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1.  Governing Healthcare through Performance Measurement in Massachusetts and the Netherlands 
Massachusetts and the Netherlands have implemented comprehensive health reforms, which have heightened the importance of performance measurement. The performance measures addressing access to health care and patient experience are similar in the two jurisdictions, but measures of processes and outcomes of care differ considerably. In both jurisdictions, the use of health outcomes to compare the quality of health care organizations is limited, and specific information about costs is lacking. New legislation in both jurisdictions led to the establishment of institutes to monitor the quality of care, similar mandates to make the performance of health care providers transparent, and to establish a shared responsibility of providers, consumers and insurers to improve the quality of health care.
In Massachusetts a statewide mandatory quality measure set was established to monitor the quality of care. The Netherlands is stimulating development of performance measures by providers based on a mandatory framework for developing such measures. Both jurisdictions are expanding the use of patient-reported outcomes to support patient care, quality improvement, and performance comparisons with the aim of explicitly linking performance to new payment incentives.
doi:10.1016/j.healthpol.2013.09.009
PMCID: PMC4744871  PMID: 24138729
Health Care Quality Assessment; Quality Indicators; Health Care Reform
2.  Variation in Hospital Length of Stay: Do Physicians Adapt Their Length of Stay Decisions to What Is Usual in the Hospital Where They Work? 
Health Services Research  2006;41(2):374-394.
Objective
To test the hypothesis that physicians who work in different hospitals adapt their length of stay decisions to what is usual in the hospital under consideration.
Data Sources
Secondary data were used, originating from the Statewide Planning and Research Cooperative System (SPARCS). SPARCS is a major management tool for assisting hospitals, agencies, and health care organizations with decision making in relation to financial planning and monitoring of inpatient and ambulatory surgery services and costs in New York state.
Study Design
Data on length of stay for surgical interventions and medical conditions (a total of seven diagnosis-related groups [DRGs]) were studied, to find out whether there is more variation between than within hospitals. Data (1999, 2000, and 2001) from all hospitals in New York state were used. The study examined physicians practicing in one hospital and physicians practicing in more than one hospital, to determine whether average length of stay differs according to the hospital of practice. Multilevel models were used to determine variation between and within hospitals. A t-test was used to test whether length of stay for patients of each multihospital physician differed from the average length of stay in each of the two hospitals.
Principal Findings
There is significantly (p<.05) more variation between than within hospitals in most of the study populations. Physicians working in two hospitals had patient lengths of stay comparable with the usual practice in the hospital where the procedure was performed. The proportion of physicians working in one hospital did not have a consistent effect for all DRGs on the variation within hospitals.
Conclusion
Physicians adapt to their colleagues or to the managerial demands of the particular hospital in which they work. The hospital and broader work environment should be taken into account when developing effective interventions to reduce variation in medical practice.
doi:10.1111/j.1475-6773.2005.00486.x
PMCID: PMC1702523  PMID: 16584454
Length of stay; variation; hospitals; multihospital physicians
3.  Incorporating shared savings programs into primary care: from theory to practice 
Background
In several countries, health care policies gear toward strengthening the position of primary care physicians. Primary care physicians are increasingly expected to take accountability for overall spending and quality. Yet traditional models of paying physicians do not provide adequate incentives for taking on this new role. Under a so-called shared savings program physicians are instead incentivized to take accountability for spending and quality, as the program lets them share in cost savings when quality targets are met. We provide a structured approach to designing a shared savings program for primary care, and apply this approach to the design of a shared savings program for a Dutch chain of primary care providers, which is currently being piloted.
Methods
Based on the literature, we defined five building blocks of shared savings models that encompass the definition of the scope of the program, the calculation of health care expenditures, the construction of a savings benchmark, the assessment of savings and the rules and conditions under which savings are shared. We apply insights from a variety of literatures to assess the relative merits of alternative design choices within these building blocks. The shared savings program uses an econometric model of provider expenditures as an input to calculating a casemix-corrected benchmark.
Results
The minimization of risk and uncertainty for both payer and provider is pertinent to the design of a shared savings program. In that respect, the primary care setting provides a number of unique opportunities for achieving cost and quality targets. Accountability can more readily be assumed due to the relatively long-lasting relationships between primary care physicians and patients. A stable population furthermore improves the confidence with which savings can be attributed to changes in population management. Challenges arise from the institutional context. The Dutch health care system has a fragmented structure and providers are typically small in size.
Conclusion
Shared savings programs fit the concept of enhanced primary care. Incorporating a shared savings program into existing payment models could therefore contribute to the financial sustainability of this organizational form.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-015-1250-0) contains supplementary material, which is available to authorized users.
doi:10.1186/s12913-015-1250-0
PMCID: PMC4696086  PMID: 26715151
Payment reform; Accountable care; Shared savings; Primary care
4.  The disciplined healthcare professional: a qualitative interview study on the impact of the disciplinary process and imposed measures in the Netherlands 
BMJ Open  2015;5(11):e009275.
Objective
It is known that doctors who receive complaints may have feelings of anger, guilt, shame and depression, both in the short and in the long term. This might lead to functional impairment. Less is known about the impact of the disciplinary process and imposed measures. Previous studies of disciplinary proceedings have mainly focused on identifying characteristics of disciplined doctors and on sentencing policies. Therefore, the aim of this study is to explore what impact the disciplinary process and imposed measures have on healthcare professionals.
Design
Semistructured interview study, with purposive sampling and inductive qualitative content analysis.
Participants
16 healthcare professionals (9 medical specialists, 3 general practitioners, 2 physiotherapists and 2 psychologists) that were sanctioned by the disciplinary tribunal.
Setting
The Netherlands.
Results
Professionals described feelings of misery and insecurity both during the process as in its aftermath. Furthermore, they reported to fear receiving new complaints and provide care more cautiously after the imposed measure. Factors that may enhance psychological and professional impact are the publication of measures online and in newspapers, media coverage, the feeling of treated as guilty before any verdict has been reached, and the long duration of the process.
Conclusions
This study shows that the disciplinary process and imposed measures can have a profound psychological and professional impact on healthcare professionals. Although a disciplinary measure is meant to have a corrective effect, our results suggest that the impact that is experienced by professionals might hamper optimal rehabilitation afterwards. Therefore, organising emotional support should be considered during the disciplinary process and in the period after the verdict.
doi:10.1136/bmjopen-2015-009275
PMCID: PMC4663436  PMID: 26608639
MEDICAL LAW
5.  Exposure to and experiences with a computerized decision support intervention in primary care: results from a process evaluation 
BMC Family Practice  2015;16:141.
Background
Trials evaluating the effects of interventions usually provide little insight into the factors responsible for (lack of) changes in desired outcomes. A process evaluation alongside a trial can shed light on the mechanisms responsible for the outcomes of a trial. The aim of this study was to investigate exposure to and experiences with a computerized decision support system (CDSS) intervention, in order to gain insight into the intervention’s impact and to provide suggestions for improvement.
Methods
A process evaluation was conducted as part of a large-scale cluster-randomized controlled trial investigating the effects of the CDSS NHGDoc on quality of care. Data on exposure to and experiences with the intervention were collected during the trial period among participants in both the intervention and control group - whenever applicable - by means of the NHGDoc server and an electronic questionnaire. Multiple data were analyzed using descriptive statistics.
Results
Ninety-nine percent (n = 229) of the included practices generated data for the NHGDoc server and 50 % (n = 116) responded to the questionnaire: both general practitioners (GPs; n = 112; 49 %) and practice nurses (PNs; n = 52; 37 %) participated. The actual exposure to the NHGDoc system and specific heart failure module was limited with 52 % of the GPs and 42 % of the PNs reporting to either never or rarely use the system. Overall, users had a positive attitude towards CDSSs. The most perceived barriers to using NHGDoc were a lack of learning capacity of the system, the additional time and work it requires to use the CDSS, irrelevant alerts, too high intensity of alerts and insufficient knowledge regarding the system.
Conclusions
Several types of barriers may have negatively affected the impact of the intervention. Although users are generally positive about CDSSs, a large share of them is insufficiently aware of the functions of NHGDoc and, finds the decision support not always useful or relevant and difficult to integrate into daily practice. In designing CDSS interventions we suggest to more intensely involve the end-users and increase the system’s flexibility and learning capacity. To improve implementation a proper introduction of a CDSS among its target group including adequate training is advocated.
Trial registration
Clinical trials NCT01773057.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-015-0364-0) contains supplementary material, which is available to authorized users.
doi:10.1186/s12875-015-0364-0
PMCID: PMC4608282  PMID: 26474603
Clinical decision support; Clinical practice guidelines; Primary care; Process evaluation; Barriers
6.  Implementation of multiple-domain covering computerized decision support systems in primary care: a focus group study on perceived barriers 
Background
Despite the widespread availability of computerized decision support systems (CDSSs) in various healthcare settings, evidence on their uptake and effectiveness is still limited. Most barrier studies focus on CDSSs that are aimed at a limited number of decision points within selected small-scale academic settings. The aim of this study was to identify the perceived barriers to using large-scale implemented CDSSs covering multiple disease areas in primary care.
Methods
Three focus group sessions were conducted in which 24 primary care practitioners (PCPs) participated (general practitioners, general practitioners in training and practice nurses), varying from 7 to 9 per session. In each focus group, barriers to using CDSSs were discussed using a semi-structured literature-based topic list. Focus group discussions were audio-taped and transcribed verbatim. Two researchers independently performed thematic content analysis using the software program Atlas.ti 7.0.
Results
Three groups of barriers emerged, related to 1) the users’ knowledge of the system, 2) the users’ evaluation of features of the system (source and content, format/lay out, and functionality), and 3) the interaction of the system with external factors (patient-related and environmental factors). Commonly perceived barriers were insufficient knowledge of the CDSS, irrelevant alerts, too high intensity of alerts, a lack of flexibility and learning capacity of the CDSS, a negative effect on patient communication, and the additional time and work it requires to use the CDSS.
Conclusions
Multiple types of barriers may hinder the use of large-scale implemented CDSSs covering multiple disease areas in primary care. Lack of knowledge of the system is an important barrier, emphasizing the importance of a proper introduction of the system to the target group. Furthermore, barriers related to a lack of integration into daily practice seem to be of primary concern, suggesting that increasing the system’s flexibility and learning capacity in order to be able to adapt the decision support to meet the varying needs of different users should be the main target of CDSS interventions.
doi:10.1186/s12911-015-0205-z
PMCID: PMC4603732  PMID: 26459233
Clinical decision support; Clinical practice guidelines; Primary care; Barriers; Interventions; Implementation
7.  Propensity to seek healthcare in different healthcare systems: analysis of patient data in 34 countries 
Background
Some people have a lower threshold to seek care for certain symptoms than others. This study aims to investigate what factors are associated with patients’ propensity to seek care. In addition, this study explores whether patients’ propensity to seek care is associated with their actual health care utilization. We hypothesized that higher scores for propensity to seek care will lead to more general practitioners (GP) consultations, but to lower rates of avoidable hospitalization.
Methods
Propensity to seek care and GP utilization were measured by the Patient Experience Questionnaire of the QUALICOPC study, a survey among 61,931 patients that recently visited GP services in 34 countries. Propensity to seek care was estimated by two questions: one question focusing on health care seeking behavior for serious symptoms and the other question focused minor complaints. Data on country level rates of avoidable hospitalization for CHF, COPD, asthma and diabetes were obtained from the OECD health care quality indicators project.
Results
Beside patient characteristics, various organizational factors, such as better accessible and continuous primary care, and better experienced communication between patient and GPs was associated with a higher propensity to seek care for both severe and minor complaints. A higher propensity to seek care was associated with a slightly higher health care utilization in terms of GP visits, with no differences between the severity of the experienced symptoms (OR 1.08 for severe complaints and OR 1.05 for minor complaints). At country level, no association was found between propensity to seek care and rates of avoidable hospitalization for CHF, COPD, asthma and diabetes, possibly due to low statistical power at country level.
Conclusions
The organization of primary care and patients’ perceived communication with their GP were found to be highly correlated with patients’ decision to seek health care for minor or severe complaints, suggesting that characteristics of healthcare systems directly influence patients’ care seeking behavior, potentially leading to overuse or underuse of health services. However, we also observed that patients’ propensity to seek care is only weakly associated with more GP use.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-015-1119-2) contains supplementary material, which is available to authorized users.
doi:10.1186/s12913-015-1119-2
PMCID: PMC4600318  PMID: 26453459
Propensity to seek care; Health care seeking behavior; Primary care; ACSCs
8.  The Relationship Between the Scope of Essential Health Benefits and Statutory Financing: An International Comparison Across Eight European Countries 
Background: Both rising healthcare costs and the global financial crisis have fueled a search for policy tools in order to avoid unsustainable future financing of essential health benefits. The scope of essential health benefits (the range of services covered) and depth of coverage (the proportion of costs of the covered benefits that is covered publicly) are corresponding variables in determining the benefits package. We hypothesized that a more comprehensive health benefit package may increase user cost-sharing charges.
Methods: We conducted a desktop research study to assess the interrelationship between the scope of covered health benefits and the height of statutory spending in a sample of 8 European countries: Belgium, England, France, Germany, the Netherlands, Scotland, Sweden, and Switzerland. We conducted a targeted literature search to identify characteristics of the healthcare systems in our sample of countries. We analyzed similarities and differences based on the dimensions of publicly financed healthcare as published by the European Observatory on Health Care Systems.
Results: We found that the scope of services is comparable and comprehensive across our sample, with only marginal differences. Cost-sharing arrangements show the most variation. In general, we found no direct interrelationship in this sample between the ranges of services covered in the health benefits package and the height of public spending on healthcare. With regard to specific services (dental care, physical therapy), we found indications of an association between coverage of services and cost-sharing arrangements. Strong variations in the volume and price of healthcare services between the 8 countries were found for services with large practice variations.
Conclusion: Although reducing the scope of the benefit package as well as increasing user charges may contribute to the financial sustainability of healthcare, variations in the volume and price of care seem to have a much larger impact on financial sustainability. Policy-makers should focus on a variety of measures within an integrated approach. There is no silver bullet for addressing the sustainability of healthcare.
doi:10.15171/ijhpm.2015.166
PMCID: PMC4676966  PMID: 26673645
Healthcare Reform; Essential Health Benefits; Cost-Sharing
9.  A multifaceted feedback strategy alone does not improve the adherence to organizational guideline-based standards: a cluster randomized trial in intensive care 
Background
Organizational data such as bed occupancy rate and nurse-to-patient ratio are related to clinical outcomes and to the efficient use of intensive care unit (ICU) resources. Standards for these performance indicators are provided in guidelines. We studied the effects of a multifaceted feedback strategy to improve the adherence to these standards.
Methods
In a cluster randomized controlled study design the intervention ICUs received extensive monthly feedback reports, they received outreach visits and initiated a quality improvement team. The control ICUs received limited quarterly feedback reports only. We collected primary data prospectively within the setting of a Dutch national ICU registry over a 14-month study period. The target indicators were bed occupancy rate (aiming at 80 % or below) and nurse-to-patient ratio (aiming at 0.5 or higher). Data were collected per 8-h nursing shift. Logistic regression analysis was performed. For both study end points, the odds ratios (OR) for improvements at follow-up versus at baseline were calculated separately for control and intervention ICUs.
Results
We analyzed data on 67,237 nursing shifts. The bed occupancy rate did not improve in the intervention group compared to baseline (adjusted OR 0.88; 95 % confidence interval (CI), 0.62–1.27) or compared to control group (OR 0.67; 95 % CI 0.39–1.15). The nurse-to-patient ratio did not improve (OR 0.72; 95 % CI 0.41–1.26 compared to baseline and OR 0.65; 95 % CI 0.35–1.19 compared to control group).
Conclusions
A multifaceted feedback intervention did not improve the adherence to guideline-based standards on the organizational issues bed occupancy rate and nurse-to-patient ratio in the ICU. The reasons may be a limited confidence in data quality, the lack of practical tools for improvement, and the relatively short follow-up.
Trial registration
ISRCTN: ISRCTN50542146
doi:10.1186/s13012-015-0285-2
PMCID: PMC4495635  PMID: 26152568
Multifaceted feedback; Critical care; Quality improvement; Bed occupancy; Nurse-to-patient ratio
10.  Multimorbidity patterns in a primary care population aged 55 years and over 
Family Practice  2015;32(5):505-513.
Background.
To support the management of multimorbid patients in primary care, evidence is needed on prevalent multimorbidity patterns.
Objective.
To identify the common and distinctive multimorbidity patterns.
Methods.
Clinical data of 120480 patients (≥55 years) were extracted from 158 general practices in 2002–11. Prevalence rates of multimorbidity were analyzed (overall, and for 24 chronic diseases), adjusted for practice, number of diseases and patients’ registration period; differentiated between patients 55–69 and ≥70 years. To investigate multimorbidity patterns, prevalence ratios (prevalence rate index-disease group divided by that in the non-index-disease group) were calculated for patients with heart failure, diabetes mellitus, migraine or dementia.
Results.
Multiple membership multilevel models showed that the overall adjusted multimorbidity rate was 86% in patients with ≥1 chronic condition, varying from 70% (migraine) to 98% (heart failure), 38% had ≥4 chronic diseases. In patients 55–69 years, 83% had multimorbidity. Numerous significant prevalence ratios were found for disease patterns in heart failure patients, ranging from 1.2 to 7.7, highest ratio for chronic obstructive pulmonary disease-cardiac dysrhythmia. For diabetes mellitus, dementia or migraine patients highest ratios were for heart failure-visual disorder (2.1), heart failure-depression (3.9) and depression-back/neck disorder (2.1), respectively (all P-values <0.001).
Conclusions.
Multimorbidity management in general practice can be reinforced by knowledge on the clinical implications of the presence of the comprehensive disease patterns among the elderly patients, and those between 55 and 69 years. Guideline developers should be aware of the complexity of multimorbidity. As a consequence of this complexity, it is even more important to focus on what matters to a patient with multimorbidity in general practice.
doi:10.1093/fampra/cmv037
PMCID: PMC4576758  PMID: 26040310
Chronic disease; general practice; multimorbidity; prevalence; primary health care.
11.  Improving the implementation of perioperative safety guidelines using a multifaceted intervention approach: protocol of the IMPROVE study, a stepped wedge cluster randomized trial 
Background
This study is initiated to evaluate the effects, costs, and feasibility at the hospital and patient level of an evidence-based strategy to improve the use of Dutch perioperative safety guidelines. Based on current knowledge, expert opinions and expertise of the project team, a multifaceted implementation strategy has been developed.
Methods/design
This is a stepped wedge cluster randomized trial including nine representative hospitals across The Netherlands. Hospitals are stratified into three groups according to hospital type and geographical location and randomized in terms of the period for receipt of the intervention. All adult surgical patients meeting the inclusion criteria are assessed for patient outcomes. The implementation strategy includes education, audit and feedback, organizational interventions (e.g., local embedding of the guidelines), team-directed interventions (e.g., multi-professional team training), reminders, as well as patient-mediated interventions (e.g., patient safety cards). To tailor the implementation activities, we developed a questionnaire to identify barriers for effective guideline adherence, based on (a) a theoretical framework for classifying barriers and facilitators, (b) an instrument for measuring determinants of innovations, and (c) 19 semi-structured interviews with perioperative key professionals. Primary outcome is guideline adherence measured at the hospital (i.e., cluster) and patient levels by a set of perioperative Patient Safety Indicators (PSIs), which was developed parallel to the perioperative guidelines. Secondary outcomes at the patient level are in-hospital complications, postoperative wound infections and mortality, length of hospital stay, and unscheduled transfer to the intensive care unit, non-elective readmission to the hospital and unplanned reoperation, all within 30 days after the initial surgery. Also, patient safety culture and team climate will be studied as potential determinants. Finally, a process evaluation is conducted to identify the compliance with the implementation strategy, as well as an economic evaluation to assess the costs. Data sources are registered clinical data and surveys. There is no form of blinding.
Discussion
The perioperative setting is an unexplored area with respect to implementation issues. This study is expected to yield important new evidence about the effects of a multifaceted approach on guideline adherence in the perioperative care setting.
Trial registration
Dutch trial registry: NTR3568
Electronic supplementary material
The online version of this article (doi:10.1186/s13012-014-0198-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s13012-014-0198-5
PMCID: PMC4296536  PMID: 25567584
Guideline adherence; Health-care quality indicators; Implementation; Multifaceted approach; Patient safety; Perioperative care; Stepped wedge design
12.  Patients’ expectations of variation in quality of care relates to their search for comparative performance information 
Background
Choice of hospital based on comparative performance information (CPI) was introduced for Dutch healthcare consumers at least 5 years ago, but CPI use has not yet become commonplace. Our aim was to assess the role of patients’ expectations regarding variation in the quality of hospital care in determining whether they search for CPI.
Methods
A questionnaire (for a cross-sectional survey) was distributed to 475 orthopaedic patients in a consecutive sample, who underwent primary hip or knee replacement in a university, teaching, or community hospital between September 2009 and July 2010.
Results
Of the 302 patients (63%) who responded, 13% reported searching for CPI to help them choose a hospital. People who expected quality differences between hospitals (67%) were more likely to search for CPI (OR =3.18 [95% CI: 1.02–9.89]; p <0.04) than those who did not. Quality differences were most often expected in hospital reputation, distance, and accessibility. Patients who did not search for CPI stated that they felt no need for this type of information.
Conclusion
Patients’ expectations regarding variation in quality of care are positively related to their reported search for CPI. To increase the relevance of CPI for patients, future studies should explore the underlying reasoning of patients about meaningful quality-of-care variation between hospitals.
doi:10.1186/s12913-014-0617-y
PMCID: PMC4265457  PMID: 25464982
Expectations; Comparative performance information; Practice variation; Quality of care; Hip replacement; Knee replacement; Elective surgery
13.  Evaluating the uptake and effects of the computerized decision support system NHGDoc on quality of primary care: protocol for a large-scale cluster randomized controlled trial 
Background
Computerized decision support systems (CDSSs) are increasingly used to improve quality of care. There is evidence for moderate to large effects from randomized controlled trials (RCTs), but evidence on their effectiveness when implemented at a national level is lacking. In the Netherlands, the Dutch College of General Practitioners (NHG) initiated their successful guideline program already 30 years ago. NHGDoc, a CDSS based on these NHG guidelines, covering multiple disease areas for general practice, was developed in 2006 with the aim to improve quality of primary care. In this paper, a protocol is presented to evaluate the uptake and effects of NHGDoc.
Methods
A cluster RCT will be conducted among 120 general practices in the Netherlands. Eligible general practices will be randomized to receive either the regular NHGDoc decision support modules (control arm) or the regular modules plus an additional module on heart failure (intervention arm). The heart failure module consists of patient-specific alerts concerning the treatment of patients with heart failure. The effect evaluation will focus on performance indicators (e.g., prescription behavior) as well as on patient outcomes (e.g., hospital admissions) relevant in the domain of heart failure. Additionally, a process evaluation will be conducted to gain insight into the barriers and facilitators that affect the uptake and impact of NHGDoc.
Discussion
Results of this study will provide insight in the uptake and impact of a multiple-domain covering CDSS for primary care implemented by a national guideline organization to improve the quality of primary care. Whereas the trial focuses on a specific domain of care—heart failure—conclusions of this study will shed light on the functioning of CDSSs covering multiple disease areas for primary care, particularly as this study also explores the factors contributing to the system’s uptake and effectiveness.
Trial registration
Clinical trials NCT01773057
Electronic supplementary material
The online version of this article (doi:10.1186/s13012-014-0145-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s13012-014-0145-5
PMCID: PMC4205280  PMID: 25322766
Clinical decision support; Clinical practice guidelines; Primary care; Process of care; Patient outcomes
14.  Comparative performance information plays no role in the referral behaviour of GPs 
BMC Family Practice  2014;15:146.
Background
Comparative performance information (CPI) about the quality of hospital care is information used to identify high-quality hospitals and providers. As the gatekeeper to secondary care, the general practitioner (GP) can use CPI to reflect on the pros and cons of the available options with the patient and choose a provider best fitted to the patient’s needs. We investigated how GPs view their role in using CPI to choose providers and support patients.
Method
We used a mixed-method, sequential, exploratory design to conduct explorative interviews with 15 GPs about their referral routines, methods of referral consideration, patient involvement, and the role of CPI. Then we quantified the qualitative results by sending a survey questionnaire to 81 GPs affiliated with a representative national research network.
Results
Seventy GPs (86% response rate) filled out the questionnaire. Most GPs did not know where to find CPI (87%) and had never searched for it (94%). The GPs reported that they were not motivated to use CPI due to doubts about its role as support information, uncertainty about the effect of using CPI, lack of faith in better outcomes, and uncertainty about CPI content and validity. Nonetheless, most GPs believed that patients would like to be informed about quality-of-care differences (62%), and about half the GPs discussed quality-of-care differences with their patients (46%), though these discussions were not based on CPI.
Conclusion
Decisions about referrals to hospital care are not based on CPI exchanges during GP consultations. As a gatekeeper, the GP is in a good position to guide patients through the enormous amount of quality information that is available. Nevertheless, it is unclear how and whether the GP’s role in using information about quality of care in the referral process can grow, as patients hardly ever initiate a discussion based on CPI, though they seem to be increasingly more critical about differences in quality of care. Future research should address the conditions needed to support GPs’ ability and willingness to use CPI to guide their patients in the referral process.
doi:10.1186/1471-2296-15-146
PMCID: PMC4161854  PMID: 25160715
Primary care; Doctor-patient relationship; Access to care; Performance information; Quality of care; Qualitative research; Quantitative research; Mixed methods
15.  Unexpectedly long hospital stays as an indicator of risk of unsafe care: an exploratory study 
BMJ Open  2014;4(6):e004773.
Objectives
We developed an outcome indicator based on the finding that complications often prolong the patient's hospital stay. A higher percentage of patients with an unexpectedly long length of stay (UL-LOS) compared to the national average may indicate shortcomings in patient safety. We explored the utility of the UL-LOS indicator.
Setting
We used data of 61 Dutch hospitals. In total these hospitals had 1 400 000 clinical discharges in 2011.
Participants
The indicator is based on the percentage of patients with a prolonged length of stay of more than 50% of the expected length of stay and calculated among survivors.
Interventions
No interventions were made.
Outcome measures
The outcome measures were the variability of the indicator across hospitals, the stability over time, the correlation between the UL-LOS and standardised mortality and the influence on the indicator of hospitals that did have problems discharging their patients to other health services such as nursing homes.
Results
In order to compare hospitals properly the expected length of stay was computed based on comparison with benchmark populations. The standardisation was based on patients’ age, primary diagnosis and main procedure. The UL-LOS indicator showed considerable variability between the Dutch hospitals: from 8.6% to 20.1% in 2011. The outcomes had relatively small CIs since they were based on large numbers of patients. The stability of the indicator over time was quite high. The indicator had a significant positive correlation with the standardised mortality (r=0.44 (p<0.001)), and no significant correlation with the percentage of patients that was discharged to other facilities than other hospitals and home (r=−0.15 (p>0.05)).
Conclusions
The UL-LOS indicator is a useful addition to other patient safety indicators by revealing variation between hospitals and areas of possible patient safety improvement.
doi:10.1136/bmjopen-2013-004773
PMCID: PMC4054630  PMID: 24902727
16.  Recognition of physiotherapists’ expertise in Parkinson’s disease 
Background
Publicly available information comparing performance across quality and costs has proliferated in recent years, both about individual healthcare professionals and hospitals. This type of information is now becoming increasingly available for physiotherapists with expertise in Parkinson’s disease (PD). Our study aimed to explore the ability of people with Parkinson’s disease to recognise expertise, and to what extent respondents selectively choose such expert physiotherapists.
Methods
We used claim data from the period 2009–2010 to select customers with PD who claimed physiotherapy. A random sample of 500 eligible respondents received a paper-based survey. We used descriptive statistics to compare the respondent characteristics, a qualitative programme to analyse the qualitative items, and univariate and multivariate regression.
Results
Most respondents (89%) took their referring physician’s advice when selecting a physiotherapist, although this advice rarely was supported with arguments. The remaining respondents (11%) searched for comparative performance information about physiotherapists. Respondents who recognised the added value of PD expertise among physiotherapists were 3.28 times as likely to search for comparative performance information as those who did not understand. Respondents were willing to switch to an expert physiotherapist (68%), and this willingness increased if they recognised the value of PD expertise (p < .001).
Conclusion
The participants were able to recognise certain aspects of expertise. Though they showed relatively few signs of selectively choice behaviour for expert physiotherapists. Both respondents and referring professionals need more understanding about the added value of an expert physiotherapist, to foster selective provider choice.
doi:10.1186/1472-6963-13-430
PMCID: PMC4016478  PMID: 24152942
Provider choice; Comparative performance information; Physiotherapy; Expertise; Parkinson’s disease
17.  Effects of auditing patient safety in hospital care: design of a mixed-method evaluation 
Background
Auditing of patient safety aims at early detection of risks of adverse events and is intended to encourage the continuous improvement of patient safety. The auditing should be an independent, objective assurance and consulting system. Auditing helps an organisation accomplish its objectives by bringing a systematic, disciplined approach to evaluating and improving the effectiveness of risk management, control, and governance. Audits are broadly conducted in hospitals, but little is known about their effects on the behaviour of healthcare professionals and patient safety outcomes. This study was initiated to evaluate the effects of patient safety auditing in hospital care and to explore the processes and mechanisms underlying these effects.
Methods and design
Our study aims to evaluate an audit system to monitor and improve patient safety in a hospital setting. We are using a mixed-method evaluation with a before-and-after study design in eight departments of one university hospital in the period October 2011–July 2014. We measure several outcomes 3 months before the audit and 15 months after the audit. The primary outcomes are adverse events and complications. The secondary outcomes are experiences of patients, the standardised mortality ratio, prolonged hospital stay, patient safety culture, and team climate. We use medical record reviews, questionnaires, hospital administrative data, and observations to assess the outcomes. A process evaluation will be used to find out which components of internal auditing determine the effects.
Discussion
We report a study protocol of an effect and process evaluation to determine whether auditing improves patient safety in hospital care. Because auditing is a complex intervention targeted on several levels, we are using a combination of methods to collect qualitative and quantitative data about patient safety at the patient, professional, and department levels. This study is relevant for hospitals that want to early detect unsafe care and improve patient safety continuously.
Trial registration
Netherlands Trial Register (NTR): NTR3343
doi:10.1186/1472-6963-13-226
PMCID: PMC3708817  PMID: 23800253
Hospital; Patient safety; Safety management; Risk management; Complications; Management system audit; Clinical governance; Professional practice; Adverse events; Auditing
18.  Behavior change in a lifestyle intervention for type 2 diabetes prevention in Dutch primary care: opportunities for intervention content 
BMC Family Practice  2013;14:78.
Background
Despite the favorable effects of behavior change interventions on diabetes risk, lifestyle modification is a complicated process. In this study we therefore investigated opportunities for refining a lifestyle intervention for type 2 diabetes prevention, based on participant perceptions of behavior change progress.
Methods
A 30 month intervention was performed in Dutch primary care among high-risk individuals (FINDRISC-score ≥ 13) and was compared to usual care. Participant perceptions of behavior change progress for losing weight, dietary modification, and increasing physical activity were assessed after18 months with questionnaires. Based on the response, participants were categorized as ‘planners’, ‘initiators’ or ‘achievers’ and frequencies were evaluated in both study groups. Furthermore, participants reported on barriers for lifestyle change.
Results
In both groups, around 80% of all participants (intervention: N = 370; usual care: N = 322) planned change. Except for reducing fat intake (p = 0.08), the number of initiators was significantly higher in the intervention group than in usual care. The percentage of achievers was high for the dietary and exercise objectives (intervention: 81–95%; usual care: 83–93%), but was lower for losing weight (intervention: 67%; usual care: 62%). Important motivational barriers were ‘I already meet the standards’ and ‘I’m satisfied with my current behavior’. Temptation to snack, product taste and lack of time were important volitional barriers.
Conclusions
The results suggest that the intervention supports participants to bridge the gap between motivation and action. Several opportunities for intervention refinement are however revealed, including more stringent criteria for participant inclusion, tools for (self)-monitoring of health, emphasis on the ‘small-step-approach’, and more attention for stimulus control.
Trial registration
Netherlands Trial Register: NTR1082
doi:10.1186/1471-2296-14-78
PMCID: PMC3706294  PMID: 23758998
Type 2 diabetes; Primary care; Behavior change; Lifestyle intervention
19.  Effects of hospital delivery during off-hours on perinatal outcome in several subgroups: a retrospective cohort study 
Background
Studies have demonstrated a higher risk of adverse outcomes among infants born or admitted during off-hours, as compared to office hours, leading to questions about quality of care provide during off-hours (weekend, evening or night). We aim to determine the relationship between off-hours delivery and adverse perinatal outcomes for subgroups of hospital births.
Methods
This retrospective cohort study was based on data from the Netherlands Perinatal Registry, a countrywide registry that covers 99% of all hospital births in the Netherlands. Data of 449,714 infants, born at 28 completed weeks or later, in the period 2003 through 2007 were used. Infants with a high a priori risk of morbidity or mortality were excluded. Outcome measures were intrapartum and early neonatal mortality, a low Apgar score (5 minute score of 0–6), and a composite adverse perinatal outcome measure (mortality, low Apgar score, severe birth trauma, admission to a neonatal intensive care unit).
Results
Evening and night-time deliveries that involved induction or augmentation of labour, or an emergency caesarean section, were associated with an increased risk of an adverse perinatal outcome when compared to similar daytime deliveries. Weekend deliveries were not associated with an increased risk when compared to weekday deliveries. It was estimated that each year, between 126 and 141 cases with an adverse perinatal outcomes could be attributed to this evening and night effect. Of these, 21 (15-16%) are intrapartum or early neonatal death. Among the 3100 infants in the study population who experience an adverse outcome each year, death accounted for only 5% (165) of these outcomes.
Conclusion
This study shows that for infants whose mothers require obstetric interventions during labour and delivery, birth in the evening or at night, are at an increased risk of an adverse perinatal outcomes.
doi:10.1186/1471-2393-12-92
PMCID: PMC3496693  PMID: 22958736
Time of birth; Night; Weekend; Delivery; Perinatal mortality; Perinatal morbidity; Hospital care; Quality of health care
20.  Lifestyle Counseling for Type 2 Diabetes Risk Reduction in Dutch Primary Care 
Diabetes Care  2011;34(9):1919-1925.
OBJECTIVE
To study the overall effect of the Active Prevention in High-Risk Individuals of Diabetes Type 2 in and Around Eindhoven (APHRODITE) lifestyle intervention on type 2 diabetes risk reduction in Dutch primary care after 0.5 and 1.5 years and to evaluate the variability between general practices.
RESEARCH DESIGN AND METHODS
Individuals at high risk for type 2 diabetes (Finnish Diabetes Risk Score ≥13) were randomly assigned into an intervention group (n = 479) or a usual-care group (n = 446). Comparisons were made between study groups and between general practices regarding changes in clinical and lifestyle measures over 1.5 years. Participant, general practitioner, and nurse practitioner characteristics were compared between individuals who lost weight or maintained a stable weight and individuals who gained weight.
RESULTS
Both groups showed modest changes in glucose values, weight measures, physical activity, energy intake, and fiber intake. Differences between groups were significant only for total physical activity, saturated fat intake, and fiber intake. Differences between general practices were significant for BMI and 2-h glucose but not for energy intake and physical activity. In the intervention group, the nurse practitioners’ mean years of work experience was significantly longer in individuals who were successful at losing weight or maintaining a stable weight compared with unsuccessful individuals. Furthermore, successful individuals more often had a partner.
CONCLUSIONS
Risk factors for type 2 diabetes could be significantly reduced by lifestyle counseling in Dutch primary care. The small differences in changes over time between the two study groups suggest that additional intervention effects are modest. In particular, the level of experience of the nurse practitioner and the availability of partner support seem to facilitate intervention success.
doi:10.2337/dc10-2293
PMCID: PMC3161269  PMID: 21775759
21.  Implementation of a lifestyle intervention for type 2 diabetes prevention in Dutch primary care: opportunities for intervention delivery 
BMC Family Practice  2012;13:79.
Background
As in clinical practice resources may be limited compared to experimental settings, translation of evidence-based lifestyle interventions into daily life settings is challenging. In this study we therefore evaluated the implementation of the APHRODITE lifestyle intervention for the prevention of type 2 diabetes in Dutch primary care. Based on this evaluation we discuss opportunities for refining intervention delivery.
Methods
A 2.5-year intervention was performed in 14 general practices in the Netherlands among individuals at high risk for type 2 diabetes (FINDRISC-score ≥ 13) (n = 479) and was compared to usual care (n = 446). Intervention consisted of individual lifestyle counselling by nurse practitioners (n = 24) and GPs (n = 48) and group-consultations. Drop-out and attendance were registered during the programme. After the intervention, satisfaction with the programme and perceived implementation barriers were assessed with questionnaires.
Results
Drop-out was modest (intervention: 14.6 %; usual care: 13.2 %) and attendance at individual consultations was high (intervention: 80-97 %; usual care: 86-94 %). Providers were confident about diabetes prevention by lifestyle intervention in primary care. Participants were more satisfied with counselling from nurse practitioners than from GPs. A major part of the GPs reported low self-efficacy regarding dietary guidance. Lack of counselling time (60 %), participant motivation (12 %), and financial reimbursement (11 %) were regarded by providers as important barriers for intervention implementation.
Conclusions
High participant compliance and a positive attitude of providers make primary care a suitable setting for diabetes prevention by lifestyle counselling. Results support a role for the nurse practitioner as the key player in guiding lifestyle modification. Further research is needed on strategies that could increase cost-effectiveness, such as more stringent criteria for participant inclusion, group-counselling, more tailor-made counselling and integration of screening and / or interventions for different disorders.
doi:10.1186/1471-2296-13-79
PMCID: PMC3457845  PMID: 22873753
Type 2 diabetes; Primary care; Lifestyle intervention; Implementation
22.  Patients' experiences of the quality of long-term care among the elderly: comparing scores over time 
Background
Every two years, long-term care organizations for the elderly are obliged to evaluate and publish the experiences of residents, representatives of psychogeriatric patients, and/or assisted-living clients with regard to quality of care. Our hypotheses are that publication of this quality information leads to improved performance, and that organizations with substandard performance will improve more than those whose performance is relatively good.
Methods
The analyses included organizational units that measured experiences twice between 2007 (t0) and 2009 (t1). Experiences with quality of care were measured with Consumer Quality Index (CQI) questionnaires. Besides descriptive analyses (i.e. mean, 5th and 95th percentile, and 90% central range) of the 19 CQI indicators and change scores of these indicators were calculated. Differences across five performance groups (ranging from 'worst' to 'best') were tested using an ANOVA test and effect sizes were measured with omega squared (ω2).
Results
At t0 experiences of residents, representatives, and assisted-living clients were positive on all indicators. Nevertheless, most CQI indicators had improved scores (up to 0.37 change score) at t1. Only three indicators showed a minor decline (up to -0.08 change score). Change scores varied between indicators and questionnaires, e.g. they were more profound for the face-to-face interview questionnaire for residents in nursing homes than for the other two mail questionnaires (0.15 vs. 0.05 and 0.04, respectively), possibly due to more variation between nursing homes on the first measurement, perhaps indicating more potential for improvement. A negative relationship was found between prior performance and change, particularly with respect to the experiences of residents (ω2 = 0.16) and assisted-living clients (ω2 = 0.15). However, the relation between prior performance and improvement could also be demonstrated with respect to the experiences reported by representatives of psychogeriatric patients and by assisted-living clients. For representatives of psychogeriatric patients, the performance groups 1 and 2 ([much] below average) improved significantly more than the other three groups (ω2 = 0.05).
Conclusions
Both hypotheses were confirmed: almost all indicator scores improved over time and long-term care organizations for the elderly with substandard performance improved more than those with a performance which was already relatively good.
doi:10.1186/1472-6963-12-26
PMCID: PMC3305532  PMID: 22293109
23.  Needs and barriers to improve the collaboration in oral anticoagulant therapy: a qualitative study 
Background
Oral anticoagulant therapy (OAT) involves many health care disciplines. Even though collaboration between care professionals is assumed to improve the quality of OAT, very little research has been done into the practice of OAT management to arrange and manage the collaboration. This study aims to identify the problems in collaboration experienced by the care professionals involved, the solutions they proposed to improve collaboration, and the barriers they encountered to the implementation of these solutions.
Methods
In the Netherlands, intensive follow-up of OAT is provided by specialized anticoagulant clinics (ACs). Sixty-eight semi-structured face-to-face interviews were conducted with 103 professionals working at an AC. These semi-structured interviews were transcribed verbatim and analysed inductively. Wagner's chronic care model (CCM) and Cabana's framework for improvement were used to categorize the results.
Results
AC professionals experienced three main bottlenecks in collaboration: lack of knowledge (mostly of other professionals), lack of consensus on OAT, and limited information exchange between professionals. They mentioned several solutions to improve collaboration, especially solutions of CCM's decision support component (i.e. education, regular meetings, and agreements and protocols). Education is considered a prerequisite for the successful implementation of other proposed solutions such as developing a multidisciplinary protocol and changing the allocation of tasks. The potential of the health care organization to improve collaboration seemed to be underestimated by professionals. They experienced several barriers to the successful implementation of the proposed solutions. Most important barriers were the lack motivation of non-AC professionals and lack of time to establish collaboration.
Conclusions
This study revealed that the collaboration in OAT is limited by a lack of knowledge, a lack of consensus, and a limited information exchange. Education was identified as the best way to improve collaboration and considered a prerequisite for a successful implementation of other proposed solutions. Hence, the implementation sequence is of importance in order to improve the collaboration successfully. First step is to establish alignment regarding collaboration with all involved professionals to encounter the lack of motivation of non-AC professionals and lack of time.
doi:10.1186/1471-2261-11-76
PMCID: PMC3268100  PMID: 22192088
24.  Evaluating the effectiveness of a tailored multifaceted performance feedback intervention to improve the quality of care: protocol for a cluster randomized trial in intensive care 
Background
Feedback is potentially effective in improving the quality of care. However, merely sending reports is no guarantee that performance data are used as input for systematic quality improvement (QI). Therefore, we developed a multifaceted intervention tailored to prospectively analyzed barriers to using indicators: the Information Feedback on Quality Indicators (InFoQI) program. This program aims to promote the use of performance indicator data as input for local systematic QI. We will conduct a study to assess the impact of the InFoQI program on patient outcome and organizational process measures of care, and to gain insight into barriers and success factors that affected the program's impact. The study will be executed in the context of intensive care. This paper presents the study's protocol.
Methods/design
We will conduct a cluster randomized controlled trial with intensive care units (ICUs) in the Netherlands. We will include ICUs that submit indicator data to the Dutch National Intensive Care Evaluation (NICE) quality registry and that agree to allocate at least one intensivist and one ICU nurse for implementation of the intervention. Eligible ICUs (clusters) will be randomized to receive basic NICE registry feedback (control arm) or to participate in the InFoQI program (intervention arm). The InFoQI program consists of comprehensive feedback, establishing a local, multidisciplinary QI team, and educational outreach visits. The primary outcome measures will be length of ICU stay and the proportion of shifts with a bed occupancy rate above 80%. We will also conduct a process evaluation involving ICUs in the intervention arm to investigate their actual exposure to and experiences with the InFoQI program.
Discussion
The results of this study will inform those involved in providing ICU care on the feasibility of a tailored multifaceted performance feedback intervention and its ability to accelerate systematic and local quality improvement. Although our study will be conducted within the domain of intensive care, we believe our conclusions will be generalizable to other settings that have a quality registry including an indicator set available.
Trial registration
Current Controlled Trials ISRCTN50542146
doi:10.1186/1748-5908-6-119
PMCID: PMC3217909  PMID: 22024188
25.  Current Guidelines Have Limited Applicability to Patients with Comorbid Conditions: A Systematic Analysis of Evidence-Based Guidelines 
PLoS ONE  2011;6(10):e25987.
Background
Guidelines traditionally focus on the diagnosis and treatment of single diseases. As almost half of the patients with a chronic disease have more than one disease, the applicability of guidelines may be limited. The aim of this study was to assess the extent that guidelines address comorbidity and to assess the supporting evidence of recommendations related to comorbidity.
Methodology/Principal Findings
We conducted a systematic analysis of evidence-based guidelines focusing on four highly prevalent chronic conditions with a high impact on quality of life: chronic obstructive pulmonary disease, depressive disorder, diabetes mellitus type 2, and osteoarthritis. Data were abstracted from each guideline on the extent that comorbidity was addressed (general comments, specific recommendations), the type of comorbidity discussed (concordant, discordant), and the supporting evidence of the comorbidity-related recommendations (level of evidence, translation of evidence). Of the 20 guidelines, 17 (85%) addressed the issue of comorbidity and 14 (70%) provided specific recommendations on comorbidity. In general, the guidelines included few recommendations on patients with comorbidity (mean 3 recommendations per guideline, range 0 to 26). Of the 59 comorbidity-related recommendations provided, 46 (78%) addressed concordant comorbidities, 8 (14%) discordant comorbidities, and for 5 (8%) the type of comorbidity was not specified. The strength of the supporting evidence was moderate for 25% (15/59) and low for 37% (22/59) of the recommendations. In addition, for 73% (43/59) of the recommendations the evidence was not adequately translated into the guidelines.
Conclusions/Significance
Our study showed that the applicability of current evidence-based guidelines to patients with comorbid conditions is limited. Most guidelines do not provide explicit guidance on treatment of patients with comorbidity, particularly for discordant combinations. Guidelines should be more explicit about the applicability of their recommendations to patients with comorbidity. Future clinical trials should also include patients with the most prevalent combinations of chronic conditions.
doi:10.1371/journal.pone.0025987
PMCID: PMC3197602  PMID: 22028802

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