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Background: Accounting for patients' perspective has become increasingly important. Based on the Consumer Quality Index method (founded on Consumer Assessment of Healthcare Providers and Systems) a questionnaire was recently developed for Dutch cancer patients. As a next step, this study aimed to adapt and pilot this questionnaire for international comparison of cancer patients experience and satisfaction with care in six European countries.Method: The Consumer Quality Index was translated into the local language at the participating pilot sites using cross-translation. A minimum of 100 patients per site were surveyed through convenience sampling. Data from seven pilot sites in six countries was collected through an online and paper-based survey. Internal consistency was tested by calculating Cronbach's alpha and validity by means of cognitive interviews. Demographic factors were compared as possible influencing factors.Results: A total of 698 patients from six European countries filled the questionnaire. Cronbach's alpha was good or satisfactory in 8 out of 10 categories. Patient satisfaction significantly differed between the countries. We observed no difference in patient satisfaction for age, gender, education, and tumor type, but satisfaction was significantly higher in patients with a higher level of activation.Conclusion: This European Cancer Consumer Quality Index(ECCQI) showed promising scores on internal consistency (reliability) and a good internal validity. The ECCQI is to our knowledge the first to measure and compare experiences and satisfaction of cancer patients on an international level, it may enable healthcare providers to improve the quality of cancer care. [ABSTRACT FROM AUTHOR]

The objective of the paper is to estimate the number of patients presenting with chest pain suspected of acute coronary syndrome (ACS) in primary care and to calculate possible cost effects of a future clinical decision rule (CDR) incorporating a point-of-care test (PoCT) as compared with current practice. The annual incidence of chest pain, referrals and ACS in primary care was estimated based on a literature review and on a Dutch and Belgian registration study. A health economic model was developed to calculate the potential impact of a future CDR on costs and effects (ie, correct referral decisions), in several scenarios with varying correct referral decisions. One-way, two-way, and probabilistic sensitivity analyses were performed to test robustness of the model outcome to changes in input parameters. Annually, over one million patient contacts in primary care in the Netherlands concern chest pain. Currently, referral of eventual ACS negative patients (false positives, FPs) is estimated to cost €1,448 per FP patient, with total annual cost exceeding 165 million Euros in the Netherlands. Based on ‘international data’, at least a 29% reduction in FPs is required for the addition of a PoCT as part of a CDR to become cost-saving, and an additional €16 per chest pain patient (ie, 16.4 million Euros annually in the Netherlands) is saved for every further 10% relative decrease in FPs. Sensitivity analyses revealed that the model outcome was robust to changes in model inputs, with costs outcomes mainly driven by costs of FPs and costs of PoCT. If PoCT-aided triage of patients with chest pain in primary care could improve exclusion of ACS, this CDR could lead to a considerable reduction in annual healthcare costs as compared with current practice. [ABSTRACT FROM PUBLISHER]

Background: A personal health record (PHR) is an online application through which individuals can access, manage, and share their health information in a private, secure, and confidential environment. Personal health records empower patients, facilitate collaboration among healthcare professionals, and improve health outcomes. Given these anticipated positive effects, we want to implement a PHR, named MyPregn@ncy, in a Dutch maternity care setting and to evaluate its effects in routine care. This paper presents the study protocol.Methods/design: The effects of implementing a PHR in maternity care on patients and professionals will be identified in a stepped-wedge, cluster-randomised, controlled trial. The study will be performed in the region of Nijmegen, a Dutch area with an average of 4,500 births a year and more than 230 healthcare professionals involved in maternity care. Data analyses will describe the effects of MyPregn@ncy on health outcomes in maternity care, quality of care from the patients' perspectives, and collaboration among healthcare professionals. Additionally, a process evaluation of the implementation of MyPregn@ncy will be performed. Data will be collected using data from the Dutch perinatal registry, questionnaires, interviews, and log data.Discussion: The study is expected to yield new information about the effects, strengths, possibilities, and challenges to the implementation and usage of a PHR in routine maternal care settings. Results may lead to new insights and improvements in the quality of maternal and perinatal care.Trial Registration: Netherlands Trial Register: NTR4063. [ABSTRACT FROM AUTHOR]

Background: Quality of care at the end of life in hospitals is often perceived to be lower compared to the care that is provided to people who die in their own home. Documenting and measuring indicators of common end-of-life symptoms could help improve end-of-life care in hospitals. This study provided insight into quality indicators for the end-of-life care of patients who died in a Dutch hospital, and assessed differences between deceased patients who were admitted for palliative/terminal care versus patients admitted for other reasons. Methods: In a retrospective record review study, trained nurses reviewed electronic health records (EHRs) of patients who died in 2019 (n = 2998), in a stratified sample of 20 Dutch hospitals. The nurses registered whether data was found in de EHRs about quality indicators for end-of-life care. This concerned: symptoms (pain, shortness of breath, anxiety, depressive symptoms), spiritual and psychological support and advance care planning. Multilevel regression analyses were performed to assess differences between patients who had been admitted for palliative/terminal care and patients admitted for other reasons. Results: Common end-of-life symptoms were rarely measured using a standardized method (e.g. Numeric Rating Scale, Visual Analogue Scale or Utrecht Symptom Diary). The symptom burden of pain was measured using a standardized method more often (63.3%) than the symptom burden of shortness of breath (2.2%), anxiety (0.5%) and depressive symptoms (0.3%). Similarly, little information was documented in the EHRs regarding wish to involve a spiritual counsellor, psychologist or social worker. Life expectancy was documented in 66%. The preferred place of death was documented less often (20%). The documentation of some quality indicators differed between patients who were admitted for palliative/terminal care compared to other patients. Conclusion: Except for the burden of pain, symptoms are rarely measured with standardized methods in patients who died in Dutch Hospitals. This study underlines the importance of documenting information about symptom burden and aspects related to advance care planning, and spiritual and psychological support to improve the quality of end-of-life care for patients in hospitals. Furthermore, uniformity in measuring methods improves the possibility to compare results between patient groups and settings. [ABSTRACT FROM AUTHOR]

Background and aims: Solid tumors account for about 30% of all pediatric cancers. The diagnosis is typically based on histological and molecular analysis of a primary tumor biopsy. Liquid biopsies carry several advantages over conventional tissue biopsy. However, their use for genomic analysis and response monitoring of pediatric solid tumors is still in experimental stages and mostly performed retrospectively without direct impact on patient management. In this case series we discuss six clinical cases of children with a solid tumor for whom a liquid biopsy assay was performed and demonstrate the potential of liquid biopsy for future clinical decision making. Methods: We performed quantitative real-time PCR (RT-qPCR), droplet digital PCR (ddPCR) or reduced representation bisulphite sequencing of cell-free DNA (cfRRBS) on liquid biopsies collected from six pediatric patients with a solid tumor treated between 2017 and 2023 at the Princess Maá xima Center for Pediatric Oncology in the Netherlands. Results were used to aid in clinical decision making by contribution to establish a diagnosis, by prognostication and response to therapy monitoring. Results: In three patients cfRRBS helped to establish the diagnosis of a rhabdomyosarcoma, an Ewing sarcoma and a neuroblastoma (case 1-3). In two patients, liquid biopsies were used for prognostication, by MYCN ddPCR in a patient with neuroblastoma and by RT-qPCR testing rhabdomyosarcomaspecific mRNA in bone marrow of a patient with a rhabdomyosarcoma (case 4 and 5). In case 6, mRNA testing demonstrated disease progression and assisted clinical decision making. Conclusion: This case series illustrates the value of liquid biopsy. We further demonstrate and recommend the use of liquid biopsies to be used in conjunction with conventional methods for the determination of metastatic status, prognostication and monitoring of treatment response in patients with pediatric solid tumors. [ABSTRACT FROM AUTHOR]

Background: There is much evidence to implement physical activity interventions for medical reasons in healthcare settings. However, the prescription of physical activity as a treatment, referring to as 'Exercise is Medicine' (E = M) is currently mostly absent in routine hospital care in The Netherlands. To support E = M prescription by clinicians in hospitals, this study aimed: (1) to develop an E = M-tool for physical activity advice and referrals to facilitate the E = M prescription in hospital settings; and (2) to provide an E = M decision guide on key decisions for implementation to prepare for E = M prescription in hospital care.Methods: A mixed method design was used employing a questionnaire and face-to-face interviews with clinicians, lifestyle coaches and hospital managers, a patient panel and stakeholders to assess the needs regarding an E = M-tool and key decisions for implementation of E = M. Based on the needs assessment, a digital E = M-tool was developed. The key decisions informed the development of an E = M decision guide.Results: An online supportive tool for E = M was developed for two academic hospitals. Based on the needs assessment, linked to the different patients' electronic medical records and tailored to the two local settings (University Medical Center Groningen, Amsterdam University Medical Centers). The E = M-tool existed of a tool algorithm, including patient characteristics assessed with a digital questionnaire (age, gender, PA, BMI, medical diagnosis, motivation to change physical activity and preference to discuss physical activity with their doctor) set against norm values. The digital E = M-tool provided an individual E = M-prescription for patients and referral options to local PA interventions in- and outside the hospital. An E = M decision guide was developed to support the implementation of E = M prescription in hospital care.Conclusions: This study provided insight into E = M-tool development and the E = M decision-making to support E = M prescription and facilitate tailoring towards local E = M treatment options, using strong stakeholder participation. Outcomes may serve as an example for other decision support guides and interventions aimed at E = M implementation. [ABSTRACT FROM AUTHOR]

Background: A high percentage of people dying at home, and a low percentage of people being admitted to hospital and dying there are regarded as indicators of appropriate care at the end of life. However, performance standards for these quality indicators are often lacking, which makes it difficult to state whether an indicator score falls between the ranges of good or poor quality care. The aim of this study was to assess quality indicators concerning place of death and hospital care utilization in people with diseases relevant for palliative care, and to establish best practice performance standards based on indicator scores in 31 regions in the Netherlands. Methods: A retrospective nationwide population-based observational study was conducted, using routinely collected administrative data concerning persons who died in 2017 in the Netherlands with underlying causes relevant for palliative care (N = 109,707). Data from four registries were linked for analysis. Scores on eight quality indicators concerning place of death and hospital care utilization were calculated, and compared across 31 healthcare insurance regions to establish relative benchmarks. Results: On average, 36.4% of the study population died at home (range between regions 30.5%-42.6%) and 20.4% in hospital (range 16.6%-25.5%). Roughly half of the population who received hospital care at any time in the last year of life were found to (also) receive hospital care in the last month of life. In the last month, 32.0% of the study population were admitted to hospital (range 29.4-36.4%), 5.3% to an Intensive Care Unit (range 3.2-6.9%) and 23.9% visited an Emergency Department (range 21.0-27.4%). In the same time period, less than 1% of the study population was resuscitated in hospital or received tube or intravenous feeding in hospital. Conclusions: The variation between regions points towards opportunities for practice improvement. The best practice performance standards as set in this study serve as ambitious but attainable targets for those regions that currently do not meet the standards. Policymakers, healthcare providers and researchers can use the suggested performance standards to further analyze causes of variance between regions and develop and test interventions that can improve practice. [ABSTRACT FROM AUTHOR]

Background: In the Netherlands, health care is regulated by the Health and Youth Care Inspectorate. Forty-six indicators are used to prioritize supervision of psychiatric hospitals. The objective of this study is to define a smaller set of weighted indicators which reflects a consensus among inspectors about which aspects are most important for risk assessment.Methods: The set of 46 indicators, complemented with missing information, was reduced to six indicators by means of interviews, group discussions and ranking among the inspectors. These indicators were used as attributes in a discrete choice experiment (DCE) to define their weights.Results: Twenty-six inspectors defined the top four indicators suitable for the risk assessment of psychiatric hospitals. These are: the policy on prevention of compulsory treatment; the policy on dysfunctional professionals; the quality of internal research after a serious incident; and the implementation of multidisciplinary guidelines on suicidal behaviour. These indicators share the same importance with regard to risk assessment. The screening of somatic symptoms and the policy on integrated care are important indicators too, but less relevant.Conclusion: Through a DCE, we reduced the amount of information for risk assessment of psychiatric hospitals to six weighted indicators. Inspectors can use these indicators to prioritize their inspections. [ABSTRACT FROM AUTHOR]

Background Audit and feedback on professional practice and health care outcomes are the most often used interventions to change behaviour of professionals and improve quality of health care. However, limited information is available regarding preferred feedback for patients, professionals and health insurers. Objective Investigate the (differences in) preferences of receiving feedback between stakeholders, using the Dutch Head and Neck Audit as an example. Methods A total of 37 patients, medical specialists, allied health professionals and health insurers were interviewed using semi-structured interviews. Questions focussed on: 'Why,' 'On what aspects' and 'How' do you prefer to receive feedback on professional practice and health care outcomes? Results All stakeholders mentioned that feedback can improve health care by creating awareness, enabling self-reflection and reflection on peers or colleagues, and by benchmarking to others. Patients prefer feedback on the actual professional practice that matches the health care received, whereas medical specialists and health insurers are interested mainly in health care outcomes. All stakeholders largely prefer a bar graph. Patients prefer a pie chart for patient-reported outcomes and experiences, while Kaplan-Meier survival curves are preferred by medical specialists. Feedback should be simple with firstly an overview, and 1-4 times a year sent by e-mail. Finally, patients and health professionals are cautious with regard to transparency of audit data. Conclusions This exploratory study shows how feedback preferences differ between stakeholders. Therefore, tailored reports are recommended. Using this information, effects of audit and feedback can be improved by adapting the feedback format and contents to the preferences of stakeholders. [ABSTRACT FROM AUTHOR]

Background: The concept of responsiveness was introduced by the World Health Organization (WHO) to address non-clinical aspects of service quality in an internationally comparable way. Responsiveness is defined as aspects of the way individuals are treated and the environment in which they are treated during health system interactions. The aim of this study is to assess responsiveness outcomes, their importance and factors influencing responsiveness outcomes during the antenatal and delivery phases of perinatal care.Method: The Responsiveness in Perinatal and Obstetric Health Care Questionnaire was developed in 2009/10 based on the eight-domain WHO concept and the World Health Survey questionnaire. After ethical approval, a total of 171 women, who were 2 weeks postpartum, were recruited from three primary care midwifery practices in Rotterdam, the Netherlands, using face-to-face interviews. We dichotomized the original five ordinal response categories for responsiveness attainment as 'poor' and good responsiveness and analyzed the ranking of the domain performance and importance according to frequency scores. We used a series of independent variables related to health services and users' personal background characteristics in multiple logistic regression analyses to explain responsiveness.Results: Poor responsiveness outcomes ranged from 5.9% to 31.7% for the antenatal phase and from 9.7% to 27.1% for the delivery phase. Overall for both phases, 'respect for persons' (Autonomy, Dignity, Communication and Confidentiality) domains performed better and were judged to be more important than 'client orientation' domains (Choice and Continuity, Prompt Attention, Quality of Basic Amenities, Social Consideration). On the whole, responsiveness was explained more by health-care and health related issues than personal characteristics.Conclusion: To improve responsiveness outcomes caregivers should focus on domains in the category 'client orientation'. [ABSTRACT FROM AUTHOR]

Background: Urine culture at the point of care minimises delay between obtaining the sample and agar inoculation in a microbiology laboratory, and quantification and sensitivity results can be available more rapidly in primary care.Objective: To identify the degree to which clinicians' interpretations of a point-of-care-test (POCT) urine culture (Flexicult™ SSI-Urinary Kit) agrees with laboratory culture in women presenting to primary care with symptoms of uncomplicated urinary tract infections (UTI).Methods: Primary care clinicians used the Flexicult™-POCT, recorded their findings and took a photograph of the result, which was interpreted by microbiology laboratory technicians. Urine samples were additionally processed in routine care laboratories. Cross tabulations were used to identify important differences in organism identification, quantification and antibiotic susceptibility between these three sources of data. The influence of various laboratory definitions for UTI on culture were assessed.Results: Primary care clinicians identified 202/289 urine samples (69.9%) as positive for UTI using the Flexicult™-POCT, whereas laboratory culture identified 94-190 (32.5-65.7%) as positive, depending on definition thresholds. 82.9% of samples identified positive for E. coli on laboratory culture were also considered positive for E. coli using the Flexicult™ -POCT, and susceptibilities were reasonably concordant. There were major discrepancies between laboratory staff interpretation of Flexicult™ photographs, clinicians' interpretation of the Flexicult™ test, and laboratory culture results.Conclusion: Flexicult™-POCT overestimated the positivity rate of urine samples for UTI when laboratory culture was used as the reference standard. However, it is unclear whether point-of-care or laboratory based urine culture provides the most valid diagnostic information. [ABSTRACT FROM AUTHOR]

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The influence of socioeconomic inequalities in pancreatic cancer patients and especially its effect in patients who had a resection is not known. Hospital type in which resection is performed might also influence outcome. Patients diagnosed with pancreatic cancer from 1989 to 2011 (n = 34,757) were selected from the population-based Netherlands Cancer Registry. Postal code was used to determine SES. Multivariable survival analyses using Cox regression were conducted to discriminate independent risk factors for death. Patients living in a high SES neighborhood more often underwent resection and more often were operated in a university hospital. After adjustment for clinicopathological factors, risk of dying was increased independently for patients with intermediate and low SES compared to patients with high SES. After resection, no survival difference was found among patients in the three SES groups. However, survival was better for patients treated in university hospitals compared to patients treated in non-university hospitals. Low SES was an independent risk factor for poor survival in patients with pancreatic cancer. SES was not an adverse risk factor after resection. Resection in non-university hospitals was associated with a worse prognosis. [ABSTRACT FROM AUTHOR]

Background: In 2006 The Dutch Health Care system changed to a market oriented system. The GP remuneration changed from ±2/3 capitation patients and 1/3 private patients before 2006 to a mixed payment scheme. From 2006 onward every patient was insured and the GP received partly capitation, partly fees for consultations and for specific services. This change coincided with many other organisational changes in General Practice care. Our research question was if during the years after 2006 patient experiences of Dutch family practice had changed. We also wanted to explore the influence of patient and practice characteristics on patient experiences. Data on patient experiences were available from 2007 to 2012. Method: In a series of annual cross sectional patient surveys the performance of GPs and practices was measured. Patient sampling took place as a part of the Dutch accreditation program in 1657 practices involving 2966 GPs. Patients' experiences, gender, age, health status, and number of annual consultations were documented as well as the type and location of practices. Linear regression analysis was used to examine time trends in patient experiences and the impact of patient and practice characteristics. Results: 78,985 patients assessed the performance of 2966 GPs, and 45,773 patients assessed the organisation of 1657 practices. The number of patients with positive experiences increased significantly between 2007 and 2012; respectively 4.8 % for GPs (beta 0.20 and p < 0.0001) and 6.6 % for practices (beta 0.10, p < 0.004). Higher age, having no chronic illness, more frequent consultations and attending single-handed practices, predicted better patient experiences. Conclusions: In our evaluation of patient experiences with general practice care from 2007 to 2012 we found an increase of 4.8 % for GPs and 6.6 % for practices respectively. This improvement is significant. While no direct causation can be made, possible explanations may be found in the various reforms in Dutch family practice since 2006. More insight is needed into key determinants of this improvement before policymakers and care providers can attribute the improvement to these reforms. [ABSTRACT FROM AUTHOR]

Background: Appropriate antibiotic use in patients with complicated urinary tract infections can be measured by a valid set of nine quality indicators (QIs). We evaluated the performance of these QIs in a national setting and investigated which determinants influenced appropriate antibiotic use. For the latter, we distinguished patient, department and hospital characteristics, including organizational interventions aimed at improving the quality of antibiotic use (antibiotic stewardship elements).Methods: A retrospective, observational multicentre study included 1964 patients (58% male sex) with a complicated urinary tract infection treated at Internal Medicine and Urology departments of 19 Dutch university and non-university hospitals. Data of 50 patients per department were extracted from medical charts. QI performance scores were calculated using previously constructed algorithms. Department and hospital characteristics were collected using questionnaires filled in by an internal medicine physician and an urologist. Regression analysis was performed to identify determinants of QI performance. Clustering at department and hospital level was taken into account through inclusion of random effects in a multi-level model.Results: Median QI performance of departments varied between 31% ('Treat urinary tract infection in men according to local guideline') and 77% ('Perform urine culture'). The patient characteristics non-febrile urinary tract infection, female sex and presence of a urinary catheter were negatively associated with performance on many QIs. The presence of an infectious diseases physician and an antibiotic formulary were positively associated with 'Prescribe empirical therapy according to guideline'. No other department or hospital characteristics, including stewardship elements, were consistently associated with better QI performance.Conclusions: A large inter-department variation was demonstrated in the appropriateness of antibiotic use. In particular certain patient characteristics (more than department or hospital characteristics) influenced the quality of antibiotic use. Some, but not all antibiotic stewardship elements did translate into better QI performance. [ABSTRACT FROM AUTHOR]

Background: Postpartum haemorrhage (PPH) remains a major contributor to maternal morbidity even in high resource settings, despite the development and dissemination of evidence-based guidelines and Advance-Trauma-Life-Support (ATLS) based courses for optimal management of PPH. We aimed to assess current influencing factors (obstacles and facilitators) for the delivery of high quality PPH-care from both patient and professional perspective.Methods: We qualitatively explored influencing factors for delivering high quality PPH-care, by having individual interviews with PPH-patients and focus group interviews with the different types of professionals working in the delivery room. For both perspectives, the theoretical frameworks of Grol and Cabana were used to classify the influencing factors for optimal PPH-care (factors of the guidelines, of professionals, of patients, of the social setting and of the organisation). In order to assess the importance of the influencing factors found among the professionals, we quantified these factors in a web-based questionnaire.Results: A total of 12 patients and 41 professionals participated in the interviews, and 315 complete surveys were analyzed. The main obstacle for high quality PPH-care identified by patients was the lack of information given by the professionals to the patient and partner before, during and after the PPH event. An informative patient website, a patient leaflet and a follow-up consultation were mentioned as facilitators. The main obstacles according to the professionals were: lack of clarity of the guidelines, lack of knowledge and failing team-communication. Team training and checklists/ flowcharts were considered facilitators.Conclusions: Different obstacles to the delivery of high quality PPH-care were identified by both patients and professionals. These data can be used to develop a focused strategy to improve PPH-care.Trial Registration: NCT 00928863. [ABSTRACT FROM AUTHOR]

Background: Perinatal audit is an established method for improving the quality of perinatal care. In audit meetings substandard factors (SSF) are identified in cases of perinatal mortality and morbidity. To our knowledge there is no classification system specifically designed for the classification of substandard factors. Such a classification may help to standardise allocation of substandard factors to categories. This will help to prioritise, guide and implement actions in quality improvement programs.Methods: A classification system of 284 substandard factors (SSF) identified in perinatal audit meetings between 2007 and 2011 was drawn up using the WHO Conceptual Framework for the International Classification for Patient Safety as a starting point. Discussions were held on inter-rater disagreements, inclusion of items, format and organisation and definitions of the main- and subcategories. A guideline was developed. An independent multidisciplinary group tested the classification. Independent of inter-rater agreement the allocations to categories were counted. For the counts in the subcategories one and two, we used the allocations in the main category as reference. The chance corrected agreement between classifiers was tested with Cohen's kappa statistic.Results: The classification consists of 9 main categories with one or two subcategories. The main categories are (1) Equipment and Materials, (2) Medication, (3) Additional tests/ investigations, (4) Transportation , (5) Documentation, (6) Communication, (7) Medical practice, (8) Other and (9) non classifiable. Of 3663 allocations by 13 classifiers 1452 SSF's were allocated (40%) to 'medical practice' and 1247 (34%) to 'documentation'. 118 (3%) times SSF's were not classifiable, mainly due to unclear phrasing of the SSF. The chance corrected agreement of 284 substandard factors in the main category was 0.68 (95% CI 0.66-0.70) and 0.57 (95% CI 0.54-0.59) for the CDG and the IGD respectively.Conclusions: Classifying substandard factors has given insight into problem area's in perinatal care and can give direction to medical, political and financial quality improvement measures. The Groningen-system has well defined categories and subcategories and the guidelines and examples are clear. The multidisciplinary inter-rater agreement is moderate to good. Improvement of the phrasing of the substandard factors is expected to improve inter-rater agreement. [ABSTRACT FROM AUTHOR]

Context Patient-reported outcomes (PROs) can play an important role in patient-centered health care by focusing on the patient's health goals guiding therapeutic decisions. When aggregated, PROs also can be used for other purposes, including comparative effectiveness research, practice improvement, assessment of the performance of clinicians and organizations, and as a metric for value-based payments. The feasibility of integrating the use of PROs for these various purposes on a wide scale has not yet been demonstrated. Our study was conducted to inform policymakers of prudent next steps for implementing PROs in clinical practice and performance measurement programs in order to maximize their impact on the quality of health care. Methods We conducted a qualitative study, interviewing 58 experts and leaders from 37 organizations (response rate: 88%) in the United States, England, and the Netherlands. Respondents included clinical practitioners ( n = 30), measure developers ( n = 11), and leaders of performance measurement programs ( n = 17). We used a qualitative content analysis to assess current strategies for applying PROs in clinical practice and performance measurement and to identify barriers to and facilitators of further implementation. Findings The use of PROs in clinical practice and for performance measurement has developed both separately and in parallel. Experts across the stakeholder spectrum support the collection of PRO data in an integrated manner that would enable using the data for these distinct purposes. We identified 2 main concerns about the feasibility for integrated use of PRO data: the complexity of establishing routine data collection and the tension among stakeholders when using PRO data for different purposes. These contrasting stakeholder views suggested varying interests among clinicians, measure developers, and purchasers of care. Conclusions Data collection approaches that support the use of PROs in health care are underdeveloped, need better integration with clinical care, and must be tailored to the characteristics of the health care system. Enabling the sustainable use of PROs will require a shared vision of clinical professionals, purchasers, and patients, with a prudent selection of the steps in implementing PROs that will maximize their impact on the quality of health care. [ABSTRACT FROM AUTHOR]

Background The increasing prevalence of cardiometabolic disease (CMD) in combination with an ageing population is a major public health problem. Early detection and management of individuals at risk for CMD is required to prevent future health problems with associated costs. General practice is the optimal health care setting to accomplish this goal. Prevention programs for identification and treatment of patients with an increased risk for CMD in primary care have been proven feasible. However, the effectiveness and cost-effectiveness have yet to be demonstrated. The 'Personalized Prevention Approach for CardioMetabolic Risk' (PPA CMR) is such a prevention program. The objective of the INTEGRATE study is to investigate the effectiveness and cost-effectiveness of PPA CMR, as well as to establish determinants for participation and compliance. Methods The INTEGRATE study is designed as a stepped-wedge randomized controlled trial with a waiting list control group. In approximately 40 general practices, all enlisted patients without CMD aged 45-70 years, are invited to participate in PPA CMR. After an online risk estimation, patients with a score above risk threshold are invited to the GP for additional measurements, detailed risk profiling and tailored treatment of risk factors through medication and/or lifestyle counseling. At baseline and after twelve months of follow-up lifestyle, health and work status of all participants are established with online questionnaires. Additionally after twelve months, we will determine health care utilization, costs of PPA CMR and compliance. Primary endpoints are the number of newly detected patients with CMD and changes in individual risk factors between the intervention and waiting list control group. Medical data will be extracted from the GPs' electronic medical records. In order to assess factors related to participation, we will send questionnaires to non-participants and assess characteristics of participating practices. For all participants, additional demographic characteristics will be available through Statistics Netherlands. Discussion The INTEGRATE study will provide insight into the effectiveness and cost-effectiveness of PPA CMR as well as determinants for participation and compliance, which represents essential information to guide further large-scale implementation of primary prevention programs for CMD. Trial registration number NTR4277, The Netherlands National Trial Register, 26-11-2013. [ABSTRACT FROM AUTHOR]

Research objective: Reliable and unambiguously defined performance indicators are fundamental to objective and comparable measurements of hospitals’ quality of care. In two separate case studies (intensive care and breast cancer care), we investigated if differences in definition interpretation of performance indicators affected the indicator scores. Design: Information about possible definition interpretations was obtained by a short telephone survey and a Web survey. We quantified the interpretation differences using a patient-level dataset from a national clinical registry (Case I) and a hospital’s local database (Case II). In Case II, there was additional textual information available about the patients’ status, which was reviewed to get more insight into the origin of the differences. Participants: For Case I, we investigated 15 596 admissions of 33 intensive care units in 2009. Case II consisted of 144 admitted patients with a breast tumour surgically treated in one hospital in 2009. Results: In both cases, hospitals reported different interpretations of the indicators, which lead to significant differences in the indicator values. Case II revealed that these differences could be explained by patient-related factors such as severe comorbidity and patients’ individual preference in surgery date. Conclusions: With this article, we hope to increase the awareness on pitfalls regarding the indicator definitions and the quality of the underlying data. To enable objective and comparable measurements of hospitals’ quality of care, organizations that request performance information should formalize the indicators they use, including standardization of all data elements of which the indicator is composed (procedures, diagnoses). [ABSTRACT FROM PUBLISHER]

Background: End-of-life care in dementia in nursing homes is often found to be suboptimal. The Feedback on End-of-Life care in dementia (FOLlow-up) project tests the effectiveness of audit- and feedback to improve the quality of end-of-life care in dementia. Methods/Design: Nursing homes systematically invite the family after death of a resident with dementia to provide feedback using the End-of-Life in Dementia (EOLD)--instruments. Two audit- and feedback strategies are designed and tested in a three-armed Randomized Controlled Trial (RCT): a generic feedback strategy using cumulative EOLD-scores of a group of patients and a patient specific feedback strategy using EOLD-scores on a patient level. A total of 18 nursing homes, three groups of six homes matched on size, geographic location, religious affiliation and availability of a palliative care unit were randomly assigned to an intervention group or the control group. The effect on quality of care and quality of dying and the barriers and facilitators of audit- and feedback in the nursing home setting are evaluated using mixed-method analyses. Discussion: The FOLlow-up project is the first study to assess and compare the effect of two audit- and feedback strategies to improve quality of care and quality of dying in dementia. The results contribute to the development of practice guidelines for nursing homes to monitor and improve care outcomes in the realm of end-of-life care in dementia. [ABSTRACT FROM AUTHOR]

Background: This study was designed to analyze a group of non-operated patients admitted to our surgical ward for incidence and type of documented complication. We classified and categorised these complications according to the definition of the Association of Surgeons of the Netherlands (ASN). Our main interest was to identify adverse events for non-operated patients that are caused by medical management and thus preventable. Methods: Complications were prospectively collected in our registry, which is part of an electronic medical patient file, and in retrospective analysed. All non-operated patients admitted to our surgical ward between January 2003 and January 2006 have been analysed for type and incidence of complications. Results: We recorded 437 complications in 364 (8%) of 4602 non-operated patients and we categorised 196 (45%) of these events in the Hospital - Provider group. In this last category 161 (82%) events were related to medical management and appeared to be preventable. Numerous different types of complications were recorded (n = 69) among the 437 events. Of all the complications, 75 (17%) were found to be a negative effect/failure of therapy. Conclusion: The incidence of complications in non-operated patients at our surgical ward was 8%, with a great variety in types of events documented. Almost half of all complications (45%) were recorded in the Hospital- Provider category and appeared to be preventable, which needs further investigation. [ABSTRACT FROM AUTHOR]

Background Proton pump inhibitors are widely used, but little is known about the usage pattern in different indications. Aim To analyse proton pump inhibitor usage patterns in the general population. Methods A cohort of 16 311 incident proton pump inhibitor users was identified in the Integrated Primary Care Information database, a Dutch general practice research database. Persistence and adherence were calculated by indication. Risk factors were identified by logistic regression analysis. Results One-year persistence was 31% in patients using proton pump inhibitors for gastro-oesophageal reflux. Persistence was higher in oesophagitis grade A/B (54%), grade C/D (73%) and Barrett's oesophagus (72%), compared to patients with only reflux symptoms (27%). Approximately 25% of patients with non-reflux dyspepsia or Helicobacter pylori-associated indications used proton pump inhibitors for more than 6 months. Half of all patients used proton pump inhibitors <80% of time indicating intermittent use, which was independent of indication. Exception were patients with Barrett's oesophagus, who were most adherent. Conclusions A substantial proportion of patients with indications not requiring long-term treatment use proton pump inhibitors for an extended period. Half of the patients used proton pump inhibitors on-demand or intermittently. Such usage pattern is probably sufficient for most patients, but may be inadequate if proton pump inhibitors are used for serious diseases, such as severe oesophagitis or Barrett's oesophagus. [ABSTRACT FROM AUTHOR]

Objective: Dyspepsia usually presents first in primary care. There are many reasons for referral including urgent problems (for example, haematemesis and melaena), treatment failure, or to exclude serious pathology. Referral will change the population characteristics of primary and secondary care dyspeptics. Many of the guidelines for primary care dyspepsia, however, are based on secondary care research on these referred patients. The aim of this study was to describe the prevalence of dyspepsia in general practice, the characteristics of patients presenting with dyspepsia in primary care, and the clinical and non-clinical determinants of referral in these patients.Design: Cross sectional survey of the consultation records of patients presenting with dyspepsia in primary care during a one year period.Methods: Dyspeptic patients who consulted their general practitioner (GP) in 1997 were selected on the basis of International Classification of Primary Care codes using a computer search among 20 sentinel practices affiliated with the Utrecht Network of General Practitioners. Cross tables and logistic regression analysis were carried out to reveal patient characteristics and determinants of referral.Results: The prevalence of dyspepsia presenting in primary care in 1997 was 3.4% (1740/48958). These patients were usually not referred during the first consultation. Men, elderly patients, and patients with a previous history of dyspepsia were referred to secondary care more frequently than other dyspeptic patients. Patients diagnosed with both irritable bowel syndrome and dyspepsia were at risk of being referred most.Conclusion: Dyspepsia is a frequently occurring complaint in primary care and patients are usually treated by their GP. Besides clinically relevant reasons for referral, dyspeptic patients with irritable bowel syndrome seem to be more "at risk" of being referred to secondary care than other dyspeptic patients. The differences between primary and secondary care dyspeptic patients should be taken into account when interpreting research for guideline purposes. Further research is needed to clarify the background of the relation between irritable bowel syndrome and dyspepsia and its influence on referral. [ABSTRACT FROM AUTHOR]

Significant treatment variation exists in the Netherlands between teams treating patients with cleft lip, alveolus, and/or palate, resulting in a confusing and undesirable situation for patients, parents, and practitioners. Therefore, to optimize cleft care, clinical practice guidelines (CPGs) were developed. The aim of this report is to describe CPG development, share the main recommendations, and indicate knowledge gaps regarding cleft care. Together with patients and parents, a multidisciplinary working group of representatives from all relevant disciplines assisted by two experienced epidemiologists identified the topics to be addressed in the CPGs. Searching the Medline, Embase, and Cochrane Library databases identified 5157 articles, 60 of which remained after applying inclusion and exclusion criteria. We rated the quality of the evidence from moderate to very low. The working group formulated 71 recommendations regarding genetic testing, feeding, lip and palate closure, hearing, hypernasality, bone grafting, orthodontics, psychosocial guidance, dentistry, osteotomy versus distraction, and rhinoplasty. The final CPGs were obtained after review by all stakeholders and allow cleft teams to base their treatment on current knowledge. With high-quality evidence lacking, the need for additional high-quality studies has become apparent. [ABSTRACT FROM AUTHOR]

Objectives: To assess if the implementation of guidelines for occupational rehabilitation of patients with low back pain by means of process variables--a set of objective criteria for technical performance and continuity of care--led to a better outcome in clinical and return to work variables.Methods: The study group consisted of 59 patients with at least 10 days of sick leave because of low back pain. Univariate analyses as well as multiple logistic regression and Cox's regression analyses were performed to assess the relation between quality of care and outcome.Results: Process indicators for technical competence, continuity of care, and total performance were all significantly related to satisfaction of employees. Continuity of care and total performance were significantly related to working status at 3 months, and time to return to work. None of the process indicators was related to pain or disability after 3 months follow up. Satisfaction was not related to any of the other outcome variables. This indicates that if guidelines for occupational rehabilitation are met, outcome is better.Conclusion: Quality of the process of care was related to outcome. Interventions of occupational physicians need improvement in the areas of continuity of care and communication with treating physicians. The effectiveness of an improved intervention should be studied in a subsequent randomised clinical trial. [ABSTRACT FROM AUTHOR]

Background: The need for palliative care is increasing. Since almost every junior doctor will come across palliative care patients, it is important to include palliative care in the undergraduate curriculum. The objective of this research is to gather undergraduate students' views on palliative care in terms of its importance, their confidence in and knowledge of the domain. Methods: Final-year medical students at four Dutch medical faculties were surveyed. The questionnaire measured their views on the education they had received, their self-reported confidence in dealing with palliative care patients and their knowledge of palliative care. Results: Two hundred twenty-two medical students participated in this study. Students considered palliative care education relevant, especially training in patient-oriented care and communication with the patient. Students felt that several topics were inadequately covered in the curriculum. Overall, the students did not feel confident in providing palliative care (59.6%), especially in dealing with the spiritual aspect of palliative care (77%). The knowledge test shows that only 48% of the students answered more than half of the questions correctly. Conclusion: The students in this study are nearly junior doctors who will soon have to care for palliative patients. Although they think that palliative care is important, in their opinion the curriculum did not cover many important aspects, a perception that is also in line with their lack of confidence and knowledge in this domain. Therefore, it is important to improve palliative care education in the medical curriculum. [ABSTRACT FROM AUTHOR]