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Background: Patient participation is fundamental in nursing care and has yielded benefits for patient outcomes. However, despite their compassionate care approach, nurses do not always incorporate patients' needs and wish into evidence‐based practice, quality improvement or learning activities. Therefore, a shift to continuous quality improvement based on evidence‐based practice is necessary to enhance the quality of care. The patient's opinion is an essential part of this process. To establish a more sustainable learning culture for evidence‐based quality improvement, it is crucial that nurses learn alongside their patients. However, to promote this, nurses require a deeper understanding of patients' care preferences. Objective: To explore patients' needs and wishes towards being involved in care processes that nurses can use in developing an evidence‐based quality improvement learning culture. Methods: A qualitative study was conducted in two hospital departments and one community care team. In total, 18 patients were purposefully selected for individual semi‐structured interviews with an average of 15 min. A framework analysis based on the fundamental of care framework was utilised to analyse the data deductively. In addition, inductive codes were added to patients' experiences beyond the framework. For reporting this study, the SRQR guideline was used. Results: Participants needed a compassionate nurse who established and sustained a trusting relationship. They wanted nurses to be present and actively involved during the care delivery. Shared decision‐making improved when nurses offered fair, clear and tailored information. Mistrust or a disrupted nurse–patient relationship was found to be time‐consuming and challenging to restore. Conclusions: Results confirmed the importance of a durable nurse–patient relationship and showed the consequences of nurses' communication on shared decision‐making. Insights into patients' care preferences are essential to stimulate the development of an evidence‐based quality improvement learning culture within nursing teams and for successful implementation processes. [ABSTRACT FROM AUTHOR]

Aim: An increasing number of centers have implemented a robotic surgical program for rectal cancer. Several randomized controls trials have shown similar oncological and postoperative outcomes compared to standard laparoscopic resections. While introducing a robot rectal resection program seems safe, there are no data regarding implementation on a nationwide scale. Since 2018 robot resections are separately registered in the mandatory Dutch Colorectal Audit. The present study aims to evaluate the trend in the implementation of robotic resections (RR) for rectal cancer relative to laparoscopic rectal resections (LRR) in the Netherlands between 2018 and 2020 and to compare the differences in outcomes between the operative approaches. Methods: Patients with rectal cancer who underwent surgical resection between 2018 and 2020 were selected from the Dutch Colorectal Audit. The data included patient characteristics, disease characteristics, surgical procedure details, postoperative outcomes. The outcomes included any complication within 90 days after surgery; data were categorized according to surgical approach. Results: Between 2018 and 2020, 6330 patients were included in the analyses. 1146 patients underwent a RR (18%), 3312 patients a LRR (51%), 526 (8%) an open rectal resection, 641 a TaTME (10%), and 705 had a local resection (11%). The proportion of males and distal tumors was higher in the RR compared to the LRR. Over time, the proportion of robotic procedures increased from 15% (95% confidence intervals (CI) 13–16%) in 2018 to 22% (95% CI 20–24%) in 2020. Conversion rate was lower in the robotic group [4% (95% CI 3–5%) versus 7% (95% CI 6–8%)]. Anastomotic leakage rate was similar with 16%. Defunctioning ileostomies were more common in the RR group [42% (95% CI 38–46%) versus 29% (95% CI 26–31%)]. Conclusion: Rectal resections are increasingly being performed through a robot-assisted approach in the Netherlands. The proportion of males and low rectal cancers was higher in RR compared to LRR. Overall outcomes were comparable, while conversion rate was lower in RR, the proportion of defunctioning ileostomies was higher compared to LRR. [ABSTRACT FROM AUTHOR]

The content of supervised group exercise (SGE) for axial spondyloarthritis (axSpA) has hardly changed in recent decades, despite new evidence-based insights to improve SGE quality. This pilot implementation study evaluated the effects and feasibility of enhancements in axSpA-specific SGE in four regions in the Netherlands. The implemented enhancements included: more high-intensity aerobic exercise; exercise personalization with periodic assessments; and patient education on home exercise. The implementation strategy included a one-day supervisor training course and telephone support. To evaluate effects, aerobic capacity [Six-Minute Walk Test (6MWT)], physical functioning [Ankylosing Spondylitis Performance-based Improvement (ASPI); improved/not improved], health status [Assessment of SpondyloArthritis international Society Health Index (ASAS HI) questionnaire], and home exercise engagement [Short QUestionnaire to ASsess Health-enhancing physical activity (SQUASH)] were assessed at baseline and after one year in 60 participants. Changes were analysed with the Wilcoxon signed-rank test. To evaluate feasibility, a survey of participants and semi-structured interviews with four SGE supervisors assessed uptake and satisfaction with the enhancements. Aerobic capacity increased significantly and 35% of participants improved functioning, whereas health status and home exercise engagement did not change. The participants' survey and supervisors' interviews showed that high-intensity aerobic exercise was implemented successfully, exercise personalization and periodic assessments were implemented partially, and patient education was not implemented at all. Most participants were satisfied with the changes. After this pilot implementation, SGE enhancements were only partially implemented. Nevertheless, aerobic capacity improved significantly and satisfaction with accomplished changes was high. Nationwide implementation would require adaptations to improve feasibility. [ABSTRACT FROM AUTHOR]

Background: Tachypnoea in acutely ill patients can be an early sign of a life-threatening condition such as sepsis. Routine measurement of the respiratory rate by GPs might improve the recognition of sepsis. Aim: To assess the accuracy and feasibility of respiratory rate measurements by GPs. Design & setting: Observational cross-sectional mixed-methods study in the setting of out-of-hours (OOH) home visits at three GP cooperatives in The Netherlands. Method: GPs were observed during the assessment of acutely ill patients, and semi-structured interviews were performed. The GP-assessed respiratory rate was compared with a reference measurement. In the event that the respiratory rate was not counted, GPs were asked to estimate the rate (dichotomised as ≥22 breaths per minute or <22 breaths per minute). Results: Observations of 130 acutely ill patients were included, and 14 GPs were interviewed. In 33 patients (25%), the GP counted the respiratory rate. A mean difference of 0.27 breaths per minute (95% confidence interval [CI] = -5.7 to 6.3) with the reference measurement was found. At a cut-off point of ≥22 breaths per minute, a sensitivity of 86% (95% CI = 57% to 98%) was found when the GP counted the rate, and a sensitivity of 43% (95% CI = 22% to 66%) when GPs estimated respiratory rates. GPs reported both medical and practical reasons for not routinely measuring the respiratory rate. Conclusion: GPs are aware of the importance of assessing the respiratory rate of acutely ill adult patients, and counted measurements are accurate. However, in most patients the respiratory rate was not counted, and the rate was often underestimated when estimated. [ABSTRACT FROM AUTHOR]

Organ preserving treatment strategies and the introduction of a colorectal cancer-screening program have likely influenced the resection rates of rectal cancer. The aim of this study is to assess the influence of these developments on rectal cancer treatment and resection rates in the Netherlands. Patients diagnosed with non-metastatic rectal cancer between 2013 and 2018, were selected from the Netherlands Cancer Registry. The distribution of surgical and neo-adjuvant treatment and resection rates were analyzed and compared over time. Between 2013 and 2018 22640 patients were diagnosed with non-metastatic rectal cancer. The incidence of early stage (cT1) disease increased from 141 (4%) in 2013 to 448 (12%) in 2018. The use of neoadjuvant radiotherapy and chemo-radiotherapy dropped from 39% to 21% and 34%–25%, respectively. A decrease in surgical resection rates (including TEM) was observed from 85% to 73%. The proportion of patients who underwent endoscopic resections increased from 3% to 10%. The decrease in surgical resection rates was larger in patients treated with neo-adjuvant chemo-radiotherapy. An increase in stage I disease is noted after the introduction of the screening program. Surgical resection rates for rectal cancer have fallen over time. Endoscopic resections due to more early-stage disease probably accounts for a large part of this decline. Furthermore, a watch and wait approach after neo-adjuvant chemo-radiotherapy may play an important role as well. [ABSTRACT FROM AUTHOR]

This study investigates how an auto-forward design, where respondents navigate through a web survey automatically, affects response times and navigation behavior in a long mixed-device web survey. We embedded an experiment in a health survey administered to the general population in The Netherlands to test the auto-forward design against a manual-forward design. Analyses are based on detailed paradata that keep track of the respondents' behavior in navigating the survey. We find that an auto-forward design decreases completion times and that questions on pages with automated navigation are answered significantly faster compared to questions on pages with manual navigation. However, we also find that respondents use the navigation buttons more in the auto-forward condition compared to the manual-forward condition, largely canceling out the reduction in survey duration. Furthermore, we also find that the answer options 'I don't know' and 'I rather not say' are used just as often in the auto-forward condition as in the manual-forward condition, indicating no differences in satisficing behavior. We conclude that auto-forwarding can be used to reduce completing times, but we also advice to carefully consider mixing manual and auto-forwarding within a survey. [ABSTRACT FROM AUTHOR]

Objective: To provide a comprehensive, evidence-based overview of the risk factors, prevention, diagnosis, imaging, treatment and prognosis for Achilles tendinopathy. To make clinical recommendations for healthcare practitioners and patients.Design: Comprehensive multidisciplinary guideline process funded by the Quality Foundation of the Dutch Federation of Medical Specialists. This process included a development, commentary and authorisation phase. Patients participated in every phase.Data Sources: Multiple databases and existing guidelines were searched up to May 2019. Information from patients, healthcare providers and other stakeholders were obtained using a digital questionnaire, focus group interview and invitational conference.Study Eligibility Criteria: Studies on both insertional and/or midportion Achilles tendinopathy were eligible. Specific eligibility criteria were described per module.Data Extraction and Synthesis: To appraise the certainty of evidence, reviewers extracted data, assessed risk of bias and used the Grading of Recommendations Assessment, Development and Evaluation method, where applicable. Important considerations were: patient values and preferences, costs, acceptability of other stakeholders and feasibility of implementation. Recommendations were made based on the results of the evidence from the literature and the considerations.Primary Outcome Measure: The primary and secondary outcome measures were defined per module and defined based on the input of patients obtained in collaboration with the Netherlands Patient Federation and healthcare providers from different professions.Results: Six specific modules were completed: risk factors and primary prevention, diagnosis, imaging, treatment prognosis and secondary prevention for Achilles tendinopathy.Summary/conclusion: Our Dutch multidisciplinary guideline on Achilles tendinopathy provides six modules developed according to the standards of the Dutch Federation of Medical Specialists. Evidence-based recommendations for clinical practice are given for risk factors, prevention, diagnosis, imaging, treatment and prognosis. This guideline can assist healthcare providers and patients in clinical practice. [ABSTRACT FROM AUTHOR]

Numerous quality improvement initiatives for rectal cancer surgery have focused on textbook outcome parameters. In these studies, resection rate and patients who did not undergo surgery are not included, but these parameters might help to evaluate the surgical care for rectal cancer. The aim of this study is to assess the variation of non-metastatic rectal cancer resection rates among hospitals and its effect on patient outcomes. All patients diagnosed with non-metastatic rectal cancer between 2013 and 2018 were selected from the Netherlands Cancer Registry. Hospitals were categorized in quartiles according to resection rates. A multivariable logistic analysis was performed to determine variation in resection rate between these quartiles using a logistic regression analysis to correct for confounders. The association between resection rates and survival was analyzed using Kaplan-Meier method and Cox-regression analysis. A total of 22,530 patients were included in the analysis. Resection rates varied from 68 to 89% between hospitals. After multivariable analysis, resection rate remained significantly different among the quartiles when correcting for several factors (odds ratio (95%Confidence-interval) 1.71 (1.56–1.88), 2.42 (2.19–2.67), and 4.04 (3.61–4.53) for increasing resection rate quartiles, in reference to the lowest quartile). A higher resection rate was associated with better overall survival, in multivariable analysis this survival benefit could no longer be identified. There is a substantial variation in resection rates for rectal cancer among hospitals in the Netherlands with an impact on overall survival. This may be a relevant issue when analyzing the overall quality of rectal cancer care. [ABSTRACT FROM AUTHOR]

Supervised group exercise (SGE) is recommended for people with axial spondyloarthritis (axSpA). Recent literature suggests that its contents and dosage must probably be revised. As a first step towards renewal, this study examined the current SGE organisation and content for people with axSpA in The Netherlands. A pen-and-paper survey was sent to the boards of the 82 local patient associations affiliated with the Dutch Arthritis Society in 2016. One member of each board was asked to complete questions on the nature and organisation of SGE and one of the supervising therapists to complete questions on the SGE supervision and contents. The questionnaire was returned by representatives of 67/82 (82%) local patient associations, of which 17 (25%) provided axSpA-specific SGE (16/17 SGE programmes with both land-based exercise and hydrotherapy and 1/17 with only hydrotherapy). These involved in total 56 groups with 684 participants and 59 supervisors, of whom 54 were physical therapists and 21 had had postgraduate education on rheumatic and musculoskeletal diseases (RMDs). Besides mobility and strengthening exercises and sports (17/17), most programmes included aerobic exercise (10/17), but rarely with heart rate monitoring (1/17), patient education (8/17), periodic assessments (2/17), or exercise personalisation (1/17). In the Netherlands, a quarter of local patient associations organised axSpA-specific SGE, mostly containing land-based exercises combined with sports and hydrotherapy. Most supervisors lacked postgraduate education on RMDs and most programmes lacked intensity monitoring, patient education, periodic assessments, and personalisation, which are needed for optimising exercise programmes according to current scientific insights. [ABSTRACT FROM AUTHOR]

Objective: To explore how nurses in hospitals enact person‐centred fundamental care delivery. Background: Effective person‐centred care is at the heart of fundamental nursing care, but it is deemed to be challenging in acute health care as there is a strong biomedical focus and most nurses are not trained in person‐centred fundamental care delivery. We therefore need to know if and how nurses currently incorporate a person‐centred approach during fundamental care. Design: Focused ethnography approach. Methods: Observations of 30 nurses on three different wards in two Dutch hospitals during their morning shift. Data were collected through passive observations and analysed using framework analysis based on the fundamentals of care framework. The COREQ guideline was used for reporting. Results: Some nurses successfully integrate physical, psychosocial and relational elements of care in patient interactions. However, most nurses were observed to be mainly focused on physical care and did not take the time at their patients' bedside to care for their psychosocial and relational needs. Many had a task‐focused way of working and communicating, seldom incorporating patients' needs and experiences or discussing care planning, and often disturbing each other. Conclusions: This study demonstrates that although some nurses manage to do so, person‐centred fundamental care delivery remains a challenge in hospitals, as most nurses have a task‐focused approach and therefore do not manage to integrate the physical, relational and physical elements of care. For further improvement, attention needs to be paid to integrated fundamental care and clinical reasoning skills. Relevance to clinical practice: Although most nurses have a compassionate approach, this study shows that nurses do not incorporate psychosocial care or encourage patient participation when helping patients with their physical fundamental care needs, even though there seems to be sufficient opportunity for them to do so. [ABSTRACT FROM AUTHOR]

Background: In the Netherlands, out-of-hours primary care is provided in general-practitioner-cooperatives (GPCs). These are increasingly located on site with emergency departments (ED), forming Emergency-Care-Access-Points (ECAP). A more efficient and economical organization of out-of-hours primary emergency care could be realized by increased collaboration at an ECAP. In this study, we compared the effects of different models with respect to access to (hospital) radiology by the GPC. We investigated patient and care characteristics, indication for diagnostics and outcomes at GPCs with and without access to radiology.Methods: A prospective observational record review study of patients referred for conventional radiology for trauma by one of five GPCs in the period April 2014-October 2015, covering three organizational models.Results: The mean age was 31 years and 56% was female. Extremities were predominately involved (91%). There was a medical indication for radiology in 85% and the assessed risk by requesting GPs on abnormalities was high in 66%. There was a significant difference in outcomes between models. Radiological abnormalities (fractures/luxations) were present in 51% without direct access and in 35% with partial and unlimited access. Overall, 61% of the included patients were referred to the ED; 100% in the models without access and 38% in the models with (partial) access.Conclusions: GPC access to radiology is beneficial for patients and professionals. The diagnostics were adequately used. With access to radiology, unnecessary referrals and specialist care are prevented. This may lead to a decrease in ED attendance and overcrowding. [ABSTRACT FROM AUTHOR]

Hospital of diagnosis is shown to have an impact on the probability of undergoing a resection in different types of gastrointestinal cancer. The aim of this study was to investigate the inter-hospital variation in resection rates and its impact on survival among patients with non-metastatic colon cancer. All patients diagnosed with non-metastatic colon cancer between 2009 and 2014 were selected from the Netherlands Cancer Registry. Multilevel logistic regression was used to examine the variation in resection rates among hospitals. The effect of variation in surgical resection on overall survival was assessed using Cox regression analyses. Relative survival was used as an estimate for disease-specific survival. 38164 patients, treated in 95 different hospitals, were included in the analysis. After adjustments, resection rates varied between hospitals from 88 to 99%. This variation increased among patients older than 75 years, from 79 to 98%. Crude overall 5-year survival was 64%. After adjustment, no significant difference in overall or relative survival between hospitals with higher and lower resection rates was observed. Resection rates are important to consider when interpreting hospital outcomes. There is a significant variation in resection rates in patients with non-metastatic colon cancer among hospitals in the Netherlands. This variation increases in the elderly. No significant effect on survival was found. This could imply that undertreatment may play a role as well as that some patients might not benefit from surgery. [ABSTRACT FROM AUTHOR]

Background: Patients with life-threatening conditions who contact out-of-hours primary care either receive a home visit from a GP of a GP cooperative (GPC) or are handed over to the ambulance service.Objective: The objective of this study was to determine whether highly urgent visits, after a call to the GPC, are delivered by the most appropriate healthcare provider: GPC or ambulance service.Methods: We performed a cross-sectional study using patient record data from a GPC and ambulance service in an urban district in The Netherlands. During a 21-month period, all calls triaged as life-threatening (U1) to the GPCs were included. The decision to send an ambulance or not was made by the triage nurse following a protocolized triage process. Retrospectively, the most appropriate care was judged by the patient's own GP, using a questionnaire.Results: Patient and care characteristics from 1081 patients were gathered: 401 GPC visits, 570 ambulance responses and 110 with both ambulance and GPC deployment. In 598 of 1081 (55.3%) cases, questionnaires were returned by the patients' own GP. About 40% of all visits could have been carried out with a lower urgency in retrospect, and almost half of all visits should have received a different type of care or different provider. In case of ambulance response, 60.7% concerned chest pain.Conclusion: Research should be done on the process of triage and allocation of care to optimize labelling complaints with the appropriate urgency and to deploy the appropriate healthcare provider, especially for patients with chest pain. [ABSTRACT FROM AUTHOR]

Objective:To examine patient safety culture in Dutch out-of-hours primary care using the safety attitudes questionnaire (SAQ) which includes five factors: teamwork climate, safety climate, job satisfaction, perceptions of management and communication openness. Design:Cross-sectional observational study using an anonymous web-survey.SettingSixteen out-of-hours general practitioner (GP) cooperatives and two call centers in the Netherlands.SubjectsPrimary healthcare providers in out-of-hours services.Main outcome measuresMean scores on patient safety culture factors; association between patient safety culture and profession, gender, age, and working experience. Results:Overall response rate was 43%. A total of 784 respondents were included; mainly GPs (N = 470) and triage nurses (N = 189). The healthcare providers were most positive about teamwork climate and job satisfaction, and less about communication openness and safety climate. The largest variation between clinics was found on safety climate; the lowest on teamwork climate. Triage nurses scored significantly higher than GPs on each of the five patient safety factors. Older healthcare providers scored significantly higher than younger on safety climate and perceptions of management. More working experience was positively related to higher teamwork climate and communication openness. Gender was not associated with any of the patient safety factors. Conclusions:Our study showed that healthcare providers perceive patient safety culture in Dutch GP cooperatives positively, but there are differences related to the respondents’ profession, age and working experience. Recommendations for future studies are to examine reasons for these differences, to examine the effects of interventions to improve safety culture and to make international comparisons of safety culture.Key PointsCreating a positive patient safety culture is assumed to be a prerequisite for quality and safety. We found that:• healthcare providers in Dutch GP cooperatives perceive patient safety culture positively;• triage nurses scored higher than GPs, and older and more experienced healthcare professionals scored higher than younger and less experienced professionals – on several patient safety culture factors; and• within the GP cooperatives, safety climate and openness of communication had the largest potential for improvement. [ABSTRACT FROM PUBLISHER]

Background: Telephone triage is a core but vulnerable part of the care process at out-of-hours general practitioner (GP) cooperatives. In the Netherlands, different instruments have been used for assessing the quality of telephone triage. These instruments focussed mainly on communicational aspects, and less on the medical quality of triage decisions. Our aim was to develop and test a minimum set of items to assess the quality of telephone triage.Methods: A national survey among all GP cooperatives in the Netherlands was performed to examine the most important aspects of telephone triage. Next, corresponding items from existing instruments were searched on these topics. Subsequently, an expert panel judged these items on importance, completeness and formulation. The concept KERNset consisted of 24 items about the telephone conversation: 13 medical, ten communicational and one regarding both types. It was pilot tested on measurement characteristics, reliability, validity and variation between triagists. In this pilot study, 114 anonymous calls from four GP cooperatives spread across the Netherlands were judged by three out of eight raters, both internal and external raters.Results: Cronbach's alpha was .94 for the medical items and .75 for the communicational items. Inter-rater reliability: complete agreement between the external raters was 45% and reasonable agreement 73% (difference of maximally one point on the five-point scale). Intra-rater reliability: complete agreement within raters was 55% and reasonable agreement 84%. There were hardly any differences between internal and external raters, but there were differences in strictness between individual raters. The construct validity was confirmed by the high correlation between the general impression of the call and the items of the KERNset. Of the differences within items 19% could be explained by differences between triage nurses, which means the KERNset is able to demonstrate differences between triage nurses.Conclusions: The KERNset can be used to assess the quality of telephone triage. The validity is good and differences between calls and between triage nurses can be measured. A more intensive training for raters could improve the reliability. [ABSTRACT FROM AUTHOR]

Background: Migrants are more likely to use out-of-hours primary care, especially for nonurgent problems. Their motives and expectations for help-seeking are as yet unknown. The objective of this study is to examine the motives and expectations of migrants for contacting out-of-hours primary care. Methods: We used data from a survey study of 11,483 patients who contacted a General Practitioner (GP) cooperative in the Netherlands between 2009 and 2014 (response rate 45.6%). Logistic regression analysis was used to test differences in motives and expectations between non-western and western migrants and native Dutch patients. Results: The main motives for contacting a GP cooperative for non-western and western migrants were an urgent need for contact with a GP (54.9%-52.4%), worry (49.3%-43.0%), and a need for medical information (21.3%-26.2%). These were also the most important motives for native Dutch patients. Compared to native Dutch patients, non-western migrants more often perceived an urgent need for a GP (OR 1.65; 99% CI 1.27-2.16), less often needed information (OR 0.59; 99% CI 0.43-0.81), and more often experienced problems contacting their own GP during office hours (OR 1.71; 99% CI 1.21-2.43). Western migrants also reported experiencing problems more often in contacting their own GP (OR 1.38; 99% CI 1.04-1.84). As well as for natives, most non-western and western migrants expected to see a doctor (46.2%-46.6%) or get advice (39.6%-41.5%). Non-western migrants expected more often to get physical examination (OR 1.53; 99% CI 1.14-2.04), and prescription (OR 1.37; 99% CI 1.00-1.88). We found no differences in expectations between western migrants and native Dutch patients. Conclusion: The main motives and expectations of migrants are similar to native Dutch patients, yet non-western migrants more often wanted action from the GP, e.g. examination or prescription, and less often passive forms of assistance such as giving information. At the same time they experience problems accessing their own GP. We recommend stimulation of self-care, education about the purpose of a GP cooperative, and examination and improvement of accessibility of daytime primary care. [ABSTRACT FROM AUTHOR]

In many Western countries, hospital emergency departments are overcrowded, leading to the desire to strengthen primary care, particularly after hours. To achieve this goal, an increasing number of Western nations are reorganizing their after-hours primary care systems into large-scale primary care physician (PCP) cooperatives. This article provides an overview of the organization, performance, and development of PCP cooperatives in the Netherlands. The Dutch after-hours primary care system might offer opportunities for other countries facing problems with after-hours care and inappropriate emergency department visits. During the past several years, the number of contacts with Dutch PCP cooperatives has increased to 245 contacts per 1000 citizens per year. Many contacts (45%) are nonurgent, and about half occur as part of a series of primary care contacts. Low accessibility and availability of daytime primary care are related to greater use of after-hours primary care. To prevent unnecessary attendance at the cooperatives, physicians advocate copayment, a stricter triage system, and a larger role for telephone doctors. More than half of the PCP cooperatives in the Netherlands have integrated with hospital emergency departments, forming "emergency care access points." This collaboration has decreased emergency department use by 13% to 22%, and treatment of self-referrals by PCP cooperatives in emergency care access points is safe and cost-effective. Direct access to diagnostic facilities may optimize efficiency even more. Other recent developments include access to electronic health records of daytime primary care practices, task substitution from physicians to nurses, and the launch of a 2-year training program for PCPs to become experts in emergency care. [ABSTRACT FROM AUTHOR]

Background: In the Netherlands, out-of-hours primary care is provided in general practitioner-cooperatives (GPCs). These are increasingly located on site and in collaboration with emergency departments of hospitals (ED). At such sites, also called emergency-care-access-points (ECAP), the GPC is generally responsible for the triage and treatment of self-referrals who used to attend the ED. To evaluate the effects and safety of this novel organisation, we studied the characteristics and the quality of care given by GPCs to self-referrals at ECAPs. Methods: Retrospective analysis (August 2011-January 2012) of 783 records of self-referred patients at three Dutch GPCs in an ECAP. This was supplemented with a retrospective analysis of patient records during a follow-up period of three-months to asses safety. Results: Patient-characteristics: 59% was male, 46% aged between 16-45 years and 59% trauma-related. Most cases (95%) were triaged low-urgent. None received the highest urgency-category. Quality: The triage outcome was correct in 79%, underestimated in 12% and overestimated in 9%. After GP consultation 20% were referred to the ED, mostly for radio-diagnostics. Of the referrals to secondary care, 98% were according to common medical practice. Thirty percent had a follow-up contact, mostly with their own general practitioner, seldom with the ED. Complications, all non-severe, were registered in 3.2%; 0.4% were possibly preventable. Conclusions: Self-referred patients at an ECAP are mostly trauma related, low-urgent and male patients. The majority could be treated by the GPC without subsequent referral to the ED. Care given at the GPC is reasonably efficient and safe. Triage and treatment of self-referrals by the GPC at ECAPs might offer opportunities for other countries facing problems with inappropriate emergency department visits. [ABSTRACT FROM AUTHOR]

Background: The Safety Attitudes Questionnaire (SAQ) is one of the most widely used instruments to assess safety culture among healthcare providers. The ambulatory version of the SAQ (SAQ-AV) can be used in the primary care setting. Our study objective was to examine the underlying factors and psychometric properties of the Dutch translation of the SAQ-AV in out-of-hours primary care services. Design: Cross-sectional observational study using a web-survey. Setting: Sixteen out-of-hours general practitioner cooperatives and two call centers in the Netherlands. Participants: Primary healthcare providers in out-of-hours services. Main outcome measures: Item-descriptive statistics, factor loadings, Cronbach’s alpha scores, corrected item-total correlations, scale correlations. Results: The questionnaire was answered by 853 (43.2%) healthcare professionals. In the factor analyses, 784 respondents were included; mainly general practitioners (N = 470) and triage nurses (N = 189). Items were included in the analyses based on question type and results from previous studies. Five factors were drawn with reliability scores between .49 and .86 and a good construct validity. The five factors covered 27 of the 62 questionnaire items, with three to five items per factor. Conclusions: The Dutch translation of the SAQ-AV, with five factors, seems to be a reliable tool for measuring patient safety culture and guide quality improvement interventions in out-of-hours primary care services. The Dutch factor structure differed from the original SAQ-AV and other translated versions. In future studies, the questionnaire should be validated further by examining if there is a relationship between the responses on the SAQ-AV, patient experiences, and the occurrence of adverse events. [ABSTRACT FROM AUTHOR]

Objective. The aim was to assess the validity and responsiveness of the Michigan Hand Questionnaire (MHQ) in patients with SSc. Methods. Data were gathered in connection with a randomized, controlled trial comparing the effectiveness of a 12-week multidisciplinary team care programme, including a hand function treatment module, with regular care. Hand function was evaluated by the MHQ (37 items, six domains: Function, Daily activities, Pain, Work, Aesthetics and Satisfaction) and other measurements, including the HAQ, Hand Mobility in Scleroderma, Sequential Occupational Dexterity Assessment (SODA), grip strength, pinch grip and modified Rodnan Skin Score. Fifty-three patients (28 intervention group and 25 control group) completed evaluation at baseline and after 12 weeks. Validity was determined by computing Spearman correlation coefficients between the baseline MHQ total score and subscales and other measures of (hand) disability. Responsiveness in the intervention group was evaluated by the standardized response mean and effect size (ES). In addition, the pooled ES for the difference between the two groups was computed. Results. Significant correlations were seen between the MHQ total score and the HAQ (r =-0.62), Hand Mobility in Scleroderma (r =-0.54), SODA (r = 0.47), SODA Pain (r = 0.32) and modified Rodnan Skin Score (r = 0.46). The ES of the MHQ total score within the intervention group was 0.49, which was larger than that of all other outcome measures. Similar results were obtained for the standardized response mean. The pooled ES of the difference between intervention and control groups for the MHQ total score was 0.86. Conclusion. The MHQ demonstrated adequate validity and responsiveness in patients with SSc. [ABSTRACT FROM AUTHOR]

Background: The Netherlands has a well-developed primary care system, which increasingly collaborates with hospital emergency departments (EDs). In this setting, insight into crowding in EDs is limited. This study explored links between patients' ED Length of Stay (LOS) and their care pathways.Methods: Observational multicenter study of 7000 ED patient records from 1 February 2013. Seven EDs spread over the Netherlands, representing overall Dutch EDs, were included. This included three EDs with and four EDs without an integrated primary-care-physician (PCP) cooperative, forming one Emergency Care Access Point (ECAP). The main outcome was LOS of patients comparing different care pathways (origin and destination of ED attenders).Results: The median LOS of ED attenders was 130.0 min (IQR 79.0-140.0), which increased with patients' age. Random coefficient regression analysis showed that LOS for patients referred by medical professionals was 32.9 min longer compared to self-referred patients (95% CI 27.7-38.2 min). LOS for patients admitted to hospital was 41.2 min longer compared to patients followed-up at the outpatient clinic (95% CI 35.3-46.6 min), 49.9 min longer compared to patients followed-up at the PCP (95% CI 41.5-58.3 min) and 44.6 min longer compared to patients who did not receive follow-up (95% CI 38.3-51.0 min). There was no difference in LOS between hospitals with or without an ECAP.Conclusions: With 130 min, the median LOS in Dutch EDs is relatively short, comparing to other Western countries, which ranges from 176 to 480 min. Although integration of EDs with out-of-hours primary care was not related to LOS, the strong primary care system probably contributed to the overall short LOS of ED patients in the Netherlands. [ABSTRACT FROM AUTHOR]

Objective: General practices increasingly use telephone triage to manage patient flows. During triage, the urgency of the call and required type of care are determined. This study examined the organization and adequacy of telephone triage in general practices in the Netherlands. Design: Cross-sectional observational study using a web-based survey among practice assistants including questions on background characteristics and triage organization. Furthermore, practice assistants were asked to assess the required type of care of written case scenarios with varying health problems and levels of urgency. To determine the adequacy of the assessments, a comparison with a reference standard was made. In addition, the association between background characteristics and triage organization and the adequacy of triage was examined. Setting: Daytime general practices. Subjects: Practice assistants. Main outcome measures: Over- and under-estimation, sensitivity, specificity. Results: The response rate was 41.1% (n973). The required care was assessed adequately in 63.6% of cases, was over-estimated in 19.3%, and under-estimated in 17.1%. The sensitivity of identifying patients with a highly urgent problem was 76.7% and the specificity was 94.0%. The adequacy of the assessments of the required care was higher for more experienced assistants and assistants with fixed daily work meetings with the GP. Triage training, use of a triage tool, and authorization of advice were not associated with adequacy of triage. Conclusion: Triage by practice assistants in general practices is efficient (high specificity), but potentially unsafe in highly urgent cases (suboptimal sensitivity). It is important to train practice assistants in identifying highly urgent cases. [ABSTRACT FROM AUTHOR]

Background: In the Netherlands, about half of the patient contacts with a general practitioner (GP) cooperative are nonurgent from a medical perspective. A part of these problems can wait until office hours or can be managed by the patient himself without further professional care. However, from the patient's perspective, there may be a need to contact a physician immediately. Our objective was to determine whether contacts with out-of-hours primary care made by patients with nonurgent problems are the result of patients' beliefs or of deficiencies in the healthcare system. Methods: We performed a survey among 2000 patients with nonurgent health problems in four GP cooperatives in the Netherlands. Two GPs independently judged the medical necessity of the contacts of all patients in this study. We examined characteristics, views and motives of patients with medically necessary contacts and those without medically necessary contacts. Descriptive statistics were used to describe the characteristics, views and reasons of the patients with medically unnecessary contacts and medically necessary contacts. Differences between these groups were tested with chi-square tests. Results: The response rate was 32.3% (N = 646). Of the nonurgent contacts 30.4 % were judged as medically necessary (95 % CI 27.0-34.2). Compared to patients with nonurgent but medically necessary contacts, patients with medically unnecessary contacts were younger and were more often frequent attenders. They had longer-existing problems, lower self-assessed urgency, and more often believed GP cooperatives are intended for all help requests. Worry was the most frequently mentioned motive for contacting a GP cooperative for patients with a medically unnecessary contact (45.3 %) and a perceived need to see a GP for patients with a medically necessary contact (44.2 %). Perceived availability (5.8 %) and accessibility (8.3 %) of a patient's own GP played a role for some patients. Conclusion: Motives for contacting a GP cooperative are mostly patient-related, but also deficiencies in access to general practice may partly explain medically unnecessary use. Efforts to change the use of GP cooperatives should focus on education of subgroups with an increased likelihood of contact for medically unnecessary problems. Improvement of access to daytime primary care may also decrease use of the GP cooperative. [ABSTRACT FROM AUTHOR]

Objective: In the Netherlands, an increasing number of emergency departments (EDs) and general practitioner cooperatives collaborate by creating one Emergency-Care-Access-Point (ECAP). This has resulted in fewer patients at ECAP EDs. The objective of this study was to explore differences in patient characteristics, presented complaints and ED discharge diagnoses between EDs with an ECAP and EDs without an ECAP. Methods: A retrospective observational study was performed with 1800 consecutive patient records sampled from six EDs spread over the Netherlands in 2013. We extracted data on time and date of presentation, sex, age, presenting complaint, discharge diagnosis, origin and follow up. Results: At ECAP EDs, the mean age was 47.8 years (95%CI 46.1-49.4) compared to 41.3 (95%CI 39.7-42.9). Compared to non-ECAP EDs, more patients were referred by medical professionals (74.7% versus 46.8%), more patients received hospital admission (45.2% versus 29.0%) and fewer patients received GP follow-up (4.1% versus 16.9%). There was no significant difference in presenting complaints between ECAP and non-ECAP EDs. Most prevalent complaints were trauma (25.7% versus 29.7%), abdominal pain (12.1% versus 10.9%) and general symptoms (7.8% versus 4.8%). The most prevalent ED diagnoses significantly differed with fractures and dislocations (10.8%), sprains and strains (10.4%) and respiratory infections (6.8%) at ECAP EDs versus fractures and dislocations (10.7%), wounds (9.3%) and sprains and strains (8.9%) at non-ECAP EDs. Conclusion: Compared to non-ECAP EDs, patients at ECAP EDs were older, medical professionals referred more patients and more patients received a hospital admission. We found some small differences in discharge diagnoses between ECAP EDs compared to non-ECAP EDs, but no difference in presented complaints. [ABSTRACT FROM AUTHOR]

Background: The use of out-of-hours healthcare services for non-urgent health problems is believed to be related to the organisation of daytime primary care but insight into underlying mechanisms is limited. Our objective was to examine the association between daytime general practice characteristics and the use of out-of-hours care GP cooperatives. Methods: A cross-sectional observational study in 100 general practices in the Netherlands, connected to five GP cooperatives. In each GP cooperative, we took a purposeful sample of the 10 general practices with the highest use of out-of-hours care and the 10 practices with the lowest use. Practice and population characteristics were obtained by questionnaires, interviews, data extraction from patient registration systems and telephone accessibility measurements. To examine which aspects of practice organisation were associated with patients' use of out-of-hours care, we performed logistic regression analyses (low versus high out-of-hours care use), correcting for population characteristics. Results: The mean out-of-hours care use in the high use group of general practices was 1.8 times higher than in the low use group. Day time primary care practices with more young children and foreigners in their patient populations and with a shorter distance to the GP cooperative had higher out-of-hours primary care use. In addition, longer telephone waiting times and lower personal availability for palliative patients in daily practice were associated with higher use of out-of-hours care. Moreover, out-of-hours care use was higher when practices performed more diagnostic tests and therapeutic procedures and had more assistant employment hours per 1000 patients. Several other aspects of practice management showed some non-significant trends: high utilising general practices tended to have longer waiting times for non-urgent appointments, lower availability of a telephone consulting hour, lower availability for consultations after 5 p.m., and less frequent holiday openings. Conclusions: Besides patient population characteristics, organisational characteristics of general practices are associated with lower use of out-of-hours care. Improving accessibility and availability of day time primary day care might be a potential effective way to improve the efficient use of out-of-hours care services. [ABSTRACT FROM AUTHOR]

Permeable pavements are a type of sustainable urban drainage system (SUDS) technique that are used around the world to infiltrate and treat urban stormwater runoff and to minimize runoff volumes. Urban stormwater runoff contains significant concentrations of suspended sediments that can cause clogging and reduce the infiltration capacity and effectiveness of permeable pavements. It is important for stormwater managers to be able to determine when the level of clogging has reached an unacceptable level, so that they can schedule maintenance or replacement activities as required. Newly-installed permeable pavements in the Netherlands must demonstrate a minimum infiltration capacity of 194 mm/h (540 l/s/ha). Other commonly used permeable pavement guidelines in the Netherlands recommend that maintenance is undertaken on permeable pavements when the infiltration falls below 0.50 m/d (20.8 mm/h). This study used a newly-developed, full-scale infiltration test procedure to evaluate the infiltration performance of eight permeable pavements in five municipalities that had been in service for over seven years in the Netherlands. The determined infiltration capacities vary between 29 and 342 mm/h. Two of the eight pavements show an infiltration capacity higher than 194 mm/h, and all infiltration capacities are higher than 20.8 mm/h. According to the guidelines, this suggests that none of the pavements tested in this study would require immediate maintenance. [ABSTRACT FROM AUTHOR]

Objective. To study the quantitative consumption in out-of-hours (OOH) primary care in Denmark and the Netherlands, in the context of OOH care services. Design. A retrospective observational study describing contacts with OOH care services, using registration data. Setting. OOH care services (i.e. OOH primary care, emergency department, and ambulance care) in one Danish and one Dutch region. Subjects. All patients contacting the OOH care services in September and October 2011. Main outcome measures. Consumption as number of contacts per 1000 inhabitants in total and per age group per contact type. Results. For the two-month period the Danes had 80/1000 contacts with OOH primary care compared with 50/1000 for the Dutch. The number of contacts per 1000 inhabitants per age group varied between the regions, with the largest difference in the 0-5 years age group and a considerable difference in the young-adult groups (20-35 years). The difference was largest for telephone consultations (47/1000 vs. 20/1000), particularly in the youngest age group (154/1000 vs. 39/1000). The Danes also had more home visits than the Dutch (10/1000 vs. 5/1000), while the Dutch had slightly more clinic consultations per 1000 inhabitants than the Danes (25/1000 vs. 23/1000). Conclusion. The Danish population has more contacts with OOH primary care, particularly telephone consultations, especially concerning young patients. Future research should focus on the relevance of contacts and identification of factors related to consumption in OOH primary care. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives In most countries, different health care providers are involved in emergency care. In the Netherlands, out-of-hours care is provided by general practitioner cooperatives (GPCs) and emergency departments (EDs). Our aim was to describe the flow of patients attending emergency care in these settings. Method A retrospective record review was performed, concerning patients who had visited a GPC or ED. Recorded information included urgency, diagnostic tests, and follow-up contacts. Descriptive figures were determined for patient flows in GPC and ED for urgent contacts and non-urgent contacts. Results We included 319 GPC contacts and 356 ED contacts, of which 78% were non-urgent. The majority of GPC contacts were completed at the GPC without follow-up; 37% of non-urgent patients had a follow-up contact, usually with primary care. Only 5% of non-urgent GPC patients received diagnostic tests compared to 63% of non-urgent ED patients (mostly X-rays). The majority of non-urgent ED patients (88%) had a follow-up contact, usually at an outpatient clinic (67%). Most non-urgent ED patients (83%) who received a diagnostic test also had an outpatient clinic follow-up contact. Of urgent ED patients, the majority had a follow-up contact (85%), mostly with an outpatient clinic (74%). Conclusion Although most out-of-hours care patients present non-urgent health problems, at the ED they are more likely to receive diagnostic tests and follow-up contacts. This may reflect differences in patient populations between the ED and GPC or suggest opportunities for improving efficiency of planning follow-up contacts. [ABSTRACT FROM AUTHOR]

Objective. For over a decade, out-of-hours primary care in the Netherlands has been provided by general practitioner (GP) cooperatives. In the past years, quality improvements have been made and patients have become acquainted with the service. This may have increased patient satisfaction. The objective of this study was to examine changes in patient satisfaction with GP cooperatives over time. Design. Longitudinal observational study. A validated patient satisfaction questionnaire was distributed in 2003-2004 (T1) and 2007-2008 (T2). Items were rated on a scale from 0 to 10 (1 = very bad; 10 = excellent). Setting. Eight GP cooperatives in the Netherlands. Subjects. Stratified sample of 9600 patients. Response was 55% at T1 (n = 2634) and 51% at T2 (n = 2462). Main outcome measures. Expectations met; satisfaction with triage nurses, GPs, and organization. Results. For most patients the care received at the GP cooperative met their expectations (T1: 86.1% and T2: 88.4%). Patients were satisfied with the triage nurses (overall grade T1: 7.73 and T2: 7.99), GPs (T1: 8.04 and T2: 8.25), and organization (overall grade T1: 7.60 and T2: 7.78). Satisfaction with triage nurses showed the largest increase over time. The quality and effectiveness of advice or treatment were given relatively low grades. Of all organizational aspects, the lowest grades were given for waiting times and information about the cooperative. Conclusion. In general, patients were initially satisfied with GP cooperatives and satisfaction had even increased four years later. However, there is room for improvement in the content of the advice, waiting times, and information supply. More research is needed into satisfaction of specific patient groups. [ABSTRACT FROM AUTHOR]

Background: In many countries out-of-hours care faces serious challenges, including shortage of general practitioners, a high workload, reduced motivation to work out of hours, and increased demand for out-of-hours care. One response to these challenges is the introduction of nurse practitioner as doctor substitutes, in order to maintain the (high) accessibility and safety of out of hours care. Although nurse practitioners have proven to provide equally safe and efficient care during daytime primary care, it is unclear whether substitution is effective and efficient in the more complex out of hours primary care. This study aims to assess the effects of substitution of care from general practitioners to nurse practitioners in an out of hours primary care setting. Design: A quasi experimental study is undertaken at one "general practitioner cooperative" to offer out-of-hours care for 304.000 people in the South East of the Netherlands. In the experimental condition patient care is provided by a team of one nurse practitioner and four general practitioners; where the nurse practitioner replaces one general practitioner during one day of the weekend from 10 am to 5 pm. In the control condition patient care is provided by a team of five general practitioners during the other day of the weekend, also from 10 am to 5 pm. The study period last 15 months, from April 2011 till July 2012. Methods: Data will be collected on number of different outcomes using a range of methods. Our primary outcome is substitution of care. This is calculated using the number and characteristics of patients that have a consultation at the GP cooperative. We compare the number of patients seen by both professionals, type of complaints, resource utilization (e.g. prescription, tests, investigations, referrals) and waiting times in the experimental condition and control condition. This data is derived from patient electronic medical records. Secondary outcomes are: patient satisfaction; general practitioners workload; quality and safety of care and barriers and facilitators. Discussion: The study will provide evidence whether substitution of care in out-of-hours setting is safe and efficient and give insight into barriers and facilitators related to the introduction of nurse practitioners in out-of-hours setting. Trial registration: ClinicalTrials.gov ID NCT01388374 [ABSTRACT FROM AUTHOR]

The article describes and examines complaints against family physicians submitted to the disciplinary tribunals in the Netherlands with a view to improving patient safety. The authors emphasize that the disciplinary system in the Netherlands is different from the malpractice system in the U.S. wherein patients can file complaints against family physicians without resorting to lawsuits or insurance claims. They state that the disciplinary system is useful in improving patient safety.

Many Western countries are seeking an organizational model for after-hours primary care that is safe, efficient, and satisfactory for patients and health care professionals. Around the year 2000, Dutch primary care physicians (PCP's) reorganized their after-hours primary care and shifted from small rotation groups to large-scale PCP cooperatives. This article provides a narrative review of studies on a range of issues about after-hours primary care in the Netherlands, including experiences of health care professionals and patients, patient-safety incidents, adherence to practice guidelines, waiting times, and quality of telephone triage. Physicians expressed high satisfaction with PCP cooperatives; their workload decreased, and job satisfaction increased compared with the situation before the reorganization. In general, patients were also satisfied, but areas for improvement included telephone consultations, patient education, and distance to a pharmacy. A study identified patient-safety incidents in 2.4% of all contacts, of which most did not result in harm to patients. The average adherence to clinical guidelines by physicians was 77%, with lowest adherence scores for prescribing antibiotics and treatment in emergency cases. The average waiting time for home visits was 30 minutes. Seventy percent of patients with life-threatening problems were visited within the time target of 15 minutes. Telephone triage by nurses had positive effects on care efficiency by increasing the proportion of telephone consultations and decreasing the proportion of clinic consultations and home visits. The after-hours primary care system in the Netherlands might set an example for other countries struggling to find a good solution for the problems they encounter with after-hours primary care. Future developments in the Netherlands include integration and extensive collaboration with the accident and emergency departments of hospitals, in which PCP's take care of self-referring patients. [ABSTRACT FROM AUTHOR]

Background. Due to emergency care overcrowding, right care at the right place and time is necessary. Uniform triage of patients contacting different emergency care settings will improve quality of care and communication between health care providers.Objective. Validation of the computer-based Netherlands Triage System (NTS) developed for physical triage at emergency departments (EDs) and telephone triage at general practitioner cooperatives (GPCs).Methods. Prospective observational study with patients attending the ED of a university-affiliated hospital (September 2008 to November 2008) or contacting an urban GPC (December 2008 to February 2009). For validation of the NTS, we defined surrogate urgency markers as best proxies for true urgency. For physical triage (ED): resource use, hospitalization and follow-up. For telephone triage (GPC): referral to ED, self-care advice after telephone consultation or GP advice after physical consultation. Associations between NTS urgency levels and surrogate urgency markers were evaluated using chi-square tests for trend.Results. We included nearly 10 000 patients. For physical triage at ED, NTS urgency levels were associated with resource use, hospitalization and follow-up. For telephone triage at GPC, trends towards more ED referrals in high NTS urgency levels and more self-care advices after telephone consultation in lower NTS urgency levels were found. The association between NTS urgency classification and GP advice was less explicit. Similar results were found for children; however, we found no association between NTS urgency level and GP advice.Conclusions. Physically and telephone-assigned NTS urgency levels were associated with majority of surrogate urgency markers. The NTS as single triage system for physical and telephone triage seems feasible. [ABSTRACT FROM AUTHOR]

Objective: To identify hand function problems and the reasons for choosing a specific finger splint in patients with rheumatoid arthritis (RA) and swan neck deformities. Methods: A qualitative study was performed alongside a randomized, controlled cross-over trial comparing the effectiveness of two types of finger splints (the silver ring splint [SRS] and the prefabricated thermoplastic splint [PTS]) in 50 patients with RA and swan neck deformities. Questions on the patients' main hand function problem and reasons for choosing a specific splint type were performed at baseline and after using each splint. The qualitative analyses included the identification of meaning units and (sub)concepts related to hand function problems and splint preferences. Results: RA patients with swan neck deformities experience problems with flexion initiation, painful proximal interphalangeal joint hyperextension, grip activities and comprehensive hand function activities. Reasons for preferring or not preferring a specific type of finger splint included: effect, ease of use, appearance, comfort and side effects. Apart from the splint slipping off and a negative attitude towards the appearance of the splint, which appeared to be more frequently mentioned in connection with the SRS, no clear pattern of positive or negative appreciation of either type of splint could be distinguished. Conclusion: RA patients with swan neck deformities experience a variety of problems, including impairments in functions and limitations in daily activities. With the prescription of finger splints, a substantial number of potentially positive and negative consequences of their use need to be taken into account. Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Building on conservation of resources theory and the dynamic equilibrium model, this three-wave longitudinal study among 260 Dutch agricultural business owners (I-year time intervals) investigated reciprocal relationships between the financial situation of the business and psychological distress. Results of structural equation modelling analyses revealed a negative spiral of farm decline, in which psychological variables played a key role. Experiencing financial problems predicted psychological distress, and acted as a self-fulfilling prophecy by strengthening intentions to quit the business, which predicted a deterioration of the objective financial situation of the business I year later. Moreover, farmers experiencing more psychological distress were more likely to get caught in this negative spiral than business owners with better mental health, because they experienced more financial problems, irrespective of their objective financial situation. Long-term psychological distress rather than temporary fluctuations in distress levels accounted for this effect. [ABSTRACT FROM AUTHOR]

Background: Insight into the frequency and seriousness of potentially unsafe situations may be the first step towards improving patient safety. Most patient safety attention has been paid to patient safety in hospitals. However, in many countries, patients receive most of their healthcare in primary care settings. There is little concrete information about patient safety in primary care in the Netherlands. The overall aim of this study was to provide insight into the current patient safety issues in Dutch general practices, out-of-hours primary care centres, general dental practices, midwifery practices, and allied healthcare practices. The objectives of this study are: to determine the frequency, type, impact, and causes of incidents found in the records of primary care patients; to determine the type, impact, and causes of incidents reported by Dutch healthcare professionals; and to provide insight into patient safety management in primary care practices.Design and Methods: The study consists of three parts: a retrospective patient record study of 1,000 records per practice type was conducted to determine the frequency, type, impact, and causes of incidents found in the records of primary care patients (objective one); a prospective component concerns an incident-reporting study in each of the participating practices, during two successive weeks, to determine the type, impact, and causes of incidents reported by Dutch healthcare professionals (objective two); to provide insight into patient safety management in Dutch primary care practices (objective three), we surveyed organizational and cultural items relating to patient safety. We analysed the incidents found in the retrospective patient record study and the prospective incident-reporting study by type of incident, causes (Eindhoven Classification Model), actual harm (severity-of-outcome domain of the International Taxonomy of Medical Errors in Primary Care), and probability of severe harm or death.Discussion: To estimate the frequency of incidents was difficult. Much depended on the accuracy of the patient records and the professionals' consensus about which types of adverse events have to be recognized as incidents. [ABSTRACT FROM AUTHOR]

This article identifies different stakeholder perspectives on future flood management in the downstream parts of the Rhine basin in Germany and The Netherlands. The perspectives were identified using Q methodology, which proved to be a good, but time-intensive, method for eliciting and analyzing stakeholder perspectives in a structured and unbiased way. Three shared perspectives were found: A) "Anticipation and institutions", B) "Space for flooding" and C) "Knowledge and engineering". These three perspectives share a central concern for the provision of safety against flooding, but disagree on the expected autonomous developments and the preferred measures. In perspective A, the expected climate change and economic growth call for fast action. To deal with the increasing flood risk, mostly institutional measures are proposed, such as the development of a stronger basin commission. In perspective B, an increasing spatial pressure on the river area is expected, and the proposed measures are focused on mitigating damage, e.g., through controlled flooding and compartmentalization. In perspective C, the role of expert knowledge and technological improvements is emphasized. Preferred strategies include strengthening the dikes and differentiation of safety standards. An overview of stakeholder perspectives can be useful in natural resources management for 1) setting the research agenda, 2) identifying differences in values and interests that need to be discussed, 3) creating awareness among a broad range of stakeholders, and 4) developing scenarios. [ABSTRACT FROM AUTHOR]

Objective: This article reports on the implementation of the individual placement and support model of supported employment in four Dutch regions. Methods: The authors used structured site visits, employment data, and semistructured interviews to assess fidelity, employment outcomes, and facilitators of and barriers to successful implementation. Results: At 24 months, the four sites reached a mean±SD fidelity score of 4.1±.3 (possible scores range from 1 to 5, with higher scores indicating closer adherence to the model). Of the 316 persons with mental illnesses, 57 (18%) obtained competitive jobs. Barriers to implementation included lack of organizational standards, loss of vocational staff, funding problems, insufficient time for program leaders, and inadequate cooperation between the involved organizations. Important facilitators were the skills and commitment of the vocational team members and the integration of vocational and mental health staff. Conclusions: To implement evidence-based supported employment in the Netherlands will require changes in financing, organizational structures, attitudes, cultural beliefs, and labor and disability regulations. [ABSTRACT FROM AUTHOR]

Urbanization, land subsidence and sea level rise will increase vulnerability to droughts in the urbanized low-lying areas in the western part of the Netherlands. In this paper a possibility is explored to decrease vulnerability of urban areas by implementing an alternative water supply option. A four component vulnerability framework is presented that includes threshold capacity, coping capacity, recovery capacity and adaptive capacity. By using the vulnerability framework it is elaborated that current water supply strategies in the Netherlands mainly focus on increasing threshold capacity by constructing improved water storage and delivery infrastructure. A complete vulnerability decreasing strategy requires measures that include all four components. Adaptive capacity can be developed by starting experiments with new modes of water supply. A concept which is symbolically called 'the closed city' uses local urban rainfall as the only source of water supply. The 'closed city' can decrease the water dependence of urban areas on (1) the surrounding rural areas that are diminishing in size and that are increasingly under strain and (2) river water resources that will probably be less constant and reliable as a result of climate change. [ABSTRACT FROM AUTHOR]

Abstract: This paper explores the way in which dairy farmers perceive their environment (PE), i.e., the external context of their farm, and the uncertainty (PEU) this poses to them. The environment is defined using the STEP concept (society, technology, economy and politics) and Porter’s five forces model. The relationship between the perception of the external farm environment and the strategy farmers choose for their farm is quantified to gain insight into the effect of the external farm environment on decision-making. Data from a survey of 103 Dutch dairy farmers was analyzed using regression analysis. The results indicate that environmental uncertainty is not related to complexity or dynamism, but to the illiberality (i.e., intolerance, hostility) of the external farm environment. The institutional environment is considered especially illiberal, thus causing high uncertainty. Farmers with high PEU are more likely to choose a diversification strategy, while low perceived uncertainty results in a process-control strategy for the farm. A growth strategy is not affected by perceived environmental uncertainty. The PE and PEU approach is new in agricultural research and shows that the farmer’s view on the external environment is a key issue for decision-making on farms The significant relationship between the perceived uncertainty caused by the external farm environment and farm strategies shows that to get a good understanding of the farm, farming system boundaries should be expanded to incorporate the effect of the external farm environment on decision making. Reduction of uncertainty will enhance decision-making because instead of farming within an uncertain context, risk management practices can be used. [Copyright &y& Elsevier]

Recent developments in agriculture have stirred up interest in the concept of “sustainable” farming systems. Still it is difficult to determine the extent to which certain agricultural practices can be considered sustainable or not. Aiming at identifying the necessary attributes with respect to sustainability in Dutch dairy farming in the beginning of the third millennium, we first compiled a list of attributes referring to all farming activities with their related side effects with respect to economic, internal social, external social, and ecological sustainability. A wide range of people (i.e., experts and stakeholders) were consulted to contribute to our list of attributes. Our consultation showed that only one attribute was selected for economic and internal social sustainability: profitability and working conditions, respectively. The list for external social sustainability contained 19 attributes and the list for ecological sustainability contained 15 attributes. To assess their relative importance, the same experts and stakeholders ranked the attributes for external social and ecological sustainability by using a questionnaire. The most important attributes for external social sustainability were food safety, animal health, animal welfare, landscape quality, and cattle grazing. For ecological sustainability they were eutrophication, groundwater pollution, dehydration of the soil, acidification, and biodiversity. The present method for identifying and ranking attributes is universal and, therefore, can be used for other agricultural sectors, for other countries, and for other time periods. [ABSTRACT FROM AUTHOR]

In 1998, the Mineral Accounting System (MINAS) was introduced in The Netherlands. MINAS penalises farms with a levy if the farm nutrient surpluses exceed a certain threshold. The threshold is strict, meaning that most farmers need to change their environmental management and performance to avoid high levies. Since MINAS is designed to leave ample room for farmers to follow the course of change of their choice, it is crucial to know whether or not different farmers and different farm strategies lead to different environmental results. A strategic management framework is used to model changes in implementation and performance on specialised dairy farms. Financial and nutrient bookkeeping data of 114 farms, collected over the period 1997–1999 are combined with survey data on farmer characteristics and farm strategies. Results of Linear Structural Equation Analysis (LISREL) showed that the main farmer characteristic explaining change in environmental management was education. Better-educated farmers chose to increase the intensity of the farming system, and cope with the corresponding increase in environmental pressure by improving the production capacity of the herd and improving operational management. Farm strategies explain the differences in the changes in nutrient management. A strategy of process control focuses on optimising tactical management, whereas a growth strategy and a diversification strategy are strongly related to changes in farm structure. Changes in technical and environmental performance in addition to changes resulting from implementation changes are positively affected by education, but show no strong relationship with any strategy, indicating that environmental improvements can be achieved regardless of the way a farmer chooses to develop his farm. Finally, an improvement of financial performance was shown to be significantly related to an improvement of environmental performance. [Copyright &y& Elsevier]

Labor force participation is considerably higher amongst cohabiting women than amongst married women. Using bargaining theory this paper provides an explanation for this association, arguing that the decision not to participate in the labor force makes cohabiting women more vulnerable to the consequences of relationship dissolution than married women. To test the causal direction of the association between marriage and labor force participation a structural model is used that allows the marriage decision and the labor force participation decision to mutually influence each other. Both decisions are modelled to also depend on other variables like earnings capacity, presence of children, relationship duration and normative constraints. The model is estimated using data from 544 couples in the 'Households in the Netherlands 1994' survey. The results suggest that the association between marriage and labor supply is due to the negative effect of being married on labor supply, and not vice versa. [ABSTRACT FROM AUTHOR]

Both cue-elicited craving and impulsivity have been involved in alcohol misuse. However, their role in relapse has not been very clear. In the present study, we ask whether cue-elicited craving, impulsivity, and their interaction term predict a lapse in problem drinkers. Participants (n=20) were former patients of the clinic, U-Center, in the Netherlands, who had completed a six-week alcohol treatment program and had an abstinence goal. While in treatment, they underwent a cue exposure paradigm in a real alcohol-related setting and their trait impulsivity was measured with the Barratt Impulsiveness Scale version 11 (BIS-11). During the follow-up assessment, patients were contacted again and asked about their alcohol drinking behavior during the first three months after the end of the treatment program. It was found that higher craving and lower trait impulsivity levels are associated with a higher probability of a lapse. [Copyright &y& Elsevier]