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Objective In 2014, the Primary Care Plus (PC+) model was introduced in the Netherlands to shift low-complex specialised care from the hospital to the primary care setting. While positive effects of PC+ have been documented at individual patient level concerning health-related quality of life, perceived quality of care and care costs, its impacts on service use at the population level remain uncertain. Methods In this observational study, we used retrospective health insurance reimbursement claims data from the largest health insurer in the intervention region to determine service use. We assessed PC+ and secondary care insurance claims (i.e. claims of the regional hospital and claims of other secondary care settings in and outside the region visited by patients from the intervention region) from 2015 to 2018 and compared these to the national level. Results The total number of claims related to low-complex specialised care in the intervention region showed an increase over time. The increase in claims was related to PC+. The number of claims related to the regional hospital and other secondary care settings decreased over time. During the same period, a declining trend in claims at the national level was observed. Conclusion The introduction of the PC+ model in one region in the Netherlands was associated with an increase in the use of low-complex specialised care. This suggests that the ability of the PC+ model to substitute for specialist care at population level may be limited. Going forward, it will be important to continue monitoring and evaluating service use as substitution effects may materialise only over a longer timeframe.

Objectives: To experiment with new approaches of collaboration in healthcare delivery, local authorities implement new models of care. Regarding the local decision-context of these models, Multi-Criteria Decision Analysis (MCDA) may be of added value to Cost-Utility Analysis (CUA), as it covers a wider range of outcomes. This study compares the two methods using a side-by-side application. Methods: A new Dutch model of care, Primary Care Plus (PC+), was used as case study to compare the results of CUA and MCDA. Data of patients referred to PC+ or care-as-usual was retrieved by questionnaires and administrative databases with a three-month follow-up. Propensity score matching together with generalised linear regression models was used to reduce confounding. Univariate and probabilistic sensitivity analyses were performed to explore uncertainty in the results. Results: Although both methods indicated PC+ as dominant alternative, complementary differences were observed. MCDA provided additional evidence that PC+ improved access to care (standardised performance score of 0.742 versus 0.670), improvement in health-related quality of life was driven by the psychological well-being component (standardised performance score of 0.710 versus 0.704), estimated the budget required for the PC+ to be affordable in addition to preferable (€521.42 per patient). Additionally, MCDA was less sensitive to the utility measures used. Conclusions: MCDA may facilitate an auditable and transparent evaluation of new models of care by providing additional information on a wider range of outcomes and incorporating affordability. However, more effort is needed to increase the usability of MCDA among local decision makers.

Patiënten hebben het recht om hun eigen huisartsendossier in te zien. Dat heeft allerlei voordelen – zo krijgen patiënten een groter inzicht in hun eigen gezondheidstoestand en kunnen ze zich beter voorbereiden op het gesprek met de huisarts. Sommige huisartsen maken zich echter zorgen, want patiënten kunnen de informatie ook verkeerd begrijpen en nodeloos ongerust worden. Zijn dergelijke zorgen terecht?

Background: Due to demographic transitions and budget restraints, it is now necessary to search for comprehensive new strategies, in order to constitute a sustainable healthcare system. Recently, various online care platforms for community-dwelling older adults were introduced in several European countries. These platforms have aimed at solidifying social cohesion in the community, so as to support the older adults in coordinating or managing their care and to enhance the self-reliance of these older adults. Consequently, these platforms might contribute to a more sustainable healthcare system. The main research question of this study was twofold: Which online care platforms for older adults are available in the Netherlands and what are their characteristics? Methods: The researchers have performed a scoping review of the online care platforms in the Netherlands, according to the six steps of Arksey & O’Malley (2005), which were as follows: (1) Identifying the research question; (2) Identifying any relevant studies; (3) Selecting the studies; (4) Charting the data; (5) Collating, summarising and reporting on the results; together with (6) consultations with the relevant stakeholders. The study searched for evidence in online scientific databases (Phase 1) and on the Internet (Phase 2). The relevant studies that were published between February 2012 and October 2017 were included. Results: The review resulted in an overview of 21 care platforms, for which 3 types were identified: (1) Community Care Platforms; (2) Care Network Platforms; and (3) System Integrator Platforms. Conclusion: This typology of platforms can guide users – for instance, older adults, care professionals, informal caregivers and municipalities, in choosing a suitable care platform, i.e. the typology gives users insight into the functionalities, goals and target groups which allows them to choose a platform that matches their needs. As far as the authors know, no studies have previously reported on the effects of the online care platforms for older adults in the Netherlands, so further research is required on their impacts and on their benefits.

Combining work and care can be very challenging. If not adequately supported, carers' employment, well-being and relationships may be at risk. Technologies can be potential solutions. We carried out a scoping review to find out what is already known about technologies used by working carers. The search included academic and grey literature published between January 2000 and June 2020. Sixteen relevant publications were analysed and discussed in the context of the broader discourse on work-care reconciliation. Technologies discussed can be classified as: (a) web-based technologies; (b) technologies for direct communication; (c) monitoring technologies; and (d) task-sharing tools. Technologies can help to make work-care reconciliation more manageable and alleviate psychosocial and emotional stress. General barriers to using technology include limited digital skills, depending on others to use technologies, privacy and data protection, cost, limited technological capabilities, and limited awareness regarding available technologies. Barriers specific to some technologies include work disruptions, limited perceived usefulness, and lacking time and energy to use technologies. More research into technologies that can address the needs of working carers and how they are able to use them at work is needed.

Background In a changing ageing society wherein older adults are increasingly expected to take care of themselves instead of relying on health care services, online community care platforms can help older adults to meet these expectations. A considerable number of these online community care platforms have been introduced in several European countries based on their potential. However, their actual impact is unclear. Objective The aim of this study was to investigate the self-reported use, expectations, and perceived impact of a Dutch online community care platform called Grubbenvorst-Online among Dutch older adults. The following 2 questions were studied: (1) What is the self-reported use of Grubbenvorst-Online among older adults? (2) What are their expectations and perceived impact of Grubbenvorst-Online regarding local participation, their social network, mutual informal caregiving, and feelings of connectedness? Methods An observational pretest-posttest study was conducted. Participants were recruited via a web-based message on the Grubbenvorst-Online platform and data were collected via postal questionnaires among older users at the start of the study and 4 months later. Data regarding the expectations and the perceived impact of Grubbenvorst-Online were compared and tested. Results Forty-seven Grubbenvorst-Online users with an average age of 74 years participated in this study. They were healthy, predominantly “internet-skilled,” and they found the internet important for maintaining social contacts. In general, the use of the online community care platform decreased during the 4-month follow-up period. The perceived impact of Grubbenvorst-Online was significantly lower than that expected regarding information provision (P=.003), seeking help from fellow villagers (P Conclusions The findings of this study indicate that online community care platforms perhaps do not provide enough “added value” in their current form. We suggest a new direction in which online community care platforms primarily support existing offline initiatives aimed at stimulating local participation, informal caregiving, and feelings of connectedness.

Background Regional population management (PM) health initiatives require insight into experienced quality of care at the regional level. Unsolicited online provider ratings have shown potential for this use. This study explored the addition of comments accompanying unsolicited online ratings to regional analyses. Objective The goal was to create additional insight for each PM initiative as well as overall comparisons between these initiatives by attempting to determine the reasoning and rationale behind a rating. Methods The Dutch Zorgkaart database provided the unsolicited ratings from 2008 to 2017 for the analyses. All ratings included both quantitative ratings as well as qualitative text comments. Nine PM regions were used to aggregate ratings geographically. Sentiment analyses were performed by categorizing ratings into negative, neutral, and positive ratings. Per category, as well as per PM initiative, word frequencies (ie, unigrams and bigrams) were explored. Machine learning—naïve Bayes and random forest models—was applied to identify the most important predictors for rating overall sentiment and for identifying PM initiatives. Results A total of 449,263 unsolicited ratings were available in the Zorgkaart database: 303,930 positive ratings, 97,739 neutral ratings, and 47,592 negative ratings. Bigrams illustrated that feeling like not being “taken seriously” was the dominant bigram in negative ratings, while bigrams in positive ratings were mostly related to listening, explaining, and perceived knowledge. Comparing bigrams between PM initiatives showed a lot of overlap but several differences were identified. Machine learning was able to predict sentiments of comments but was unable to distinguish between specific PM initiatives. Conclusions Adding information from text comments that accompany online ratings to regional evaluations provides insight for PM initiatives into the underlying reasons for ratings. Text comments provide useful overarching information for health care policy makers but due to a lot of overlap, they add little region-specific information. Specific outliers for some PM initiatives are insightful.

Cardiovascular Disease (CVD) epidemiology varies significantly among Low and Middle-Income Countries. Honduras is the Central American country with the highest Ischemic Heart Disease and CVD mortality rates. The aim of this study was to assess the individual CVD risk factors and calculate Cardiovascular Risk Assessment Scores (CVRAS) from the population. Methods: A cross-sectional study in western Honduras. Estimation of CV risk was performed using Framingham, MESA, ACC/AHA-PCEs and ESC SCORE calculators. Results: 38% were male. For men and women respectively; 49% and 48% had self-reported hypertension (HTN), on measured blood pressure only 18% and 30% had normal readings. Diabetes Mellitus was reported in 19% and 22%. Tobacco use was 14% and 3%. Self-reported regular exercise was 39.9% and 25%. Obesity was diagnosed in 24% and 24%. Lipid profile; total cholesterol was ≥200 mg/dl in 63% of subjects. LDL-C was elevated (>100 mg/dl) in 74% of participants, 9% had LDL-C levels higher than 190 mg/dl. Triglycerides were high (>160 mg/dl) in 60%, of these subjects 22% were taking lipid-lowering medications. 52% reported family-history of CVD. The risk calculation for men and women respectively for each CVRAS were; AHA/ACC-PCEs high risk (score ≥ 7.5%) in 62% and 30%, FRS high risk (score ≥ 20%) 46% and 15%, MESA high risk (Score ≥ 7.5%) in 70.6% and 17.7%, ESC SCORE high risk (score ≥ 5% in 32.4% and 11.8%). Conclusions: CV risk calculations revealed higher than rates than expected with consequently reflected on higher than estimated CVRAS. This represents the first report of its kind in Honduras.

Health care no longer focuses solely on patients and increasingly emphasizes regions and their populations. Strategies, such as population management (PM) initiatives, aim to improve population health and well-being by redesigning health care and community services. Hence, insight into population health is needed to tailor interventions and evaluate their effects. This study aims to assess whether population health differs between initiatives and to what extent demographic, personal, and lifestyle factors affect these differences. A population health survey that included the Short Form 12 version 2 (SF12, physical and mental health status), Patient Activation Measure 13 (PAM13), and demographic, personal, and lifestyle factors was administered in 9 Dutch PM initiatives. Potential confounders were determined by comparing these factors between PM initiatives using analyses of variance and chi-square tests. The influence of these potential confounders on the health outcomes was studied using multivariate linear regression. Age, education, origin, employment, body mass index, and smoking were identified as potential confounders for differences found between the 9 PM initiatives. Each had a noteworthy influence on all of the instruments' scores. Not all health differences between PM initiatives were explained, as the SF12 outcomes still differed between PM initiatives once corrected. For the PAM13, the differences were no longer significant. Demographic and lifestyle factors should be included in the evaluation of PM initiatives and population health differences found can be used to tailor initiatives. Other factors beyond health care (eg, air quality) should be considered to further refine the tailoring and evaluation of PM initiatives.

Population health management initiatives are introduced to transform health and community services by implementing interventions that combine various services and address the continuum of health and well-being of populations. Insight is required into a population's health to evaluate implementation of these initiatives. This study aims to determine the performance of commonly used instruments for measuring a population's experienced health and explores the assessed concepts of population health. Survey-based Short Form 12, version 2 (SF12, health status), Patient Activation Measure 13 (PAM13), and Kessler 10 (K10, psychological distress) data of 3120 respondents was used. Floor/ceiling effects were studied using descriptive statistics. Validity was assessed using factor and discriminant analyses, and reliability was assessed using Cronbach α. Finally, to study covered concepts, exploratory factor analyses (EFAs) were conducted, which included additional surveyed characteristics. The SF12 and PAM13 sum scores showed acceptable averages and distributions, while results of the K10 indicated a floor effect. SF12 and K10 measured their expected constructs, while PAM13 did not. The EFA of PAM13 displayed 1 instead of the expected 4 constructs. Reliability was good for all instruments (α 0.89–0.93). The overall EFA identified 4 concepts: mental, physical ability, lifestyle, and self-management. SF12 and PAM13, combined with lifestyle characteristics, are shown to provide insightful information to measure the physical, mental, lifestyle, and self-management concepts of population health. Future research should include additional instruments that cover new aspects introduced by recent definitions of health.

Due to the ageing population, the prevalence of musculoskeletal disorders will continue to rise, as well as healthcare expenditure. To overcome these increasing expenditures, integration of orthopaedic care should be stimulated. The Primary Care Plus (PC+) intervention aimed to achieve this by facilitating collaboration between primary care and the hospital, in which specialised medical care is shifted to a primary care setting. The present study aims to evaluate the referral decision following orthopaedic care in PC+ and in particular to evaluate the influence of diagnostic tests on this decision. Therefore, retrospective monitoring data of patients visiting PC+ for orthopaedic care was used. Data was divided into two periods; P1 and P2. During P2, specialists in PC+ were able to request additional diagnostic tests (such as ultrasounds and MRIs). A total of 2,438 patients visiting PC+ for orthopaedic care were included in the analysis. The primary outcome was the referral decision following PC+ (back to the general practitioner (GP) or referral to outpatient hospital care). Independent variables were consultation- and patient-related predictors. To describe variations in the referral decision, logistic regression modelling was used. Results show that during P2, significantly more patients were referred back to their GP. Moreover, the multivariable analysis show a significant effect of patient age on the referral decision (OR 0.86, 95% CI = 0.810.91) and a significant interaction was found between the treating specialist and the period (p = 0.015) and between patient's diagnosis and the period (p. 0.001). Despite the significant impact of the possibility of requesting additional diagnostic tests in PC+, it is important to discuss the extent to which the availability of diagnostic tests fits within the vision of PC+. In addition, selecting appropriate profiles for specialists and patients for PC+ are necessary to further optimise the effectiveness and cost of care.

The number of people who combine work and unpaid care is increasing rapidly as more people need care, public and private care systems are progressively under pressure and more people are required to work for longer. Without adequate support, these working carers may experience detrimental effects on their well‐being. To adequately support working carers, it is important to first understand the challenges they face. A scoping review was carried out, using Arksey and O’Malley's framework, to map the challenges of combining work and care and solutions described in the literature to address these challenges. The search included academic and grey literature between 2008 and 2018 and was conducted in April 2018, using electronic academic databases and reference list checks. Ninety‐two publications were mapped, and the content analysed thematically. A conceptual framework was derived from the analysis which identified primary challenges (C1), directly resulting from combining work and care, primary solutions (S1) aiming to address these, secondary challenges (C2) resulting from solutions and secondary solutions (S2) aiming to address secondary challenges. Primary challenges were: (a) high and/or competing demands; (b) psychosocial/‐emotional stressors; (c) distance; (d) carer's health; (e) returning to work; and (f) financial pressure. This framework serves to help those aiming to support working carers to better understand the challenges they face and those developing solutions for the challenges of combining work and care to consider potential consequences or barriers. Gaps in the literature have been identified and discussed.

Introduction: Broadening perspectives on the concept of population health, such as positive health, focus on people’s perception of resilience, meaningfulness and ability to adapt and self-manage. So far, no validated instruments are available for assessing health that encompass these perspectives. The goal of this study was to determine whether the MijnKwaliteitVanLeven.nl “MyQualityOfLife.nl”, MKVL survey is a valid and reliable instrument for assessing the broader health perspectives at population level.Theory/Method: 19,809 individual entries of the MKVLsurvey were used. Huber’s positive health concept and its six dimensions physical functioning, mental health, meaningfulness, quality of life, social participation and daily functioning were used as a conceptual framework for analyses. First, face validity was assessed by means of expert feedback using this framework. The clustering of the MKVL items over the six dimensions by the experts was used for confirmative factor analyses CFA, followed by a data-driven explorative factor analyses EFA. Finally, reliability tests Cronbach’s alpha were performed.Results: Experts distributed 74 of 118 MKVL-items over the six dimensions of positive health. The other forty-four items either reached no consensus or were considered not applicable. The CFA-model based on expert classification was not confirmed by the data. The subsequent EFA excluded most items based on factor loading and suggested two factors; one generally covering ‘quality of life’ 23 items and the other ‘daily functioning’ seven items. Both EFA factors showed excellent reliability Cronbach’s alpha > 0.9.Discussion: The MKVL survey shows promise as a comprehensive health instrument. When the goal is to assess specific dimensions of positive health, the MKLV survey seemed to fall short. Explanations for this discrepancy could come from two sides. First, the MKVL survey was not specifically developed for the purposes tested in this study. Second, the dimensions of positive health are themselves not distinct enough and thus difficult to evaluate separately in a quantitative manner.Conclusion: The MKVL survey can be used to assess the broader concept of health in a population as well as the more specific ‘quality of life’ and ‘daily functioning’ dimensions. The survey lacks the ability to evaluate several new health dimensions separately, such as ‘meaningfulness’ and ‘social participation. Lesson learned: It is difficult for instruments to keep up with rapid changing concepts such as health, while there is a lot of demand from the field. Studying and expanding the use existing instruments could fill this gap.Limitations: The characteristics of the study population have to be taken into account. More elderly, chronically ill and highly educated participants were included in this study when compared to the Dutch population. Furthermore, alternate definitions of positive health, in addition to Huber’s, exist and could have led to different results.Suggestions for future research: Future research should try to further study the potential use of the MKVL survey. For example, gaining the ability to evaluate specific new dimensions individually would be valuable when designing targeted interventions.

Item does not contain fulltext The systematic development of a counselling protocol in primary care combined with a monitoring and feedback tool to support chronically ill patients to achieve a more active lifestyle. An iterative user-centred design method was used to develop a counselling protocol: the Self-management Support Programme (SSP). The needs and preferences of future users of this protocol were identified by analysing the literature, through qualitative research, and by consulting an expert panel. The counselling protocol is based on the Five A's model. Practice nurses apply motivational interviewing, risk communication and goal setting to support self-management of patients in planning how to achieve a more active lifestyle. The protocol consists of a limited number of behaviour change consultations intertwined with interaction with and responses from the It's LiFe! monitoring and feedback tool. This tool provides feedback on patients' physical activity levels via an app on their smartphone. A summary of these levels is automatically sent to the general practice so that practice nurses can respond to this information. A SSP to stimulate physical activity was defined based on user requirements of care providers and patients, followed by a review by a panel of experts. By following this user-centred approach, the organization of care was carefully taken into account, which has led to a practical and affordable protocol for physical activity counselling combined with mobile technology.

BackgroundMany Western countries face the challenge of providing high-quality care while keeping the healthcare system accessible and affordable. In an attempt to deal with this challenge a new healthcare delivery model called primary care plus (PC+) was introduced in the Netherlands. Within the PC+ model, medical specialists perform consultations in a primary care setting. PC+ aims to support the general practitioners in gatekeeping and prevent unnecessary referrals to hospital care. The aim of this study was to examine the effects of a cardiology PC+ intervention on the Triple Aim outcomes, which were operationalized by patient-perceived quality of care, health-related quality of life (HRQoL) outcomes, and healthcare costs per patient.MethodsThis is a quantitative study with a longitudinal observational design. The study population consisted of patients, with non-acute and low-complexity cardiology-related health complaints, who were referred to the PC+ centre (intervention group) or hospital-based outpatient care (control group; care-as-usual). Patient-perceived quality of care and HRQoL (EQ-5D-5L, EQ-VAS and SF-12) were measured through questionnaires at three different time points. Healthcare costs per patient were obtained from administrative healthcare data and patients were followed for nine months. Chi-square tests, independent t-tests and multilevel linear models were used to analyse the data.ResultsThe patient-perceived quality of care was significantly higher within the intervention group for 26 out of 27 items. HRQoL outcomes did significantly increase in both groups (P ConclusionsWhile this study showed no improvements on HRQoL outcomes, PC+ seemed to be promising as it results in improved quality of care as experienced by patients and lower healthcare costs per patient.

Introduction: To deal with the pressures on the healthcare system, the healthcare system should focus on high-value health care by pursuing the three aims: improving the health of the population, improving the quality of care as experienced by patients and reducing the increase of healthcare costs. In the Netherlands, several initiatives focus on strengthening the primary care and substituting hospital care with primary care in order to keep the health care system sustainable. This study is concentrated on a cardiology primary care plus PC+ centre where cardiologists provide specialist consultations in a primary care setting. This PC+ intervention aims to improve the health of the population and patients’ experience of care while reducing the healthcare costs by decreasing the number of unnecessary referrals to specialist care in the hospital setting. Methods: This is a practice-based study with a longitudinal observational design. The study population consisted of adult patients with non-acute and low-complexity cardiology-related health complaints, who will be referred to the cardiology PC+ centre intervention group or hospital-based outpatient cardiology care control group. Data of the PC+ centre and the hospital were used to investigate the referral and follow-up patterns of intervention group patients compared to the control group. Furthermore, patients were asked to complete questionnaires at three different time points before consultation, directly after consultation, three months after consultation consisting of items about their demographics, health status SF-12, EQ-5D-5L and EQ-VAS and experience of care. Results: The data of the PC+ centre and the hospital consists of 1838 intervention patients and 2155 control patients. Preliminary results show that 27.9 % n= 513 of the intervention group was referred to hospital care after a consultation at the PC+ centre. Moreover, 437 intervention patients and 328 control patients were included in the questionnaire study. In 25 out of 27 items PC+ results in significantly higher levels of patient satisfaction compared to hospital-based outpatient care. The results of the EQ5D-5L indicate no differences in health status between the groups, taking into account the follow-up period of three months F=0.133; P=0.865. Discussion: PC+ is a new concept in the Dutch healthcare system and evidence about its effects is scarce. The findings of this study will fill a gap in knowledge about the effects of PC+ and in particular whether PC+ is able to pursue the Triple Aim outcomes. Conclusion: Whilethis study showed no effects on the health status of the patients, there are promising results looking at the patients’ experience of care and healthcare utilization. Lessons learned: The implementation, as well as the evaluation, of PC+ initiatives is a dynamic process which requires time and continuous interaction with the stakeholders. Limitations: This study does not yet provide insight in the actual effects of PC+ on healthcare costs. Suggestions for future research: Future research, concentrated on PC+, should continue focusing on the Triple Aim outcomes, with a particular focus on healthcare costs.

Introduction: In one of the nine pioneer sites appointed by the Dutch Ministry of Health, namely MyCare MijnZorg in the Southern part of the Netherlands, the healthcare costs per capita are among the highest of the country. The regional primary care organization HuisartsenOZL and healthcare insurer CZ started ‘the Plus Practices’ initiative together with fifteen out of the approximately 75 general practitioner GP practices in the MyCare region. The goal of these stakeholders is to improve on Triple Aim outcomes of the ‘Plus Practices’ patient population. The ‘Plus Practices’ aspire to become the best general practices in the near future by combining innovative interventions focused on three main topics, namely patient-centred care, efficiency, and community-centred care. Objective: The aim of this study is to describe the approach of primary care organization HuisartsenOZL in guiding, facilitating and stimulating the ‘Plus Practices’ to innovate in order to improve on Triple Aim outcomes. Methods: A qualitative approach was used. The researcher had a role as participant-observer and made observational notes of meetings. Provisional insights of the researchers were shared with HuisartsenOZL, CZ and GPs in order to improve the implementation of the ‘Plus Practices’. Interviews n=13 with the stakeholders were conducted to complement the data. The Consolidated Framework for Implementation Research CFIR was used to analyse the data. Results: The initiative started with selecting a set of possible interventions related to the three main topics. Every ‘Plus Practice’ was expected to implement this same set. However, an analysis for each of the practices revealed that the performance indicators, such as referrals to hospitals and prescribed medication, differed substantially among the practices. Based on the results and in close collaboration with the GPs, norms for each of the indicators were formulated as a next step. Subsequently, practices that performed below a certain norm were asked to draft a plan e.g. how will your practice decrease the number of patients for whom expensive medication was prescribed in order to work towards achieving the norm. Finally, each practice started to implement a selection of the broader set of interventions. Discussion: Based on a close collaboration between the primary care organization, the GPs and the researchers, the initial initiative shifted from a universal to a practice-centred approach. Conclusion: The preliminary results indicate that a practice-centred approach is most feasible to implement a complex intervention to improve on Triple Aim outcomes. Lesson learned: A practice-centred approach is needed for innovation in general practices. Limitations: Data saturation is not yet achieved. However, preliminary results will be complemented with several interviews. Suggestions for future research: The process of how dissemination of the experiences of best practices to the other practices can be supported will be studied and the effect on Triple Aim outcomes will be monitored.

BACKGROUND: In an attempt to deal with the pressures on the healthcare system and to guarantee sustainability, changes are needed. This study is focused on a cardiology Primary Care Plus intervention in which cardiologists provide consultations with patients in a primary care setting in order to prevent unnecessary referrals to the hospital. This study explores which patients with non-acute and low-complexity cardiology-related health complaints should be excluded from Primary Care Plus and referred directly to specialist care in the hospital.METHODS: This is a retrospective observational study based on quantitative data. Data collected between January 1 and December 31, 2015 were extracted from the electronic medical record system. Logistic regression analyses were used to select patient groups that should be excluded from referral to Primary Care Plus.RESULTS: In total, 1525 patients were included in the analyses. Results showed that male patients, older patients, those with the referral indication 'Stable Angina Pectoris' or 'Dyspnoea' and patients whose reason for referral was 'To confirm disease' or 'Screening of unclear pathology' had a significantly higher probability of being referred to hospital care after Primary Care Plus.CONCLUSIONS: To achieve efficiency one should exclude patient groups with a significantly higher probability of being referred to hospital care after Primary Care Plus.TRIAL REGISTRATION NUMBER: NTR6629 (Data registered: 25-08-2017) (registered retrospectively).

Background\ud Recent transitions in long-term care in the Netherlands have major consequences for community-dwelling older adults. A new paradigm expects them to manage and arrange their own care and support as much as possible. Technology can support this shift. A study has been conducted to explore the needs of community-dwelling frail older adults with regard to an online platform. An existing platform was subsequently modified, based upon these needs, resulting in an online community care platform (OCC-platform) comprising of care, health, and communication functions. The purpose of this platform was to support frail older adults in their independence and functioning, by stimulating self-care and providing reliable information, products and services.\ud \ud Methods\ud The study used a User-Centred Design. The development processes involved the following steps: Step 1) Identification of the User Requirements. To assess the user requirements, direct observations (N = 3) and interviews (N = 14) were performed. Step 2) Modification of an Existing Online Platform. Based upon Step 1, available online platforms were explored to determine whether an existing useful product was available. Two companies collaborated in modifying such a platform; Step 3) Testing the Modified Platform. A total of 73 older adults were invited to test a prototype of the OCC-platform during 6 months, which comprised of two phases: (1) a training phase; and (2) a testing phase.\ud \ud Results\ud An iterative process of modifications resulted in an interactive software concept on a Standard PC, containing 11 Functions. The Functions of ‘contacts’, ‘services’ and ‘messaging’, were by far, the most frequently used. The use was at its highest during the first 2 weeks of the testing and then its use steadily declined. The vast majority of the subjects (94%) were positive about the usability of the platform. Only a minority of the subjects (27%) indicated that the platform had added value for them.\ud \ud Conclusion\ud The overall prospect was that an OCC-platform can contribute to the social participation and the self-management competencies of frail older adults, together with their social cohesion in the community. In order to validate these prospects, further research is needed on the characteristics and the impact of online platforms.

Objective: Consistent evidence on the effects of specialist services in the primary care setting is lacking. Therefore, this study evaluated the effects of an in-house internist at a GP practice on the number of referrals to specialist care in the hospital setting. Additionally, the involved GPs and internist were asked to share their experiences with the intervention.Design: A retrospective interrupted times series study.Setting: Two multidisciplinary general practitioner (GP) practices.Intervention: An internist provided in-house patient consultations in two GP practices and participated in the multidisciplinary meetings.Subjects: The referral data extracted from the electronic medical record system of the GP practices, including all referral letters from the GPs to specialist care in the hospital setting.Main outcome measures: The number of referrals to internal medicine in the hospital setting. This study used an autoregressive integrated moving average model to estimate the effect of the intervention taking account of a time trend and autocorrelation among the observations, comparing the pre-intervention period with the intervention period.Results: It was found that the referrals to internal medicine did not statistically significant decrease during the intervention period.Conclusions: This small explorative study did not find any clues to support that an in-house internist at a primary care setting results in a decrease of referrals to internal medicine in the hospital setting.Key points:An in-house internist at a primary care setting did not result in a significant decrease of referrals to specialist care in the hospital setting. The GPs and internist experience a learning-effect, i.e. an increase of knowledge about internal medicine issues.

Introduction: Population health Management (PM) initiatives are introduced to transform healthcare by integrating multiple care domains and addressing the continuum of health and well-being of a population. Insight is required into a population’s health and population health differences to evaluate and tailor these initiatives. This creates a demand for usable and accurate instruments for measuring population health and variations in population health between PM initiatives. This study aims to determine the usability of commonly used instruments for measuring population health and assesses population health differences between nine Dutch PM initiatives and the impact of demographic, personal and lifestyle factors. Method: In nine Dutch PM initiatives a population health survey was administered covering the Short Form 12 version 2 (SF12, physical and mental health status), Kessler 10 (K10) and Patient Activation Measure 13 (PAM13), as well as demographic, personal and lifestyle factors. The performance within a general population was assessed for the SF12, PAM13 and K10 instruments using descriptive and (confirmatory and exploratory) factor analyses as well as discriminant and reliability (Cronbach’s alpha) analyses. Subsequently, the impact of differences in demographic, personal and lifestyle factors on differences in population health were studied using multiple regression analyses. Results: The SF12 and PAM13 sum scores showed acceptable averages and distributions, while the results of the K10 indicated a floor effect. Construct validity was supported for the SF12 and K10, but was disproven for the PAM13. Reliability was good for all instruments. Consequently, age, education, origin, employment, Body Mass Index and smoking were identified as confounders for the studied nine PM initiatives. These confounders explained the differences found in PAM13 scores. However, not all health differences between PM initiatives were explained, as the SF12 outcomes still differed between PM initiatives once controlled. Conclusions: The SF12 and the PAM13 combined with demographic, personal and lifestyle characteristics can be used to measure the physical, mental, lifestyle and self-management constructs of population health. The K10 proved to be less useful for measuring a population’s health, due to a lack of dispersion in scores. Differences in population health found by these instruments, corrected for demographic and lifestyle factors, can be used to tailor initiatives by focusing interventions on variables that are shown to affect the health of their population. Additionally,results indicate that health is affected by variables not measured by this study, as not all variation in population health between PM initiatives was explained. Efforts should be made to seek out these influencers. Suggestions for future research: Future research should develop and study instruments that cover constructs of health introduced by recent definitions of health, such as participation and ‘positive health’. Other factors beyond healthcare, e.g. air quality, should be considered to further refine PM initiatives’ tailoring and evaluation.

Older people prefer to stay independent and active in their own environment. Information and communication technology can support them in accomplishing these goals. This is challenging though, as many are not familiar with technology. We introduced a community ICT platform in Heerlen, a city with a highly ageing population, in close collaboration with older persons and active citizens. By means of simple and clear apps, the platform offers a market place for mutual services, community information, access to professional services, and possibilities to set up new community activities. A process evaluation is conducted to study the use of and experiences with the platform. In addition, the platform’s impact on independent functioning, social contacts and involvement in community activities is studied in 150 users over a 12 months period. We will report data over the first 4 months and discuss the role of such platforms in future care and support models.

Rationale, aims and objectiveSubstituting outpatient hospital care with primary care is seen as a solution to decrease unnecessary referrals to outpatient hospital care and decrease rising healthcare costs. This systematic review aimed to evaluate the effects on quality of care, health and costs outcomes of substituting outpatient hospital care with primary care-based interventions, which are performed by medical specialists in face-to-face consultations in a primary care setting.MethodThe systematic review was performed using the PICO framework. Original papers in which the premise of the intervention was to substitute outpatient hospital care with primary care through the involvement of a medical specialist in a primary care setting were eligible.ResultsA total of 14 papers were included. A substitution intervention in general practitioner (GP) practices was described in 11 papers, three described a joint consultation intervention in which GPs see patients together with a medical specialist. This study showed that substitution initiatives result mostly in favourable outcomes compared to outpatient hospital care. The initiatives resulted mostly in shorter waiting lists, shorter clinic waiting times and higher patient satisfaction. Costs for treating one extra patient seemed to be higher in the intervention settings. This was mainly caused by inefficient planning of consultation hours and lower patient numbers.ConclusionsDespite the fact that internationally a lot has been written about the importance of performing substitution interventions in which preventing unnecessary referrals to outpatient hospital care was the aim, only 14 papers were included. Future systematic reviews should focus on the effects on the Triple Aim of substitution initiatives in which other healthcare professions than medical specialists are involved along with new technologies, such as e-consults. Additionally, to gain more insight into the effects of substitution initiatives operating in a dynamic healthcare context, it is important to keep evaluating the interventions in a longitudinal study design.

Background The system informs the nurse about levels of physical activity in the daily living of patients who are using the It’s LiFe! tool. The tool consists of an accelerometer that transfers data to a smartphone, which is subsequently connected to a server. Nurses can monitor patients’ physical activity via a secured website. Physical activity levels are measured in minutes per day compared with pre-set activity goals, which are set in dialogue with the patient.Objective To examine user requirements and to evaluate the usability of the secured website, in order to increase the probability of effective use by nurses.Method The needs and preferences of nurses towards the system were determined through qualitative research. The usability of the system was evaluated in a laboratory situation and during a three-month pilot study.Results A monitoring and feedback system to support patients in their intention to be more active was developed in a systematic way. Automatically generated feedback messages were defined based on the requirements of nurses. The results from the usability tests gave insights into how to improve the structure and quality of the information provided. Nurses were positive about the features and ease of use of the system, but made critical remarks about the time that its use entails.Conclusion The system supports nurses when performing physical activity counselling in a structured and profound way. The opportunity to support self-management of patients in between regular consultations needs further investigation, and adaptation into the clinical workflow of the nurses.

Background In an attempt to deal with the pressures on the health-care system and to guarantee sustainability, changes are needed. This study focuses on a cardiology primary care plus intervention. Primary care plus (PC+) is a new health-care delivery model focused on substitution of specialist care in the hospital setting with specialist care in the primary care setting. The intervention consists of a cardiology PC+ centre in which cardiologists, supported by other health-care professionals, provide consultations in a primary care setting. The PC+ centre aims to improve the health of the population and quality of care as experienced by patients, and reduce the number of referrals to hospital-based outpatient specialist care in order to reduce health-care costs. These aims reflect the Triple Aim principle. Hence, the objectives of the study are to evaluate the cardiology PC+ centre in terms of the Triple Aim outcomes and to evaluate the process of the introduction of PC+. Methods/Design The study is a practice-based, quantitative study with a longitudinal observational design, and an additional qualitative study to supplement, interpret and improve the quantitative study. The study population of the quantitative part will consist of adult patients (≥18 years) with non-acute and low-complexity cardiology-related health complaints, who will be referred to the cardiology PC+ centre (intervention group) or hospital-based outpatient cardiology care (control group). All eligible patients will be asked to complete questionnaires at three different time points consisting of questions about their demographics, health status and experience of care. Additionally, quantitative data will be collected about health-care utilization and related health-care costs at the PC+ centre and the hospital. The qualitative part, consisting of semi-structured interviews, focus groups, and observations, is designed to evaluate the process as well as to amplify, clarify and explain quantitative results. Conclusions This study will evaluate a cardiology PC+ centre using quantitative and supplementary qualitative methods. The findings of both sub-studies will fill a gap in knowledge about the effects of PC+ and in particular whether PC+ is able to pursue the Triple Aim outcomes. Trial registration NTR6629 (Data registered: 25-08-2017) (registered retrospectively). Electronic supplementary material The online version of this article (10.1186/s12913-017-2580-x) contains supplementary material, which is available to authorized users.

A B S T R A C T Purpose of the study: Falls are frequent in LTC, with considerable health consequences. This study explores the relationship between malnutrition, activity, and falls in Dutch LTC residents and the influence of nutritional intervention on this relationship. Design and methods: A secondary data analysis of a cross-sectional, multi-center point prevalence and incidence measurement. Setting: 81 LTC settings in The Netherlands. Participants: 6.701 LTC residents aged 65 and older; mean age 84; 70% female. Prevalence measurements of nutritional status and activity, and a 30 days incidence measurement of falls. Results: Of all participating residents, 9.8% sustained at least one fall, and 22.8% was malnourished. Malnourished residents were more often a faller (odd ratio (OR) 1.78; p < 0.01) and inactive (OR 1.7, p < 0.01) than non-malnourished residents. Multivariate analysis confirmed the relation between malnutrition and fallers, without interference of activity. In the malnourished group with nutritional intervention, the percentage of fallers was lower than in the malnourished group without nutritional intervention (OR 0.738; p = 0.056). Implications: Malnutrition is associated with an increased risk of being a faller and with impaired activity in Dutch LTC residents. Malnourished residents who receive nutritional intervention have a lower risk of being a faller. 2012 Elsevier Ireland Ltd.

Background/Objectives: Our objective was to investigate effects of an oral nutritional supplement containing n-3 polyunsaturated fatty acids (FAs) on quality of life, performance status, handgrip strength and physical activity in patients with non-small cell lung cancer (NSCLC) undergoing multimodality treatment. Subjects/Methods: In a double-blind experiment, 40 patients with stage III NSCLC were randomised to receive 2 cans/day of a protein- and energy-dense oral nutritional supplement containing n-3 polyunsaturated FAs (2.02 g eicosapentaenoic acid+0.92 g docosahexaenoic acid/day) or an isocaloric control supplement, during multimodality treatment. Quality of life, Karnofsky Performance Status, handgrip strength and physical activity (by wearing an accelerometer) were assessed. Effects of intervention were analysed by generalised estimating equations. P-values

Methylation-mediated silencing of the tumour suppressor CADM1 has been functionally linked to lung cancer development. We aimed to determine whether CADM1 promoter methylation is a candidate early detection marker for lung cancer. To this end frozen tissue samples of 36 non-small cell lung cancers, 26 corresponding tumour distant normal tissue samples as well as 6 samples of normal lung from non-lung cancer patients were tested for DNA methylation at three different regions within the CADM1 promoter (M1, M5 and M9) using methylation specific PCR followed by methylation specific reverse line blot analysis.Sixty-four percentage of tumour samples tested positive at the M1 region, 47% at M5 and 74% at the M9 region, compared with 65% (M1), 23% (M5) and 46% (M9) of paired normal tissue samples. Methylation of each of these promoter regions was also detected in the majority of non-lung cancer control samples. Dense methylation, defined as methylation at ≥2 promoter regions, was detected in 66% of tumour samples compared with 38% of paired normal tissues and 67% of non-lung cancer control samples. Within the small subgroup of female patients dense methylation was found in all tumour samples but only 22% of paired normal samples. Neither methylation of individual sites nor dense methylation was correlated with disease free survival. In conclusion, CADM1 promoter methylation is a frequent event in NSCLC as well as normal lung, both of lung cancer and non-lung cancer patients. Hence, CADM1 methylation analysis is unlikely to have diagnostic value for the early detection of lung cancer in an unselected population. However, a diagnostic value for selected subjects, such as females, cannot be excluded.

Background: No previous studies have compared the effectiveness of different modalities of psychotherapeutic treatment, as defined by different settings and durations, for patients with cluster C personality disorders. The aim of this multicentre study was to compare the effectiveness of 5 treatment modalities for patients with cluster C personality disorders in terms of psychiatric symptoms, psychosocial functioning, and quality of life. The following treatment modalities were compared: long-term outpatient (more than 6 months), short-term day hospital (up to 6 months), long-term day hospital, short-term inpatient, and long-term inpatient psychotherapy. Methods: The study was conducted between March 2003 and June 2008 in 6 mental health care centres in the Netherlands, with a sample of 371 patients with a DSM-IV-TR axis-II cluster C diagnosis. Patients were assigned to 5 different modalities of psychotherapeutic treatment, and effectiveness was assessed at 12 months after baseline. An intention-to-treat analysis was conducted for psychiatric symptoms (Brief Symptom Inventory), psychosocial functioning (Outcome Questionnaire-45), and quality of life (EQ-5D), using multilevel statistical modelling. As the study was non-randomised, the propensity score method was used to control for initial differences. Results: Patients in all treatment groups had improved on all outcomes 12 months after baseline. Patients receiving short-term inpatient treatment showed more improvement than patients receiving other treatment modalities. Conclusions: Psychotherapeutic treatment, especially in the short-term inpatient modality, is an effective treatment for patients with cluster C personality disorders.

During acute myocardial infarction (AMI), ischemia leads to necrotic areas surrounded by border zones of reversibly damaged cardiomyocytes, showing membrane flip-flop. During reperfusion type IIA secretory phopholipase A(2) (sPLA(2)-IIA) induces direct cell-toxicity and facilitates binding of other inflammatory mediators on these cardiomyocytes. Therefore, we hypothesized that the specific sPLA(2)-IIA-inhibitor PX-18 would reduce cardiomyocyte death and infarct size in vivo. Wistar rats were treated with PX-18 starting minutes after reperfusion, and at day 1 and 2 post AMI. After 28 days hearts were analyzed. Furthermore, the effect of PX-18 on membrane flip-flop and apoptosis was investigated in vitro. PX-18 significantly inhibited sPLA(2)-IIA activity and reduced infarct size (reduction 73 +/- 9%, P0.05), compared to the vehicle-treated group, without impairing wound healing. In vitro, PX-18 significantly reduced reversible membrane flip-flop and apoptosis in cardiomyocytes. However, no sPLA(2)-IIA activity could be detected, suggesting that PX-18 also exerted a protective effect independent of sPLA(2)-IIA. In conclusion, PX-18 is a potent therapeutic to reduce infarct size by inhibiting sPLA(2)-IIA, and possibly also by inhibiting apoptosis of cardiomyocytes in a sPLA(2)-IIA independent manner.

Positron emission tomography (PET) using (18)F-3'-deoxy-3'-fluorothymidine ([(18)F]FLT) allows noninvasive monitoring of tumour proliferation. For serial imaging in individual patients, good reproducibility is essential. The purpose of the present study was to evaluate the reproducibility of quantitative [(18)F]FLT measurements.Nine patients with non-small-cell lung cancer (NSCLC) and six with head-and-neck cancer (HNC) underwent [(18)F]FLT PET twice within 7 days prior to therapy. The maximum pixel value (SUV(max)) and a threshold defined volume (SUV(41%)) were defined for all delineated lesions. The plasma to tumour transfer constant (K(i)) was estimated using both Patlak graphical analysis and nonlinear regression (NLR). NLR was also used to estimate k(3), which, at least in theory, selectively reflects thymidine kinase 1 activity. The level of agreement between test and retest values was assessed using the intraclass correlation coefficient (ICC) and Bland-Altman analysis.All primary tumours and90% of clinically suspected locoregional metastases could be delineated. In total, 24 lesions were defined. NLR-derived K(i), Patlak-derived K(i), SUV(41%) and SUV(max) showed excellent reproducibility with ICCs of 0.92, 0.95, 0.98 and 0.93, and SDs of 16%, 12%, 7% and 11%, respectively. Reproducibility was poor for k(3) with an ICC of 0.43 and SD of 38%.Quantitative [(18)F]FLT measurements are reproducible in both NSCLC and HNC patients. When monitoring response in individual patients, changes of more than 15% in SUV(41%), 20-25% in SUV(max) and Patlak-derived K(i), and 32% in NLR3k-derived K(i) are likely to represent treatment effects.

Background: Randomized controlled trials are considered the best scientific proof of effectiveness. There is increasing concern, though, about their feasibility in psychotherapy research. We discuss a quasi-experimental study design for situations in which a randomized controlled trial is not feasible. Here, as an alternative strategy, the propensity score (PS) method is used to correct for selection bias. Methods: We used data from a Dutch research project, SCEPTRE (Study on Cost-Effectiveness of Personality Disorder Treatment). The sample consisted of 749 psychotherapy patients with personality pathology. We tested whether the PS method was useful and applicable. We examined differences between 2 treatment groups (short vs. long treatment duration) in pretreatment characteristics before and after PS correction. This revealed the impact of the PS on outcome differences. Results: The PS offered statistical control over observed pretreatment differences between patients in a non-randomized study. Conclusions: When a randomized controlled trial is not possible, this quasi-experimental design using the PS could be a feasible alternative. Its advantages and limitations are discussed. Implemented carefully, this method is promising for future effectiveness research.

PET and 15O-labeled water (H2 15 O) can be used to noninvasively monitor tumor perfusion. This allows evaluation of the direct target of antiangiogenic drugs, that is, tumor vasculature. Because these drugs often result in consolidation rather than regression of the tumor mass, a change in perfusion might be a more sensitive way to evaluate response than are indirect size measures on a CT scan. However, to use the technique for serial imaging of individual patients, good reproducibility is essential. The purpose of the present study was to evaluate the reproducibility of quantitative H2 15 O measurements.Methods: Nine patients with non– small-cell lung cancer (NSCLC) were scanned twice within 7 d and before any therapy. All H2 15 O scans were followed by an 18 F-fluorothymidine scan to allow for adequate volume-of-interest (VOI) definition. VOIs were defined using a 3-dimensional threshold technique. Tumor perfusion and the volume of distribution (VT) were obtained using a 1-tissue-compartment model including an arterial blood volume component and an image-derived input function. The level of agreement between test and retest values was assessed using the intraclass correlation coefficient (ICC) and Bland–Altman analyses. Possible dependency on absolute values and lesion size was assessed by linear regression. Results: All primary tumors and more than 90% of clinically suspected locoregional metastases could be delineated. In total, 14 lesions in 9 patients were analyzed. Tumor perfusion showed excellent reproducibility, with an ICC of 0.95 and SD of 9%. The VT was only moderately reproducible, with an ICC of 0.52 and SD of 16%. No dependency was found on absolute values of perfusion (P 5 0.14) and VT (P 5 0.15). In addition, tumor volume did not influence the reproducibility of perfusion (P 5 0.46) and VT (P 5 0.25). Conclusion: Quantitative measurements of tumor perfusion using H2 15 O and PET are reproducible in NSCLC. When patients are repeatedly being scanned during therapy, changes of more than 18% in tumor perfusion and 32% in VT (.1.96 · SD)

Objective: To analyse barriers and facilitators in substituting hospital care with primary care to define preconditions for successful implementation. Methods: A descriptive feasibility study was performed to collect information on the feasibility of substituting hospital care with primary care. General practitioners were able to refer patients, about whom they had doubts regarding diagnosis, treatment and/or the need to refer to hospital care, to medical specialists who performed low-complex consultations at general practitioner practices. Qualitative data were collected through interviews with general practitioners and medical specialists, focus groups and notes from meetings in the Netherlands between April 2013 and January 2014. Data were analysed using a conventional content analysis which resulted in categorised barriers, facilitators and policy adjustments, after which preconditions were formulated. Results: The most important preconditions were make arrangements on governmental level, arrange a collective integrated IT-system, determine the appropriate profile for medical specialists, design a referral protocol for eligible patients, arrange deliberation possibilities for general practitioners and medical specialists and formulate a diagnostic protocol. Conclusions: The barriers, facilitators and formulated preconditions provided relevant input to change the design of substituting hospital care with primary care.

Purpose: Cardiovascular magnetic resonance (CMR) is considered the standard imaging modality in clinical trials to monitor patients after acute myocardial infarction (AMI). However, limited data is available with respect to infarct size, presence, and extent of microvascular injury (MVO), and changes over time, in relation to cardiac function in these optimally treated patients. In this study, we prospectively investigate the change of infarct size over time, and the incidence and significance of MVO in a uniform, optimally treated patient group after AMI. Methods: Forty patients underwent cine and late gadolinium-enhanced CMR within 9 days and at 4 months after primary stenting. Left ventricular ejection fraction (LVEF), infarct size (IS) and MVO size were calculated. Results: IS decreased with 19.0% at follow-up (p < 0.01). The 23 (57.5%) patients with MVO had larger infarct size, higher left ventricular volumes and lower LVEF and more involution of IS at follow-up. Overall, LVEF improved from 42.3 ± 9.8% to 44.0 ± 9.8% (p = 0.06), irrespective of presence or size of MVO. Conclusion: Infarct size reduces over time by 19.0% in optimally treated patients after AMI. Despite optimal reperfusion, MVO was found in the majority of patients. Although patients with MVO had larger infarcts and worse indices of left ventricular remodelling, functional change at follow-up was comparable to patients without MVO.

AIMS: This study investigated the relationship between right ventricular (RV) structure and function and survival in idiopathic pulmonary arterial hypertension (IPAH).METHODS AND RESULTS: In 64 patients, cardiac magnetic resonance, right heart catheterization, and the six-minute walk test (6MWT) were performed at baseline and after 1-year follow-up. RV structure and function were analysed as predictors of mortality. During a mean follow-up of 32 months, 19 patients died. A low stroke volume (SV), RV dilatation, and impaired left ventricular (LV) filling independently predicted mortality. In addition, a further decrease in SV, progressive RV dilatation, and further decrease in LV end-diastolic volume (LVEDV) at 1-year follow-up were the strongest predictors of mortality. According to Kaplan-Meier survival curves, survival was lower in patients with an inframedian SV index or= 84 mL/m(2), and an inframedian LVEDVCONCLUSIONS: The RV contains prognostic information in IPAH. A large RV volume, low SV, and a reduced LV volume are strong independent predictors of mortality and treatment failure.

Contains fulltext : 152403.pdf (Publisher’s version ) (Open Access) BACKGROUND: Physical inactivity is a major public health problem. The It's LiFe! monitoring and feedback tool embedded in the Self-Management Support Program (SSP) is an attempt to stimulate physical activity in people with chronic obstructive pulmonary disease or type 2 diabetes treated in primary care. OBJECTIVE: Our aim was to evaluate whether the SSP combined with the use of the monitoring and feedback tool leads to more physical activity compared to usual care and to evaluate the additional effect of using this tool on top of the SSP. METHODS: This was a three-armed cluster randomised controlled trial. Twenty four family practices were randomly assigned to one of three groups in which participants received the tool + SSP (group 1), the SSP (group 2), or care as usual (group 3). The primary outcome measure was minutes of physical activity per day. The secondary outcomes were general and exercise self-efficacy and quality of life. Outcomes were measured at baseline after the intervention (4-6 months), and 3 months thereafter. RESULTS: The group that received the entire intervention (tool + SSP) showed more physical activity directly after the intervention than Group 3 (mean difference 11.73, 95% CI 6.21-17.25; P

Background: There are indications that older adults who suffer from poor balance have an increased risk for adverse health outcomes, such as falls and disability. Monitoring the development of balance over time enables early detection of balance decline, which can identify older adults who could benefit from interventions aimed at prevention of these adverse outcomes. An innovative and easy-to-use device that can be used by older adults for home-based monitoring of balance is a modified bathroom scale. Objective: The objective of this paper is to study the relationship between balance scores obtained with a modified bathroom scale and falls and disability in a sample of older adults. Methods: For this 6-month follow-up study, participants were recruited via physiotherapists working in a nursing home, geriatricians, exercise classes, and at an event about health for older adults. Inclusion criteria were being aged 65 years or older, being able to stand on a bathroom scale independently, and able to provide informed consent. A total of 41 nursing home patients and 139 community-dwelling older adults stepped onto the modified bathroom scale three consecutive times at baseline to measure their balance. Their mean balance scores on a scale from 0 to 16 were calculated—higher scores indicated better balance. Questionnaires were used to study falls and disability at baseline and after 6 months of follow-up. The cross-sectional relationship between balance and falls and disability at baseline was studied using t tests and Spearman rank correlations. Univariate and multivariate logistic regression analyses were conducted to study the relationship between balance measured at baseline and falls and disability development after 6 months of follow-up. Results: A total of 128 participants with complete datasets—25.8% (33/128) male—and a mean age of 75.33 years (SD 6.26) were included in the analyses of this study. Balance scores of participants who reported at baseline that they had fallen at least once in the past 6 months were lower compared to nonfallers—8.9 and 11.2, respectively ( P

BACKGROUND: During haemodialysis (HD), polymorphonuclear cells (PMNs) and platelets are activated and release various granule products, including myeloperoxidase (MPO) and platelet factor 4 (PF4). MPO triggers the generation of reactive oxygen species, leading to irreversible protein, carbohydrate and lipid modification. PF4 probably also contributes to oxidative stress. As previously shown, HD-induced PMN degranulation is almost completely abolished during citrate anticoagulation, most probably due to its calcium chelation ability.METHODS: In the present study, apart from HD-induced PMN and platelet degranulation, oxidative stress was analysed during three modes of anticoagulation. Heparin, dalteparin and citrate (HDhep, HDdal and HDcit) were compared in a randomized, crossover fashion in eight chronic HD patients. Multiple blood samples were taken during the third HD session of each modality, from both the afferent and efferent line. Besides the degranulation markers MPO and PF4, various markers of oxidative stress were measured, including oxidized low-density lipoprotein (ox-LDL), malondialdehyde (MDA) and carboxymethyllysine (CML).RESULTS: During HDhep and HDdal, marked degranulation was observed shortly after the start of HD. In contrast, during HDcit, PF4 and MPO levels remained unaltered, suggesting no release at all. After 1 week of HDcit, ox-LDL levels were markedly reduced [median 26% (3-65%), P=0.01], if compared with HDhep and HDdal. As regards MDA and CML, no differences were found.CONCLUSIONS: This study shows first, that HD-induced PMN and platelet degranulation are early, most probably calcium-dependent processes and, secondly, that the formation of ox-LDL is clearly dependent on the type of anticoagulant applied.

Introduction: Health care delivery models should change to keep health care affordable, accessible and of high quality (1). In the Netherlands, a considerable number of reforms and interventions are focused on limiting volume growth of expensive hospital care by stimulating substitution of care (2, 3). This study focuses on a cardiology primary care plus (PC+) centre where cardiologists provide specialist consultations in a primary care setting. PC+ interventions intend to support GPs in gatekeeping and treating patients by intensifying and strengthening collaboration and communication between GPs and specialists. Additionally, PC+ aims to improve the health of the population and patients’ experience of care while reducing the health care costs by decreasing the number of (unnecessary) referrals to specialist care in the hospital setting (4).Aims: The objective of the study is to evaluate the effects of the cardiology PC+ centre on population health, experience of care and health care costs.Methods: The study is a practice-based, mixed-methods research involving a qualitative evaluation and a quantitative longitudinal observational study. The study population consists of adult patients with non-acute and low-complexity cardiology-related health complaints, who will be referred to the cardiology PC+ centre (intervention group) or hospital-based outpatient cardiology care (control group). All eligible patients will be asked to complete questionnaires at three different time points (before consultation, directly after consultation, three months after consultation) consisting of items about their demographics, health status (SF-12, EQ-5D-5L and EQ-VAS) and experience of care (based on the Consumer Quality Index). In addition, data will be collected about health care utilization and related medical spending.Results: Preliminary results are available. At the moment, 437 intervention patients and154 control patients are included. The results show no differences in health status between the groups on the EQ-VAS (F = 1.372; P = 0.242). In 25 out of 27 items the patient experience of care is rated significantly higher for PC+ compared to hospital care. The average grade for the patient experience on the provided care differs significantly between the groups (PC+ 9.04 ±0.945 vs. hospital care 7.89 ±1.025; P