The effect of a local promotional campaign on preconceptional lifestyle changes and the use of preconception care.

PURPOSE: The objective of this study was to investigate the effect of a local promotional campaign on preconceptional lifestyle changes and the use of preconception care (PCC). MATERIAL AND METHODS: This quasi-comparative study was carried out between February 2015 and February 2016 at a community midwifery practice in the Netherlands. The intervention consisted of a dual track approach (i) a promotional campaign for couples who wish to conceive and (ii) a PCC pathway for health care providers. Questionnaires were collected from a sample of women who received antenatal care during the pre-intervention (n = 283) and post-intervention (n = 257) period. Main outcome measures were preconceptional lifestyle changes and PCC use (defined as searching for information and/or consulting a health care provider). RESULTS: Women who were exposed to the intervention were significantly more likely to make at least one lifestyle change during the preconception period [adjusted OR 1.56 (95% CI 1.02-2.39)]. Women were especially more likely to preconceptionally reduce or quit [adjusted OR 1.72 (95% CI 1.05-2.83)] their alcohol consumption after exposure to the intervention. Although non-significant, it appeared that women who were exposed to the intervention more often prepared themselves for pregnancy by means of independently searching for preconception health information [adjusted OR 1.13 (95% CI 0.77-1.65)] or consulting a health care provider regarding their wish to conceive [adjusted OR 1.24 (95% CI 0.81-1.92)]. CONCLUSIONS: Exposure to a local promotional campaign targeted at preconceptional health was associated with improved preconceptional lifestyle behaviours, especially with regard to alcohol consumption, and has the potential to improve the use of PCC.

Multi-faceted implementation strategy to increase use of a clinical guideline for the diagnosis of deep venous thrombosis in primary care.

Background: A clinical decision rule (CDR), combined with a negative D-dimer test, can safely rule out deep venous thrombosis (DVT) in primary care. This strategy is recommended by guidelines, yet uptake by GPs is low. Objective: To evaluate a multi-faceted implementation strategy aimed at increased use of the guideline recommended CDR plus D-dimer test in primary care patients with suspected DVT. Methods: This multi-faceted implementation strategy consisted of educational outreach visits, financial reimbursements and periodical newsletters. 217 Dutch GPs (implementation group) received this strategy and included patients. Effectiveness was measured through the following patient-level outcomes: (i) proportion of non-referred patients, (ii) proportion of missed DVT cases within this group and (iii) the proportion of patients in whom the guideline was applied incorrectly. Implementation outcomes ('acceptability', 'feasibility', 'fidelity' and 'sustainability') were assessed with an online questionnaire. Patient-level outcomes were compared with those of patients included by 450 GPs, uninformed about the study's purposes providing information about usual care. Results: 336 (54%) of 619 analyzable implementation group patients were not referred, missing 6 [1.8% (95% confidence interval 0.7% to 3.9%)] DVT cases. Incorrect guideline use was observed in 199 patients (32%). Self-reported acceptability, feasibility and expected sustainability were high. Guideline use increased from 42% to an expected continuation of use of 91%. Only 32 usual care GPs included 62 patients, making formal comparison unreliable. Conclusions: This multi-faceted implementation strategy safely reduced patient referral to secondary care, despite frequently incorrect application of the guideline and resulted in high acceptability, feasibility and expected sustainability.

A comparison of the quality of care in accident and emergency departments in England and the Netherlands as experienced by patients.

BACKGROUND: Measuring patients' experiences to determine health-care performance and quality of care from their perspective can provide valuable evidence for international improvements in the quality of care. We compare patients' experiences in Accident & Emergency departments (A&E) in England and the Netherlands and discuss the usefulness of this comparison. METHODS: A cross-sectional survey was conducted among patients attending A&Es aged 18 years and older. In England, 134 A&Es were surveyed. In the Netherlands, nine hospitals participated in the study. Main outcome measures were patients' experiences represented by six domain scores aggregated on the country level or on the A&E level. RESULTS: In England, 43 892 completed questionnaires were received (40%). In the Netherlands, 1865 completed questionnaires were received (42%). Three of six domain scores were significantly higher for patients in the Netherlands: 'waiting time' [mean scores of 73.8 (NL) versus 67.2 (ENG)], 'doctors and nurses' [mean scores of 85.7 (NL) versus 80.6 (ENG)] and 'your care and treatment' [mean scores of 82.6 (NL) and 80.2 (ENG)]. The variance among the English A&Es was large. The best and worst practices on five domains were English. CONCLUSIONS: The mean quality of care in the A&E appeared to be better in the Netherlands on three domains, but the best practices were English A&Es. The within-country differences between A&Es were much larger than differences between countries. Healthcare performance in the A&E can be compared between countries by surveying patients' experiences, and there seems much to learn across A&Es both within and among countries.

A screening protocol for child abuse at out-of-hours primary care locations: a descriptive study.

BACKGROUND: Child abuse is often unrecognized at out-of-hours primary care (OOH-PC) services. The aim of our study was to evaluate the clinical outcome of the screening instrument SPUTOVAMO-R2 for child abuse (checklist), followed by a structured approach (reporting code), at OOH-PC services. The reporting code with five steps should ensure consistent action in case of a suspicion. METHODS: All children attending one of the five participating OOH-PC services in the region of Utrecht, the Netherlands, in a year time, were included. The checklist is an obligatory field in the electronic patient file and was filled in for all children. In case of a positive checklist, the steps in the reporting code were followed. Additionally, the case was evaluated in a multidisciplinary team to determine the probability of child abuse. RESULTS: The checklist was filled in for 50671 children; 108 (0.2 %) were positive. The multidisciplinary team diagnosed child abuse in 24 (22 %) of the 108 positive checklists, and no child abuse in 36 (33 %). Emotional neglect was the most frequent type of abuse diagnosed. For all abused children, care was implemented according to the protocol. The most frequent care given was a referral to the hospital (N = 7) or contact with child's own general practitioner (N = 6). CONCLUSION: A checklist followed by a reporting code guarantees consistent actions and care for children with a suspicion of child abuse. The percentage of positive checklists is lower than expected. Validity of the checklist should be assessed in a diagnostic study.

Laparoscopic versus open gastrectomy for gastric cancer, a multicenter prospectively randomized controlled trial (LOGICA-trial).

BACKGROUND: For gastric cancer patients, surgical resection with en-bloc lymphadenectomy is the cornerstone of curative treatment. Open gastrectomy has long been the preferred surgical approach worldwide. However, this procedure is associated with considerable morbidity. Several meta-analyses have shown an advantage in short-term outcomes of laparoscopic gastrectomy compared to open procedures, with similar oncologic outcomes. However, it remains unclear whether the results of these Asian studies can be extrapolated to the Western population. In this trial from the Netherlands, patients with resectable gastric cancer will be randomized to laparoscopic or open gastrectomy. METHODS: The study is a non-blinded, multicenter, prospectively randomized controlled superiority trial. Patients (≥18 years) with histologically proven, surgically resectable (cT1-4a, N0-3b, M0) gastric adenocarcinoma and European Clinical Oncology Group performance status 0, 1 or 2 are eligible to participate in the study after obtaining informed consent. Patients (n = 210) will be included in one of the ten participating Dutch centers and are randomized to either laparoscopic or open gastrectomy. The primary outcome is postoperative hospital stay (days). Secondary outcome parameters include postoperative morbidity and mortality, oncologic outcomes, readmissions, quality of life and cost-effectiveness. DISCUSSION: In this randomized controlled trial laparoscopic and open gastrectomy are compared in patients with resectable gastric cancer. It is expected that laparoscopic gastrectomy will result in a faster recovery of the patient and a shorter hospital stay. Secondly, it is expected that laparoscopic gastrectomy will be associated with a lower postoperative morbidity, less readmissions, higher cost-effectiveness, better postoperative quality of life, but with similar mortality and oncologic outcomes, compared to open gastrectomy. The study started on 1 December 2014. Inclusion and follow-up will take 3 and 5 years respectively. Short-term results will be analyzed and published after discharge of the last randomized patient. TRIAL REGISTRATION: NCT02248519.

Early detection of parenting and developmental problems in toddlers: A randomized trial of home visits versus well-baby clinic visits in the Netherlands.

OBJECTIVE: The early detection of parenting and developmental problems by preventive child health care (CHC) services in the Netherlands takes place almost exclusively at the well-baby clinic. This study assesses whether, compared to a visit to the well-baby clinic, a home visit improves early detection. METHODS: 4481 eligible 18-month-old children and their parents were randomized to either a visit to the well-baby clinic or a home visit in the period from December 2006 to January 2008. A CHC nurse held structured interviews using the validated Structured Problem Analysis of Raising Kids (SPARK). Differences in the percentage of children with high or increased risks of parenting and developmental problems as assessed by the SPARK were analyzed with ordinal regression. Secondary outcomes included the percentage of parents attending, parents' concerns, needs assessment by parents and CHC professionals and user experience. RESULTS: Response rates were 94.0% for the home visit group and 93.2% for the well-baby clinic group. Using the SPARK at home identified significantly more high-risk children compared to clinic visits (3.7 vs. 2.6%) and fewer children with increased risk (19.1 vs. 20.7%; overall p=0.028). Home visits more often involved both parents and other children. At home, parents reported more concerns. Both parents and CHC nurses more often expressed the need for support and reported significantly better experiences at home. CONCLUSIONS: Aided by a validated structured interview, CHC professionals detect more children with high risks of parenting and child-developmental problems during home visits than during clinic visits. CLINICAL TRIAL REGISTRATION: www.trialregister.nl Identifier: NTR1413.

The Consumer Quality Index in an accident and emergency department: internal consistency, validity and discriminative capacity.

BACKGROUND: Patients' experiences are an indicator of health-care performance in the accident and emergency department (A&E). The Consumer Quality Index for the Accident and Emergency department (CQI A&E), a questionnaire to assess the quality of care as experienced by patients, was investigated. The internal consistency, construct validity and discriminative capacity of the questionnaire were examined. METHODS: In the Netherlands, twenty-one A&Es participated in a cross-sectional survey, covering 4883 patients. The questionnaire consisted of 78 questions. Principal components analysis determined underlying domains. Internal consistency was determined by Cronbach's alpha coefficients, construct validity by Pearson's correlation coefficients and the discriminative capacity by intraclass correlation coefficients and reliability of A&E-level mean scores (G-coefficient). RESULTS: Seven quality domains emerged from the principal components analysis: information before treatment, timeliness, attitude of health-care professionals, professionalism of received care, information during treatment, environment and facilities, and discharge management. Domains were internally consistent (range: 0.67-0.84). Five domains and the 'global quality rating' had the capacity to discriminate among A&Es (significant intraclass correlation coefficient). Four domains and the 'global quality rating' were close to or above the threshold for reliably demonstrating differences among A&Es. The patients' experiences score on the domain timeliness showed the largest range between the worst- and best-performing A&E. CONCLUSIONS: The CQI A&E is a validated survey to measure health-care performance in the A&E from patients' perspective. Five domains regarding quality of care aspects and the 'global quality rating' had the capacity to discriminate among A&Es.

The effect of acute kidney injury on long-term health-related quality of life: a prospective follow-up study.

INTRODUCTION: Acute kidney injury (AKI) is a serious complication in critically ill patients admitted to the Intensive Care Unit (ICU). We hypothesized that ICU survivors with AKI would have a worse health-related quality of life (HRQOL) outcome than ICU survivors without AKI. METHODS: We performed a long-term prospective observational study. Patients admitted for > 48 hours in a medical-surgical ICU were included and divided in two groups: patients who fulfilled RIFLE criteria for AKI and patients without AKI. We used the Short-Form 36 to evaluate HRQOL before admission (by proxy within 48 hours after admission of the patient), at ICU discharge, hospital discharge, 3 and 6 months following ICU discharge (all by patients). Recovery in HRQOL from ICU-admission onwards was assessed using linear mixed modelling. RESULTS: Between September 2000 and January 2007 all admissions were screened for study participation. We included a total of 749 patients. At six months after ICU discharge 73 patients with AKI and 325 patients without AKI could be evaluated. In survivors with and without AKI, the pre-admission HRQOL (by proxy) and at six months after ICU discharge was significantly lower compared with an age matched general population. Most SF-36 dimensions changed significantly over time from ICU discharge. Change over time of HRQOL between the different AKI Rifle classes (Risk, Injury, Failure) showed no significant differences. At ICU discharge, scores were lowest in the group with AKI compared with the group without AKI for the physical functioning, role-physical and general health dimensions. However, there were almost no differences in HRQOL between both groups at six months. CONCLUSIONS: The pre-admission HRQOL (by proxy) of AKI survivors was significantly lower in two dimensions compared with the age matched general population. Six months after ICU discharge survivors with and without AKI showed an almost similar HRQOL. However, compared with the general population with a similar age, HRQOL was poorer in both groups.

Clustering of health-related behaviors, health outcomes and demographics in Dutch adolescents: a cross-sectional study.

BACKGROUND: Recent studies show several health-related behaviors to cluster in adolescents. This has important implications for public health. Interrelated behaviors have been shown to be most effectively targeted by multimodal interventions addressing wider-ranging improvements in lifestyle instead of via separate interventions targeting individual behaviors. However, few previous studies have taken into account a broad, multi-disciplinary range of health-related behaviors and connected these behavioral patterns to health-related outcomes. This paper presents an analysis of the clustering of a broad range of health-related behaviors with relevant demographic factors and several health-related outcomes in adolescents. METHODS: Self-report questionnaire data were collected from a sample of 2,690 Dutch high school adolescents. Behavioral patterns were deducted via Principal Components Analysis. Subsequently a Two-Step Cluster Analysis was used to identify groups of adolescents with similar behavioral patterns and health-related outcomes. RESULTS: Four distinct behavioral patterns describe the analyzed individual behaviors: 1- risk-prone behavior, 2- bully behavior, 3- problematic screen time use, and 4- sedentary behavior. Subsequent cluster analysis identified four clusters of adolescents. Multi-problem behavior was associated with problematic physical and psychosocial health outcomes, as opposed to those exerting relatively few unhealthy behaviors. These associations were relatively independent of demographics such as ethnicity, gender and socio-economic status. CONCLUSIONS: The results show that health-related behaviors tend to cluster, indicating that specific behavioral patterns underlie individual health behaviors. In addition, specific patterns of health-related behaviors were associated with specific health outcomes and demographic factors. In general, unhealthy behavior on account of multiple health-related behaviors was associated with both poor psychosocial and physical health. These findings have significant meaning for future public health programs, which should be more tailored with use of such knowledge on behavioral clustering via e.g. Transfer Learning.

Both cardiovascular and non-cardiovascular comorbidity are related to health status in well-controlled type 2 diabetes patients: a cross-sectional analysis.

BACKGROUND: Type 2 diabetes patients have a decreased health-related quality of life compared to healthy persons, especially regarding physical functioning and well-being. Health-related quality of life is even lower in type 2 diabetes patients when other diseases co-exist. In contrast to earlier studies, we assessed the associations between the number and type of comorbidities and health status in well-controlled type 2 diabetes patients, in whom treatment goals for HbA1c, blood pressure and cholesterol had been reached. Approximately one in five type 2 diabetes patients belongs to this group. METHODS: Cross-sectional analysis was performed in 2086 well-controlled (HbA1c ≤58 mmol/mol, systolic blood pressure ≤145 mmHg, total cholesterol ≤5.2 mmol/l and not using insulin) type 2 diabetes patients in general practice. Both number and type (cardiovascular and non-cardiovascular) of comorbidities were determined for each patient. Health status was assessed with the questionnaires Short Form-36 (SF-36) and EuroQol (EQ). The SF-36 generates eight dimensions of health and a Physical and Mental Component Score (PCS and MCS), scale: 0-100. The EQ consists of two parts: EQ-5D and EQ Visual Analogue Scale. Multivariable linear regression analysis was used to assess if number and type of comorbidities were associated with health status. RESULTS: Well-controlled type 2 diabetes patients with comorbidities had a much lower health status, with a decrease ranging from -1.5 for the MCS to -26.3 for role limitations due to physical problems, compared to those without. Health status decreased when the number of comorbidities increased, except for mental health, role limitations due to emotional problems, MCS and both EQ measures. In patients with both cardiovascular and non-cardiovascular comorbidity, physical functioning, role limitations due to physical problems and PCS were significantly lower than in patients with only cardiovascular comorbidity. Physical functioning was also lower compared to patients with only non-cardiovascular comorbidity. CONCLUSIONS: Even acceptable values of HbA1c, blood pressure and cholesterol in type 2 diabetes patients are not necessarily related with a good health status. We have shown that comorbidities have a large impact on health status. Physicians may take into account patient's health status and integrate the impact of comorbidities into diabetes care.

Impact of secondary cardiovascular events on health status.

OBJECTIVES: Estimates regarding the impact of secondary cardiovascular events on health status in patients treated for cardiovascular disease are scarce and of limited accuracy. METHODS: We obtained individual patient data on health status (EuroQol five-dimensional questionnaire) and secondary cardiovascular events (death, myocardial infarction, cerebrovascular accidents, amputation, extracranial bleeding, and reinterventions) observed during 12 to 36 months of follow-up. Data originated from five completed clinical trials on revascularization in coronary heart disease (n = 2593) or peripheral arterial disease (PAD; n = 1379). We used linear mixed-effects modeling to estimate the acute impact of the initial secondary event and the health status before and after the event. RESULTS: A total of 1595 patients had at least one secondary event. Loss of health status just before the event ranged from 0.36 utility score for amputation in women with PAD to zero for cerebrovascular accident in men with PAD. In patients with coronary heart disease, pre-event health status loss ranged from 0.34 for extracranial bleeding in women to 0.10 for myocardial infarction in women. The acute impact of secondary events ranged from minor deterioration for cerebrovascular accident (-0.03) to improvement after all other events, ranging from +0.01 for occlusion to +0.22 for amputation. Women had significantly lower pre-event scores than did men: -0.04 to -0.10 in coronary heart disease and -0.04 to -0.27 in PAD. Older patients had mostly large but insignificantly lower pre-event scores than did younger patients (range +0.04 to -0.67). CONCLUSIONS: Secondary events after revascularization in patients with cardiovascular disease are associated with health status loss before the event, while acute impact of the events was mostly small.

Validity and reliability of a structured interview for early detection and risk assessment of parenting and developmental problems in young children: a cross-sectional study.

BACKGROUND: Preventive child health care is well suited for the early detection of parenting and developmental problems. However, as far as the younger age group is concerned, there are no validated early detection instruments which cover both the child and its environment. Therefore, we have developed a broad-scope structured interview which assesses parents' concerns and their need for support, using both the parental perspective and the experience of the child health care nurse: the Structured Problem Analysis of Raising Kids (SPARK). This study reports the psychometric characteristics of the SPARK. METHOD: A cross-sectional study of 2012 18-month-old children, living in Zeeland, a province of the Netherlands. Inter-rater reliability was assessed in 67 children. Convergent validity was assessed by comparing SPARK-domains with domains in self-report questionnaires on child development and parenting stress. Discriminative validity was assessed by comparing different outcomes of the SPARK between groups with different levels of socio-economic status and by performing an extreme-groups comparison. The user experience of both parents and nurses was assessed with the aid of an online survey. RESULTS: The response rate was 92.1% for the SPARK. Self-report questionnaires were returned in the case of 66.9% of the remaining 1721 children. There was selective non-reporting: 33.1% of the questionnaires were not returned, covering 65.2% of the children with a high-risk label according to the SPARK (p < 0.001). Inter-rater reliability was good to excellent with intraclass correlations between 0.85 and 1.0 for physical topics; between 0.61 and 0.8 for social-emotional topics and 0.92 for the overall risk assessment. Convergent validity was unexpectedly low (all correlations ≤0.3) although the pattern was as expected. Discriminative validity was good. Users were satisfied with the SPARK and identified some topics for improvement. CONCLUSION: The SPARK discriminates between children with a high, increased and low risk of parenting and developmental problems. It does so in a reliable way, but more research is needed on aspects of validity and in other populations.

The Consumer Quality index (CQ-index) in an accident and emergency department: development and first evaluation.

BACKGROUND: Assessment of patients' views are essential to provide a patient-centred health service and to evaluating quality of care. As no standardized and validated system for measuring patients' experiences in accident and emergency departments existed, we have developed the Consumer Quality index for the accident and emergency department (CQI A&E). METHODS: Qualitative research has been undertaken to determine the content validity of the CQI A&E. In order to assess psychometric characteristics an 84-item questionnaire was sent to 653 patients who had attended a large A&E in the Netherlands. Also, fifty importance questions were added to determine relevance of the questions and for future calculations of improvement scores. Exploratory factor analysis was applied to detect the domains of the questionnaire. RESULTS: Survey data of 304 (47%) patients were used for the analysis. The first exploratory factor analysis resulted in three domains based on 13 items: 'Attitude of the healthcare professionals', 'Environment and impression of the A&E' and 'Respect for and explanation to the patient'. The first two had an acceptable internal consistency. The second analysis, included 24 items grouped into 5 domains: 'Attitude of the healthcare professionals', 'Information and explanation', 'Environment of the A&E','Leaving the A&E' and 'General information and rapidity of care'. All factors were internal consistent. According to the patients, the three most important aspects in healthcare performance in the A&E were: trust in the competence of the healthcare professionals, hygiene in the A&E and patients' health care expectations. In general, the highest improvement scores concerned patient information. CONCLUSIONS: The Consumer Quality index for the accident and emergency department measures patients' experiences of A&E healthcare performance. Preliminary psychometric characteristics are sufficient to justify further research into reliability and validity.

Safety and efficiency of triaging low urgent self-referred patients to a general practitioner at an acute care post: an observational study.

OBJECTIVE: To assess the safety and efficiency of triaging low urgent self-referred patients at the emergency department (ED) to a general practitioner (GP) based on the Manchester triage system (MTS). METHODS: All self-referred patients in the evening, night and weekends were included in this prospective observational study. Patients were triaged by an ED nurse according to the MTS and allocated to a GP or the ED according to a predefined care scheme. For patients treated by the GP, assessments were made of safety as measured by hospitalisation and return to the ED within 2 weeks, and efficiency as measured by referral to the ED. RESULTS: In 80% of cases allocation of the self-referrals to the ED or GP was according to a predefined scheme. Of the 3129 low urgent self-referred patients triaged to the GP, 2840 (90.8%) were sent home, 202 (6.5%) were directly referred to the ED, 36 (1.2%) were hospitalised. Within a random sample of low urgent patients sent home by the GP (222 of 2840), 8 (3.6%) returned to the ED within 2 weeks. Against the agreed MTS scheme, the ED also directly treated 664 low urgent patients, mainly for extremity problems (n=512). Despite the care agreements, 227 urgent patients were treated by the GP, with a referral rate to the ED of 18.1%, a hospitalisation rate of 4.0% and a 4.5% return rate to the ED within 2 weeks. CONCLUSIONS: Low urgent self-referrals, with the exception of extremity problems, were shown to be treated efficiently and safely by a GP. A selected group of more urgent patients also seem to be handled adequately by the GP. Triage of low urgent patients with extremity problems and reasons for nurses not following a predefined triage allocation scheme need further elaboration.

Attitudes of Klinefelter men and their relatives towards TESE-ICSI.

PURPOSE: At the start of the implementation of TESE-ICSI for Klinefelter men in the Netherlands, we aimed to evaluate their wish to father children and their attitudes towards this artificial reproduction technique. METHODS: Questionnaires were distributed to members of the Dutch Klinefelter Association (n = 365) and to Klinefelter cases known at our Department (n = 58). Questions addressed several aspects: socio-demographic characteristics, ascertainment of diagnosis, children and child wish, and TESE-ICSI. Data were characterized using descriptive statistics. RESULTS: A total of 260 questionnaires (corresponding to 194 cases, 46%) were returned. A possible wish to father children was reported by 90% of Klinefelter men. 70% of Klinefelter men and 74% of their partners would (probably) opt for TESE-ICSI. CONCLUSION: The majority of Dutch Klinefelter men and their partners desire to have children and have a positive attitude towards TESE-ICSI. Concerns include the risk of congenital malformations/developmental delay of the child and the limited success rate of TESE-ICSI.

Associations of the Emergency Severity Index triage categories with patients' vital signs at triage: a prospective observational study.

STUDY OBJECTIVE: Previous studies on the construct validity of the Emergency Severity Index (ESI) were focused on outcome measures which could not be obtained directly at triage. A study was conducted to the construct validity of the ESI by measuring the association between the ESI triage categories and patients' vital signs at triage. METHODS: A prospective observational study was conducted at an emergency department (ED) in the Netherlands. All patients who entered the ED between 20 July 2009 and 21 August 2009 were eligible for inclusion in the study. Patients' vital signs, triage category, age, gender, referrer and main complaint were registered. Vital signs were scored according to the Worthing Physiological Scoring System (WPSS) and the numerical pain rating scale. The data were analysed using ordinal logistic regression analyses. RESULTS: An association was found between ESI triage categories and patients' vital signs at triage. Patients in WPSS categories 'urgent' and 'alert' were more likely triaged into the urgent triage categories (ESI triage categories 1 and 2) than patients with normal WPSS scores. However, no associations were found between pain scores and ESI triage categories. CONCLUSION: This study supports the validity of the ESI as it showed that patients' vital signs are associated with the ESI triage categories. However, a revision of the ESI guidelines concerning pain assessments is necessary.

Pain assessments at triage with the Manchester triage system: a prospective observational study.

OBJECTIVE: Pain is one of the six general discriminators of the Manchester triage system (MTS). The frequency of pain assessments conducted at triage with the MTS, and patient, nurse and triage characteristics associated with pain assessments were studied. Also, nurses' reasons for not assessing pain at triage were studied. METHODS: The study consisted of two parts. In part 1, nurses from two emergency departments (ED) registered patient characteristics and the process of triage for every presenting patient during 1 week in May 2009. The characteristics of triage nurses were registered on a second form. In part 2 of the study, 13 nurses were interviewed about reasons for not assessing pain at triage. RESULTS: According to the MTS guidelines, pain assessments should have been conducted in 86.1% of the patient presentations. It was only assessed in 32.2% of these patients. Characteristics associated with conducting pain assessments were children under 12 years of age, patients referred by others than a general practitioner or ambulance service, intake of medication before an ED visit, experience of the nurse with the MTS and the duration of triage. Reasons for not assessing pain according to the guidelines included the thought of triage nurses that pain assessments result in overtriage. CONCLUSIONS: Pain assessments at triage are conducted infrequently because of insufficient education, conducting activities at triage that are not necessary for estimating urgency and a lack of clarity in the MTS guidelines. Changes in these areas are necessary to improve the reliability and validity of pain assessments and the MTS.

Assessing Concerns and Care Needs of Expectant Parents: Development and Feasibility of a Structured Interview.

Many adverse situations for parenting and healthy child development can be detected before a child's birth. The aim of this project was to develop and test an instrument to use in prenatal home visits, to improve the identification of adverse situations and care needs during pregnancy. The preSPARK is based on a valid and reliable broad-scope structured interview called SPARK (Structured Problem Analysis of Raising Kids). The preSPARK focuses on 12 topics ranging from aspects of the period before pregnancy to future parents' expectations. The preSPARK was tested in daily practice for feasibility and discriminative capacity. User experience was assessed from the perspective of the professional. In total, 64 home visits using the preSPARK were carried out by 21 nurses. About 24% of the expectant parents needed intensive help or immediate action on one or more topics. The risk assessment showed 29% of the participants were at high risk, 40% at increased risk, and 31% at low risk for future parenting and child developmental problems. The nurses indicated that the preSPARK provides a good structure for home visits and gives insight in interrelated factors. The preSPARK is feasible in daily practice and clarifies risks and care needs of expectant parents.

The sensory-reactivity PROM set: identification of a parent reported outcome measure set for autism spectrum disorder.

BACKGROUND: Most children with autism spectrum disorder (ASD) suffer from aberrant responses to sensory stimuli that significantly impact the quality of life. To develop sensory interventions, individually tailored outcome measures are crucially needed for the domain of sensory reactivity problems. Here, we describe the identification of relevant sensory themes according to caregivers of children with ASD according to the guidelines for developing a (parent proxy) patient-reported outcome measure set. Subsequently, we identify parallels between these themes and a well-validated and supported PROMIS® portal to facilitate implementation. Interviews with clinicians and focus groups and interviews with parents of children with ASD were used in the initial phase for concept elicitation. Codes and themes were generated by qualitative thematic data analysis on the transcripts and cognitive interviews with different parents were used for revisions. The resulting themes were compared to existing generic PROMIS-item banks and other existing questionnaires. RESULTS: A total of 11 parent-reported outcomes were identified that could be either classified as directly or indirectly related to sensory reactivity. Directly related themes comprised of: (1) sensory stimulation tolerance and (2) sensitivity to sensory stimuli. Indirectly related themes were: (3) irritable behavior (4) anxiety problems (5) mood problems (6) sleep problems (7) fatigue (8) physical complaints (9) daily functioning and participation (10) routines, structure and dealing with change and (11) problems in social interaction and communication. Seven out of 11 themes could be measured with generic PROMIS item banks. The four remaining outcomes (sensory stimulation tolerance; irritable behaviour; routines, structure and dealing with change; and sensitivity to sensory stimuli) were found suitable to be inventoried by existing PROMs. CONCLUSION: The majority of parent-reported problems seemed related to indirect consequences of sensory reactivity, which are suitable to be measured with generic item banks. In sum, we identified a sensory-reactivity PROM (parent-proxy) set consisting of PROMIS® item banks and additional domains that together form a comprehensive and readily available outcome set for sensory reactivity problems in children with ASD.

Weekly self-monitoring and treatment adjustment benefit patients with partly controlled and uncontrolled asthma: an analysis of the SMASHING study.

BACKGROUND: Internet-based self-management has shown to improve asthma control and asthma related quality of life, but the improvements were only marginally clinically relevant for the group as a whole. We hypothesized that self-management guided by weekly monitoring of asthma control tailors pharmacological therapy to individual needs and improves asthma control for patients with partly controlled or uncontrolled asthma. METHODS: In a 1-year randomised controlled trial involving 200 adults (18-50 years) with mild to moderate persistent asthma we evaluated the adherence with weekly monitoring and effect on asthma control and pharmacological treatment of a self-management algorithm based on the Asthma Control Questionnaire (ACQ). Participants were assigned either to the Internet group (n = 101) that monitored asthma control weekly with the ACQ on the Internet and adjusted treatment using a self-management algorithm supervised by an asthma nurse specialist or to the usual care group (UC) (n = 99). We analysed 3 subgroups: patients with well controlled (ACQ ACQ 1.5) asthma at baseline. RESULTS: Overall monitoring adherence was 67% (95% CI, 60% to 74%). Improvements in ACQ score after 12 months were -0.14 (p = 0.23), -0.52 (p < 0.001) and -0.82 (p < 0.001) in the Internet group compared to usual care for patients with well, partly and uncontrolled asthma at baseline, respectively. Daily inhaled corticosteroid dose significantly increased in the Internet group compared to usual care in the first 3 months in patients with uncontrolled asthma (+278 microg, p = 0.001), but not in patients with well or partly controlled asthma. After one year there were no differences in daily inhaled corticosteroid use or long-acting beta2-agonists between the Internet group and usual care. CONCLUSIONS: Weekly self-monitoring and subsequent treatment adjustment leads to improved asthma control in patients with partly and uncontrolled asthma at baseline and tailors asthma medication to individual patients' needs.