxiliary administrative data for the population as predictors, the missing responses are then predicted and aggregated to the desired geographical level. In this paper we compare gradient boosted trees (XGBoost), a well-known machine learning technique, to a structured additive regression model (STAR) designed for the specific problem of estimating public health and well-being in the whole population of the Netherlands. Results: We compare the accuracy and performance of these models using out-of-sample predictions with five-fold Cross Validation (5CV). We do this for three data sets of different sample sizes and outcome types. Compared to the STAR model, gradient boosted trees are able to improve both the accuracy of the predictions and the total time taken to get these predictions. Even though the models appear quite similar in overall accuracy, the small area predictions at neighborhood level sometimes differ significantly. It may therefore make sense to pursue slightly more accurate models for better predictions into small areas. However, one of the biggest benefits is that XGBoost does not require prior knowledge or model specification. Data preparation and modelling is much easier, since the method automatically handles missing data, non-linear responses, interactions and accounts for spatial correlation structures. Conclusions: In this paper we provide new nationwide estimates of health, housing and well-being indicators at neighborhood level in the Netherlands, see 'Online materials'. We demonstrate that machine learning provides a good alternative to complex statistical regression modelling for small area estimation in terms of accuracy, robustness, speed and data preparation. These results can be used to make appropriate policy decisions at a local level and make recommendations about which estimation methods are beneficial in terms of accuracy, time and budget constraints. [ABSTRACT FROM AUTHOR]

Background: Continuous monitoring using wireless wearable sensors is a promising solution for use in clinical practice and in the home setting. It is important to involve nurses to ensure successful implementation. This paper aims to provide an overview of 1) factors affecting implementation of continuous monitoring using wireless wearable sensors by evaluating nurses' experiences with its use on the nursing ward, and 2) nurses' expectations for use in the home setting. Methods: Semi-structured interviews were conducted with 16 nurses from three teaching hospitals in the Netherlands, covering constructs from the Consolidated Framework for Implementation Research (CFIR). A deductive approach of directed content analysis was applied. One additional factor was added using the Unified Theory for Acceptance of Technology (UTAUT). The quotes and domains were rated on valence (positive, neutral, negative) and strength (strong: − 2, + 2, neutral 0, and weak: − 1, + 1). Results: Data was collected on 27 CFIR constructs and 1 UTAUT construct. In the experience of at least 8 nurses, five constructs had a strong positive influence on implementation on the nursing ward, including relative advantage (e.g., early detection of deterioration), patient needs and resources (e.g. feeling safe), networks and communications (e.g. execute tasks together), personal attributes (e.g. experience with intervention), and implementation leaders (e.g., project leader). Five constructs had a strong negative influence: evidence strength and quality (e.g. lack of evidence from practical experience), complexity (e.g. number of process steps), design quality and packaging (e.g., bad sensor quality), compatibility (e.g, change in work) and facilitating conditions (e.g, Wi-Fi connection). Nurses expected continuous monitoring in the home setting to be hindered by compatibility with work processes and to be facilitated by staff's access to information. Technical facilitating conditions (e.g. interoperability) were suggested to be beneficial for further development. Conclusions: This paper provides an overview, of factors influencing implementation of continuous monitoring including relative importance, based on nurses' experiences with use on nursing wards, and their perspectives for use in the home setting. Implementation of continuous monitoring is affected by a wide range of factors. This overview may be used as a guideline for future implementations. [ABSTRACT FROM AUTHOR]

Background : Informal caregivers of people with dementia are crucial in dementia care. However, they are insufficiently supported and report caregiver burdens, which urges the need for cost-effective interventions aimed at supporting caregivers. This paper presents the design of a study evaluating the effectiveness, cost-effectiveness, and cost-utility of a blended self-management program for early-stage dementia caregivers. Methods/design: A pragmatic, cluster randomized controlled trial with a shared control group will be conducted. Participants will be informal caregivers of people with early-stage dementia and will be recruited by local care professionals. Randomization will be carried out at the level of the care professional level in a ratio of 35% to 65% (control arm vs. intervention arm). Participants in the control arm will receive care as usual and the intervention arm will receive the blended care self-management program "Partner in Balance" within a usual care setting in the Netherlands. Data will be collected at baseline and at 3-, 6-, 12-, and 24-month follow-ups. The primary outcome for effectiveness (part 1) is care management self-efficacy. For the health-economic evaluation (part 2) total care costs and the quality of life for individuals with dementia (cost-effectiveness) and quality-adjusted life years (cost-utility) will be the base case analysis. Secondary outcomes (parts 1 and 2) will include depression, anxiety, perceived informal caregiving stress, service-use self-efficacy, quality of life, caregivers' gain, and perseverance time. A process evaluation (part 3) will investigate the internal and external validity of the intervention. Discussion: In this trial, we plan to evaluate the effectiveness, cost-effectiveness, and cost-utility of "Partner in Balance" among informal caregivers of people with dementia. We expect to find a significant increase in care management self-efficacy, and the program to be cost-effective, and provide valuable insights to stakeholders of "Partner in Balance." Trial registration: ClinicalTrials.gov, NCT05450146. Registered on 4 November 2022. [ABSTRACT FROM AUTHOR]

Background: Each year, many help seekers in need contact health helplines for mental support. It is crucial that they receive support immediately, and that waiting times are minimal. In order to minimize delay, helplines must have adequate staffing levels, especially during peak hours. This has raised the need for means to predict the call and chat volumes ahead of time accurately. Motivated by this, in this paper, we analyze real-life data to develop models for accurately forecasting call volumes, for both phone and chat conversations for online mental health support. Methods: This research was conducted on real call and chat data (adequately anonymized) provided by 113 Suicide Prevention (Over ons | 113 Zelfmoordpreventie) (throughout referred to as '113'), the online helpline for suicide prevention in the Netherlands. Chat and phone call data were analyzed to better understand the important factors that influence the call arrival process. These factors were then used as input to several Machine Learning (ML) models to forecast the number of call and chat arrivals. Next to that, senior counselors of the helpline completed a web-based questionnaire after each shift to assess their perception of the workload. Results: This study has led to several remarkable and key insights. First, the most important factors that determine the call volumes for the helpline are the trend, and weekly and daily cyclic patterns (cycles), while monthly and yearly cycles were found to be non-significant predictors for the number of phone and chat conversations. Second, media events that were included in this study only have limited—and only short-term—impact on the call volumes. Third, so-called (S)ARIMA models are shown to lead to the most accurate prediction in the case of short-term forecasting, while simple linear models work best for long-term forecasting. Fourth, questionnaires filled in by senior counselors show that the experienced workload is mainly correlated to the number of chat conversations compared to phone calls. Conclusion: (S)ARIMA models can best be used to forecast the number of daily chats and phone calls with a MAPE of less than 10 in short-term forecasting. These models perform better than other models showing that the number of arrivals depends on historical data. These forecasts can be used as support for planning the number of counselors needed. Furthermore, the questionnaire data show that the workload experienced by senior counselors is more dependent on the number of chat arrivals and less on the number of available agents, showing the value of insight into the arrival process of conversations. [ABSTRACT FROM AUTHOR]

Background: Optimizing return to work (RTW) after knee arthroplasty (KA) is becoming increasingly important due to a growing incidence of KA and poor RTW outcomes after KA. We developed the Back At work After Surgery (BAAS) clinical pathway for optimized RTW after KA. Since the effectiveness and cost analysis of the BAAS clinical pathway are still unknown, analysis on effectiveness and costs of BAAS is imperative. Method: This protocol paper has been written in line with the standards of Standard Protocol Items: Recommendations for Interventional Trails. To assess the effectiveness and cost-effectiveness for RTW, we will perform a multicenter prospective cohort study with patients who decided to receive a total KA (TKA) or an unicompartmental KA (UKA). To evaluate the effectiveness of BAAS regarding RTW, a comparison to usual care will be made using individual patient data on RTW from prospectively performed cohort studies in the Netherlands. Discussion: One of the strengths of this study is that the feasibility for the BAAS clinical pathway was tested at first hand. Also, we will use validated questionnaires and functional tests to assess the patient's recovery using robust outcomes. Moreover, the intervention was performed in two hospitals serving the targeted patient group and to reduce selection bias and improve generalizability. The limitations of this study protocol are that the lead author has an active role as a medical case manager (MCM) in one of the hospitals. Additionally, we will use the data from other prospective Dutch cohort studies to compare our findings regarding RTW to usual care. Since we will not perform an RCT, we will use propensity analysis to reduce the bias due to possible differences between these cohorts. Trail Registration: This study was retrospectively registered at clinicaltrails.gov (https://clinicaltrials.gov/ct2/show/NCT05690347, date of first registration: 19–01-2023). [ABSTRACT FROM AUTHOR]

Background: In this paper we explore how staff involved with infection prevention managed the emerging COVID-19 crisis in the context of scarcity of Personal Protective Equipment (PPE), focussing specifically on the (re)writing of guidelines. We conceptualize guidelines as 'mediating devices' as they translate between evidence and clinical practice, between management and the workplace, as well as the different values embedded in these domains. It is this mediation, we argue, that adds to the resilience of healthcare organizations. The setting for this research is an elite academic hospital in the Netherlands during the emergence of the COVID-19 pandemic.Methods: We conducted non-participative observations, semi-structured interviews, and document analysis during the emerging pandemic (March-July 2020). We observed meetings from the crisis team and the unit for infection prevention (210 hours), interviewed members of these teams (21 interviews) and analysed guidelines and flowcharts concerning infection prevention, as such collecting a unique and rich qualitative dataset. Analysis was done through thematic coding.Results: Our results show the writing and rewriting of guidelines as a fundamental characteristic of dealing with scarcity and adding to resilience. We found three main practices our research participants engage in while trying to manage the uncertain situations emerging from the scarcity of personal protection equipment. The first practice we observe is defining safety; dealing with different perspectives and experiences of what 'working safely' means. The second entails the anticipation of scarcity by which our participants aim to control the situation through monitoring, research and creating scenarios. The third practice we observe is finding new ways to use PPE that is available, by experimenting and tinkering with the material.Conclusion: Infection prevention guidelines are crucial in managing the emerging crisis. We discuss how the writing of guidelines mediates between different settings, timeframes, and different worlds of quality. Through (re)writing there is a constant negotiation and discussion with the various actors about what works, and there is a continuous adaptive attitude. At the cost of a lot of work and struggle, this creates a resilient and inclusive work environment useful in a long-lasting crisis. [ABSTRACT FROM AUTHOR]

Background: Since the 1980s, markets have turned increasingly to intangible goods - healthcare, education, the arts, and justice. Over 40 years, the authors investigated healthcare commoditisation to produce policy knowledge relevant to patients, physicians, health professionals, and taxpayers. This paper revisits their objectives, methods, and results to enlighten healthcare policy design and research.Main Text: This paper meta-analyses the authors' research that evaluated the markets impact on healthcare and professional culture and investigated how they influenced patients' timely access to quality care and physicians' working conditions. Based on these findings, they explored the political economic of healthcare. In low-income countries the analysed research showed that, through loans and cooperation, multilateral agencies restricted the function of public services to disease control, with subsequent catastrophic reductions in access to care, health de-medicalisation, increased avoidable mortality, and failure to attain the narrow MDGs in Africa. The pro-market reforms enacted in middle-income countries entailed the purchaser-provider split, privatisation of healthcare pre-financing, and government contracting of health finance management to private insurance companies. To establish the materiality of a cause-and-effect relationship, the authors compared the efficiency of Latin American national health systems according to whether or not they were pro-market and complied with international policy standards. While pro-market health economists acknowledge that no market can offer equitable access to healthcare without effective regulation and control, the authors showed that both regulation and control were severely constrained in Asia by governance and medical secrecy issues. In high-income countries they questioned the interest for population health of healthcare insurance companies, whilst comparing access to care and health expenditures in the European Union vs. the U.S., the Netherlands, and Switzerland. They demonstrated that commoditising healthcare increases mortality and suffering amenable to care considerably and carries professional, cultural, and ethical risks for doctors and health professionals. Pro-market policies systems cause health systems inefficiency, inequity in access to care and strain professionals' ethics.Conclusion: Policy research methodologies benefit from being inductive, as health services and systems evaluations, and population health studies are prerequisites to challenge official discourse and to explore the historical, economic, sociocultural, and political determinants of public policies. [ABSTRACT FROM AUTHOR]

Background: Several approaches to medication optimisation by identifying drug-related problems in older people have been described. Although some interventions have shown reductions in drug-related problems (DRPs), evidence supporting the effectiveness of medication reviews on clinical and economic outcomes is lacking. Application of the STOPP/START (version 2) explicit screening tool for inappropriate prescribing has decreased inappropriate prescribing and significantly reduced adverse drug reactions (ADRs) and associated healthcare costs in older patients with multi-morbidity and polypharmacy. Therefore, application of STOPP/START criteria during a medication review is likely to be beneficial. Incorporation of explicit screening tools into clinical decision support systems (CDSS) has gained traction as a means to improve both quality and efficiency in the rather time-consuming medication review process. Although CDSS can generate more potential inappropriate medication recommendations, some of these have been shown to be less clinically relevant, resulting in alert fatigue. Moreover, explicit tools such as STOPP/START do not cover all relevant DRPs on an individual patient level. The OPERAM study aims to assess the impact of a structured drug review on the quality of pharmacotherapy in older people with multi-morbidity and polypharmacy. The aim of this paper is to describe the structured, multi-component intervention of the OPERAM trial and compare it with the approach in the comparator arm.Method: This paper describes a multi-component intervention, integrating interventions that have demonstrated effectiveness in defining DRPs. The intervention involves a structured history-taking of medication (SHiM), a medication review according to the systemic tool to reduce inappropriate prescribing (STRIP) method, assisted by a clinical decision support system (STRIP Assistant, STRIPA) with integrated STOPP/START criteria (version 2), followed by shared decision-making with both patient and attending physician. The developed method integrates patient input, patient data, involvement from other healthcare professionals and CDSS-assistance into one structured intervention.Discussion: The clinical and economical effectiveness of this experimental intervention will be evaluated in a cohort of hospitalised, older patients with multi-morbidity and polypharmacy in the multicentre, randomized controlled OPERAM trial (OPtimising thERapy to prevent Avoidable hospital admissions in the Multi-morbid elderly), which will be completed in the last quarter of 2019.Trial Registration: Universal Trial Number: U1111-1181-9400 Clinicaltrials.gov: NCT02986425, Registered 08 December 2016. FOPH (Swiss national portal): SNCTP000002183. Netherlands Trial Register: NTR6012 (07-10-2016). [ABSTRACT FROM AUTHOR]

Background: Tests to predict the development of chronic diseases in those with a family history of the disease are becoming increasingly available and can identify those who may benefit most from preventive interventions. It is important to understand the acceptability of these predictive approaches to inform the development of tools to support decision making. Whilst data are lacking for many diseases, data are available for ischemic heart disease (IHD). Therefore, this study investigates the willingness of those with a family history of IHD to take a predictive test, and the effect of the test results on risk-related behaviours.Method: Medline, EMBASE, PsycINFO, LILACS and grey literature were searched. Primary research, including adult participants with a family history of IHD, and assessing a predictive test were included. Qualitative and quantitative outcomes measuring willingness to take a predictive test and the effect of test results on risk-related behaviours were also included. Data concerning study aims, participants, design, predictive test, intervention and findings were extracted. Study quality was assessed using the Standard Quality Assessment Criteria for Evaluating Research Papers from a Variety of Fields and a narrative synthesis undertaken.Results: Five quantitative and two qualitative studies were included. These were conducted in the Netherlands (n = 1), Australia (n = 1), USA (n = 1) and the UK (n = 4). Methodological quality ranged from moderate to good. Three studies found that most relatives were willing to take a predictive test, reporting family history (n = 2) and general practitioner (GP) recommendation (n = 1) as determinants of interest. Studies assessing the effect of test results on behavioural intentions (n = 2) found increased intentions to engage in physical activity and smoking cessation, but not healthy eating in those at increased risk of developing IHD. In studies examining actual behaviour change (n = 2) most participants reported engaging in at least one preventive behaviour, particularly medication adherence.Conclusion: The results suggests that predictive approaches are acceptable to those with a family history of IHD and have a positive impact on health behaviours. Further studies are needed to provide a comprehensive understanding of predictive approaches in IHD and other chronic conditions. [ABSTRACT FROM AUTHOR]

Objective: The accessibility of acute care services is currently under pressure, and one way to improve services is better integration. Adequate methodology will be required to provide for a clear and accessible evaluation of the various intervention initiatives. The aim of this paper is to develop and propose a Population Health Management(PHM) methodology framework for evaluation of transitions in acute care services. Results: Our methodological framework is developed from several concepts found in literature, including Triple Aim, integrated care and PHM, and includes continuous monitoring of results at both project and population levels. It is based on a broad view of health rather than focusing on a specific illness and facilitates the evaluation of various intervention initiatives in acute care services in the Netherlands and distinctly explains every step of the evaluation process and can be applied to a heterogeneous group of patients. [ABSTRACT FROM AUTHOR]

Introduction: Drug reimbursement decisions are often made based on a price set by the manufacturer. In some cases, this price leads to public and scientific debates about whether its level can be justified in relation to its costs, including those related to research and development (R&D) and manufacturing. Such considerations could enter the decision process in collectively financed health care systems. This paper investigates whether manufacturers' costs in relation to drug prices, or profit margins, are explicitly mentioned and considered by health technology assessment (HTA) organisations. Method: An analysis of reimbursement reports for cancer drugs was performed. All relevant Dutch HTA-reports, published between 2017 and 2019, were selected and matched with HTA-reports from three other jurisdictions (England, Canada, Australia). Information was extracted. Additionally, reimbursement reports for three cases of expensive non-oncolytic orphan drugs prominent in pricing debates in the Netherlands were investigated in depth to examine consideration of profit margins. Results: A total of 66 HTA-reports concerning 15 cancer drugs were included. None of these reports contained information on manufacturer's costs or profit margins. Some reports contained general considerations of the HTA organisation which related prices to manufacturers' costs: six contained a statement on the lack of price setting transparency, one mentioned recouping R&D costs as a potential argument to justify a high price. For the case studies, 21 HTA-reports were selected. One contained a cost-based price justification provided by the manufacturer. None of the other reports contained information on manufacturer's costs or profit margins. Six reports contained a discussion about lack of transparency. Reports from two jurisdictions contained invitations to justify high prices by demonstrating high costs. Conclusion: Despite the attention given to manufacturers' costs in relation to price in public debates and in the literature, this issue does not seem to get explicit systematic consideration in the reimbursement reports of expensive drugs. [ABSTRACT FROM AUTHOR]

Background: Respondents in a health valuation study may have different sources of error (i.e., heteroskedasticity), tastes (differences in the relative effects of each attribute level), and scales (differences in the absolute effects of all attributes). Although prior studies have compared values by preference-elicitation tasks (e.g., paired comparison [PC] and best-worst scaling case 2 [BWS]), no study has yet controlled for heteroskedasticity and heterogeneity (taste and scale) simultaneously in health valuation.Methods: Preferences on EQ-5D-5L profiles were elicited from a random sample of 380 adults from the general population of the Netherlands, using 24 PC and 25 BWS case 2 tasks. To control for heteroskedasticity and heterogeneity (taste and scale) simultaneously, we estimated Dutch EQ-5D-5L values using conditional, heteroskedastic, and scale-adjusted latent class (SALC) logit models by maximum likelihood.Results: After controlling for heteroskedasticity, the PC and BWS values were highly correlated (Pearson's correlation: 0.9167, CI: 0.9109-0.9222) and largely agreed (Lin's concordance: 0.7658, CI: 0.7542-0.7769) on a pits scale. In terms of preference heterogeneity, some respondents (mostly young men) failed to account for any of the EQ-5D-5L attributes (i.e., garbage class), and others had a lower scale (59%; p-value: 0.123). Overall, the SALC model produced a consistent Dutch EQ-5D-5L value set on a pits scale, like the original study (Pearson's correlation:0.7295; Lin's concordance: 0.6904).Conclusions: This paper shows the merits of simultaneously controlling for heteroskedasticity and heterogeneity in health valuation. In this case, the SALC model dispensed with a garbage class automatically and adjusted the scale for those who failed the PC dominant task. Future analysis may include more behavioral variables to better control heteroskedasticity and heterogeneity in health valuation.Highlights: The Dutch EQ-5D-5L values based on paired comparison [PC] and best-worst scaling [BWS] responses were highly correlated and largely agreed after controlling for heteroskedasticity. Controlling for taste and scale heterogeneity simultaneously enhanced the Dutch EQ-5D-5Lvalues by automatically dispensing with a garbage class and adjusting the scale for those who failed the dominant task. After controlling for heteroskedasticity and heterogeneity, this study produced Dutch EQ-5D-5L values on a pits scale moderately concordant with the original values. [ABSTRACT FROM AUTHOR]

Background: Colorectal cancer (CRC) is the third most prevalent type of cancer in the world. Its prognosis is closely related to the disease stage at the time of diagnosis. Early detection of symptomless CRC or precursor lesions through population screening could reduce CRC mortality. However, screening programs are only effective if enough people are willing to participate. This study aims to asses the uptake of a second round of fecal occult blood test (FOBt) based screening and to explore factors that could potentially increase this uptake. Methods and design: Two years after the first screening round, 10.000 average risk persons, aged 50 to 75, will again receive an invitation to participate in immunohistochemical FOBt (iFOBt) based screening. Eligible persons will be recruited through a city population database. Invitees will be randomized to receive either an iFOBt with a faeces collection paper or an iFOBt without a collection paper. The iFOBts will be analyzed in a specialized laboratory at the Academic Medical Centre. Positive iFOBts will be followed by a consultation at our outpatient clinic and, in the absence of contra-indications and after informed consent, by a colonoscopy. The primary outcome measure is the participation rate. Secondary outcome measures are the effect of the addition of a collection paper on the participation rate, reasons for participation and non-participation, measures of informed choice and psychological consequences of screening and measures of psychological and physical burden associated with the iFOBt and the colonoscopy. Another secondary outcome measure is the diagnostic yield of the program. Discussion: In order to implement population screening for colorectal cancer in the Netherlands, information is needed on the uptake of repeated rounds of FOBt-based screening and on factors that could potentially increase this uptake in the future since effectiveness of such a program depends on the willingness of persons to participate. This study will provide information on the actual uptake and perception of a second round of iFOBt-based screening. The results of this study will contribute to the future implementation of a national colorectal screening program in the Netherlands. Trial registration: Dutch Trial register: NTR1327 [ABSTRACT FROM AUTHOR]

Background: Burnout is related to huge costs, for both individuals and organizations and is recognized as an occupational disease or work-related disorder in many European countries. Given that burnout is a major problem it is important to measure the levels of burnout in a valid and reliable way. The Burnout Assessment Tool (BAT) is a newly developed self-report questionnaire to measure burnout. So far, studies concerning the psychometric properties of the original version of the Burnout Assessment Tool (BAT) including 23 items show promising results and suggest that the instrument can be used in many different settings. For various reasons there is a need of a shorter instrument. For example, burnout questionnaires are typically included in employee surveys to evaluate psychosocial risk-factors, which according to the European Occupational Safety and Health Framework Directive, should be carried out in organizations on a regular basis. The aims of this paper are to develop a shorter version of the BAT, including only 12 items (BAT12) and to evaluate its construct validity and differential item functioning regarding age, gender and country.Methods: Using data from representative samples of working populations in the Netherlands and Belgium (Flanders) a shorter version of the BAT was developed by combining quantitative (Rasch analysis) and qualitative approaches (item content analysis and expert judgements). Construct validity of the new BAT12 was evaluated by means of Rasch analysis.Results: In an iterative procedure, deleting one item from each subscale at each step, a short version of the BAT - BAT12 was developed. The BAT12 fulfils the measurement criteria according to the Rasch model after accounting for local dependency between items within each subscale. The four subscales can be combined into a single burnout score.Conclusion: The new BAT12 developed in the present study maintains the breath of item content of the original version of the BAT. The new BAT12 has sound psychometric properties. The scale works invariantly for older and younger, women and men and across two countries. A shorter version of the BAT is timesaving compared to the BAT23 and can be used in e.g. employee surveys. [ABSTRACT FROM AUTHOR]

Background: The main aim of this paper is to see to what extent mortality patterns between migrants living in the Netherlands converge. This might be an indicator of health and health care acculturation.Methods: This is an observational study on the basis of standard mortality registration data collected between 1996 and 2007. Eight ethnic groups living in Amsterdam are examined to see if mortality converges or diverges over time. Trends in mortality are studied using Poisson regression. The life expectancy between groups is compared for three time periods.Results: The data showed that for males and females the life expectancy and death rates improved between 1996-1999 and 2004-2007. Most ethnic groups, both males and females, followed this positive trend. For most indicators the ethnic groups converged in terms of mortality. The data also shows the healthy migrant effect with those in Amsterdam from Dutch origin having a relatively high mortality and low life expectancy.Discussion: In this paper the "healthy migrant effect" can be clearly observed. An important cause is the emigration of the original and relatively affluent and healthy Dutch population to suburban areas. Mortality trends tend to converge between ethnic groups during the period 1997-2000 and 2004-2007. The data presented here shows further that trends in mortality and life expectancy which apply to all ethnic groups are much more powerful as this convergence. One wonders if bridging the mortality gap between groups is of much benefit for minority groups, or that minority groups would benefit more from an overall decrease in mortality.Conclusion: Mortality trends that apply to all groups tend to be much stronger compared with trends for individual groups. This shows that dynamics affecting all groups similarly have a considerably stronger effect on mortality outcomes in various ethnic groups compared with possible convergence. [ABSTRACT FROM AUTHOR]

Background: In the city of Maastricht in the Netherlands, a highway crossing several deprived neighborhoods was tunneled in 2016. The vacant space on top of this tunnel was redesigned and prioritized for pedestrians and cyclists. The aim of this study was to evaluate the effect of this major infrastructural change, named the Green Carpet, on total and transport-based physical activity (PA) levels. Methods: Participants (≥18 years) were part of one of three area-based exposure groups. The maximal exposure group lived in neighborhoods directly bordering the Green Carpet. The minimal exposure group consisted of individuals living at the other side of the city, and the no exposure group consisted of individuals living in a nearby city. Actual use of the new infrastructure was incorporated as a second measure of exposure. Data were collected before and 3-15 months after the opening of the Green Carpet. Device-based measurements were conducted to obtain PA levels and collect location data. Changes in PA over time and intervention effects were determined using linear mixed models. Results: PA levels in the Green Carpet area increased for the maximal and minimal exposure groups, but did not lead to an increase in total or transport-based PA. For the no exposure group, transport-based MVPA decreased and transport-based SB increased. The significant interaction (time x exposure) for transport-based SB, indicated differences in trends between the no exposure and maximal exposure group (B=-3.59, 95% CI - 7.15; -0.02) and minimal exposure group (B= -4.02, 95% CI -7.85, -0.19). Trends in the results based on analyses focusing on actual use and non-use of the new infrastructure were similar to those of the area-based analyses. Conclusions: Results suggest that the Green Carpet led to more PA in this specific area, but did not increase the total volume of PA. The area-based differences might reflect the differences between users and non-users, but we should be careful when interpreting these results, due to possible interference of selective mobility bias. This paper reflects that the relationship between infrastructure and PA is not unambiguous. Trial registration: This research was retrospectively registered at the Netherlands Trial Register (NL8108). [ABSTRACT FROM AUTHOR]

Background: Based on the case of palliative care and euthanasia in the Netherlands, this paper presents an analysis of frames and counter-frames used in the ongoing public debate about these two intertwined topics. Each (counter)frame presents a cultural theme that can act as a prism to give meaning to palliative care and/or euthanasia. Each frame comprehends a different problem definition, consequences and policy options. Typical word choices and metaphors are identified that can evoke these frames and the underlying reasoning. The frames do not belong to a specific stakeholder but a pattern can be seen in their use that is related to interests and ideology. Methods: An inductive framing analysis was conducted of 2,700 text fragments taken from various Dutch newspapers, websites of stakeholders and policy documents in the period 2016–2018. After an extensive process of thematic coding, axial coding, selective coding and peer review seven frames and seven counter-frames about palliative care and euthanasia were constructed. Fifteen experts in the field of palliative and/or end-of-life care commented on the overview during a member check. Results: Two frames about palliative care were constructed: the Fear of death frame, which stresses the hopeless 'terminality' of palliative care and the Heavy burden frame, in which palliative care is too big a responsibility for the relatives of the patient. In addition, two counter-frames were constructed: palliative care as a contributor to Quality of life and Completion. With regard to euthanasia, five frames were identified that lead to a problematising definition: Thou shalt not kill, Slippery slope, Lack of willpower, I am not God, and Medical progress. Five counter-frames offer a non-problematising definition of euthanasia in the debate: Mercy, Prevention, Triumph of reason, Absolute autonomy, and Economic utility thinking. Conclusions: The debate in the Netherlands on euthanasia and palliative care is characterized by a plurality of angles that goes beyond the bipolar distinction between the pros and cons of euthanasia and palliative care. Only with an overview of all potential frames in mind can an audience truly make informed decisions. The frame matrix is not only useful for policy makers to know all perspectives when joining public debate, but also to health care workers to get into meaningful conversations with their patients and families. [ABSTRACT FROM AUTHOR]

Background: Since decision making about treatment with disease-modifying drugs (DMDs) for multiple sclerosis (MS) is preference sensitive, shared decision making between patient and healthcare professional should take place. Patient decision aids could support this shared decision making process by providing information about the disease and the treatment options, to elicit the patient's preference and to support patients and healthcare professionals in discussing these preferences and matching them with a treatment. Therefore, a prototype of a patient decision aid for MS patients in the Netherlands-based on the principles of multi-criteria decision analysis (MCDA) -was developed, following the recommendations of the International Patient Decision Aid Standards. MCDA was chosen as it might reduce cognitive burden of considering treatment options and matching patient preferences with the treatment options.Results: After determining the scope to include DMDs labelled for relapsing-remitting MS and clinically isolated syndrome, users' informational needs were assessed using focus groups (N = 19 patients) and best-worst scaling surveys with patients (N = 185), neurologists and nurses (N = 60) to determine which information about DMDs should be included in the patient decision aid. Next, an online format and computer-based delivery of the patient decision aid was chosen to enable embedding of MCDA. A literature review was conducting to collect evidence on the effectiveness and burden of use of the DMDs. A prototype was developed next, and alpha testing to evaluate its comprehensibility and usability with in total thirteen patients and four healthcare professionals identified several issues regarding content and framing, methods for weighting importance of criteria in the MCDA structure, and the presentation of the conclusions of the patient decision aid ranking the treatment options according to the patient's preferences. Adaptations were made accordingly, but verification of the rankings provided, validation of the patient decision aid, evaluation of the feasibility of implementation and assessing its value for supporting shared decision making should be addressed in further development of the patient decision aid.Conclusion: This paper aimed to provide more transparency regarding the developmental process of an MCDA-based patient decision aid for treatment decisions for MS and the challenges faced during this process. Issues identified in the prototype were resolved as much as possible, though some issues remain. Further development is needed to overcome these issues before beta pilot testing with patients and healthcare professionals at the point of clinical decision-making can take place to ultimately enable making conclusions about the value of the MCDA-based patient decision aid for MS patients, healthcare professionals and the quality of care. [ABSTRACT FROM AUTHOR]

Background: Within the Dutch health care system the focus is shifting from a disease oriented approach to a more population based approach. Since every inhabitant in the Netherlands is registered with one general practice, this offers a unique possibility to perform Population Health Management analyses based on general practitioners' (GP) registries. The Johns Hopkins Adjusted Clinical Groups (ACG) System is an internationally used method for predictive population analyses. The model categorizes individuals based on their complete health profile, taking into account age, gender, diagnoses and medication. However, the ACG system was developed with non-Dutch data. Consequently, for wider implementation in Dutch general practice, the system needs to be validated in the Dutch healthcare setting. In this paper we show the results of the first use of the ACG system on Dutch GP data. The aim of this study is to explore how well the ACG system can distinguish between different levels of GP healthcare utilization.Methods: To reach our aim, two variables of the ACG System, the Aggregated Diagnosis Groups (ADG) and the mutually exclusive ACG categories were explored. The population for this pilot analysis consisted of 23,618 persons listed with five participating general practices within one region in the Netherlands. ACG analyses were performed based on historical Electronic Health Records data from 2014 consisting of primary care diagnoses and pharmaceutical data. Logistic regression models were estimated and AUC's were calculated to explore the diagnostic value of the models including ACGs and ADGs separately with GP healthcare utilization as the dependent variable. The dependent variable was categorized using four different cut-off points: zero, one, two and three visits per year.Results: The ACG and ADG models performed as well as models using International Classification of Primary Care chapters, regarding the association with GP utilization. AUC values were between 0.79 and 0.85. These models performed better than the base model (age and gender only) which showed AUC values between 0.64 and 0.71.Conclusion: The results of this study show that the ACG system is a useful tool to stratify Dutch primary care populations with GP healthcare utilization as the outcome variable. [ABSTRACT FROM AUTHOR]

Background: One of the strategies to promote the quality of palliative care in non-specialised settings is the appointment of palliative care nurse champions. It is unclear what the most effective model to implement the concept of nurse champions is and little is known about palliative care nurse champions' own views on their role and responsibilities. This paper aims to describe views of palliative care nurse champions in hospitals and home care on their role, responsibilities and added value. Methods: In 2018, a qualitative interview study was conducted with 16 palliative care nurse champions in two hospitals and four home care organisations in the southwest of the Netherlands. The framework approach was used to analyse the data. Results: Most palliative care nurse champions described their role by explaining concrete tasks or activities. Most nurse champions perceive their main task as disseminating information about palliative care to colleagues. A few nurses mentioned activities aimed at raising awareness of palliative care among colleagues. Most nurses were to a limited extent involved in collaboration with the palliative care expert team. Hospital nurse champions suggested that more support from the palliative care expert team would be helpful. Most nurse champions feel little responsibility for organisational tasks and inter-organisational collaboration. Especially hospital nurses found it difficult to describe their role. Conclusion: The role of palliative care nurse champions in hospital and home care varies a lot and nurses have diverging views on palliative care in these settings. Comprehensively fulfilling the role of palliative care nurse champion is a challenge. Careful selection, training, support and task descriptions for nurse champions are needed to make the concept of nurse champions work in palliative care. [ABSTRACT FROM AUTHOR]

Background: Treatment decisions concerning older patients can be very challenging and individualised treatment plans are often required in this very heterogeneous group. In 2015 we have implemented a routine clinical care pathway for older patients in need of intensive treatment, including a comprehensive geriatric assessment (CGA) that was used to support clinical decision making. An ongoing prospective cohort study, the Triaging Elderly Needing Treatment (TENT) study, has also been initiated in 2016 for participants in this clinical care pathway, to study associations between geriatric characteristics and outcomes of treatment that are relevant to older patients. The aim of this paper is to describe the implementation and rationale of the routine clinical care pathway and design of the TENT study.Methods: A routine clinical care pathway has been designed and implemented in multiple hospitals in the Netherlands. Patients aged ≥70 years who are candidates for intensive treatments, such as chemotherapy, (chemo-)radiation therapy or major surgery, undergo frailty screening based on the Geriatric 8 (G-8) questionnaire and the Six-Item Cognitive Impairment Test (6CIT). If screening reveals potential frailty, a CGA is performed. All patients are invited to participate in the TENT study. Clinical data and blood samples for biomarker studies are collected at baseline. During follow-up, information about treatment complications, hospitalisations, functional decline, quality of life and mortality is collected. The primary outcome is the composite endpoint of functional decline or mortality at 1 year.Discussion: Implementation of a routine clinical care pathway for older patients in need of intensive treatment provides the opportunity to study associations between determinants of frailty and outcomes of treatment. Results of the TENT study will support individualised treatment for future patients.Trial Registration: The study is retrospectively registered at the Netherlands Trial Register (NTR), trial number NL8107 . Date of registration: 22-10-2019. [ABSTRACT FROM AUTHOR]

Background: Heavy cannabis use is associated with adverse physical and mental health effects. Despite available effective treatments, the majority of heavy cannabis users does not seek professional help. Web-based interventions can provide an alternative for cannabis users who are reluctant to seek professional help. Several web-based cannabis interventions are effective in reducing cannabis use; however, the effect sizes are typically small and attrition rates are typically high. This suggests that web-based programs can be an effective cannabis use intervention for some, while others may need additional substance use treatment after completing a web-based intervention. Therefore, it is important that web-based interventions do not solely focus on reducing cannabis use, but also on improving attitudes towards substance use treatment. The Screening Brief Intervention and Referral to Treatment (SBIRT) approach appears to be well suited for the purpose of reducing cannabis use and improving substance use treatment utilization. Based on the SBIRT approach-and based on cognitive behavioral therapy (CBT) and motivational interviewing (MI)-we developed the Internet-based cannabis reduction intervention ICan.Methods/design: This protocol paper presents the design of a randomized controlled trial (RCT) in which we evaluate the effectiveness of the ICan intervention compared to four online modules of educational information on cannabis in a sample of Dutch frequent cannabis users. The primary outcome measure is frequency of cannabis use. Secondary outcome measures include the quantity of cannabis used (grams), the attitudes towards seeking help and the number of participants who enter specialized treatment services for cannabis use-related problems.Discussion: To the best of our knowledge, ICan is the first Internet-based intervention for cannabis users that combines screening, a brief intervention-based on CBT and MI-and referral to treatment options.Trial Registration: The study is registered in the Netherlands Trial Register; identifier NL7668 . Registered on 17 April 2019. [ABSTRACT FROM AUTHOR]

Background: A large mental health treatment gap exists among conflict-affected populations, and Syrian refugees specifically. Promising brief psychological interventions for conflict-affected populations exist such as the World Health Organization's Problem Management Plus (PM+) and the Early Adolescent Skills for Emotions (EASE) intervention, however, there is limited practical guidance for countries of how these interventions can be taken to scale. The aim of this study was to unpack pathways for scaling up PM+ and EASE for Syrian refugees.Methods: We conducted three separate Theory of Change (ToC) workshops in Turkey, the Netherlands, and Lebanon in which PM+ and EASE are implemented for Syrian refugees. ToC is a participatory planning process involving key stakeholders, and aims to understand a process of change by mapping out intermediate and long-term outcomes on a causal pathway. 15-24 stakeholders were invited per country, and they participated in a one-day interactive ToC workshop on scaling up.Results: A cross-country ToC map for scale up brief psychological interventions was developed which was based on three country-specific ToC maps. Two distinct causal pathways for scale up were identified (a policy and financing pathway, and a health services pathway) which are interdependent on each other. A list of key assumptions and interventions which may hamper or facilitate the scaling up process were established.Conclusion: ToC is a useful tool to help unpack the complexity of scaling up. Our approach highlights that scaling up brief psychological interventions for refugees builds on structural changes and reforms in policy and in health systems. Both horizontal and vertical scale up approaches are required to achieve sustainability. This paper provides the first theory-driven map of causal pathways to help support the scaling-up of evidence-based brief psychological interventions for refugees and populations in global mental health more broadly. [ABSTRACT FROM AUTHOR]

Background: Clinical Ethics Support (CES) services are offered to support healthcare professionals in dealing with ethically difficult situations. Evaluation of CES is important to understand if it is indeed a supportive service in order to inform and improve future implementation of CES. Yet, methods to measure outcomes of CES are scarce. In 2014, the European Moral Case Deliberation Outcomes Instrument (Euro-MCD) was developed to measure outcomes of Moral Case Deliberation (MCD). To further validate the instrument, we tested it in field studies and revised it. This paper presents the Euro-MCD 2.0 and describes the revision process.Methods: The revision process comprised an iterative dialogue among the authors as Euro-MCD-project team, including empirical findings from six Euro-MCD field-studies and input from European experts in CES and theory. Empirical findings contained perceptions and experiences of MCD outcomes among healthcare professionals who participated in MCDs in various settings in Norway, Sweden and the Netherlands. Theoretical viewpoints on CES, literature on goals of CES and MCD and ethics theory guided the interpretation of the empirical findings and final selection of MCD outcomes.Results: The Euro-MCD 2.0 Instrument includes three domains: Moral Competence, Moral Teamwork and Moral Action. Moral Competence consists of items about moral sensitivity, analytical skills and virtuous attitude. Moral Teamwork includes open dialogue and supportive relationships and Moral Action refers to moral decision-making and responsible care. During the revision process, we made decisions about adding and reformulating items as well as decreasing the number from 26 to 15 items. We also altered the sentence structure of items to assess the current status of outcomes (e.g. 'now') instead of an assumed improvement over time (e.g. 'better') and we omitted the question about perceived importance.Conclusions: The Euro-MCD 2.0 is shorter, less complex and more strongly substantiated by an integration of empirical findings, theoretical reflections and dialogues with participants and experts. Use of the Euro-MCD 2.0 will facilitate evaluation of MCD and can thereby monitor and foster implementation and quality of MCD. The Euro-MCD 2.0 will strengthen future research on evaluation of outcomes of MCD. [ABSTRACT FROM AUTHOR]

Background: This paper describes a participatory methodology that supports investigation of the synergistic collaboration between communities affected by infectious disease outbreak events and relevant official institutions. The core principle underlying the methodology is the recognition that synergistic relationships, characterised by mutual trust and respect, between affected communities and official institutions provide the most effective means of addressing outbreak situations.Methods: The methodological approach and lessons learned were derived from four qualitative case studies including (i) two tick-borne disease events (Crimean-Congo haemorrhagic fever in Spain, 2016, and tick-borne encephalitis in the Netherlands, 2016); and (ii) two outbreaks of acute gastroenteritis (norovirus in Iceland, 2017, and verocytotoxin-producing Escherichia coli [VTEC] in Ireland, 2018). An after-event qualitative case study approach was taken using mixed methods. The studies were conducted in collaboration with the respective national public health authorities in the affected countries by the European Centre for Disease Prevention and Control (ECDC). The analysis focused on the specific actions undertaken by the participating countries' public health and other authorities in relation to community engagement, as well as the view from the perspective of affected communities.Results: Lessons highlight the critical importance of collaborating with ECDC National Focal Points during preparation and planning and with anthropological experts. Field work for each case study was conducted over one working week, which although limiting the number of individuals and institutions involved, still allowed for rich data collection due to the close collaboration with local authorities. The methodology enabled efficient extraction of synergies between authorities and communities. Implementing the methodology required a reflexivity among fieldworkers that ackowledges that different versions of reality can co-exist in the social domain. The method allowed for potential generalisability across studies. Issues of extra attention included insider-outsider perspectives, politically sensitivity of findings, and how to deal with ethical and language issues.Conclusions: The overall objective of the assessment is to identify synergies between institutional decision-making bodies and community actors and networks before, during and after an outbreak response to a given public health emergency. The methodology is generic and could be applied to a range of public health emergencies, zoonotic or otherwise. [ABSTRACT FROM AUTHOR]

Background: Recurrent bleeding from an intracranial aneurysm after subarachnoid hemorrhage (SAH) is associated with unfavorable outcome. Recurrent bleeding before aneurysm occlusion can be performed occurs in up to one in five patients and most often happens within the first 6 h after the primary hemorrhage. Reducing the rate of recurrent bleeding could be a major factor in improving clinical outcome after SAH. Tranexamic acid (TXA) reduces the risk of recurrent bleeding but has thus far not been shown to improve functional outcome, probably because of a higher risk of delayed cerebral ischemia (DCI). To reduce the risk of ultraearly recurrent bleeding, TXA should be administered as soon as possible after diagnosis and before transportation to a tertiary care center. If TXA is administered for a short duration (i.e., < 24 h), it may not increase the risk of DCI. The aim of this paper is to present in detail the statistical analysis plan (SAP) of the ULTRA trial (ULtra-early TRranexamic Acid after Subarachnoid Hemorrhage), which is currently enrolling patients and investigating whether ultraearly and short-term TXA treatment in patients with aneurysmal SAH improves clinical outcome at 6 months.Methods/design: The ULTRA trial is a multicenter, prospective, randomized, open, blinded endpoint, parallel-group trial currently ongoing at 8 tertiary care centers and 16 of their referral centers in the Netherlands. Participants are randomized to standard care or to receive TXA at a loading dose of 1 g, immediately followed by 1 g every 8 h for a maximum of 24 h, in addition to standard care, as soon as SAH is diagnosed. In the TXA group, TXA administration is stopped immediately prior to treatment (coil or clip) of the causative aneurysm. Primary outcome is the modified Rankin Scale (mRS) score at 6 months after SAH, dichotomized into good (mRS 0-3) and poor (mRS 4-6) outcomes, assessed blind to treatment allocation. Secondary outcomes include case fatalities at 30 days and at 6 months and causes of poor clinical outcome. Safety outcomes are recurrent bleeding, DCI, hydrocephalus, per-procedural complications, and other complications such as infections occurring during hospitalization. Data analyses will be according to this prespecified SAP.Trial Registration: Netherlands Trial Register, NTR3272. Registered on 25 January 2012. ClinicalTrials.gov, NCT02684812. Registered on 17 February 2016. [ABSTRACT FROM AUTHOR]