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Objective: To systematically review the literature on the severity and risk factors for loneliness in adult cancer patients.Methods: We systematically reviewed quantitative studies addressing loneliness in cancer patients. Exclusion criteria were absence of a validated loneliness questionnaire, and studies that focused on loneliness determined by specific circumstances, and not cancer in general (e.g. appearance concerns, cultural and language barriers, requiring palliative care). We searched PsycINFO, CINAHL, Embase, Cochrane Library, and Pubmed in compliance with the predefined in- and exclusion criteria. The search, quality appraisal, and data extraction were performed by two independent reviewers. Weighted mean scores were calculated by using random effects adjusted inverse variance weighting.Results: We included 15 studies. In 13 studies the UCLA loneliness scale was used (range 20-80; higher scores indicate higher loneliness). The weighted mean loneliness score was 38.26 (95% CI: 35.51-41.00), which corresponds to moderate loneliness. Time since diagnosis was positively associated with degree of loneliness. Other cancer-related factors, such as cancer site, treatment type, or stage of disease were not associated with loneliness. The non-cancer related determinants of loneliness in cancer patients that emerged from our review were being unmarried (people who have never been married, are widowed or divorced), and lack of psychological or social support.Conclusion: Our findings suggest that the level of loneliness rises with increasing time after cancer diagnosis. Furthermore, social functioning emerged as a consistent theme, for which it was shown that lack of social support was associated with increasing levels of loneliness.

OBJECTIVE: Spontaneous diffusion of the evidence-based Enhanced Recovery After Surgery (ERAS) program from an early adopter department (colorectal surgery) to other closely related departments (gynecologic surgery) within the same hospital could be expected. Given this diffusion hypothesis, this quality improvement study examines the value of active implementation of ERAS in addition to spontaneous diffusion. METHODS: A nonrandomized, pre-post intervention study was conducted at a tertiary referral hospital. Prospective data of consecutive patients who underwent abdominal surgery between March, 2010 and March, 2011 for gynecologic malignancies were collected and compared with those of a historical cohort of patients treated before the structured implementation of ERAS by an expert team. Outcomes were length of hospital stay, length of functional recovery, and compliance to protocol care elements. RESULTS: Seventy-seven patients treated after structured implementation of ERAS were compared with 38 patients included in the historical cohort. Most women had surgery for ovarian or endometrial cancer (48% and 37% respectively). Postoperative care mostly lacked ERAS elements and needed to be actively implemented. With structured implementation, a reduced time to functional recovery (median 3 versus 6days, p

OBJECTIVE: To evaluate the psychometric properties of the Indonesian version of the Dutch National Prevalence Measurement of Care Problems. The questionnaire consists of 6 parts: patient characteristics (including pressure ulcer [PrU] risk; assessed by the Braden Scale) and care dependency (assessed by the Care Dependency Scale [CDS]), PrU categorization, prevention, treatment, and structural quality indicators at ward and hospital level. DESIGN, PARTICIPANTS, AND SETTING: A 3-phase design was used, including questionnaire translation and psychometric testing. The questionnaire was translated into Indonesian on March 2012. Content validity was assessed by 18 Indonesian experts on July 2012. The interrater agreement and reliability of the PrU categories, Braden Scale, and CDS were assessed on October 2012 in 4 Indonesian large public general hospitals. RESULTS: Most Indonesian experts (91.8%) rated the Indonesian version of the questionnaire as "good" on clarity of wording. The content validity indices of the questionnaire ranged from 0.50 to 1.00. The PrU categories assessed showed an interrater reliability of J = 0.92 (95% confidence interval [CI], 0.87-0.97) and an interrater agreement of p(o) = 98.6% (95% CI, 97.5-99.3). The interrater reliability intraclass correlation coefficient (1,1) of the Braden Scale sum score was 0.90 (95% CI, 0.85-0.93). The exact proportion of agreement sum score was 39%. The interrater reliability intraclass correlation coefficient (1,1) of the CDS sum score was 0.88 (95% CI, 0.83-0.92). There was a 45% exact agreement on the CDS sum scores. CONCLUSIONS: The questionnaire can be used in Indonesian hospitals to measure the PrU prevalence and quality of PrU care.

Objectives: To investigate the malnutrition prevalence in Dutch care home residents with dementia over the years. Secondly, to examine the relationship of malnutrition and dementia and the role of care dependency and co-morbidity within this relationship. Design: This study is a secondary analysis of data of the annual independent Dutch National Prevalence Measurement of Care Problems of Maastricht University. The design involves a cross-sectional, multicenter point prevalence measurement. Setting: Care homes. Participants: 75399 residents older than 65 years (4523 resident with dementia) participated over 5 years (2006-2010). Sixty organizations measured 4 times, 31 organizations 3 times, 68 organizations 2 times, 511 organizations 1 time. Measurements: A standardized questionnaire was used to register amongst others data of weight, height, nutritional intake, undesired weight loss, comorbidity, dementia, and care dependency. Results: The study was able to show that there is a significant decline in malnutrition prevalence in the group of non-demented residents over the years (Non-demented group p

Considering many psychosocial health risk factors are interrelated, determining psychosocial health risk might benefit from a more person-centered perspective. This paper explores to what extent a psychosocial profile that combines potentially synergistic effects of different psychosocial characteristics, including psychological attributes and functioning, coping styles and social support, predicts self-rated health, morbidity and mortality. Prospective, longitudinal data from 1,912 Dutch participants aged 55–91 years were used to determine distinct psychosocial profiles by means of two-step cluster analysis. The predictive power of these profiles over a 5-year follow-up was calculated with Cox regression models for all-cause mortality and general practitioner-diagnosed somatic morbidity, and logistic regression models for self-rated health. Three distinct psychosocial risk profiles emerged: an adverse, an average and a beneficial profile. These profiles strongly predicted self-rated health but not morbidity or mortality. The health effects of the cluster (profile) model suggest synergism between the psychosocial characteristics. Future research should replicate our findings to further validate the approach.

AIM: To agree a draft pressure ulcer risk factor Minimum Data Set to underpin the development of a new evidenced-based Risk Assessment Framework.BACKGROUND: A recent systematic review identified the need for a pressure ulcer risk factor Minimum Data Set and development and validation of an evidenced-based pressure ulcer Risk Assessment Framework. This was undertaken through the Pressure UlceR Programme Of reSEarch (RP-PG-0407-10056), funded by the National Institute for Health Research and incorporates five phases. This article reports phase two, a consensus study.DESIGN: Consensus study.METHOD: A modified nominal group technique based on the Research and Development/University of California at Los Angeles appropriateness method. This incorporated an expert group, review of the evidence and the views of a Patient and Public Involvement service user group. Data were collected December 2010-December 2011.FINDINGS: The risk factors and assessment items of the Minimum Data Set (including immobility, pressure ulcer and skin status, perfusion, diabetes, skin moisture, sensory perception and nutrition) were agreed. In addition, a draft Risk Assessment Framework incorporating all Minimum Data Set items was developed, comprising a two stage assessment process (screening and detailed full assessment) and decision pathways.CONCLUSION: The draft Risk Assessment Framework will undergo further design and pre-testing with clinical nurses to assess and improve its usability. It will then be evaluated in clinical practice to assess its validity and reliability. The Minimum Data Set could be used in future for large scale risk factor studies informing refinement of the Risk Assessment Framework.

Objectives: The aim of this review was to identify studies on patterns of associative multimorbidity, defined as the nonrandom association between diseases, focusing on the main methodological features of the studies and the similarities among the detected patterns.Study Design and Setting: Studies were identified through MEDLINE and EMBASE electronic database searches from their inception to June 2012 and bibliographies.Results: The final 14 articles exhibited methodological heterogeneity in terms of the sample size, age and recruitment of study participants, the data source, the number of baseline diseases considered, and the statistical procedure used. A total of 97 patterns composed of two or more diseases were identified. Among these, 63 patterns were composed of three or more diseases. Despite the methodological variability among studies, this review demonstrated relevant similarities for three groups of patterns. The first one comprised a combination of cardiovascular and metabolic diseases, the second one was related with mental health problems, and the third one with musculoskeletal disorders.Conclusion: The existence of associations beyond chance among the different diseases that comprise these patterns should be considered with the aim of directing future lines of research that measure their intensity, clarify their nature, and highlight the possible causal underlying mechanisms. (C) 2014 Elsevier Inc. All rights reserved.

ObjectivesCare dependency is a determinant of quality of life and survival among patients with advanced chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), or chronic renal failure (CRF). The objectives of this study were to explore the profiles of care dependency in patients with advanced COPD, CHF, or CRF; to study the changes in care dependency during 1-year follow-up; and to study whether 1-year changes in care dependency are comparable between patients with advanced COPD, CHF, or CRF.DesignLongitudinal observational study.ParticipantsClinically stable patients with advanced COPD (n = 105), CHF (n = 80), or CRF (n = 80) were recruited at outpatient clinics of 7 Dutch hospitals.MeasurementsPatients were visited at home at baseline, and at 4, 8, and 12 months to assess demographic and clinical characteristics, comorbidities (Charlson comorbidity index), care dependency (Care Dependency Scale), mobility, health status, and symptom burden.ResultsCOPD and CHF patients reported a higher baseline level of care dependency than patients with CRF. Care dependency differed between patients with COPD, CHF, or CRF in the items ‘getting (un)dressed,’ ‘hygiene,’ ‘contact with others,’ and ‘sense of rules/values.’ One-year follow-up was completed by 206 patients (77.7%). Patients with COPD were more likely to experience an increase in care dependency. An increase in care dependency was associated with higher age, higher number of hospital admissions, decrease in health status, and worsening of Charlson comorbidity index score.ConclusionsCare dependency profiles differ between patients with COPD, CHF, or CRF. Patients with advanced COPD are at risk for a 1-year increase in care dependency. Regular assessment of care dependency and addressing care dependency in palliative care programs for patients with advanced COPD, CHF, or CRF are needed.

summary To date, no information is available about the effect of structural and process factors of nutritional care on the prevalence of malnutrition over time in the long-term care sector. This study analyzes the trend of malnutrition prevalence rates between 2007 and 2011 in the long-term care sector, and the related effects of 1 process indicators such as nutritional screening and treatment and 2) structural indicators (guideline, protocol or nutritional screening policy). From 2007 to 2011, the Dutch National Prevalence Measurement of Care Problems (LPZ) was performed in Dutch long-term care organizations using a standardized questionnaire involving measurements at institutional, ward and resident level. The data were analyzed by mixed-linear regression for longitudinal data. Presence of malnutrition was assessed by BMI, undesired weight loss and nutritional intake. Seventy-four care homes were included (26,101 residents). The malnutrition prevalence trend significantly decreased (P < 0.001) from 26% to 18% from 2007 to 2011. In the final model of the mixed effects analysis only the interacted process indicators nutritional screening and oral nutritional supplementation (ONS) were significant in influencing malnutrition prevalence rates over time. Structural indicators had no impact on the malnutrition prevalence over time. In conclusion, over time a lower prevalence of malnutrition is associated with a higher degree of nutritional screening. As might be expected, a higher prevalence of malnutrition is associated with higher use of ONS. Structural nutritional screening is an important intervention to tackle the problem of malnutrition in the long term care sector.

Background Multimorbidity, the co-occurrence of two or more chronic medical conditions within a single individual, is increasingly becoming part of daily care of general medical practice. Literature-based discovery may help to investigate the patterns of multimorbidity and to integrate medical knowledge for improving healthcare delivery for individuals with co-occurring chronic conditions.Objective To explore the usefulness of literature-based discovery in primary care research through the key-case of finding associations between psychiatric and somatic diseases relevant to general practice in a large biomedical literature database (Medline).Methods By using literature based discovery for matching disease profiles as vectors in a high-dimensional associative concept space, co-occurrences of a broad spectrum of chronic medical conditions were matched for their potential in biomedicine. An experimental setting was chosen in parallel with expert evaluations and expert meetings to assess performance and to generate targets for integrating literature-based discovery in multidisciplinary medical research of psychiatric and somatic disease associations.Results Through stepwise reductions a reference set of 21 945 disease combinations was generated, from which a set of 166 combinations between psychiatric and somatic diseases was selected and assessed by text mining and expert evaluation.Conclusions Literature-based discovery tools generate specific patterns of associations between psychiatric and somatic diseases: one subset was appraised as promising for further research; the other subset surprised the experts, leading to intricate discussions and further eliciting of frameworks of biomedical knowledge. These frameworks enable us to specify targets for further developing and integrating literature-based discovery in multidisciplinary research of general practice, psychology and psychiatry, and epidemiology.

Background: Sarcopenia is probably an important causal factor for functional decline in acutely illhospitalized geriatric patients. Low skeletal muscle mass, low gait speed and low grip strength are hallmarks ofdiagnosing sarcopenia. However there are many different diagnostic criteria to assess sarcopenia. Objectives:Inthis study the influence of different criteria for sarcopenia was studied on sarcopenia prevalence in geriatricpatients admitted to an acute care hospital. Design:Cross sectional study design. Setting:A geriatric ward of alarge Dutch hospital. Participants:Geriatric patients. Measurements:Skeletal muscle mass measured using bioimpedance analysis (BIA), gait speed using the 4 meter walking test and grip strength. The sarcopenia prevalencewas investigated according to criteria of: muscle mass, grip strength, the European Working Group on Sarcopeniain Elderly People, the International Working Group on Sarcopenia and the Special Interest Group of Society ofSarcopenia, Cachexia and Wasting Disorders. Results:85 geriatric patients were included (61 women). Applyingthe 17 different criteria, the sarcopenia prevalence varied from 26-75% for women and from 42-100% for men. Comparing the Janssen calculation with the Maltron calculation sarcopenia prevalence ranged from respectively26-67% and 67-70% for women and from 42-71% and 75-100% for men. Almost all patients (96%) had a lowgait speed. Conclusions: Sarcopenia is highly prevalent in an acute hospitalized geriatric population, although theprevalence varies widely depending on the diagnostic criteria applied. A prospective study is needed to discoverwhich criteria of sarcopenia can predict best adverse outcomes.

Through their tumor-promoting and/or tumor-suppressive properties, cytokines can influence progression of cancer. We systematically reviewed the current literature on the prognostic value of the circulating cytokines IL-1α/β, IL-6, IL-8, IL-10, IL-12, TNF-α, TGF-β and IFN-γ to predict overall and disease-free survival in any type of cancer patients. PubMed was systematically searched and based on eligibility assessment using our five criteria of the Reporting Recommendations for Tumor Marker Prognostic Studies (REMARK) checklist, six unique studies were reviewed. Elevated IL-6 and IL-10 levels seem independently associated with worse prognosis in terms of overall and disease-free survival. The prognostic value of IL-1α/β, IL-8, IL-12, TNF-α, TGF-β and IFN-γ could not be demonstrated. The small number of selected studies underlines the need for large well-designed prospective studies, using the REMARK checklist as a guideline, to determine which cytokines have prognostic value on survival in cancer patients.

Economic evaluations for medical nutrition, such as oral nutritional supplements (ONS), are relatively uncommon compared with other health technologies, and represent an area that has not been reviewed so far. In this systematic review, economic evaluations of enteral medical nutrition in the management of disease-related malnutrition (DRM) were reviewed and qualified to estimate the economic value. Initially, 481 studies were found, of which 37 full-text articles were assessed for eligibility and were rated on their quality using the Quality of Health Economic Studies (QHES) instrument. The final review focused on the high QHES quality economic evaluation studies. As both the studied medical nutrition intervention and the form of the economic evaluation varied, a quantitative synthesis (meta-analysis) was not attempted but a critical analysis and comparison of the individual study results were performed. ONS was the most studied intervention, covering several patient populations and different health care settings. Outcomes included cost savings (n = 3), no significant extra costs per unit of clinical and/or functional improvement (n = 1), or significantly higher costs per unit of clinical and/or functional improvement but still cost-effective for the used threshold (n = 4). This review shows that the use of enteral medical nutrition in the management of DRM can be efficient from a health economic perspective. Copyright (C) 2014 - American Medical Directors Association, Inc.

Aim: This paper discusses the critical determinants of pressure ulcer development and proposes a new pressure ulcer conceptual framework.Background: Recent work to develop and validate a new evidence-based pressure ulcer risk assessment framework was undertaken. This formed part of a Pressure UlceR Programme Of reSEarch (RP-PG-0407-10056), funded by the National Institute for Health Research. The foundation for the risk assessment component incorporated a systematic review and a consensus study that highlighted the need to propose a new conceptual framework.Design: Discussion Paper.Data Sources: The new conceptual framework links evidence from biomechanical, physiological and epidemiological evidence, through use of data from a systematic review (search conducted March 2010), a consensus study (conducted December 2010–2011) and an international expert group meeting (conducted December 2011).Implications for Nursing: A new pressure ulcer conceptual framework incorporating key physiological and biomechanical components and their impact on internal strains, stresses and damage thresholds is proposed. Direct and key indirect causal factors suggested in a theoretical causal pathway are mapped to the physiological and biomechanical components of the framework. The new proposed conceptual framework provides the basis for understanding the critical determinants of pressure ulcer development and has the potential to influence risk assessment guidance and practice. It could also be used to underpin future research to explore the role of individual risk factors conceptually and operationally.Conclusion: By integrating existing knowledge from epidemiological, physiological and biomechanical evidence, a theoretical causal pathway and new conceptual framework are proposed with potential implications for practice and research.

Projects within the Dutch National Program for Elderly Care (NPO) have been experimenting since 2008 to increase coherence in care for the frail elderly. Invest-NPO explored the problems and solutions to secure the financing of these innovative projects. Problems were expected with coordination because there was not yet a structural reimbursement for such an activity for the frail elderly. There where doubts about the adequacy of reimbursement for multidisciplinary consultation and certain structural conditions. The existing fragmentation across multiple domains and reimbursement rules made it difficult to achieve an integrated approach and creativeness in care. The principles of bundled payment can be helpful in problems concerning multidisciplinary consultation, structural conditions and coordination because joint agreements are needed. According to many, capitation is even a better solution if properly applied, because there are fewer boundaries in deciding how care is organized. Initiatives from entrepreneurs may represent first steps in the right direction. The findings of Invest-NPO may contribute to the development of further steps.

Item does not contain fulltext OBJECTIVE: Existing theoretical work in decision making and behavior change has focused on how individuals arrive at decisions or form intentions. Less attention has been given to theorizing the requirements that might be necessary for individuals to work collaboratively to address difficult decisions, consider new alternatives, or change behaviors. The goal of this work was to develop, as a forerunner to a middle range theory, a conceptual model that considers the process of supporting patients to consider alternative health care options, in collaboration with clinicians, and others. METHODS: Theory building among researchers with experience and expertise in clinician-patient communication, using an iterative cycle of discussions. RESULTS: We developed a model composed of five inter-related propositions that serve as a foundation for clinical communication processes that honor the ethical principles of respecting individual agency, autonomy, and an empathic approach to practice. We named the model 'collaborative deliberation.' The propositions describe: (1) constructive interpersonal engagement, (2) recognition of alternative actions, (3) comparative learning, (4) preference construction and elicitation, and (5) preference integration. CONCLUSIONS: We believe the model underpins multiple suggested approaches to clinical practice that take the form of patient centered care, motivational interviewing, goal setting, action planning, and shared decision making.

Item does not contain fulltext OBJECTIVES: To systematically review the literature on the effect of providing oral healthcare education to care home nurses on their oral healthcare knowledge and attitude and their oral hygiene care skills. METHODS: A literature search was obtained for relevant articles on oral healthcare education of nurses in care homes, using five electronic retrieval systems and databases. The search was limited to human studies, articles published in English and articles published during the period January 1990 to December 2011. The methodological quality of an article was assessed on the basis of criteria published by the Cochrane Collaboration. For articles not meeting all methodological quality criteria, relevance criteria were used to determine how much scientific evidence could be assigned to the study findings. RESULTS: In accordance with the methodological quality criteria, two randomized controlled trials were included. Additionally, four studies were included after determining the scientific evidence of the study findings. The studies included revealed some scientific evidence and indications that an oral healthcare education programme for care home nurses may improve the nurses' oral healthcare knowledge and attitude. Any effect of oral healthcare education to care home nurses' oral hygiene care skills could not be determined. CONCLUSIONS: Oral healthcare education may have a positive effect on care home nurses' oral healthcare knowledge and attitude and on care home residents' oral hygiene, whereas any effect on care home nurses' oral hygiene care skills could not be found.

BackgroundPatients with large abdominal aortic aneurysms (AAAs) are usually offered reparative treatment given the high mortality risk. There is uncertainty about how to treat juxtarenal AAAs (JRAAAs) or thoracoabdominal aortic aneurysms (TAAAs). Endovascular repair of an abdominal aortic aneurysm (EVAR) is often seen as safer and easier than open surgical repair (OSR). However, endovascular treatment of JRAAAs or TAAAs requires specially manufactured stent grafts, with openings to allow blood to reach branches of the aorta. Commissioners are receiving increasing requests for fenestrated EVAR (fEVAR) and branched EVAR (bEVAR), but it is unclear whether or not the extra cost of fEVAR or bEVAR is justified by advantages for patients.Objective(s)To assess the clinical effectiveness, safety and cost-effectiveness of fEVAR and bEVAR in comparison with conventional treatment (i.e. no surgery) or OSR for two populations: JRAAAs and TAAAs.Data sourcesResources were searched from inception to October 2013, including MEDLINE (OvidSP), EMBASE (OvidSP) and the Cochrane Central Register of Controlled Trials (Wiley) and, additionally, for cost-effectiveness, NHS Economic Evaluation Database (NHS EED; Wiley) and EconLit (EBSCOhost). Conference abstracts were also searched.Review methodsStudies were included based on an intervention of either fEVAR or bEVAR and a comparator of either OSR or no surgery. For clinical effectiveness, observational studies were excluded only if they were not comparative, i.e. explicitly selected on the basis of prognosis.ResultsFor clinical effectiveness, searches retrieved 5253 records before deduplication. Owing to overlap between the databases, 1985 duplicate records were removed. Of the remaining 3268 records, based on titles and abstracts, 3244 records were excluded, leaving 24 publications to be ordered. All 24 studies were excluded as none of them satisfied the inclusion criteria. Sixteen studies were excluded on study design, six on intervention and two on comparator. Five out of 16 studies excluded on study design reported a comparison. However, all of the studies acknowledged that they had groups that were not comparable at baseline given that they had selectively assigned younger, fitter patients to OSR. Therefore, these studies were considered ‘non-comparative’. For cost-effectiveness, searches identified 104 references before deduplication. Owing to overlap between the databases, 34 duplicate records were removed. Of the remaining 70 records, seven were included for the full assessment based on initial screening. After a full-text review, no studies were included. Because of the lack of clinical effectiveness evidence and difficulty in estimating costs given the rapidly changing and variable technology, a cost-effectiveness analysis (CEA) was not performed. Instead a detailed description of modelling methods was provided.ConclusionsDespite a thorough search, no studies could be found that met the inclusion criteria. All studies that compared either fEVAR or bEVAR with either OSR or no surgery explicitly selected patients based on prognosis, i.e. essentially the populations for each comparator were not the same. Despite not being able to conduct a CEA, we have provided detailed methods for the conduct if data becomes available.Future workWe recommend at least one clinical trial to provide an unbiased estimate of effect for fEVAR/bEVAR compared with OSR or no surgery. This trial should also collect data for a CEA.Study registrationThis study is registered as PROSPERO CRD42013006051.FundingThe National Institute for Health Research Health Technology Assessment programme.

Background: The 2014 updated Global initiative for chronic Obstructive Lung Disease (GOLD) strategy added the St. George's Respiratory Questionnaire (SGRQ) as the fourth possible symptoms measure. The impact of the suggested tools for symptoms of COPD and the different definitions of future risk on the frequency distribution and clinical characteristics of the GOLD groups remain unknown. Methods: Demographic and clinical characteristics were assessed in 542 patients with COPD (57.7% male, age 64.6 [9.0] years, FEV1 54.7 [22.3]% predicted). Health status was assessed by the COPD-specific SGRQ and symptoms of anxiety and depression by the Hospital Anxiety and Depression Scale, anxiety (HADS-A) and depression (HADS-D) subscale. Cohen's Kappa was used to assess agreement between groups. Results: Level of agreement in frequency distribution using the modified Medical Research Council dyspnea (mMRC) scale ≥2, COPD Assessment Test (CAT) ≥10, Clinical COPD Questionnaire (CCQ) ≥1 and SGRQ ≥25 was moderate to very good. Best agreement was reached between CCQ and SGRQ (К = 0.838 or 0.851, p

Bij evidence-based practice gaat het om het nemen van klinische beslissingen op grond van drie pijlers: het huidige best beschikbare bewijs, de professionele expertise van de zorgverlener en de waarden van de individuele patiënt.1) in onderwijs en onderzoek met betrekking tot ebp ligt echter vaak de nadruk op het gebruik van kennis uit wetenschappelijk onderzoek in de dagelijkse praktijk. In het algemeen gaat weinig aandacht uit naar de waarden van de individuele patiënt in de besluitvorming.2).

Background: A quality improvement collaborative is an intensive project involving a combination of implementation strategies applied in a limited "breakthrough" time window. After an implementation project, it is generally difficult to sustain its success. In the current study, sustainability was described as maintaining an implemented innovation and its benefits over a longer period of time after the implementation project has ended. The aim of the study was to explore potentially promising strategies for sustaining the Enhanced Recovery After Surgery (ERAS) programme in colonic surgery as perceived by professionals, three to six years after the hospital had successfully finished a quality improvement collaborative.Methods: A qualitative case study was performed to identify promising strategies to sustain key outcome variables related to the ERAS programme in terms of adherence, time needed for functional recovery and hospital length of stay (LOS), as achieved immediately after implementation. Ten hospitals were selected which had successfully implemented the ERAS programme in colonic surgery (2006-2009), with success defined as a median LOS of 6 days or less and protocol adherence rates above 70%. Fourteen semi-structured interviews were held with eighteen key participants of the care process three to six years after implementation, starting with the project leader in every hospital. The interviews started by confronting them with the level of sustained implementation results. A direct content analysis with an inductive coding approach was used to identify promising strategies. The mean duration of the interviews was 37 minutes (min 26 minutes - max 51 minutes).Results: The current study revealed strategies targeting professionals and the organisation. They comprised internal audit and feedback on outcomes, small-scale educational booster meetings, reminders, changing the physical structure of the organisation, changing the care process, making work agreements and delegating responsibility, and involving a coordinator. A multifaceted self-driven promising strategy was applied in most hospitals, and in most hospitals promising strategies were suggested to sustain the ERAS programme.Conclusions: Joining a quality improvement collaborative may not be enough to achieve long-term normalisation of transformed care, and additional investments may be needed. The findings suggest that certain post-implementation strategies are valuable in sustaining implementation successes achieved after joining a quality improvement collaborative.

Rationale, aims and objectives Aquality improvement strategy consisting of comparative feedback and peer review embedded in available local quality improvement collaboratives proved to be effective in changing the test-ordering behaviour of general practitioners. However, implementing this strategy was problematic. We aimed for large-scale implementation of an adapted strategy covering both test ordering and prescribing performance. Because we failed to achieve large-scale implementation, the aim of this study was to describe and analyse the challenges of the transferring process.Methods In a qualitative study 19 regional health officers, pharmacists, laboratory specialists and general practitioners were interviewed within 6 months after the transfer period. The interviews were audiotaped, transcribed and independently coded by two of the authors. The codes were matched to the dimensions of the normalization process theory.Results The general idea of the strategy was widely supported, but generating the feedback was more complex than expected and the need for external support after transfer of the strategy remained high because participants did not assume responsibility for the work and the distribution of resources that came with it.Conclusion Evidence on effectiveness, a national infrastructure for these collaboratives and a general positive attitude were not sufficient for normalization. Thinking about managing large databases, responsibility for tasks and distribution of resources should start as early as possible when planning complex quality improvement strategies. Merely exploring the barriers and facilitators experienced in a preceding trial is not sufficient. Although multifaceted implementation strategies to change professional behaviour are attractive, their inherent complexity is also a pitfall for large-scale implementation.

Objectives: To develop a framework to identify and classify interactions within and among treatments and conditions and to test this framework with guidelines on chronic heart failure (CHF) and its frequent comorbidity.Study Design and Setting: Text analysis of evidence-based clinical practice guidelines on CHF and 18 conditions co-occurring in >= 5% of CHF patients (2-4 guidelines per disease). We extracted data on interactions between CHF and comorbidity and key recommendations on diagnostic and therapeutic management. From a subset of data, we derived 13 subcategories within disease-disease (Di-Di-I), disease-drug (Di-D-I), drug-drug interactions (DDI) and synergistic treatments. We classified the interactions and tested the interrater reliability, refined the framework, and agreed on the matrix of interactions.Results: We included 48 guidelines; two-thirds provided information about comorbidity. In total, we identified N = 247 interactions (on average, 14 per comorbidity): 68 were Di-Di-I, 115 were Di-D-I, 12 were DDI, and 52 were synergisms. All 18 comorbidities contributed at least one interaction.Conclusion: The interaction matrix provides a structure to present different types of interactions between an index disease and comorbidity. Guideline developers may consider the matrix to support clinical decision making in multimorbidity. Further research is needed to show its relevance to improve guidelines and health outcomes. (C) 2014 Elsevier Inc. All rights reserved.

Objective: To record and assess the application and the progression of wound healing in patients who received Sorbion sachet S or Sorbion Sana wound dressings. Method: A convenience sample of patients with chronic wounds was recruited from nursing homes or community wound clinics in the Netherlands and the UK. Wound surface area measurements, pain assessment using a visual analogue scale score, patient affect (mood) and social interaction were recorded using a specifically designed evaluation template. Results: Pressure ulcer (PU) (n=11) and leg ulcer (LU) (n=20) patients had a mean age of 64.6 years and 71.7 years, respectively. Mean PU surface area decreased from 15.27cm2 in week 0 to 7.63cm2 in week 8, while mean LU surface area decreased from 19.43cm2 in week 0 to 7.19cm2 in week 8. Mean PU pain decreased from 3.69 in week 0 to 0.67 in week 8, while pain at dressing change decreased from 3.23 in week 0 to 0.75 in week 8. Furthermore, mean LU pain decreased from 3.45 in week 0 to 1.90 in week 8, and pain at dressing change decreased from 3.4 in week 0 to 1.3 in week 8. The number of patients experiencing a negative influence of the PU on affect reduced from 6 in week 0 to 2 in week 8 and on social interaction from 6 in week 0 to 2 in week 8. The number of patients experiencing a negative influence of their LU on affect reduced from 7 in week 0 to zero in week 8 and on social interaction from 7 in week 0 to 2 in week 8. Conclusion: This case series records the response of patients’ chronic wounds in terms of wound progress, patient pain and additional psycho-social factors following the application of the superabsorbent dressings and indicates that the dressings have a positive role to play in creating an environment conductive to the promotion of healing in LUs and PUs. Declaration of interest: Keith Cutting Ltd received an unrestricted research grant for participating in the collation of the two case series.

Rationale, aims and objectivesChronic pain patients referred to a pain treatment facility have no guarantee that they will receive a proper diagnostic procedure or treatment. To obtain information about organizational aspects of pain treatment facilities and the content of their daily pain practice, we performed a questionnaire survey. The aim of the study was to evaluate the amount of pain treatment facilities, the content of organized specialized pain care and adherence to the criteria of the internationally accepted guidelines for pain treatment services. MethodThe University Pain Centre Maastricht in the Department of Anaesthesiology and Pain Management at Maastricht University Medical Centre developed a questionnaire survey based on the Recommendations for Pain Treatment Services of the International Association for the Study of Pain (IASP). The questionnaire was sent to the medical boards of all hospitals in the Netherlands (n=94). ResultsThe response rate was 86% (n=81). Of all hospitals, 88.9% (n=72) reported the provision of organized specialized pain care, which was provided by a pain management team in 86.1% (n=62) and by an individual specialist in 13.9% (n=10). Insight was obtained from pain treatment facilities in five different domains: the organizational structure of pain management, composition of the pain team, pain team practice, patient characteristics, and research and education facilities. ConclusionAlthough 88.9% of all hospitals stated that organized specialized pain care was provided, only a few hospitals could adhere to the criteria for pain treatment services of the IASP. The outcome of the questionnaire survey may help to define quality improvement standards for pain treatment facilities.

BackgroundBowel cancer is the third most common cancer in the UK. Most bowel cancers are initially treated with surgery, but around 17% spread to the liver. When this happens, sometimes the liver tumour can be treated surgically, or chemotherapy may be used to shrink the tumour to make surgery possible. Kirsten rat sarcoma viral oncogene (KRAS) mutations make some tumours less responsive to treatment with biological therapies such as cetuximab. There are a variety of tests available to detect these mutations. These vary in the specific mutations that they detect, the amount of mutation they detect, the amount of tumour cells needed, the time to give a result, the error rate and cost.ObjectivesTo compare the performance and cost-effectiveness ofKRASmutation tests in differentiating adults with metastatic colorectal cancer whose metastases are confined to the liver and are unresectable and who may benefit from first-line treatment with cetuximab in combination with standard chemotherapy from those who should receive standard chemotherapy alone.Data sourcesThirteen databases, including MEDLINE and EMBASE, research registers and conference proceedings were searched to January 2013. Additional data were obtained from an online survey of laboratories participating in the UK National External Quality Assurance Scheme pilot forKRASmutation testing.MethodsA systematic review of the evidence was carried out using standard methods. Randomised controlled trials were assessed for quality using the Cochrane risk of bias tool. Diagnostic accuracy studies were assessed using the QUADAS-2 tool. There were insufficient data for meta-analysis. For accuracy studies we calculated sensitivity and specificity together with 95% confidence intervals (CIs). Survival data were summarised as hazard ratios and tumour response data were summarised as relative risks, with 95% CIs. The health economic analysis considered the long-term costs and quality-adjusted life-years associated with different tests followed by treatment with standard chemotherapy or cetuximab plus standard chemotherapy. The analysis took a ‘no comparator’ approach, which implies that the cost-effectiveness of each strategy will be presented only compared with the next most cost-effective strategy. The de novo model consisted of a decision tree and Markov model.ResultsThe online survey indicated no differences between tests in batch size, turnaround time, number of failed samples or cost. The literature searches identified 7903 references, of which seven publications of five studies were included in the review. Two studies provided data on the accuracy ofKRASmutation testing for predicting response to treatment in patients treated with cetuximab plus standard chemotherapy. Four RCTs provided data on the clinical effectiveness of cetuximab plus standard chemotherapy compared with that of standard chemotherapy in patients withKRASwild-type tumours. There were no clear differences in the treatment effects reported by different studies, regardless of whichKRASmutation test was used to select patients. In the ‘linked evidence’ analysis the Therascreen®KRASRGQ PCR Kit (QIAGEN) was more expensive but also more effective than pyrosequencing or direct sequencing, with an incremental cost-effectiveness ratio of £17,019 per quality-adjusted life-year gained. In the ‘assumption of equal prognostic value’ analysis the total costs associated with the various testing strategies were similar.LimitationsThe results assume that the differences in outcomes between the trials were solely the result of the different mutation tests used to distinguish between patients; this assumption ignores other factors that might explain this variation.ConclusionsThere was no strong evidence that any oneKRASmutation test was more effective or cost-effective than any other test.Study registrationPROSPERO CRD42013003663.FundingThe National Institute for Health Research Health Technology Assessment programme.

Background Diagnostic self-tests are becoming increasingly available. Since the pros and cons of self-testing are unclear and neutral information on self-testing is lacking, two decision aids (DAs) on self-testing for cholesterol and diabetes were developed to support consumers in making an informed choice that is in line with their personal values. We aimed to evaluate the effect of the DAs on the intention to self-test for cholesterol or diabetes, as well as socio-cognitive determinants of that intention. Methods 1137 people of an internet panel with an intention to use a diagnostic self-test for cholesterol or diabetes were enrolled in a web-based randomized controlled trial consisting of four groups: a cholesterol intervention and control group and a diabetes intervention and control group. The study was conducted in September and October 2011. The intervention groups received an interactive online DA with general information on self-testing and test-specific information on cholesterol or diabetes self-testing, whereas the control groups received a limited information sheet with general information on self-testing. The intention to use a self-test for cholesterol or diabetes and perceived susceptibility, perceived severity, cues to action, perceived benefits, perceived barriers, self-efficacy and ambivalence towards self-testing were assessed directly after being exposed to the intervention or control information. Results Follow-up measurement was completed by 922 people. Analyses showed a significant group by intention at baseline interaction effect within the diabetes condition. Further exploration of this interaction showed that a main group-effect was only observed among maybe-intenders; intention of participants in the intervention group did not change between baseline and follow-up, while intention slightly increased in the control group. We observed a significant main effect of group on cues to action in the cholesterol condition. Conclusions We found limited effects of the DAs on intention and its determinants. Although the time spent on the DAs was limited, we might assume that our DAs contain neutral information on self-testing for cholesterol and diabetes. By implementing our DAs in real life among people who probably or definitely intend to use a self-test and by assessing weblog files, we might be able to determine the effectiveness of our DAs on self-test behaviour. Dutch trial register NTR3149.

Objective: To undertake a review of the most recent data on the relationship between quality of life (QoL) and chronic pain, as a basis for discussions about healthy aging in Europe. Method: A search was conducted to obtain studies on the relationship between pain severity and QoL and intervention studies reporting both QoL and pain severity in those with chronic pain in Europe. Medline and Embase were searched for observational studies and systematic reviews from 2009 to 2011. Four further databases were searched for systematic reviews and guidance from 2005 to 2011. Update searches for observational studies and systematic reviews for the period November 2011 to January 2013 were performed on Medline and Embase. Results: We identified 8 observational studies and 1 systematic review that generally showed a statistically significant relationship between pain severity and QoL. We identified 5 systematic reviews of interventions in chronic pain that summarized both pain and QoL data that generally showed both a statistically significant reduction in pain and statistically significant increase in QoL. Conclusion: There is strong evidence of a correlation between pain severity and QoL. There is some evidence that treatment in chronic pain patients can reduce pain and simultaneously improve QoL. Prevention and treatment of chronic pain may be of significant help in reaching the aim to increase the healthy lifespan.

Objective: To compare the similarities among the multimorbidity patterns identified in primary care patients from two European regions (Spain and the Netherlands) with similar organisational features of their primary care systems, using validated methodologies.Methodology: This observational, retrospective, multicentre study analysed information from primary care electronic medical records. Multimorbidity patterns were assessed using exploratory factor analysis of the diagnostic information of patients over 14 years of age. The analysis was stratified by age groups and sex.Results: The analysis of Dutch data revealed a higher prevalence of multimorbidity which corresponds with the clustering of a higher number of diseases in each of the patterns. Relevant clinical similarities were found between both countries for three multimorbidity patterns that were previously identified in the original Spanish study: cardiometabolic, mechanical and psychiatric-substance abuse. In addition, the clinical evolution towards complexity of the cardiometabolic pattern with advancing age -already demonstrated in the original study-was corroborated in the Dutch context. A clear association between mechanical and psychosocial disorders was unique to the Dutch population, as well as the recurrent presentation of the psychiatric-substance abuse pattern in all age and sex groups.Conclusions: The similarities found for the cardiometabolic, mechanical and psychiatric-substance abuse patterns in primary care patients from two different European countries could offer initial clues for the elaboration of clinical practice guidelines, if further evidenced in other contexts. This study also endorses the use of primary care electronic medical records for the epidemiologic characterization of multimorbidity.

Background : Taking the family history helps the doctor in estimating the probability of disease in individual patients. However, significant barriers to obtaining adequate family history information remain. Tools overcoming these barriers might support family physicians in this task.Objective : To review systematically the characteristics of existing family history tools and discuss their potential use in primary care.Methods : Studies were identified through searches of PubMed, Embase and Cinahl from 1 January 2002 until May 2012. All authors independently screened studies and included original research papers on family history tools of which assessment had been performed or was planned. We reviewed diseases for which family history information was collected, study setting, tool design, type of family history collection, presence of risk-assessment and recommendations for management, and assessment (categorized as either validity or benefit).Results : Eighteen family history tools were identified: six generic, two on cardiovascular disease and ten on cancer. The six generic tools were partly tested in primary care (3x), are mainly computerized (4x), rarely include management recommendations for the physician (1x) and were partly validated against a reference standard (genetic counsellor) (3x, plus one planned). Of the five specific tools studied in primary care, none was validated. No family history tool allows electronic transfer of family history information to electronic medical record systems. Use of a family history tool improved identification of patients at risk for disease.Conclusion : Several promising family history tools for primary care have been developed but large-scale implementation cannot be advised yet, based on available validation studies.

Background Physical activity is important for a healthy lifestyle. Although physical activity can delay complications and decrease the burden of the disease, the level of activity of patients with chronic obstructive pulmonary disease (COPD) or type 2 Diabetes Mellitus (DM2) is often far from optimal. To stimulate physical activity, a monitoring and feedback tool, consisting of an accelerometer linked to a smart phone and webserver (It’s LiFe! tool), and a counselling protocol for practice nurses in primary care was developed (the Self-management Support Program). The main objective of this study is to measure the longitudinal effects of this counselling protocol and the added value of using the tool. Methods/Design This three-armed cluster randomised controlled trial with 120 participants with COPD and 120 participants with DM2 (aged 40–70), compares the counselling protocol with and without the use of the tool (group 1 and 2) with usual care (group 3). Recruitment takes place at GP practices in the southern regions of the Netherlands. Randomisation takes place at the practice level. The intended sample (three arms of 8 practices) powers the study to detect a 10-minute difference of moderate and intense physical activity per day between groups 1 and 3. Participants in the intervention groups have to visit the practice nurse 3–4 times for physical activity counselling, in a 4-6-month period. Specific activity goals tailored to the individual patient's preferences and needs will be set. In addition, participants in group 1 will be instructed to use the tool in daily life. The primary outcome, physical activity, will be measured in all groups with a physical activity monitor (PAM). Secondary outcomes are quality of life, general - and exercise - self-efficacy, and health status. Follow-up will take place after 6 and 9 months. Separately, a process evaluation will be conducted to explore reasons for trial non-participation, and the intervention’s acceptability for participating patients and nurses. Discussion Results of this study will give insight into the effects of the It’s LiFe! monitoring and feedback tool combined with care from a practice nurse for people with COPD or DM2 on physical activity. Trial registration ClinicalTrials.gov: NCT01867970

Background The patient perspective is increasingly considered in healthcare policy decisions. The use of research on patient preferences seems however limited. Using the available research on patient preferences would make healthcare policy decisions more evidence-based regarding the patient perspective. Objective of this study is to investigate whether and how results of research on patient preferences are incorporated in current procedures for pharmaceutical coverage decisions and clinical practice guideline (CPG) development. Methods A document analysis on procedure descriptions was combined with case studies. Analyses were performed for five European countries. In the document analysis we systematically checked whether the procedure provides guidance on the systematic use of research on patient preferences, and whether the search and use of research on patient preferences is mentioned in the decision making procedure. In the case studies, which were for exploratory purposes, we scored whether or not research question on patient preferences were formulated, whether or not a search strategy including terms relating to patient preferences was mentioned, whether results of this search strategy were shown and finally, how many references with preference-related terms were included in the reference list of the case. Results None of the procedures for pharmaceutical coverage decisions mentions the systematic consideration of research on patient preferences. For CPG development, the Scottish procedure refers to a mandatory literature search. In the Netherlands this step is optional. In the case studies for pharmaceutical coverage decisions only one reference related to patient preferences was found. Some of the case studies for CPG included research questions, search strategies and references relating to patient preferences. Conclusions This study illustrates that systematic consideration of research on patient preferences in pharmaceutical coverage decisions and guideline development is limited, or if taken into account, this is not visible. This contrasts the strong movement towards patient involvement in health care. Several potential barriers may explain the limited use of research on patient preferences. Electronic supplementary material The online version of this article (doi:10.1186/s12913-014-0540-2) contains supplementary material, which is available to authorized users.

Background In recent years, self-tests have become increasingly available to the general public, though their value is still being debated. Because these tests are available, consumers should have access to clear information about self-testing. Examining experiences of self-testers could contribute to the development of consumer information. Objective Detailed exploration of consumers' experiences with self-testing for cardiovascular risk factors. Methods Semi-structured interviews with 20 consumers who had performed a self-test for glucose, cholesterol or albuminuria. The main topics of the interviews were reasons for self-testing, performing the self-test, follow-up behaviour and perceived need for information on self-testing. Data were analysed using thematic content analysis. Results Regarding the reason for self-testing, three types of users were distinguished: those who engaged in self-testing when a test was offered, either with or without previous knowledge about the disease or risk factor, and those who had actively decided to test and had searched for a self-test themselves. Self-testers had generally experienced no problems performing the test or interpreting the result and had considerable confidence in the result. They were easily reassured by a normal result, while an abnormal result did not automatically mean they consulted a doctor. Most participants did not feel the need for more information. Conclusions Self-testers often perform tests for reassurance, without considering the disadvantages, such as the absence of professional counselling and the risk of false-positive or false-negative results. Consumer information should promote more informed and deliberate choices for self-testing.

Item does not contain fulltext OBJECTIVE: To develop a patient decision aid (PtDA) for mode of delivery after caesarean section that integrates personalised prediction of vaginal birth after caesarean (VBAC) with the elicitation of patient preferences and evidence-based information. DESIGN: A PtDA was developed and pilot tested using the International Patients Decision Aid Standards (IPDAS) criteria. SETTING: Obstetric health care in the Netherlands. POPULATION: A multidisciplinary steering group, an expert panel, and 25 future users of the PtDA, i.e. women with a previous caesarean section. METHODS: The development consisted of a construction phase (definition of scope and purpose, and selection of content, framework, and format) and a pilot testing phase by interview. The process was supervised by a multidisciplinary steering group. MAIN OUTCOME MEASURES: Usability, clarity, and relevance. RESULTS: The construction phase resulted in a booklet including unbiased balanced information on mode of birth after caesarean section, a preference elicitation exercise, and tailored risk information, including a prediction model for successful VBAC. During pilot testing, visualisation of risks and clarity formed the main basis for revisions. Pilot testing showed the availability of tailored structured information to be the main factor involving women in decision-making. The PtDA meets 39 out of 50 IPDAS criteria (78%): 23 out of 23 criteria for content (100%) and 16 out of 20 criteria for the development process (80%). Criteria for effectiveness (n = 7) were not evaluated. CONCLUSIONS: An evidence-based PtDA was developed, with the probability of successful VBAC and the availability of structured information as key items. It is likely that the PtDA enhances the quality of decision-making on mode of birth after caesarean section.

Multimorbidity is a health issue mostly dealt with in primary care practice. As a result of their generalist and patient-centered approach, long-lasting relationships with patients, and responsibility for continuity and coordination of care, family physicians are particularly well placed to manage patients with multimorbidity. However, conflicts arising from the application of multiple disease oriented guidelines and the burden of diseases and treatments often make consultations challenging. To provide orientation in decision making in multimorbidity during primary care consultations, we developed guiding principles and named them after the Greek mythological figure Ariadne. For this purpose, we convened a two-day expert workshop accompanied by an international symposium in October 2012 in Frankfurt, Germany. Against the background of the current state of knowledge presented and discussed at the symposium, 19 experts from North America, Europe, and Australia identified the key issues of concern in the management of multimorbidity in primary care in panel and small group sessions and agreed upon making use of formal and informal consensus methods. The proposed preliminary principles were refined during a multistage feedback process and discussed using a case example. The sharing of realistic treatment goals by physicians and patients is at the core of the Ariadne principles. These result from i) a thorough interaction assessment of the patient’s conditions, treatments, constitution, and context; ii) the prioritization of health problems that take into account the patient’s preferences – his or her most and least desired outcomes; and iii) individualized management realizes the best options of care in diagnostics, treatment, and prevention to achieve the goals. Goal attainment is followed-up in accordance with a re-assessment in planned visits. The occurrence of new or changed conditions, such as an increase in severity, or a changed context may trigger the (re-)start of the process. Further work is needed on the implementation of the formulated principles, but they were recognized and appreciated as important by family physicians and primary care researchers. Please see related article: http://www.biomedcentral.com/1741-7015/12/222. Electronic supplementary material The online version of this article (doi:10.1186/s12916-014-0223-1) contains supplementary material, which is available to authorized users.

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The incidence of cancer rises among older populations [1, 2], and continuous improvement in treatment outcomes is resulting in even greater increases in the prevalence of cancer survivors in this age group [3]. There is considerable variation in cancer mortality rates in the elderly among high-income countries, with the UK having poorer outcomes compared to the USA and Western and Northern European countries [4]. The diagnosis of cancer and treatment decisions following diagnosis at an older age bring specific challenges to health care providers. Further, living with cancer has specific characteristics and consequences for older people. The five papers (three from North America, two from Europe) included in this special issue address some of these topics: increasing awareness of breast cancer symptoms, management of patients with lung and breast cancers, and survivorship issues specific to older patients.

Involving patients in decisions on primary prevention can be questioned from an ethical perspective, due to a tension between health promotion activities and patient autonomy. A nurse-led intervention for prevention of cardiovascular diseases, including counselling (risk communication, and elements of shared decision-making and motivational interviewing) and supportive tools such as a decision aid, was implemented in primary care. The aim of this study was to evaluate the nurse-led intervention from an ethical perspective by exploring in detail the experiences of patients with the intervention, and their views on the role of both the nurse and patient. The study had a qualitative design. 18 patients who had received the intervention participated. Data were gathered by in-depth interviews. The interviews were analysed using directed content analysis. The findings revealed that patients perceived the consultations not as an infringement on their autonomy, but as supportive to risk reduction efforts they tried but found hard to realise. They specifically emphasised the role of the nurse, and appreciated the nurse's realistic advice, encouragement, and help in understanding. Patients' views on and experiences with risk management are in line with notions of relational autonomy, caring cooperation and communicative action found in the literature. We conclude that patients define the relationship with the nurse as shared work in the process of developing a healthier lifestyle.

Ivacaftor (Kalydeco(?), Vertex Pharmaceuticals) is the first of a new class of drugs that target the underlying protein defect in cystic fibrosis (CF). It is aimed at patients with the G551D (glycine to aspartate change in nucleotide 1784 in exon 11) mutation; 5.7% of patients with CF in the UK have this mutation.To review the clinical effectiveness and cost-effectiveness of ivacaftor for the treatment of CF in patients aged ? 6 years who have the G551D mutation.Ten databases, including MEDLINE and EMBASE, were searched from inception to July 2012. Studies that evaluated ivacaftor for the treatment of adults and children (? 6 years) with at least one G551D mutation were eligible. There were insufficient data to conduct a formal meta-analysis. The manufacturer of ivacaftor, Vertex Pharmaceuticals, submitted a deterministic patient-level simulation model for the assessment of the lifetime cost-effectiveness of ivacaftor. We modified the model where values were not UK-specific or not recent, or where better estimates could be found. The only change to the model structure was the addition of lung transplantations. We changed utility values, annual decline in percentage predicted forced expiratory volume in 1 second (FEV1), and the baseline exacerbation rate, and used data from the CF Registry to estimate the relation between costs, age and percentage predicted FEV1. Estimates of treatment effect of ivacaftor came from the clinical effectiveness review. We modelled three scenarios for the longer-term effects of ivacaftor. We also modelled an 'optimistic' scenario for patients aged

Introduction: The concept of participation has been extensively used in health and social care literature since the World Health Organization introduced its description in the International Classification of Functioning, Disability and Health (ICF) in 2001. More recently, the concept of social participation is frequently used in research articles and policy reports. However, in the ICF, no specific definition exists for social participation, and an explanation of differences between the concepts is not available. Aim: The central question in this discussion article is whether participation, as defined by the ICF, and social participation are distinct concepts. This article illustrates the concepts of participation and social participation, presents a critical discussion of their definitions, followed by implications for rehabilitation and possible future directions. Discussion: A clear definition for participation or social participation does not yet exist. Definitions for social participation differ from each other and are not sufficiently distinct from the ICF definition of participation. Although the ICF is regarded an important conceptual framework, it is criticised for not being comprehensive. The relevance of societal involvement of clients is evident for rehabilitation, but the current ICF definition of participation does not sufficiently capture societal involvement. Conclusion: Changing the ICF’s definition of participation towards social roles would overcome a number of its shortcomings. Societal involvement would then be understood in the light of social roles. Consequently, there would be no need to make a distinction between social participation and participation.

Between 2005 and 2007 a short stay programme for breast cancer surgery was successfully implemented in early adopter hospitals. The current study evaluates the sustainability of this success five years following implementation. A retrospective audit of 160 consecutive patients undergoing breast cancer surgery was performed five years following implementation of short stay. The total proportion of patients treated in short stay was 82% (hospital 1 83%, hospital 2 78%, hospital 3 87%, hospital 4 80%) after five years follow-up, which was comparable to the proportion in short stay directly after implementation (p = 0.938). Overall compliance to the key recommendations to facilitate short stay after breast cancer surgery increased from 65% directly after implementation to 78% five years after implementation. This study shows that short stay after breast cancer surgery was successfully sustained in early adopter hospitals five years following implementation.

Sanne van der Weegen,1 Renée Verwey,1,2 Huibert J Tange,3 Marieke D Spreeuwenberg,1 Luc P de Witte1,2 1Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Life Sciences, Maastricht University, the Netherlands; 2Research Centre Technology in Care, Zuyd University of Applied Sciences, Heerlen, the Netherlands; 3Department of General Practice, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Life Sciences, Maastricht University, the Netherlands Introduction: A monitoring and feedback tool to stimulate physical activity, consisting of an activity sensor, smartphone application (app), and website for patients and their practice nurses, has been developed: the 'It's LiFe!' tool. In this study the usability of the tool was evaluated by technology experts and end users (people with chronic obstructive pulmonary disease or type 2 diabetes, with ages from 40–70 years), to improve the user interfaces and content of the tool. Patients and methods: The study had four phases: 1) a heuristic evaluation with six technology experts; 2) a usability test in a laboratory by five patients; 3) a pilot in real life wherein 20 patients used the tool for 3 months; and 4) a final lab test by five patients. In both lab tests (phases 2 and 4) qualitative data were collected through a thinking-aloud procedure and video recordings, and quantitative data through questions about task complexity, text comprehensiveness, and readability. In addition, the post-study system usability questionnaire (PSSUQ) was completed for the app and the website. In the pilot test (phase 3), all patients were interviewed three times and the Software Usability Measurement Inventory (SUMI) was completed. Results: After each phase, improvements were made, mainly to the layout and text. The main improvement was a refresh button for active data synchronization between activity sensor, app, and server, implemented after connectivity problems in the pilot test. The mean score on the PSSUQ for the website improved from 5.6 (standard deviation [SD] 1.3) to 6.5 (SD 0.5), and for the app from 5.4 (SD 1.5) to 6.2 (SD 1.1). Satisfaction in the pilot was not very high according to the SUMI. Discussion: The use of laboratory versus real-life tests and expert-based versus user-based tests revealed a wide range of usability issues. The usability of the It's LiFe! tool improved considerably during the study. Keywords: accelerometry, chronic obstructive pulmonary disease, diabetes mellitus type 2, heuristic evaluation, telemonitoring, thinking aloud

The use of growth monitoring and promotion (GMP) has become widespread. It is a potential contributor towards achieving the Millennium Development Goals of halving hunger and reducing child mortality by two-thirds within 2015. Yet, GMP appears to be a prerequisite for good child health but several studies have shown that there is a discrepancy between the purpose and the practice of GMP. The high prevalence of malnutrition in many developing countries seems to confirm this fact. A descriptive qualitative study was carried out from April to September 2011. Focus group discussions and in-depth interviews were conducted amongst mothers and health workers. Data were analyzed using a qualitative content analysis technique, with the support of ATLAS.ti 5.0 software. The results suggest that most mothers were aware of the need for regular weight monitoring while health workers also seemed to be well-aware and to practise GMP according to the international guidelines. However, there was a deficit in maternal knowledge with regard to child-feeding and a lack of basic resources to keep and/or to buy healthful and nutritionally-rich food. Furthermore, the role of the husband was not always supportive of proper child-feeding. In general, GMP is unlikely to succeed if mothers lack awareness of proper child-feeding practices, and if they are not supported by their husbands.

Contains fulltext : 137818.pdf (Publisher’s version ) (Open Access) BACKGROUND: In view of the paucity of evidence regarding effective ways of reassuring worried patients, this study explored reassuring strategies that are considered useful by general practitioners (GPs). METHODS: In a study using a qualitative observational design, we re-analysed an existing dataset of fifteen stimulated recall interviews in which GPs elaborated on their communication with patients in two videotaped consultations. Additionally we held stimulated recall interviews with twelve GPs about two consultations selected for a strong focus on reassurance. RESULTS: To reassure patients, GPs pursued multiple goals: 1. influencing patients' emotions by promoting trust, safety and comfort, which is considered to be reassuring in itself and supportive of patients' acceptance of reassuring information and 2. influencing patients' cognitions by challenging patients' belief that their symptoms are indicative of serious disease, often followed by promoting patients' belief that their symptoms are benign. GPs described several actions to activate mechanisms to achieve these goals. CONCLUSIONS: GPs described a wealth of reassuring strategies, which make a valuable contribution to the current literature on doctor-patient communication. This detailed description may provide practicing GPs with new tools and can inform future studies exploring the effectiveness of reassurance strategies.

Rationale, aims and objectivesThe diagnostic work-up of patients with shoulder pain in general practice is complex. General practitioners' (GPs) guidelines advise a pragmatic diagnostic work-up in which additional imaging has a limited role. However, diagnostic ultrasounds are increasingly ordered by GPs, which seems to reflect complexity in management of shoulder pain. This study aimed to explore GPs' perspectives on the diagnostic work-up of patients with shoulder pain. MethodThis study has a qualitative exploratory design with an inductive approach and was carried out in Dutch general practice. The study population consisted of 18 Dutch GPs who were sampled purposefully with a spread in clinical experience and ordering diagnostic ultrasound. Data were gathered by means of semi-structured interviews and analysed following principles of the constant comparative method. ResultsThree main categories with subcategories emerged that captured the diagnostic work-up of shoulder pain: variety in diagnostic classifications [(non-)specific diagnosis and interdisciplinary differences], establishing strategies for diagnostic work-up (use of existing tools and motives to deviate from existing tools), and strategies dealing with diagnostic uncertainties (accepting diagnostic uncertainties, diagnostic imaging tests, and interdisciplinary consultation and referral). ConclusionsDespite the availability of evidence-based shoulder guidelines, GPs experience uncertainties during diagnostic work-up and apply different strategies when dealing with these uncertainties. At some point, GPs as well as patients seem to have a need for a specific diagnosis. Currently, there appears to be little agreement if, or in which phase of shoulder pain, diagnostic ultrasound is useful or indicated.

Introduction: The patient’s perspective is becoming increasingly important in clinical and policy decisions. In this study, we aimed to evaluate the preferences of patients with, or at risk of, osteoporosis for medication attributes, and to establish how patients trade between these attributes. Methods: A discrete choice experiment survey was designed and patients were asked to choose between two hypothetical unlabelled drug treatments (and an opt-out option) that vary in five attributes: efficacy in reducing the risk of fracture, type of potential common side-effects, mode and frequency of administration and out-of-pocket costs. An efficient experimental design was used to construct the treatment option choice sets and a mixed logit panel data model was used to estimate patients’ preferences and trade-offs between attributes. Results: A total of 257 patients with, or at risk of, osteoporosis completed the experiment. As expected, patients preferred treatment with higher effectiveness and lower cost. They also preferred either an oral monthly tablet or 6-month subcutaneous injection above weekly oral tablets, 3-month subcutaneous, 3-month intravenous or yearly intravenous injections. Patients disliked being at risk of gastro-intestinal disorders more than being at risk of skin reactions and flu-like symptoms. There was significant variation in preferences across the sample for all attributes except subcutaneous injection. Conclusions: This study revealed that osteoporotic patients preferred 6-month subcutaneous injection and oral monthly tablet, and disliked gastro-intestinal disorders. Moreover, patients were willing to pay a personal contribution or to trade treatment efficacy for better levels of other attributes. Preferences for treatment attributes varied across patients and this highlights the importance of clinical decision-making taking individual preferences into account to improve osteoporosis care.

Introduction. Pulmonary embolism (PE) of ten presents with nonspecific symptoms and may be an easily missed diagnosis. When the differential diagnosis includes PE, an empirical list of frequently occurring alternative diagnoses could support the GP in diagnostic decision making. Objectives. To identify common alternative diagnoses in patients in whom the GP suspected PE but in whom PE could be ruled out. To investigate how the Wells clinical decision rule for PE combined with a point-of-care d-dimer test is associated with these alternative diagnoses. Methods. Secondary analysis of the Amsterdam Maastricht Utrecht Study on thrombo-Embolism (Amuse-2) study, which validated the Wells PE rule combined with point-of-care d-dimer testing in primary care. All 598 patients had been referred to and diagnosed in secondary care. All diagnostic information was retrieved from the GPs’ medical records. Results. In 516 patients without PE, the most frequent alternati ve diagnoses were nonspecific thoracic pain/dyspnoea (42.6%), pneumonia (13.0%), myalgia (11.8%), asthma/chronic obstructive pulmonary disease (4.8%), panic disorder/hyperventilation (4.1%) and respiratory tract infection (2.3%). Pneumonia occurred almost as frequent as PE. Patients without PE with either a positive Wells rule (>4) or a positive d-dimer test, were more often (odds ratio = 2.1) diagnosed with a clinically relevant disease than patients with a negative Wells rule and negative d-dimer test. Conclusion. In primary care patients suspected of PE, the most common clinically relevant diagnosis other than PE w as pneumonia. A positive Wells rule or a positive d-dimer test are not only positively associated with PE, but also with a high probability of other clinically relevant disease.