Nieboer, A.P.

Explaining variation in perceived team effectiveness: Results from eleven quality improvement collaboratives (Article)

2013-06-01T00:00:00Z

Aims and objectives. Explore effectiveness of 11 collaboratives focusing on 11 different topics, as perceived by local improvement teams and to explore associations with collaborative-, organisational- and team-level factors. Background. Evidence underlying the effectiveness of quality improvement collaboratives is inconclusive and few studies investigated determinants of implementation success. Moreover, most evaluation studies on quality improvement collaboratives are based on one specific topic or quality problem, making it hard to compare across collaboratives addressing different topics. Design. A multiple-case cross-sectional study. Methods. Quality improvement teams in 11 quality improvement collaboratives focusing on 11 different topics. Team members received a postal questionnaire at the end of each collaborative. Of the 283 improvement teams, 151 project leaders and 362 team members returned the questionnaire. Results. Analysis of variance revealed that teams varied widely on perceived effectiveness. Especially, members in the Prevention of Malnutrition and Prevention of Medication Errors collaboratives perceived a higher effectiveness than other groups. Multilevel regression analyses showed that educational level of professionals, innovation attributes, organisational support, innovative culture and commitment to change were all significant predictors of perceived effectiveness. In total, 27·9% of the individual-level variance, 57·6% of the team-level variance and 80% of the collaborative-level variance could be explained. Conclusion. The innovation's attributes, organisational support, an innovative team culture and professionals' commitment to change are instrumental to perceived effectiveness. The results support the notion that a layered approach is necessary to achieve improvements in quality of care and provides further insight in the determinants of success of quality improvement collaboratives. Relevance to clinical practice. Understanding which factors enhance the impact of quality improvement initiatives can help professionals to achieve breakthrough improvement in care delivery to patients on a wide variety of quality problems.

A validation of the ICECAP-O in a population of post-hospitalized older people in the Netherlands (Article)

2013-04-08T00:00:00Z

Background: Various healthcare and social services may impact not only health, but wellbeing as well. Such effects may be more fully captured by capability-wellbeing instruments than with Health-related Quality of Life (HrQol) instruments. The aim of this study is to validate the ICEpop (Investigating Choice Experiments for the Preferences of Older People) CAPability measure for Older people (ICECAP-O) capability wellbeing instrument in a population of post-hospitalized older people admitted to a hospital 3 months earlier.Methods: 296 post-hospitalized older people in the Netherlands were interviewed 3 months after admission between September 2010 and January 2011. We investigated the convergent validity of the ICECAP-O and overall wellbeing measures (Cantril's ladder and Social Production Function: Instrument for Level of Well-being (SPF-IL)), as well as with various health measures (EQ5D, Katz-15 Instrumental Activities of Daily Living (IADL) scale, Geriatric Depression Scale (GDS) and the Medical Outcomes Study Short form (SF-20) social functioning dimension). Additionally, we assessed discriminant validity by comparing several relevant subgroups in our sample (based on age, depression, IADL dependency, living situation, etc.). We also investigated the relationship between overall wellbeing and the ICECAP-O, controlling for HrQol and background characteristics.Results: This study suggests that the ICECAP-O has good convergent validity with wellbeing measures as well as health measures and discriminates between various groups of post-hospitalized older people. Wellbeing measured by both Cantril's ladder and SPF-IL is associated with the ICECAP-O in a multivariate analysis controlling for HRQoL as well.Conclusion: The ICECAP-O seems to be a valid instrument of capability-wellbeing in older, post-hospitalized people, showing good convergent validity with health and wellbeing instruments, and is able to discriminate between elderly with various health profiles. The ICECAP-O measure seems to capture both health and wellbeing. Therefore it is a promising instrument for assessing the outcomes of health and social services aimed at older people.

A large-scale longitudinal study indicating the importance of perceived effectiveness, organizational and management support for innovative culture (Article)

2013-04-01T00:00:00Z

Teams participating in QI collaboratives reportedly enhance innovative culture in long-term care, but we currently lack empirical evidence of the ability of such teams to enhance (determinants of) innovative culture over time. The objectives of our study are therefore to explore innovative cultures in QI teams over time and identify its determinants. The study included QI teams participating between 2006 and 2011 in a national Dutch quality program (Care for Better), using an adapted version of the Breakthrough Method. Each QI team member received a questionnaire by mail within one week after the second (2-3 months post-implementation of the collaborative = T0) and final conference (12 months post-implementation = T1). A total of 859 (out of 1161) respondents filled in the questionnaire at T0 and 541 at T1 (47% response). A total of 307 team members filled in the questionnaire at both T0 and T1. We measured innovative culture, respondent characteristics (age, gender, education), perceived team effectiveness, organizational support, and management support. Two-tailed paired t-tests showed that innovative culture was slightly but significantly lower at T1 compared to T0 (12 months and 2-3 months after the start of the collaborative, respectively). Univariate analyses revealed that perceived effectiveness, organizational and management support were significantly related to innovative culture at T1 (all at p ≤ 0.001). Multilevel analyses showed that perceived effectiveness, organizational support, and management support predicted innovative culture. Our QI teams were not able to improve innovative culture over time, but their innovative culture scores were higher than non-participant professionals. QI interventions require organizational and management support to enhance innovative culture in long-term care settings.

Development and Validation of the Older Patient Assessment of Chronic Illness Care (O-PACIC) Scale After Hospitalization (Article)

2013-03-25T00:00:00Z

Objectives of this study were to develop and validate an instrument to assess older patients' experiences with integrated care delivery after hospitalization. Our study was conducted among older individuals (≥65) who had recently been discharged from a hospital. At T1, 3 months after hospital admission, 296/457 patients (65 % response) were interviewed in their homes. At T2 12 months after hospital admission, 242/436 patients (56 % response) were interviewed. Point of departure for the development of the scale was the 20-item Patient Assessment of Chronic Illness Care (PACIC), which is proven to be a valid measure to assess chronically-ill patients' assessment of integrated primary care delivery. We tested both the PACIC and new instrument by means of structural equation modeling, and examined its validity and reliability. After eliminating 10 items of the PACIC, the confirmatory factor analyses revealed good indices of fit with the 10-item Older Patient Assessment of Chronic Illness Care (O-PACIC) Scale. To estimate construct validity of the instrument, we looked at correlations between PACIC and O-PACIC scores and the satisfaction with stroke care home subscale (SASC-Home) questionnaire. Both the PACIC and O-PACIC significantly correlated with SASC-Home subscale (at p ≤ 0.001), which indicated validity. This study demonstrated that O-PACIC is a feasible, reliable and valid tool, with strong psychometric properties. We conclude that the O-PACIC is a promising instrument to evaluate integrated care delivery after hospitalization among older patients.

The experiences of neighbour, volunteer and professional support-givers in supporting community dwelling older people (Article)

2013-03-01T00:00:00Z

Public policy increasingly emphasises the importance of informal support networks to meet the needs of the ageing population. Evidence for the types of support neighbours provide to older people and how neighbours collaborate with formal support-givers is currently insufficient. Our study therefore explored (i) types of informal neighbour support and (ii) experiences of neighbours, volunteers and professionals providing support. Interviews with nine Dutch neighbour support-givers, five volunteers and 12 professionals were conducted and subjected to latent content analysis. Findings indicate that commitment occurred naturally among neighbours; along with providing instrumental and emotional support, neighbour support seems to be a matter of carefully 'watching over each other'. Neighbour support-givers, however, are often frail themselves and become overburdened; they furthermore lack support from professionals. Neighbour, volunteer and professional support-givers seem to operate in distinct, non-collaborative spheres. Findings suggest that policy-makers should consider the opportunities and limitations of neighbour and volunteer support. Professionals have an indispensable role in providing back-up and accountable, specialised support. They may be trained to adopt a visible and proactive attitude in neighbourhoods to facilitate, cooperate with and mediate between neighbour and volunteer support-givers.

The influence of organizational characteristics on employee solidarity in the long-term care sector (Article)

2013-03-01T00:00:00Z

Aim. This article is a report of a study that identifies organizational characteristics explaining employee solidarity in the long-term care sector. Background. Employee solidarity reportedly improves organizations' effectiveness and efficiency. Although general research on solidarity in organizations is available, the impact of the organizational context on solidarity in long-term care settings is lacking. Design. Cross-sectional survey. Method. The study was carried out in Dutch long-term care. A total of 313 nurses, managers and other care professionals in 23 organizations were involved. Organizational characteristics studied were centralization, hierarchical culture, formal and informal exchange of information and leadership style. The study was carried out in 2009. Findings. All organizational characteristics significantly correlated with employee solidarity in the univariate analyses. In the multivariate analyses hierarchical culture, centralization, exchange of formal and informal information and transformational leadership appears to be important for solidarity among nurses, managers and other professionals in long-term care organizations, but not transactional and passive leadership styles. Conclusion. The study increased our knowledge of solidarity among nurses, managers and other professionals in the long-term care settings. Organizational characteristics that enhance solidarity are high levels of formal and informal information exchange, less hierarchical authority, decentralization and transformational leadership styles.

Relational coordination between community health nurses and other professionals in delivering care to community-dwelling frail people (Article)

2013-03-01T00:00:00Z

Aims: The first aim of this study was to investigate whether relational coordination is higher between primary care professionals and community health nurses than among other professionals. The second aim of this study was to investigate the relationship between different levels of relational coordination and primary care professionals' satisfaction with the care delivery of community health nurses. Background: Community health nursing is based on the notion that all activities should respond to frail people's needs in a coordinated way, together with other professionals. Relational coordination is therefore important for the effective health-care delivery by these nurses. Methods: This cross-sectional study was performed among 167 professionals (n = 323, response rate 52%) who regularly worked with community health nurses. Results: The results showed a higher degree of relational coordination with community health nurses than with other primary care professionals. Multilevel analyses revealed that professionals' satisfaction with the care delivered by community health nurses was influenced positively by relational coordination. Conclusion: Enhancing relational coordination between community health nurses and other primary care professionals in the neighborhood may improve the delivery of care to community-dwelling frail people. Implications for nursing management: Comprehensive care delivery to community-dwelling frail people requires strong connections between all health and social care professionals. Community health nurses may be an important factor in strengthening these connections.

Understanding older patients' self-management abilities: functional loss, self-management, and well-being (Article)

2013-02-01T00:00:00Z

Purpose: This study aimed to increase our understanding of self-management abilities and identify better self-managers among older individuals. Methods: Our cross-sectional research was based on a pilot study of older people who had recently been admitted to a hospital. In the pilot study, all patients (>65 years of age) who were admitted to the Vlietland hospital between June and October 2010 were asked to participate, which led to the inclusion of 456 older patients at baseline. A total of 296 patients (65% response rate) were interviewed in their homes 3 months after admission. Measures included social, cognitive, and physical functioning, self-management abilities, and well-being. We used descriptive, correlations, and multiple regression analyses. In addition, we evaluated the mediation effect of self-management abilities on well-being. Results: Social, cognitive, and physical functioning significantly correlated with self-management abilities and well-being (all p ≤ 0.001). After controlling for background characteristics, multiple regression analysis indicated that social, cognitive, and physical functioning still related to self-management abilities (β = 0.17-0.25; all p ≤ 0.001). Older people with low levels of social, cognitive, and physical functioning were worse self-managers than were those with higher levels of functioning. Conclusions: Self-management abilities mediate the relationship between social, cognitive, and physical functioning and well-being. Interventions to improve self-management abilities may help older people better deal with function losses as they age further.

The Longitudinal Relationship Between Satisfaction with Transitional Care and Social and Emotional Quality of Life Among Chronically Ill Adolescents (Article)

2013-01-28T00:00:00Z

This study aimed to identify the relationship between satisfaction with transitional care and quality of life of chronically ill adolescents over time. This longitudinal study included adolescents with type I diabetes, juvenile idiopathic arthritis (JIA), and neuromuscular disorders (NMD). At baseline 138 respondents (response rate 31 %) filled in a questionnaire and 188 about 1 year later (response rate 43 %). Analysis of variance showed that adolescents with diabetes reported the highest physical quality of life, followed in order by those with NMD and JIA (p ≤ 0.01). Adolescents with diabetes reported the highest social quality of life, followed in order by those with JIA and NMD (both at p ≤ 0.001). Univariate analyses showed that satisfaction with transitional care at T0 was significantly related to emotional and physical quality of life at T1 (both at p ≤ 0.05). At T1, satisfaction with transitional care was significantly related to the emotional, physical, and social domains of quality of life (all at p ≤ 0.001). Multiple regression analyses revealed that satisfaction with transitional care at T1 was related to emotional (β -0.20; p ≤ 0.05) and social (β -0.35; p ≤ 0.01) quality of life domains over time. This indicates that lower gap scores, which measured differences between 'best care' and 'current care,' are associated with better social and emotional quality of life in this sample of adolescents. Satisfaction with transitional care and social and emotional quality of life are related over time.

A measurement instrument for spread of quality improvement in healthcare (Article)

2013-01-01T00:00:00Z

Abstract Objective. The aim of this study was to develop and test a measurement instrument for spread of quality improvement in healthcare. The instrument distinguishes: (i) spread of work practices and their results and (ii) spread practices and effectiveness. Relations between spread and sustainability of changed work practices were also explored to assess convergent validity. Design. We developed and tested a measurement instrument for spread in a follow-up study. The instrument consisted of 18-items with four subscales. Setting and participants. The sample consisted of former improvement teams in a quality improvement program for longterm care (nteams = 73, nrespondents = 127). Data were collected in a questionnaire about 1 year post-pilot site improvement implementation. Interventions. Quality improvements in long-term care practices. Main outcome measures. Four variables were construed: (i) actions for spread of work practices, (ii) actions for spread of results, (iii) effectiveness of spread of work practices and (iv) effectiveness of spread of results. Results. Psychometric analysis yielded positive results on the item level. The intended four-factor model yielded satisfactory fit. The internal consistency of each scale was fine (Cronbach’s α 0.70–0.93). Bivariate correlations revealed that the spread variables were strongly related but distinct, and positively related to the sustainability variables. Conclusions. The psychometric properties are in line with methodological standards. Convergent validity was confirmed with sustainability. The measurement instrument offers a good starting point for the analysis of spread. Keywords: spread, measurement instrument, quality improvement, sustainability, spread practices

The Prevention and Reactivation Care Program: intervention fidelity matters (Article)

2013-01-01T00:00:00Z

Background: The Prevention and Reactivation Care Program (PReCaP) entails an innovative multidisciplinary, integrated and goal oriented approach aimed at reducing hospital related functional decline among elderly patients. Despite calls for process evaluation as an essential component of clinical trials in the geriatric care field, studies assessing fidelity lag behind the number of effect studies. The threefold purpose of this study was (1) to systematically assess intervention fidelity of the hospital phase of the PReCaP in the first year of the intervention delivery; (2) to improve our understanding of the moderating factors and modifications affecting intervention fidelity; and (3) to explore the feasibility of the PReCaP fidelity assessment in view of the modifications. Methods: Based on the PReCaP description we developed a fidelity instrument incorporating nineteen (n=19) intervention components. A combination of data collection methods was utilized, i.e. data collection from patient records and individual Goal Attainment Scaling care plans, in-depth interviews with stakeholders, and non-participant observations. Descriptive analysis was performed to obtain levels of fidelity of each of the nineteen PReCaP components. Moderating factors were identified by using the Conceptual Framework for Implementation Fidelity. Results: Ten of the nineteen intervention components were always or often delivered to the group of twenty elderly patients. Moderating factors, such as facilitating strategies and context were useful in explaining the non- or low-adherence of particular intervention components. Conclusions: Fidelity assessment was carried out to evaluate the adherence to the PReCaP in the Vlietland Ziekenhuis in the Netherlands. Given that the fidelity was assessed in the first year of PReCaP implementation it was commendable that ten of the nineteen intervention components were performed always or often. The adequate delivery of the intervention components strongly depended on various moderating factors. Since the intervention is still developing and undergoing continuous modifications, it has been concluded that the fidelity criteria should evolve with the modified intervention. Furthermore, repeated intervention fidelity assessments will be necessary to ensure a valid and reliable fidelity assessment of the PReCaP.

Relationships between frailty, neighborhood security, social cohesion and sense of belonging among community-dwelling older people (Article)

2012-12-03T00:00:00Z

Aim: The relationships between frailty and neighborhood social resources and neighborhood quality among community-dwelling older people are poorly understood. We therefore enquired into these associations while controlling for important individual characteristics. Methods: Our cross-sectional study included 945 out of 1440 (66% response rate) community-dwelling older people (aged ≥70 years) in Rotterdam. The sample included approximately 430 older adults per district and was proportional with respect to neighborhood and age. Potential participants were mailed questionnaires, non-respondents were first sent a reminder, then asked by telephone and finally visited at home to complete the questionnaire. Results: Age, sex, marital status and level of education varied between the frail and non-frail. A significantly larger proportion of the frail was female (64.4% vs 48.0%; P≤0.001), fewer were married (22.1% vs 48.4%; P≤0.001) and the frail were, on average, older than the non-frail (78.8 vs 76.0 years; P≤0.001). A significantly larger proportion of the frail were poorly educated (25.9% vs 18.6%; P≤0.01). Multilevel regression analyses showed that older age (P<0.001) was associated with higher likelihood of frailty and marital status (P<0.001) with lower likelihood of frailty. Feeling more secure (P<0.001) and having a stronger sense of social cohesion and neighborhood belonging (P<0.05) seemed to protect against frailty. Conclusion: The results of this study support the importance of feeling safe, social cohesion and a sense of belonging within the neighborhood. These findings could have important implications for efforts to reduce frailty of older people within communities.

The relationship between older adults' self-management abilities, well-being and depression (Article)

2012-12-01T00:00:00Z

This study aimed to identify the relationship between self-management abilities, well-being and depression. Our study was conducted among older adults (>65 years of age) who were vulnerable to loss of function after hospital discharge. Three months after hospital admission, 296/456 patients (65 % response rate) were interviewed in their homes. The 30-item Self-Management Ability Scale was used to measure six self-management abilities: taking initiative, investing in resources for long-term benefits, taking care of a variety of resources, taking care of resource multifunctionality, being self-efficacious and having a positive frame of mind. Well-being was measured with the Social Production Function (SPF) Instrument for the Level of Well-being (SPF-IL) and Cantril's ladder. The Geriatric Depression Scale was used to assess depression. Correlation analyses showed that all self-management abilities were strong indicators for well-being (p < 0.001 for all). Regression analyses revealed that investing in resources for long-term benefits, taking care of a variety of resources, taking care of resource multifunctionality and being self-efficacious were associated with well-being. While no significant relationship was found between well-being and having a positive frame of mind or taking initiative, regression analyses revealed that these self-management abilities were related to depression. Investing in resources for long-term benefits and taking care of a variety of resources were significantly related to depression. This research showed that self-management abilities are related to well-being and depression among older adults. In addition, this study identified key self-management abilities for older adults who had recently been discharged from a hospital.

The role of partnership functioning and synergy in achieving sustainability of innovative programmes in community care (Article)

2012-11-27T00:00:00Z

This cross-sectional study (conducted in April-May 2011) explored associations between partnership functioning synergy and sustainability of innovative programmes in community care. The study sample consisted of 106 professionals (of 244 individuals contacted) participating in 21 partnerships that implemented different innovative community care programmes in Rotterdam, The Netherlands. Partnership functioning was evaluated by assessing leadership, resources administration and efficiency. Synergy was considered the proximal outcome of partnership functioning, which, in turn, influenced the achievement of programme sustainability. On a 5-point scale of increasing sustainability, mean sustainability scores ranged from 1.9 to 4.9. The results of the regression analysis demonstrated that sustainability was positively influenced by leadership (standardised regression coefficient β=0.32; P<0.001) and non-financial resources (β=0.25; P=0.008). No significant relationship was found between administration or efficiency and programme sustainability. Partnership synergy acted as a mediator for partnership functioning and significantly affected sustainability (β=0.39; P<0.001). These findings suggest that the sustainability of innovative programmes in community care is achieved more readily when synergy is created between partners. Synergy was more likely to emerge with boundary-spanning leaders, who understood and appreciated partners' different perspectives, and could bridge their diverse cultures and were comfortable sharing ideas, resources and power. In addition, the acknowledgement of and ability to use members' resources were found to be valuable in engaging partners' involvement and achieving synergy in community care partnerships.

The care span: In the netherlands, rich interaction among professionals conducting disease management led to better chronic care (Article)

2012-11-01T00:00:00Z

Disease management programs based on the Chronic Care Model are expected to improve the quality of chronic care delivery. However, evidence to date for such improvement and how it is achieved is scarce. In 2010 and again in 2011, we surveyed professionals in twentytwo primary care practices in the Netherlands that had implemented the Chronic Care Model of disease management beginning in 2009. The responses showed that, over time, chronic illness care delivery improved to advanced levels. The gains were attributed primarily to improved relational coordination-that is, raising the quality of communication and task integration among professionals from diverse disciplines who share common objectives. These findings may have implications for other disease management efforts by collaborative care teams, in that they suggest that diverse health care professionals must be strongly connected to provide effective, holistic care.

Relational coordination promotes quality of chronic care delivery in Dutch disease-management programs (Article)

2012-10-01T00:00:00Z

BACKGROUND:: Previous studies have shown that relational coordination is positively associated with the delivery of hospital care, acute care, emergency care, trauma care, and nursing home care. The effect of relational coordination in primary care settings, such as disease-management programs, remains unknown. PURPOSE:: This study examined relational coordination between general practitioners and other professionals in disease-management programs and assessed the impact of relational coordination on the delivery of chronic illness care. METHODOLOGY:: Professionals (n = 188; response rate = 57%) in 19 disease-management programs located throughout the Netherlands completed surveys that assessed relational coordination and chronic care delivery. We used a cross-sectional study design. FINDINGS:: Our study demonstrated that the delivery of chronic illness care was positively related to relational coordination. We found positive relationships with community linkages (r = .210, p < .01), self-management support (r = .217, p < .01), decision support (r = .190, p < .01), delivery system design (r = .278, p < .001), and clinical information systems (r = .193, p < .01). Organization of the health delivery system was not significantly related to relational coordination. The regression analyses showed that even after controlling for all background variables, relational coordination still significantly affected chronic care delivery (β = .212, p ≤ .01). As expected, our findings showed a lower degree of relational coordination among general practitioners than between general practitioners and other core disease-management team members: practice nurses (M = 2.69 vs. 3.73; p < .001), dieticians (M = 2.69 vs. 3.07; p < .01), physical therapists (M = 2.69 vs. 3.06; p < .01), medical specialists (M = 2.69 vs. 3.16; p < .01), and nurse practitioners (M = 2.69 vs. 3.19; p < .001). PRACTICE IMPLICATIONS:: The enhancement of relational coordination among core disease-management professionals with different disciplines is expected to improve chronic illness care delivery.

Factorial validation of the patient assessment of chronic illness care (PACIC) and PACIC short version (PACIC-S) among cardiovascular disease patients in the Netherlands (Article)

2012-08-31T00:00:00Z

Objective: The Chronic Care Model (CCM) has achieved widespread acceptance and reflects the core elements of patient-centred care in chronic diseases such as cardiovascular diseases (CVD). In the Netherlands the extent to which CVD patients receive care congruent with the CCM is unknown. The main objectives of this study were to validate the 20-item Patient Assessment of Chronic Illness Care (PACIC) and the 11-item (PACIC-S) in the Netherlands among CVD patients and investigate the validity, reliability, and sensitivity to change of both instruments.Methods: The Dutch version of the PACIC and PACIC-S were tested among 1484 CVD patients (out of 2760; response rate 54%) enrolled in Disease Management Programmes (DMPs) at T0 and 1167 respondents (out of 2545; response rate = 46%) at T1. Five hundred-eighty-five CVD patients filled in the questionnaire at both T0 and T1. We tested the instrument by means of structural equation modeling, and examined its construct validity, reliability and sensitivity to change. Reliability of the instrument was assessed by determining the statistical coherence of the scaled items. Internal consistency of the subscales was assessed by calculating Cronbach's alphas and correlations between the PACIC and PACIC-S. We investigated the sensitivity to change of the original PACIC and the PACIC-S with paired t-tests among CVD patients in DMPs who filled in the questionnaire at both T0 and T1 (N = 585).Results: The confirmatory factor analyses revealed good indices of fit with the PACIC and PACIC-S. Internal consistency as represented by Cronbach's alphas were also good. Correlations between the PACIC and PACIC-S subscales were excellent: 0.98 at both T0 and T1. Paired t-tests results show that the PACIC and PACIC-S improved significantly over time (p < 0.01).Conclusions: The psychometric properties of the Dutch PACIC and PACIC-S were satisfactory and it is sensitive to change, rendering it a valid and reliable instrument for assessing chronic illness care among CVD patients.

The chronic care model: Congruency and predictors among patients with cardiovascular diseases and chronic obstructive pulmonary disease in the Netherlands (Article)

2012-08-07T00:00:00Z

Objective: The Chronic Care Model (CCM) achieved widespread acceptance and reflects the core elements of patient-centred care in chronic diseases such as CVD and COPD. Our aim is to assess the extent to which current care for CVD and COPD patients aligns with the CCM in Dutch healthcare practices in the early stages of implementing disease-management programs, thereby revealing possible predictors that tell us whether certain patients are more likely to receive CCM-compliant care than others. Methods: We use a cross-sectional study, addressing CVD or COPD patients from 106 primary care practices in the Netherlands. Our response rate was 53%; i.e., 2,487 of 4,681 questionnaires were returned. The Patient Assessment of Chronic Illness Care (PACIC) was used to assess compliance with CCM. Quality of life was assessed with the Short-Form 36 Health Survey (SF-36) and we used the Hospital Anxiety and Depression Scale (HADS) to assess depressive symptoms. Multilevel regression models were performed to reveal predictors of high CCM compliance. Results: With a mean (SD) of 2.77 (0.86) in CVD patients and 2.89 (0.89) in COPD patients (p = 0.002), the PACIC sum score was lower than in previous studies conducted in HMOs in the US, but similar to a European primary care setting study. The PACIC score was associated with age and depressive symptoms in both patient groups. Conclusions: Younger and less depressed patients report higher PACIC scores, indicating that their care better aligns to the CCM.

Self-management abilities, physical health and depressive symptoms among patients with cardiovascular diseases, chronic obstructive pulmonary disease, and diabetes (Article)

2012-06-01T00:00:00Z

Objective: This study aimed to identify the predictive role of direct resources (educational level and marital status) and self-management abilities on physical health and depressive symptoms in patients with cardiovascular diseases (CVD), diabetes, or chronic obstructive pulmonary disease (COPD). Methods: Our cross-sectional questionnaire-based study included 1570 CVD patients, 917 COPD patients, and 412 patients with diabetes. Results: Physical health and depressive symptoms of COPD patients was lower than those of CVD and diabetic patients. Correlation analyses indicated that self-management abilities were strong indicators for physical health and depressive symptoms (all . p<. 0.001). This relationship was strongest for depressive symptoms. Self-management abilities were related to educational level in all groups (all . p<. 0.001). Regression analyses revealed that self-management abilities were strong predictors of physical health and depressive symptoms in all three patient groups (all . p<. 0.001). Conclusion: This research showed that self-management abilities are strong predictors of physical health and depressive symptoms. Practice implications: Interventions that improve self-management abilities may counteract a decline in physical health and depressive symptoms. Such interventions may be important tools in the prevention of the loss of self-management abilities, because they may motivate people who are not yet experiencing serious problems.

Disease-management partnership functioning, synergy and effectiveness in delivering chronic-illness care (Article)

2012-06-01T00:00:00Z

Objective: This study explored associations among disease-management partnership functioning, synergy and effectiveness in the delivery of chronic-illness care. Design: This study had a cross-sectional design. Setting and participants: The study sample consists of 218 professionals (out of 393) participating in 22 disease-management partnerships in various regions of the Netherlands. Main outcome measures: We assessed the relationships among partnership functioning, synergy and effectiveness in the delivery of chronic-illness care. Partnership functioning was assessed through leadership, resources, administration and efficiency. Synergy was considered the proximal outcome of partnership functioning, which, in turn, influenced the effectiveness of disease-management partnerships [measured with the Assessment of Chronic Illness Care (ACIC) survey instrument]. Results: Overall ACIC scores ranged from 3 to 10, indicating basic/intermediate to optimal/comprehensive delivery of chronic-illness care. The results of the regression analysis demonstrate that partnership effectiveness was positively associated with leadership (β = 0.25; P≤ 0.01), and resources (β = 0.31; P≤ 0.001). No significant relationship was found between administration, efficiency and partnership effectiveness. Partnership synergy acted as a mediator for partnership functioning and was statistically significantly associated with partnership effectiveness (β = 0.25; P≤ 0.001). Conclusion: Disease-management partnerships seemed better able to deliver higher levels of chronic-illness care when synergy is created between partners. Synergy was more likely to emerge with boundary-spanning leaders who understood and appreciated partners' different perspectives, could bridge their diverse cultures and were comfortable sharing ideas, resources and power. In addition, the acknowledgement of and ability to use members' resources are valuable in engaging partners' involvement and achieving synergy in disease-management partnerships.

Capabilities and quality of life in Dutch psycho-geriatric nursing homes: An exploratory study using a proxy version of the ICECAP-O (Article)

2012-06-01T00:00:00Z

Purpose: To validate the ICECAP-O capability measure in psycho-geriatric elderly in nursing homes, we compared the capability scores of restrained and unrestrained clients. Both nursing staff and family were used as proxies for assessing clients' capabilities. Method: For 122 psycho-geriatric elderly, a total of 96 nursing professionals and 68 family members completed a proxy questionnaire. We investigated the convergent and discriminant validity of the ICECAP-O and measures of care dependency, health-related quality of life, and overall quality of life. We also directly compared ICECAP-O scores of the 56 clients for whom both nursing staff and family members had completed the questionnaire. Results: Convergent validity between ICECAP-O and care dependency, health-related, and overall quality of life measures could be established, as well as discriminant validity for the restrained and unrestrained groups. Nursing and family proxy ICECAP-O tariffs were not significantly correlated. Discussion ICECAP-O measures a more general concept than health-related quality of life and can differentiate between restrained and non-restrained psycho-geriatric clients. Since nurses seem to be able to assess the current quality of life of clients using the ICECAP-O more precisely than the family proxies, for now the use of nursing proxies is recommended in a nursing home setting.

Disease management projects and the Chronic CareModel in action: Baseline qualitative research (Article)

2012-05-11T00:00:00Z

Background: Disease management programs, especially those based on the Chronic Care Model (CCM),are increasingly common in the Netherlands. While disease management programs have beenwell-researched quantitatively and economically, less qualitative research has been done. Theoverall aim of the study is to explore how disease management programs are implementedwithin primary care settings in the Netherlands; this paper focuses on the early developmentand implementation stages of five disease management programs in the primary care setting,based on interviews with project leadership teams. Methods: At the five sites, eleven semi-structured interviews were conducted at the five selected siteswith sixteen professionals interviewed; all project leaders were interviewed. The interviewsfocused on each project's chosen chronic illness (diabetes, eating disorders, COPD, multimorbidity,CVRM) and project plan, barriers to development and implementation, the projectleaders' action and reactions, as well as their roles and responsibilities, and diseasemanagement strategies. Analysis was inductive and interpretive, based on the content of theinterviews. After analysis, the results of this research on disease management programs andthe Chronic Care Model are viewed from a traveling technology framework. Results: This analysis uncovered four themes that can be mapped to disease management and theChronic Care Model: (1) changing the health care system, (2) patient-centered care, (3)technological systems and barriers, and (4) integrating projects into the larger system. Projectleaders discussed the paths, both direct and indirect, for transforming the health care systemto one that addresses chronic illness. Patient-centered care was highlighted as needed and aparadigm shift for many. Challenges with technological systems were pervasive. Projectleaders managed the expenses of a traveling technology, including the social, financial, andadministration involved. Conclusions: At the sites, project leaders served as travel guides, assisting and overseeing the programs asthey traveled from the global plans to local actions. Project leaders, while hypothetically incontrol of the programs, in fact shared control of the traveling of the programs with patients,clinicians, and outside consultants. From this work, we can learn what roadblocks andexpenses occur while a technology travels, from a project leader's point of view.

Innovative culture in long-term care settings: The influence of organizational characteristics (Article)

2012-04-01T00:00:00Z

Background: Innovative cultures have been reported to enhance the creation and implementation of new ideas and working methods in organizations. Although there is considerable research on the impact of organizational context on the innovativeness of organizations, the same is not the case for research on the organizational characteristics responsible for an innovative culture in (long-term) care settings. Purpose: The aim of this study was to identify organizational characteristics that explain innovative culture in the (long-term) care sector. Methodology: A large cross-sectional study in Dutch long-term care - nursing homes and/or elderly homes, care organizations for the handicapped, and long-term mental health care organizations - was conducted. A total of 432 managers and care professionals in 37 organizations participated. The Group Innovation Inventory was used to measure innovative culture in long-term care organizations. Structural characteristics of the organization were centralization and formalization, environmental dynamism and competitiveness, internal and external exchange of information, leadership style, commitment to quality improvement, and the organization's innovative strategy. Findings: The determinants of an innovative culture were estimated with a two-level random-intercepts and fixed-slopes model. Multilevel regression models were used to account for the organizational clustering of individuals within the 37 care organizations. Environmental dynamism, job codification, formal external exchange of information, transformational leadership, commitment to quality, and an exploratory and exploitative innovation strategy were all significantly correlated with an innovative culture in the multivariate multilevel analysis; the other characteristics were not. The explained organizational- and individual-level variance was 52.5% and 49.2%, respectively. Practice Implications: The results point to substantial differences in innovative cultures between and within care organizations that can, in part, be explained by organizational characteristics. Efforts must be made to ensure that organizational characteristics such as environmental dynamism do not hamper the development of innovative cultures in long-term care organizations. Organizations' human resource practices and knowledge management are particularly promising in strengthening innovative cultures. Copyright

Gaps in transitional care: What are the perceptions of adolescents, parents and providers? (Article)

2012-02-15T00:00:00Z

Background Several studies have investigated preferences and experiences of adolescents with different chronic conditions and their parents. Some have included the provider's perspective. Studies comparing the three perspectives on satisfaction with (transitional) care for different chronic conditions, however, are lacking. The main aim of this paper was to explore differences and similarities in perspectives between adolescents with chronic conditions, their parents and providers on transitional care. A secondary aim was to explore the extent to which such perspectives are disease-specific. Methods This quantitative study included 127 adolescents with juvenile rheumatoid arthritis (JRA), neuromuscular disorder with chronic ventilation (NMD), or diabetes Type I; 166 parents; and 19 care providers. To assess the experiences and perceptions of adolescents and parents on transitional care, we used the 'Mind the Gap' instrument. The survey for providers included a checklist of shortcomings in transitional care. Results Adolescents rate current care significantly worse than parents on opportunities to make their own decisions and be seen without parents present. Adolescents also rated providers' current social skills lower than parents. Adolescents are more satisfied than their parents about transitional care process aspects such as co-ordination and communication between providers, but both groups indicated that the care process offers most room for improvement. Providers reported other aspects such as adolescents' lack of responsibility with regard to self-care and parents' difficulties with ceding control to their children. When looking at the three disease groups - JRA, NMD, diabetes, we found only small differences. According to providers, shortcomings in the care process with respect to guidelines, protocols and co-ordination are most prevalent. Conclusion Adolescents, parents and providers all report that there is room for improvement with regard to aspects of the care delivery process in transitional care. With respect to disease-specific issues we only found small differences.

Satisfaction with care as a quality-of-life predictor for stroke patients and their caregivers (Article)

2012-01-09T00:00:00Z

Purpose: We sought to identify indicators associated with the quality of life (QoL) of stroke patients and caregivers. Methods: The cross-sectional study was conducted at nine Dutch stroke service facilities involving 251 stroke patients and their caregivers. We used the EuroQol (EQ-5D) and Satisfaction with Stroke Care questionnaires, and included the variables (1) disability at hospital admission, (2) length of hospital stay, (3) demographic data, and (4) caregivers' relationship with stroke patients. The Actor-Partner (patient-caregiver) Interdependence Model (APIM) was used to examine dependence between patients' and caregivers' QoL scores through dyad membership. Results: Patients' age was significantly related to their QoL, and caregivers' age and educational level were significantly related to their QoL. Patients' disability on hospital admission and length of stay were associated with patients' QoL, and their disability on admission was related to caregivers' QoL. No relationship was found between length of stay and caregivers' QoL. Satisfaction with care was associated with both patients' and caregivers' QoL. Conclusions: The APIM distinguished the different roles of patients and caregivers while acknowledging the interdependence of their QoL scores. Satisfaction with care was identified as important indicator of stroke patients' and caregivers' QoL.

Governing Mental Health Care: How Power Is Exerted In And Through A Quality Improvement Collaborative (Article)

2012-01-01T00:00:00Z

We investigated the role of power in public governance using a Foucauldian conceptualization of power, i.e., power is produced by a range of techniques as diverse as language and measuring. We draw on an evaluation study of a quality improvement collaborative, in which different mental health care organizations were encouraged to improve their care in a structured way. We analyzed how the different actors involved in the collaborative were governed and came to govern themselves differently. Measurement instruments were an example of a dominant mechanism by which actors at different levels of the collaborative were governed: by accounting for improvements, introducing or strengthening a certain way of thinking about health care clients, and changing how clients thought about and acted upon themselves. We argue that the focus on consequences of governing techniques is fruitful for studying governmentality and leads to new research questions in the context of public policy analyses.

Longitudinal study of parents' impact on quality of life of children and young adults with intellectual disabilities (Article)

2012-01-01T00:00:00Z

Background Earlier research has distinguished five domains of Quality of life (QoL) for people with ID: material well-being, development and activity, physical well-being, social well-being, and emotional well-being. We investigated parents' perspectives on these domains and QoL for children and young adults with ID and hypothesized that parents' well-being would be a predictive factor in QoL of their children with ID. Methods Our longitudinal study administered questionnaires to parents at T0(n=147) and T1(n=108). The inclusion criteria were: (i) the child's age 0-24years and (ii) the child's intellectual disability (IQ<70 or IQ<85 in combination with behavioural problems). Results Social well-being of parents (P≤0.001), changes in parents' social well-being (P≤0.01) and changes in children's social well-being (P≤0.05) were strong predictors of QoL for children with ID. Emotional well-being of children with ID (P≤0.01), changes in children's emotional well-being (P≤0.01) and changes in emotional well-being of parents (P≤0.05) also predicted QoL of children with ID. Material well-being of parents, and health, development and activity of the children were not predictors. Conclusion Our study revealed that predictors of QoL in children and young adults with ID occurred in the following domains: physical well-being (children), social well-being (parents and children) and emotional well-being (parents and children).

The importance of relational coordination for integrated care delivery to older patients in the hospital (Article)

2012-01-01T00:00:00Z

Aim: This study investigated relational coordination among professionals providing healthcare to hospitalized older patients and assessed its impact on integrated care delivery. Background: Previous studies have shown that relational coordination is positively associated with the delivery of acute, emergency and trauma care. The effect of relational coordination in integrated care delivery to hospitalized older patients remains unknown. Methods: This cross-sectional study was part of an examination of integrated care delivery to hospitalized older patients. Data were collected using questionnaires distributed to hospital professionals (192 respondents; 44% response rate). Results: After controlling for demographic variables, regression analyses showed that relational coordination was positively related to integrated care delivery (β = 0.20; P ≤ 0.05). Relational coordination was lower among professionals in the same discipline, and higher between nurses and others than between medical specialists and others. Relational coordination and integrated care delivery were significantly higher in geriatrics than in other units (both P ≤ 0.001). Conclusions: The enhancement of relational coordination among healthcare professionals is positively associated with integrated care delivery to older patients. Implications for nursing management: Relational coordination should be improved between medical specialists and others and higher levels of relational coordination and integrated care delivery should be achieved in all hospital units.

The Importance of Neighborhood Social Cohesion and Social Capital for the Well Being of Older Adults in the Community (Article)

2012-01-01T00:00:00Z

We aimed to investigate whether social capital (obtaining support through indirect ties such as from neighbors) and social cohesion (interdependencies among neighbors) within neighborhoods positively affect the well being of older adults. Design and Methods: This crosssectional study included 945 of 1,440 (66% response rate) independently living older adults (aged !70 years) in Rotterdam. We fitted a hierarchical random effects model to account for the hierarchical structure of the study design: 945 older adults (Level 1) nested in 72 neighborhoods (Level 2). Results: Univariate analyses showed that being born in the Netherlands, house ownership, education, income, social capital of individuals, neighborhood security, neighborhood services, neighborhood social capital, and neighborhood social cohesion were significantly related to the well being of older adults. Multilevel analyses showed that social capital of individuals, neighborhood services, neighborhood social capital, and neighborhood social cohesion predicted the well being of older adults. Single and poor older adults reported lower well being than did better off and married older adults. However, the effects of marital status and income were mediated by neighborhood services, social capital, and social cohesion. Neighborhood services, social capital, and social cohesion may act as buffer against the adverse effects of being single and poor on the well being of older adults. Implications: The results of this study support the importance of social capital of individuals, as well as social capital within the neighborhood and social cohesion within the neighborhood for well being of older adults. The well being of older adults may also be enhanced through the improvement of quality of neighborhood services.

Differences in the association of subjective wellbeing measures with health, socioeconomic status, and social conditions among residents of an Eastern Cape township (Article)

2012-01-01T00:00:00Z

The use of variably self-reported measures of wellbeing may produce differing outcomes. This study examined the differences in association with health, socioeconomic status, and social conditions (marital status, social capital) of two widely used cognitive subjective wellbeing measurements: Cantril’s ladder and Diener’s five-item Satisfaction with Life Scale. Methods: A stratified sampling design was used to collect data from representative households in the 20 neighborhoods of Rhini, a deprived suburb of Grahamstown in the Eastern Cape province of South Africa. Correlation and stepwise multiple regression analyses investigated differences in the associations between wellbeing and health, demographics, socioeconomic status, and social conditions determined by the three measurements. Results: We found that the multiple-item satisfaction with life scale elicited more discriminating responses that took into account a broader range of life domains. This scale reported more significant relationships between subjective wellbeing and health, socioeconomic status, and social conditions. Cantril’s ladder produced a narrower range of career-like comparisons. The direction of association between measures of wellbeing and socioeconomic characteristics never changed according to the measures used. Conclusions: Policy-makers, researchers, and practitioners using these instruments should be aware of the differences between single- and multiple-item wellbeing measures, and recognize that the choice of instrument will affect the life domains found to be associated with wellbeing.

The potential for integrated care programmes to improve quality of care as assessed by patients with COPD: early results from a real-world implementation study in The Netherlands (Article)

2012-01-01T00:00:00Z

Objective: We investigated whether patients with chronic obstructive pulmonary disease (COPD) who were enrolled in disease-management programmes (DMPs) felt that they received a better quality of care than non-enrolled COPD patients. Methods: Our cross-sectional study was performed among patients (n=665) enrolled in four DMPs in the Netherlands. We also evaluated COPD patients (n=227) not enrolled in such programmes. Patients’ assessment of chronic-illness care (PACIC) was measured with a 20-item questionnaire. The instrument had five pre-defined domains: patient activation (three items), delivery-system/practice design (three items), goal setting/tailoring (five items), problem solving/contextual (four items), and follow-up/coordination (five items). Results: The mean overall PACIC score (scale: 1–5) of enrolled DMP patients was 2.94, and that of non-enrolled DMP patients was 2.73 (p≤0.01). Differences in the same direction were found in the subscales of patient activation (p≤0.01), delivery-system/practice design (p≤0.001), and problem solving/contextual (p≤0.001). Conclusions: Our results suggest that even in the early stages of implementation, DMPs for COPD may significantly improve care.

Quality improvement in long-term mental health: Results from four collaboratives (Article)

2011-10-06T00:00:00Z

Accessible summary: Overall, the four collaboratives lead to significant improvement in most objective outcomes, such as health, loneliness, and clients' problem areas. With respect to perceived effectiveness significant differences between the four collaboratives were found. Team members participating in the Social Psychiatric Care collaborative scored significantly lower than team members in the other three collaboratives. The Recovery-Oriented Care collaborative scored weakly higher. Multilevel regression analyses indicated that innovation attributes, appropriate measures, usable data collection tools, and an innovative team culture could explain variation in perceived effectiveness. The results supported the notion that a layered approach is necessary to achieve improvements in quality of care. This multiple case study evaluates four quality improvement collaboratives (QICs) in long-term mental health care focusing on social psychiatric care, recovery oriented care, social participation and somatic co-morbidity of psychiatric patients. The aim is to explore (1) effectiveness in terms of objective outcome indicators and impact of changes as perceived by team members; and (2) associations between collaborative-, organizational- and team-level factors and perceived effectiveness. Most objective outcomes, such as health, loneliness and clients' problem areas, showed significant improvement. Because of the diversity in content no single measure for objective effectiveness could be computed across the four collaboratives. Perceived effectiveness of team members was used as an indicator of the overall impact. In all, 55 of the 94 participating team leaders and 117 remaining team members completed a written survey at the end of each quality improvement collaborative. Multilevel regression analyses indicated that innovation attributes, appropriate measures, usable data collection tools and an innovative team culture could explain variation in perceived effectiveness. In conclusion, overall positive changes for clients were realized as demonstrated by objective outcomes and team members' perceptions of improvements in care processes. The results supported the notion that a layered approach is necessary to achieve improvements in quality of care.

Evaluation design of a reactivation care program to prevent functional loss in hospitalised elderly: A cohort study including a randomised controlled trial (Article)

2011-08-05T00:00:00Z

Background: Elderly persons admitted to the hospital are at risk for hospital related functional loss. This evaluation aims to compare the effects of different levels of (integrated) health intervention care programs on preventing hospital related functional loss among elderly patients by comparing a new intervention program to two usual care programs. Methods/Design. This study will include an effect, process and cost evaluation using a mixed methods design of quantitative and qualitative methods. Three hospitals in the Netherlands with different levels of integrated geriatric health care will be evaluated using a quasi-experimental study design. Data collection on outcomes will take place through a prospective cohort study, which will incorporate a nested randomised controlled trial to evaluate the effects of a stay at the centre for prevention and reactivation for patients with complex problems. The study population will consist of elderly persons (65 years or older) at risk for functional loss who are admitted to one of the three hospitals. Data is prospectively collected at time of hospital admission (T0), three months (T1), and twelve months (T2) after hospital admission. Patient and informal caregiver outcomes (e.g. health related quality of life, activities of daily living, burden of care, (re-) admission in hospital or nursing homes, mortality) as well as process measures (e.g. the cooperation and collaboration of multidisciplinary teams, patient and informal caregiver satisfaction with care) will be measured. A qualitative analysis will determine the fidelity of intervention implementation as well as provide further context and explanation for quantitative outcomes. Finally, costs will be determined from a societal viewpoint to allow for cost effectiveness calculations. Discussion. It is anticipated that higher levels of integrated hospital health care for at risk elderly will result in prevention of loss of functioning and loss of quality of life after hospital discharge as well as in lower burden of care and higher quality of life for informal caregivers. Ultimately, the results of this study may contribute to the implementation of a national integrated health care program to prevent hospital related functional loss among elderly patients. Trial registration. The Netherlands National Trial Register: NTR2317.

Development and validation of a short version of the Partnership Self-Assessment Tool (PSAT) among professionals in Dutch disease-management partnerships (Article)

2011-07-04T00:00:00Z

Background: The extent to which partnership synergy is created within quality improvement programmes in the Netherlands is unknown. In this article, we describe the psychometric testing of the Partnership Self-Assessment Tool (PSAT) among professionals in twenty-two disease-management partnerships participating in quality improvement projects focused on chronic care in the Netherlands. Our objectives are to validate the PSAT in the Netherlands and to reduce the number of items of the original PSAT while maintaining validity and reliability. Methods. The Dutch version of the PSAT was tested in twenty-two disease-management partnerships with 218 professionals. We tested the instrument by means of structural equation modelling, and examined its validity and reliability. Results: After eliminating 14 items, the confirmatory factor analyses revealed good indices of fit with the resulting 15-item PSAT-Short version (PSAT-S). Internal consistency as represented by Cronbach's alpha ranged from acceptable (0.75) for the 'efficiency' subscale to excellent for the 'leadership' subscale (0.87). Convergent validity was provided with high correlations of the partnership dimensions and partnership synergy (ranged from 0.512 to 0.609) and high correlations with chronic illness care (ranged from 0.447 to 0.329). Conclusion: The psychometric properties and convergent validity of the PSAT-S were satisfactory rendering it a valid and reliable instrument for assessing partnership synergy and its dimensions of partnership functioning.

Development and validation of a short version of the Assessment of Chronic Illness Care (ACIC) in Dutch Disease Management Programs (Article)

2011-07-04T00:00:00Z

Background: In the Netherlands the extent to which chronically ill patients receive care congruent with the Chronic Care Model is unknown. The main objectives of this study were to (1) validate the Assessment of Chronic Illness Care (ACIC) in the Netherlands in various Disease Management Programmes (DMPs) and (2) shorten the 34-item ACIC while maintaining adequate validity, reliability, and sensitivity to change.Methods: The Dutch version of the ACIC was tested in 22 DMPs with 218 professionals. We tested the instrument by means of structural equation modelling, and examined its validity, reliability and sensitivity to change.Results: After eliminating 13 items, the confirmatory factor analyses revealed good indices of fit with the resulting 21-item ACIC (ACIC-S). Internal consistency as represented by Cronbach's alpha ranged from 'acceptable' for the 'clinical information systems' subscale to 'excellent' for the 'organization of the healthcare delivery system' subscale. Correlations between the ACIC and ACIC-S subscales were also good, ranging from .87 to 1.00, indicating acceptable coverage of the core areas of the CCM. The seven subscales were significantly and positively correlated, indicating that the subscales were conceptually related but also distinct. Paired t-tests results show that the ACIC scores of the original instrument all improved significantly over time in regions that were in the process of implementing DMPs (all components at p < 0.0001).Conclusion: We conclude that the psychometric properties of the ACIC and the ACIC-S are good and the ACIC-S is a promising alternate instrument to assess chronic illness care.

Implementing Community Care for People with Intellectual Disability: The Role of Organizational Characteristics and the Innovation's Attributes (Article)

2011-07-01T00:00:00Z

Background Community care is the support of people with intellectual disability in everyday life aimed at enhancing their integration into society. This article investigates influences of organizational characteristics on the implementation of community care in the Netherlands. In addition, we explored whether the attributes of community care as an innovative process might impede successful implementation. Methods Findings from a questionnaire among 96 managers in seven care organizations for people with intellectual disability are presented. Results The main reasons for innovation are to meet the demands of clients and to improve the primary care process. The most important external influence on the implementation process is government finance. The results also support the notion that problems with the implementation process of community care are related to organizational characteristics and the attributes of community care. Conclusion An innovative management style was found to be associated with a more successful implementation of community care. Lack of observability of the innovation, perceived complexity, incompatibility with norms and values of employees, and lack of possibilities to experiment (triability) are important barriers in the implementation process.

Validation of the Caregivers' Satisfaction with Stroke Care Questionnaire: C-SASC hospital scale (Article)

2011-06-01T00:00:00Z

To date, researchers have lacked a validated instrument to measure stroke caregivers' satisfaction with hospital care. We adjusted a validated patient version of satisfaction with hospital care for stroke caregivers and tested the 11-item caregivers' satisfaction with hospital care (C-SASC hospital scale) on caregivers of stroke patients admitted to nine stroke service facilities in the Netherlands. Stroke patients were identified through the stroke service facilities; caregivers were identified through the patients. We collected admission demographic data from the caregivers and gave them the C-SASC hospital scale. We tested the instrument by means of structural equation modeling and examined its validity and reliability. After the elimination of three items, the confirmatory factor analyses revealed good indices of fit with the resulting eight-item C-SASC hospital scale. Cronbach's α was high (0.85) and correlations with general satisfaction items with hospital care ranged from 0.594 to 0.594 (convergent validity). No significant relations were found with health and quality of life (divergent validity). Such results indicate strong construct validity. We conclude that the C-SASC hospital scale is a promising instrument for measuring stroke caregivers' satisfaction with hospital stroke care.

Choice processes and satisfaction with care according to parents of children and young adults with intellectual disability in the Netherlands (Article)

2011-06-01T00:00:00Z

Background Despite the expressed desire for access to information on care providers and increased availability of this information, the use of available information falls short of expectations. We lack research on the decision-making processes and on how these processes are influenced. A study that employs "real-life" decisions is necessary. Methods Our experimental study design established the effects of providing decision-support information only (services/quality indicators) and providing a combination of information and personal decision-making support (counselling/peer meetings) on the choice process and satisfaction with care. Results These forms of support affected the choice process, but did not affect satisfaction with care. Decision-support information combined with personal decision-making support led to less frequent switching of care providers and to more satisfaction with choice information. Parents make limited use of online decision-support information, but did use decision counselling. Conclusion This population is better supported with an intensified personal approach rather than through the current generic approach using websites.

Psychological well-being of caregivers of children with intellectual disabilities: Using parental stress as a mediating factor (Article)

2011-06-01T00:00:00Z

Parental stress has been identified as a major affecter of caregivers' psychological well-being and a risk increaser for unwillingly placing children with disabilities in the care of others. Recognition of effective means to ease caregiving burdens must guide policymaking and will help to provide better and tailored support and intervention for the children. This study aims to characterize caregivers of children with intellectual disabilities who are about to seek outside support and care and to identify the conditions under which psychological well-being and parental stress are affected using parental stress as a mediating factor. We found that parental stress and the child's depressive feelings strongly affected psychological well-being. We also found an indirect relation of restricted caregiver social activities through parental stress. To protect psychological well-being of caregivers, support services should address depressive feelings among children with intellectual disabilities, facilitate caregivers' social activity, and reduce stress.

Constructing the social: An evaluation study of the outcomes and processes of a 'social participation' improvement project (Article)

2011-05-01T00:00:00Z

This paper reports on an evaluation of a 'social participation' improvement project in a mental health care and care for the intellectually disabled setting. The main research question is how sociality (i.e. clients' social lives) was constructed and what consequences this had for the project and for the clients. We undertook a dual approach: investigating the predefined outcomes and analysing the improvement processes in terms of how these processes construct sociality. As to the predefined outcomes, clients' social networks were not widened, but clients felt significantly less lonely at the end of the project. In a bottom-up analysis of data gathered on the improvement processes, we articulated two ways of constructing sociality: individualization, in which clients had to verbalize their wishes (verbalization) and to act upon them more actively (enterprising); and normalization, in which a good social life was one embedded in 'normal' community. We argue that this (explorative) way of conceptualizing change corresponds with some of the quantitative findings but also brings to light aspects that would have gone unnoticed by using only the predefined outcomes. Therefore, a mixed methods approach in studying effectiveness is a fruitful addition to the quality improvement literature.

Creating effective quality-improvement collaboratives: A multiple case study (Article)

2011-04-01T00:00:00Z

Objective: To explore whether differences between collaboratives with respect to type of topic, type of targets, measures (systems) are also reflected in the degree of effectiveness. Study setting: 182 teams from long-term healthcare organisation developed improvement initiatives in seven quality-improvement collaboratives (QICs) focusing on patient safety and autonomy. Study design: Multiple case before-after study. Data collection: 75 team leaders completed a written questionnaire at the end of each QIC on achievability and degree of challenge of targets and measurability of progress. Main outcome indicators were collaborative-specific measures (such as prevalence of pressure ulcers). Principal findings: The degree of effectiveness and percentage of teams realising targets varied between collaboratives. Collaboratives also varied widely in perceived measurability (F=6.798 and p=0.000) and with respect to formulating achievable targets (F=6.566 and p=0.000). The Problem Behaviour collaborative scored significantly lower than all other collaboratives on both dimensions. The collaborative on Autonomy and control scored significantly lower on measurability than the other collaboratives. Topics for which there are best practices and evidence of effective interventions do not necessarily score higher on effectiveness, measurability, achievable and challenging targets. Conclusions: The effectiveness of a QIC is associated with the efforts of programme managers to create conditions that provide insight into which changes in processes of care and in client outcomes have been made. Measurability is not an inherent property of the improvement topic. Rather, creating measurability and formulating challenging and achievable targets is one of the crucial tasks for programme managers of QICs.

The relationship between (stigmatizing) views and lay public preferences regarding tuberculosis treatment in the Eastern Cape, South Africa (Article)

2011-01-18T00:00:00Z

Background: Tuberculosis (TB) and human immune virus/acquired immune deficiency syndrome (HIV/AIDS) stigmas affect public attitudes toward TB treatment and policy. This study examined 'stigmatizing' ideas and the view that 'TB patients should line-up in the chronic illness queue' in relation to preferences and attitudes toward TB treatment. Methods: Data were gathered through a survey administered to respondents from 1,020 households in Grahamstown. The survey measured stigmatization surrounding TB and HIV/AIDS, and determined perceptions of respondents whether TB patients should queue with other chronically ill patients. Respondents selected support and treatment options they felt would benefit TB patients. Statistical analysis identified the prevalence of TB and HIV/AIDS stigmas. Logistic regression analyses explored associations between stigmatizing ideas, views regarding TB patients in the chronic illness queue, and attitudes toward support and treatment. Results: Respondents with TB stigmatizing ideas held positive attitudes toward volunteer support, special TB queues, and treatment at clinics; they held negative attitudes toward temporary disability grants, provision of information at work or school, and treatment at the TB hospital. Respondents who felt it beneficial for TB patients to queue with other chronically ill patients conversely held positive attitudes toward provision of porridge and disability grants, and treatment at the TB hospital; they held negative attitudes toward volunteer support, special TB queues, information provision at work or school, and treatment at clinics. Conclusion: These results showed that two varying views related to visibility factors that expose patients to stigmatization (one characterized by TB stigma, the other by the view that TB patients should queue with other chronically ill patients) are associated with opposing attitudes and preferences towards TB treatment. These opposing attitudes complicate treatment outcomes, and suggest that complex behaviors must be taken into account when designing health policy.

Evaluation of a large scale implementation of disease management programmes in various Dutch regions: A study protocol (Article)

2011-01-12T00:00:00Z

Background. Disease management programmes (DMPs) have been developed to improve effectiveness and economic efficiency within chronic care delivery by combining patient-related, professional-directed, and organisational interventions. The benefits of DMPs within different settings, patient groups, and versions remain unclear. In this article we propose a protocol to evaluate a range of current DMPs by capturing them in a single conceptual framework, employing comparable structure, process, and outcome measures, and combining qualitative and quantitative research methods. Methods. To assess DMP effectiveness a practical clinical trial will be conducted. Twenty-two disease management experiments will be studied in various Dutch regions consisting of a variety of collaborations between organisations and/or professionals. Patient cohorts include those with cardiovascular diseases, chronic obstructive pulmonary disease, diabetes, stroke, depression, psychotic diseases, and eating disorders. Our methodological approach combines qualitative and quantitative research methods to enable a comprehensive evaluation of complex programmes. Process indicators will be collected from health care providers' data registries and measured via physician and staff questionnaires. Patient questionnaires include health care experiences, health care utilisation, and quality of life. Qualitative data will be gathered by means of interviews and document analysis for an in depth description of project interventions and the contexts in which DMPs are embedded, and an ethnographic process evaluation in five DMPs. Such a design will provide insight into ongoing DMPs and demonstrate which elements of the intervention are potentially (cost)-effective for which patient populations. It will also enable sound comparison of the results of the different programmes. Discussion. The study will lead to a better understanding of (1) the mechanisms of disease management, (2) the feasibility, and cost-effectiveness of a disease management approach to improving health care, and (3) the factors that determine success and failure of DMPs. Our study results will be relevant to decision makers and managers who confront the challenge of implementing and integrating DMPs into the health care system. Moreover, it will contribute to the search for methods to evaluate complex healthcare interventions.

Bottom-up implementation of disease-management programmes: Results of a multisite comparison (Article)

2011-01-01T00:00:00Z

Objectives: To evaluate the implementation of three regional disease-management programmes on chronic obstructive pulmonary disease (COPD) based on bottlenecks experienced in professional practice. Methods: The authors performed a multisite comparison of three Dutch regional diseasemanagement programmes combining patient-related, professional-directed and organisational interventions. Process (Assessing Chronic Illness Care survey) and outcome (disease specific quality of life (clinical COPD questionnaire (CCQ); chronic respiratory questionnaire (CRQ)), Medical Research Council dyspnoea and patients' experiences) data were collected for 370 COPD patients and their care providers. Results: Bottlenecks in region A were mostly related to patient involvement, in region B to organisational issues and in region C to both. Selected interventions related to identified bottlenecks were implemented in all programmes, except for patient-related interventions in programme A. Within programmes, significant improvements were found on dyspnoea and patients' experiences with practice nurses. Outcomes on quality of life differed between programmes: programme A did not show any significant improvements; programme B did show any significant improvements on CCQ total (p<0.001), functional (p=0.011) and symptom (p<0.001), CRQ fatigue (p<0.001) and emotional scales (p<0.001); in programme C, CCQ symptom (p<0.001) improved significantly, whereas CCQ mental score (p<0.001) deteriorated significantly. Regression analyses showed that programmes with better implementation of selected interventions resulted in relatively larger improvements in quality of life (CCQ). Conclusions: Bottom-up implementation of COPD disease-management programmes is a feasible approach, which in multiple settings leads to significant improvements in outcomes of care. Programmes with a better fit between implemented interventions and bottlenecks showed more positive changes in outcomes.

Quest for client autonomy in improving long-term mental health care (Article)

2010-12-01T00:00:00Z

The objective of the present study was to explore how mental health-care professionals initiate, improve, and maintain client autonomy while improving other aspects of quality of care. We studied the different ways in which they approach autonomy and the dilemmas associated with them. As a methodology, we used the insights of actor-network theory, where concepts cannot be predefined, but are formed within specific situations, and therefore, should be studied by addressing the actors involved. Data were gathered by conducting ethnographic observations of national conferences of a quality-improvement collaborative and by interviewing actors involved in the improvement practices. In a bottom-up analysis, four approaches to autonomy emerged: (i) professionals removed constraints to autonomy and passed initiative to clients; (ii) professionals made an active effort to learn and support client preferences; (iii) clients were given opportunities towards independent lifestyles; and (iv) professionals tried to 'normalize' their relationship with clients to encourage roles other than those of client. The study showed that autonomy is an important issue throughout the process of quality improvement. Articulating the different approaches to autonomy and the dilemmas in these approaches contributed to reflection on the concept and highlighted the limits of the concept within a mental health-care setting.

Improving subjective well-being of the poor in the Eastern Cape (Article)

2010-10-01T00:00:00Z

This study investigated the effects of income, health, social capital, marital status, employment, education and crime experience on subjective well-being within a poor community in the Eastern Cape of South Africa. It appeared that higher income is associated with higher subjective well-being and that social capital serves as an important subjective well-being predictor in all income groups. Efforts must be made to ensure that countries do not develop economically at the expense of other aspects of life important for well-being in the very poor, such as social capital.

Cognitive and behavioral interventions for the management of chronic neuropathic pain in adults - A systematic review (Article)

2010-08-01T00:00:00Z

Background: Chronic neuropathic pain is often associated with conditions such as depression and anxiety and strongly affects daily functioning and overall quality of life. It is argued, therefore, that psychosocial interventions should be added to traditional biomedical interventions. This systematic review evaluates the effectiveness of cognitive and behavioral interventions for the management of chronic neuropathic pain. Methods: Electronic databases were searched for all types of studies. Studies were selected by predefined inclusion criteria. Methodological quality was assessed with the Health Technology Assessment-Disease Management instrument. Furthermore, an explorative meta-analysis of four selected studies was performed. Results: Fourteen studies were assessed: three randomized controlled trials, three controlled before-after studies, seven uncontrolled before-after studies and one time series analysis. The findings of the meta-analysis were not consistent with a significant effect on pain intensity. Only one study had good methodological quality; it showed some significant effects of the interventions, but only in female participants. Other studies of limited methodological quality did report positive effects on pain and quality of life. Conclusions: This is the first systematic review that has evaluated the effectiveness of cognitive and behavioral techniques for the management of chronic neuropathic pain. Given the limited methodological quality, no informative conclusions can be drawn with respect to the study objective. However, this review does provide insight into the difficulties of this specific area, the need for a clear and widely accepted definition of neuropathic pain and the need for standardized multidimensional measurement instruments.

Norms for creativity and implementation in healthcare teams: testing the group innovation inventory (Article)

2010-08-01T00:00:00Z

Abstract OBJECTIVE: To test to what extent the four-factor structure of the group innovation inventory (GII) is confirmed for improvement teams participating in a quality improvement collaborative. DESIGN: Quasi-experimental design with baseline and end-measurement after intervention. SETTING: This study included quality improvement teams participating in the Care for Better improvement programme for home care, care for the handicapped and the elderly in the Netherlands between 2006 and 2008. PARTICIPANTS: As part of a larger evaluation study, 261 written questionnaires from team members were collected at baseline (pre-project sample) and 129 questionnaires at end-measurement (post-project sample). MAIN OUTCOME MEASURE: Group innovation inventory. RESULTS: Confirmatory factor analyses revealed the expected four-factor structure and good fit indices. The subscales 'group functioning' and 'speed of action' showed acceptable Cronbach's alphas and high inter-item correlations. The subscales 'support for risk taking' and 'tolerance of mistakes' showed insufficient reliability and validity. CONCLUSIONS: The group functioning and speed of action subscales of the GII showed acceptable psychometric properties and are applicable to quality improvement teams in health care. In order to understand how social expectations within teams working in health care organizations exert influence over attitudes and behaviours thought to stimulate creativity, further conceptualization of the norms for enhancing creativity within health care is needed.

Costh-effectiveness of a pressure ulcer quality collaborative (Article)

2010-06-01T00:00:00Z

ABSTRACT. BACKGROUND: A quality improvement collaborative (QIC) in the Dutch long-term care sector (nursing homes, assisted living facilities, home care) used evidence-based prevention methods to reduce the incidence and prevalence of pressure ulcers (PUs). The collaborative consisted of a core team of experts and 25 organizational project teams. Our aim was to determine its cost-effectiveness from a healthcare perspective. METHODS: We used a non-controlled pre-post design to establish the change in incidence and prevalence of PUs in 88 patients over the course of a year. Staff indexed data and prevention methods (activities, materials). Quality of life (Qol) weights were assigned to the PU states. We assessed the costs of activities and materials in the project. A Markov model was built based on effectiveness and cost data, complemented with a probabilistic sensitivity analysis. To illustrate the results of longer term, three scenarios were created in which change in incidence and prevalence measures were (1) not sustained, (2) partially sustained, and (3) completely sustained. RESULTS: Incidence of PUs decreased from 15% to 4.5% for the 88 patients. Prevalence decreased from 38.6% to 22.7%. Average Quality of Life (Qol) of patients increased by 0.02 Quality Adjusted Life Years (QALY)s in two years; healthcare costs increased by euro2000 per patient; the Incremental Cost-effectiveness Ratio (ICER) was between 78,500 and 131,000 depending on whether the changes in incidence and prevalence of PU were sustained. CONCLUSIONS: During the QIC PU incidence and prevalence significantly declined. When compared to standard PU care, the QIC was probably more costly and more effective in the short run, but its long-term cost-effectiveness is questionable. The QIC can only be cost-effective if the changes in incidence and prevalence of PU are sustained.

Application of a theoretical model to evaluate COPD disease management (Article)

2010-05-06T00:00:00Z

Background: Disease management programmes are heterogeneous in nature and often lack a theoretical basis. An evaluation model has been developed in which theoretically driven inquiries link disease management interventions to outcomes. The aim of this study is to methodically evaluate the impact of a disease management programme for patients with chronic obstructive pulmonary disease (COPD) on process, intermediate and final outcomes of care in a general practice setting. Methods. A quasi-experimental research was performed with 12-months follow-up of 189 COPD patients in primary care in the Netherlands. The programme included patient education, protocolised assessment and treatment of COPD, structural follow-up and coordination by practice nurses at 3, 6 and 12 months. Data on intermediate outcomes (knowledge, psychosocial mediators, self-efficacy and behaviour) and final outcomes (dyspnoea, quality of life, measured by the CRQ and CCQ, and patient experiences) were obtained from questionnaires and electronic registries. Results. Implementation of the programme was associated with significant improvements in dyspnoea (p < 0.001) and patient experiences (p < 0.001). No significant improvement was found in mean quality of life scores. Improvements were found in several intermediate outcomes, including investment beliefs (p < 0.05), disease-specific knowledge (p < 0.01; p < 0.001) and medication compliance (p < 0.01). Overall, process improvement was established. The model showed associations between significantly improved intermediate outcomes and improvements in quality of life and dyspnoea. Conclusions. The application of a theory-driven model enhances the design and evaluation of disease management programmes aimed at improving health outcomes. This study supports the notion that a theoretical approach strengthens the evaluation designs of complex interventions. Moreover, it provides prudent evidence that the implementation of COPD disease management programmes can positively influence outcomes of care.

Preferences for long-term care services: Willingness to pay estimates derived from a discrete choice experiment (Article)

2010-05-01T00:00:00Z

Abstract: Ageing populations increase pressure on long-term care. Optimal resource allocation requires an optimal mix of care services based on costs and benefits. Contrary to costs, benefits remain largely unknown. This study elicits preferences in the general elderly population for long-term care services for varying types of patients. A discrete choice experiment was conducted in a general population subsample aged 50-65 years (N = 1082) drawn from the Dutch Survey Sampling International panel. To ascertain relative preferences for long-term care and willingness to pay for these, participants were asked to choose the best of two care scenarios for four groups of hypothetical patients: frail and demented elderly, with and without partner. The scenarios described long-term care using ten attributes based on Social Production Function theory: hours of care, organized social activities, transportation, living situation, same person delivering care, room for individual preferences, coordination of services, punctuality, time on waiting list, and co-payments. We found the greatest value was attached to same person delivering care and transportation services. Low value was attached to punctuality and room for individual preferences. Nursing homes were generally considered to be detrimental for well-being except for dementia patients without a partner. Overall, long-term care services were thought to produce greatest well-being for the patients 'without a partner' and those 'with dementia'. Individuals combining these two risk factors would benefit the most from all services except transportation which was considered more important for the frail elderly. The results support the notion that long-term care services represent different value for different types of patients and that the value of a service depends upon the social context. Examination of patient profiles confirmed the notion that physical, mental and social vulnerability affect valuation of the services. Policy-making would profit from allocation models in which budgetary requirements of different services can be balanced against the well-being they produce for individuals.

TB treatment initiation and adherence in a South African community influenced more by perceptions than by knowledge of tuberculosis (Article)

2010-03-08T00:00:00Z

Background. Tuberculosis (TB) is a global health concern. Inadequate case finding and case holding has been cited as major barrier to the control of TB. The TB literature is written almost entirely from a biomedical perspective, while recent studies show that it is imperative to understand lay perception to determine why people seek treatment and may stop taking treatment. The Eastern Cape is known as a province with high TB incidence, prevalence and with one of the worst cure rates of South Africa. Its inhabitants can be considered lay experts when it comes to TB. Therefore, we investigated knowledge, perceptions of (access to) TB treatment and adherence to treatment among an Eastern Cape population. Methods. An area-stratified sampling design was applied. A total of 1020 households were selected randomly in proportion to the total number of households in each neighbourhood. Results. TB knowledge can be considered fairly good among this community. Respondents' perceptions suggest that stigma may influence TB patients' decision in health seeking behavior and adherence to TB treatment. A full 95% of those interviewed believe people with TB tend to hide their TB status out of fear of what others may say. Regression analyses revealed that in this population young and old, men and women and the lower and higher educated share the same attitudes and perceptions. Our findings are therefore likely to reflect the actual situation of TB patients in this population. Conclusions. The lay experts' perceptions suggests that stigma appears to effect case holding and case finding. Future interventions should be directed at improving attitudes and perceptions to potentially reduce stigma. This requires a patient-centered approach to empower TB patients and active involvement in the development and implementation of stigma reduction programs.

Towards integrated care for chronic conditions: Dutch policy developments to overcome the (financial) barriers (Article)

2010-01-01T00:00:00Z

Chronic non-communicable diseases are a major threat to population health and have a major economic impact on health care systems. Worldwide, integrated chronic care delivery systems have been developed to tackle this challenge. In the Netherlands, the recently introduced integrated payment system - the chain-DTC - is seen as the cornerstone of a policy stimulating the development of a well-functioning integrated chronic care system. The purpose of this paper is to describe the recent attempts in the Netherlands to stimulate the delivery of integrated chronic care, focusing specifically on the new integrated payment scheme and the barriers to introducing this scheme. We also highlight possible threats and identify necessary conditions to the success of the system. This paper is based on a combination of methods and sources including literature, government documents, personal communications and site visits to disease management programs (DMPs). The most important conditions for the success of the new payment system are: complete care protocols describing both general (e.g. smoking cessation, physical activity) and disease-specific chronic care modules, coverage of all components of a DMP by basic health care insurance, adequate information systems that facilitate communication between caregivers, explicit links between the quality and the price of a DMP, expansion of the amount of specialized care included in the chain-DTC, inclusion of a multi-morbidity factor in the risk equalization formula of insurers, and thorough economic evaluation of DMPs.

Sociological refigurations of patient safety; ontologies of improvement and ‘acting with’ quality collaboratives in healthcare (Article)

2009-12-01T00:00:00Z

Abstract The increasing focus on patient safety in the field of health policy is accompanied by research programs that articulate the role of the social sciences as one of contributing to enhancing safety in healthcare. Through these programs, new approaches to studying safety are facing a narrow definition of 'usefulness' in which researchers are to discover the factors that support or hamper the implementation of existing policy agendas. This is unfortunate since such claims for useful involvement in predefined policy agendas may undo one of the strongest assets of good social science research: the capacity to complexify the taken-for-granted conceptualizations of the object of study. As an alternative to this definition of 'usefulness', this article proposes a focus on multiple ontologies in the making when studying patient safety. Through such a focus, the role of social scientists becomes the involvement in refiguring the problem space of patient safety, the relations between research subjects and objects, and the existing policy agendas. This role gives medical sociologists the opportunity to focus on the question of which practices of 'effective care' are being enacted through different approaches for dealing with patient safety and what their consequences are for the care practices under study. In order to explore these questions, this article draws on empirical material from an ongoing evaluation of a large quality improvement collaborative for the care sectors in the Netherlands. It addresses how issues like 'effectiveness' and 'client participation' are at present articulated in this collaborative and shows that alternative figurations of these notions dissolve many 'implementation problems' presently experienced. Further it analyzes how such a focus of medical sociology on multiple ontologies engenders new potential for exploring particular spaces for 'acting with' quality improvement agents.

Professional commitment to changing chronic illness care: Results from disease management programmes (Article)

2009-08-05T00:00:00Z

Objectives. The aim of this exploratory study was to investigate to what extent primary care professionals are able to change their systems for delivering care to chronic obstructive pulmonary disease (COPD) patients and what professional and organizational factors are associated with the degree of process implementation. Design. Quasi-experimental design with 1 year follow-up after intervention. Setting. Three regional COPD management programmes in the Netherlands, in which general practices cooperated with regional hospitals. Participants. All participating primary care professionals (n = 52). Intervention COPD management programme. Main Outcome Measures. Professional commitment, organizational context and degree of process implementation. Results. Professionals significantly changed their systems for delivering care to COPD patients, namely self-management support, decision support, delivery system design and clinical information systems. Associations were found between organizational factors, professional commitment and changes in processes of care. Group culture and professional commitment appeared to be, to a moderate degree, predictors of process implementation. Conclusions. COPD management was effective; all processes improved significantly. Moreover, theoretically expected associations between organizational context and professional factors with the implementation of COPD management were indeed confirmed to some extent. Group culture and professional commitment are important facilitators.

Psychometric test of the Team Climate Inventory-short version investigated in Dutch quality improvement teams (Article)

2009-07-01T00:00:00Z

Abstract BACKGROUND: Although some studies have used the Team Climate Inventory within teams working in health care settings, none of these included quality improvement teams. The aim of our study is to investigate the psychometric properties of the 14-item version of the Team Climate Inventory in healthcare quality improvement teams participating in a Dutch quality collaborative. METHODS: This study included quality improvement teams participating in the Care for Better improvement program for home care, care for the handicapped and the elderly in the Netherlands between 2006 and 2008. As part of a larger evaluation study 270 written questionnaires from team members were collected at baseline and 139 questionnaires at end measurement. Confirmatory factor analyses, reliability, Pearson correlations and paired samples t-tests were conducted to investigate construct validity, reliability, predictive validity and temporal stability. RESULTS: Confirmatory factor analyses revealed the expected four-factor structure and good fit indices. For the four subscales--vision, participative safety, task orientation and support for innovation--acceptable Cronbach's alpha coefficients and high inter-item correlations were found. The four subscales all proved significant predictors of perceived team effectiveness, with participatory safety being the best predictor. As expected the four subscales were found to be stable over time; i.e. without significant changes between baseline and end measurement. CONCLUSION: The psychometric properties of the Dutch version of the TCI-14 are satisfactory. Together these results show that the TCI-14 is a useful instrument to assess to what extent aspects of team climate influence perceived team effectiveness of quality improvement teams.

A systematic review of integrated use of disease-management interventions in asthma and COPD (Article)

2009-05-01T00:00:00Z

Background: The effectiveness of multiple interventions in asthma and chronic obstructive pulmonary disease (COPD) is unclear. Objective: To examine the effectiveness of multiple interventions as compared to single interventions or usual care on health outcomes and health care utilisation within the context of integrated disease management in asthma and COPD. Methods: MEDLINE and the Cochrane Library (1995-May 2008) were searched for controlled trials. Two reviewers independently extracted data and assessed study quality. Meta-analyses were performed on quality of life and health care utilisation data. Furthermore, the effects of multiple interventions versus single interventions and usual care were assessed qualitatively. Results: Of the 36 studies included, 17 targeted double interventions (patient-related and organisational interventions); 19 studies performed triple interventions (patient-related, professional-directed and organisational interventions). They were heterogeneous in terms of (combinations of) interventions, outcomes measured, study design and setting. Pooled data showed that studied disease management programmes significantly improved quality of life on several domains. Patients within triple intervention programmes had less chance of at least one hospital admission compared with usual care. No significant effects were found in number of emergency department visits. Qualitative analyses revealed positive trends on process improvements and satisfaction. Inconclusive results were reported on symptoms; no effects were found in lung function. Conclusion: In spite of the heterogeneity of disease management studies in asthma and COPD care, this review showed promising improvements in quality of life and reductions in hospitalisations, especially for triple intervention programmes.

Identifying potentially cost effective chronic care programs for people with COPD (Article)

2009-01-01T00:00:00Z

Objective: To review published evidence regarding the cost effectiveness of multi-component COPD programs and to illustrate how potentially cost effective programs can be identified. Methods: Systematic search of Medline and Cochrane databases for evaluations of multicomponent disease management or chronic care programs for adults with COPD, describing process, intermediate, and end results of care. Data were independently extracted by two reviewers and descriptively summarized. Results: Twenty articles describing 17 unique COPD programs were included. There is little evidence for significant improvements in process and intermediate outcomes, except for increased provision of patient self-management education and improved disease-specific knowledge. Overall, the COPD programs generate end results equivalent to usual care, but programs containing ≥3 components show lower relative risks for hospitalization. There is limited scope for programs to break-even or save money. Conclusion: Identifying cost effective multi-component COPD programs remains a challenge due to scarce methodologically sound studies that demonstrate significant improvements on process, intermediate and end results of care. Estimations of potential cost effectiveness of specific programs illustrated in this paper can, in the absence of 'perfect data', support timely decision-making regarding these programs. Nevertheless, well-designed health economic studies are needed to decrease the current decision uncertainty.

Op weg naar duurzaam verbeteren in de langdurige zorg? (Article)

2009-01-01T00:00:00Z

Het nationaal verbeterprogramma Zorg voor Beter beoogt een duurzame kwaliteitsverbetering in de langdurige zorg die verspreid kan worden binnen en buiten de deelnemende instellingen. Het evaluatieonderzoek richt zich op de vraag welke condities op programma- en organisatieniveau aanwezig moeten zijn om op de korte termijn tot effectieve kwaliteitsverbetering te komen en om deze resultaten en nieuwe werkwijzen ook vast te houden en te verspreiden. De korte termijn resultaten van de verbetertrajecten blijken veelal positief te zijn. De projectspecifieke doelstellingen worden echter niet altijd door de beoogde 70% van de teams behaald en er is grote variatie tussen teams en trajecten. De mate van evidentie van effectiviteit van interventies kan bijdragen aan het meetbaar maken van resultaten en het formuleren van haalbare en uitdagende doelstellingen, maar blijkt niet doorslaggevend te zijn voor de effectiviteit van een verbetertraject. Observaties binnen de trajecten Decubitus en Eten en Drinken laten zien dat de organisatorische context waarbinnen een verbeterteam tot kwaliteitsverbetering moet komen essentieel is. Om te leren wat duurzaam verbeteren betekent, zijn beschrijvingen van wat er op de werkvloer plaatsvindt noodzakelijk.

A model to evaluate quality and effectiveness of disease management (Article)

2008-12-01T00:00:00Z

Disease management has emerged as a new strategy to enhance quality of care for patients suffering from chronic conditions, and to control healthcare costs. So far, however, the effects of this strategy remain unclear. Although current models define the concept of disease management, they do not provide a systematic development or an explanatory theory of how disease management affects the outcomes of care. The objective of this paper is to present a framework for valid evaluation of disease-management initiatives. The evaluation model is built on two pillars of disease management: patient-related and professional-directed interventions. The effectiveness of these interventions is thought to be affected by the organisational design of the healthcare system. Disease management requires a multifaceted approach; hence disease-management programme evaluations should focus on the effects of multiple interventions, namely patient-related, professional-directed and organisational interventions. The framework has been built upon the conceptualisation of these disease-management interventions. Analysis of the underlying mechanisms of these interventions revealed that learning and behavioural theories support the core assumptions of disease management. The evaluation model can be used to identify the components of disease-management programmes and the mechanisms behind them, making valid comparison feasible. In addition, this model links the programme interventions to indicators that can be used to evaluate the disease-management programme. Consistent use of this framework will enable comparisons among disease-management programmes and outcomes in evaluation research.

Needs of persons with severe intellectual disabilities: A Q-methodological study of clients with severe behavioural disorders and severe intellectual disabilities (Article)

2008-09-01T00:00:00Z

Background: A demand-oriented approach is becoming increasingly important in care provision. The purpose of this study was to identify the primary needs of clients with Severe Behavioural Disorders and Severe Intellectual Disabilities. Materials and Methods: We used the theory of Social Production Function and Maslow's hierarchy of needs to operationalize different types of needs of clients with Severe Behavioural Disorders and Severe Intellectual Disabilities. A Q-methodological study enabled us to distinguish the needs of 23 clients. Results: Two needs prioritizations were found. Physical well-being ultimately weighs most heavily for all clients, but in one of the two groups affection and behavioural confirmation (i.e. social needs) were also found to be important. There were no significant differences in needs between clients whose main behavioural difficulty was aggression and clients whose main behavioural difficulty was self-harm. Conclusions: A demand-oriented policy for clients with Severe Behavioural Disorders and Severe Intellectual Disabilities should be targeted at groups with different needs prioritizations, rather than groups with different behavioural problems. That does not mean that the same needs of different clients can be met in exactly the same way. It takes creativity and a person-centred approach to find ways to enable clients to realize their social and physical needs.

Designing patient-related interventions in COPD care: Empirical test of a theoretical model (Article)

2008-08-01T00:00:00Z

Objectives: The aim of this exploratory study was to test the applicability of a theoretical model to develop patient-related interventions. In this model knowledge, psychosocial mediators, self-efficacy and behaviour are determinants of patient-related interventions. Methods: The model was tested on 278 patients with mild or moderate chronic obstructive pulmonary disease (COPD), recruited in a primary care setting. Hierarchical regression analyses were applied using data from self-reported questionnaires and clinical data from an electronic data registry. Results: Knowledge, psychosocial mediators, self-efficacy and behaviour proved to be, to a moderate degree, predictors of outcomes in COPD care. Moreover, physical activity appeared to be a significant predictor for all clinical and functional outcomes. Conclusion: Theoretically expected associations of patient-related interventions are existent in patients with mild or moderate COPD. The application of theoretical models in designing patient-directed interventions in COPD care is therefore feasible. Practice implications: More attention should be paid to the patterns of physical activity in patients with mild to moderate COPD. The results of this study are also useful in the development of patient-related interventions. Future interventions should be designed along the lines of theory on behaviour change, such as social cognitive theory.

Samenwerking tussen huisartsen en praktijkverpleegkundigen: het belang van visie, gedeelde verantwoordelijkheid en het vastleggen van afspraken. Toegeleiding in de Medische Opvang Asielzoekers (Research Paper)

2003-12-22T00:00:00Z

Sinds 2000 worden asielzoekers door praktijkverpleegkundigen van de Medische Opvang Asielzoekers (MOA) voor diagnostiek en behandeling 'toegeleid' naar reguliere huisartsen. Hierbij beoordeelt de praktijkverpleegkundige of de hulpvraag van de asielzoeker zogenaamde zelfzorg betreft of dat de asielzoeker doorverwezen moet worden naar de huisarts. Om te onderzoeken hoe de samenwerking in de toegeleiding verloopt en welke factoren hierop van invloed zijn, is een survey verricht onder huisartsen die zorg verlenen aan asielzoekers (N=342) en praktijkverpleegkundigen van de MOA (N=332). De samenwerking is geoperationaliseerd in termen van de hoeveelheid werkafspraken en besprekingen, en de waardering voor de samenwerking. Factoren die de samenwerking naar verwachting beïnvloeden zijn de lokale context, het draagvlak onder huisartsen en praktijkverpleegkundigen en hun persoonsgebonden kenmerken. Uit dit onderzoek komt naar voren dat huisartsen en praktijkverpleegkundigen gemiddeld drie (overwegend mondelinge) werkafspraken hebben, dat 80% van beide groepen een patiëntenbespreking houdt en dat zij de samenwerking gemiddeld beoordelen met een 4 op een vijfpuntsschaal van heel slecht (1) tot heel goed (5). Echter, een groot deel van de huisartsen en praktijkverpleegkundigen, die als koppel samenwerken op dezelfde lokatie, verschillen van mening over de inhoud en vorm van de afspraken. Hoewel de toegeleiding beschouwd wordt als een gedelegeerde taak, zien veel huisartsen zichzelf niet als eindverantwoordelijke. Multiple lineaire regressie toonde aan dat een gedeelde visie op de toegeleiding en een betere informatievoorziening naar de huisartsen de samenwerking bevordert. Praktijkverpleegkundigen waarderen de samenwerking beter indien werkafspraken en overleg met de huisarts duidelijk zijn vastgelegd.