Care networks of home-dwelling older adults in the Netherlands: proof of concept of a network typology.

BACKGROUND: Studies on care networks of home-dwelling older adults often focus on network composition. However, looking at network mechanisms (negotiation, navigation and contagion) can be helpful to improve the support generated by the care network. A European study on diabetes patients identified network types based on interaction, which can be beneficial (generative, proxy) or detrimental (struggling, avoidant) to support. This study explored whether these network types are present in care networks of home-dwelling older adults in the Netherlands, and how these types manifest in composition or mechanisms. METHODS: The present study is a cross-sectional qualitative study of care networks supporting 19 home-dwelling older adults. Face-to-face interviews were conducted with the older adult and their informal and formal caregivers between March and September 2016. Network composition and mechanisms were abstracted from content analysis of interview transcripts, then network type was determined for each network. RESULTS: Three of the 19 networks had only one respondent and were excluded, yielding 16 for analysis: eight proxy networks, three generative networks, two avoidant networks, one struggling network, and two possibly hybrid networks. In the proxy networks, all negotiation and navigation were centralised by the proxy. In generative networks, negotiation was possible if the older adult could reciprocate, and the network supported this. In avoidant networks, informal and formal caregivers had to deal with an older adult who refused support. In the struggling network, the underlying problem could not be addressed. Furthermore, two networks could either be hybrid network types or networks in a transition process from generative to proxy network. CONCLUSION: Our results suggest that the network typology developed in the context of diabetes patients is relevant and mostly replicable in networks of multi-morbid older adults. We found that a care network typology based on mechanisms offered additional information beyond network composition. It also appears that the network type can change over time, but more research is needed to confirm this. This study suggests that interventions in avoidant or struggling networks are difficult. Also, actions of network participants seemed aimed at developing proxy networks. Interventions designed to develop or maintain generative networks seem underused.

The influence of government policies on the nurse practitioner and physician assistant workforce in the Netherlands, 2000-2022: a multimethod approach study.

BACKGROUND: Many countries are looking for ways to increase nurse practitioner (NP) and physician assistant/associate (PA) deployment. Countries are seeking to tackle the pressing issues of increasing healthcare demand, healthcare costs, and medical doctor shortages. This article provides insights into the potential impact of various policy measures on NP/PA workforce development in the Netherlands. METHODS: We applied a multimethod approach study using three methods: 1) a review of government policies, 2) surveys on NP/PA workforce characteristics, and 3) surveys on intake in NP/PA training programs. RESULTS: Until 2012, the annual intake into NP and PA training programs was comparable to the number of subsidized training places. In 2012, a 131% increase in intake coincided with extending the legal scope of practice of NPs and PAs and substantially increasing subsidized NP/PA training places. However, in 2013, the intake of NP and PA trainees decreased by 23% and 24%, respectively. The intake decreased in hospitals, (nursing) home care, and mental healthcare, coinciding with fiscal austerity in these sectors. We found that other policies, such as legal acknowledgment, reimbursement, and funding platforms and research, do not consistently coincide with NP/PA training and employment trends. The ratios of NPs and PAs to medical doctors increased substantially in all healthcare sectors from 3.5 and 1.0 per 100 full-time equivalents in medical doctors in 2012 to 11.0 and 3.9 in 2022, respectively. For NPs, the ratios vary between 2.5 per 100 full-time equivalents in medical doctors in primary care and 41.9 in mental healthcare. PA-medical doctor ratios range from 1.6 per 100 full-time equivalents in medical doctors in primary care to 5.8 in hospital care. CONCLUSIONS: This study reveals that specific policies coincided with NP and PA workforce growth. Sudden and severe fiscal austerity coincided with declining NP/PA training intake. Furthermore, governmental training subsidies coincided and were likely associated with NP/PA workforce growth. Other policy measures did not consistently coincide with trends in intake in NP/PA training or employment. The role of extending the scope of practice remains to be determined. The skill mix is shifting toward an increasing share of medical care provided by NPs and PAs in all healthcare sectors.

Facilitators for developing an interprofessional learning culture in nursing homes: a scoping review.

BACKGROUND: Healthcare professionals in nursing homes face complex care demands and nursing staff shortages. As a result, nursing homes are transforming into home-like personalised facilities that deliver person-centred care. These challenges and changes require an interprofessional learning culture in nursing homes, but there is little understanding of the facilitators that contribute to developing such a culture. This scoping review aims to identify those facilitators. METHODS: A scoping review was performed in accordance with the JBI Manual for Evidence Synthesis (2020). The search was carried out in 2020-2021 in seven international databases (PubMed, Cochrane Library, CINAHL, Medline, Embase, PsycINFO and Web of Science). Two researchers independently extracted reported facilitators that contribute to an interprofessional learning culture in nursing homes. Then the researchers inductively clustered the extracted facilitators into categories. RESULTS: In total, 5,747 studies were identified. After removing duplicates and screening titles, abstracts and full texts, 13 studies that matched the inclusion criteria were included in this scoping review. We identified 40 facilitators and clustered them into eight categories: (1) shared language, (2) shared goals, (3) clear tasks and responsibilities, (4) learning and sharing knowledge, (5) work approaches, (6) facilitating and supporting change and creativity by the frontline manager, (7) an open attitude, and (8) a safe, respectful and transparent environment. CONCLUSION: We found facilitators that could be used to discuss the current interprofessional learning culture in nursing homes and identify where improvements are required. Further research is needed to discover how to operationalise facilitators that develop an interprofessional learning culture in nursing homes and to gain insights into what works, for whom, to what extent and in what context.

Interprofessional learning in a student-run dental clinic: The effect on attitudes of students in oral healthcare.

The purpose of this study was to gain insight into change in attitudes held by students in oral healthcare about interprofessional learning and collaboration after one year of work in a student-run dental clinic (SRDC). Third- and fourth-year bachelor of dental hygiene students (n = 221) and first- and second-year master of dentistry students (n = 203) participated in baseline and follow-up measurements and completed 570 questionnaires. The Readiness for Interprofessional Learning Scale (RIPLS) was used to measure changes in attitudes toward Interprofessional Education (IPE) during participation in the SRDC. To validate the questionnaire for the setting, professional groups, and wording of RIPLS, we performed exploratory and confirmatory factor analyses. Two modified subscales remained: "Teamwork & Collaboration" and "Negative Professional Identity." Mixed linear models were used to assess relationships between students' attitudes toward IPE and participation in the SRDC. Overall, the students had positive attitudes toward IPE. At baseline, the attitudes of the dental hygiene and dentistry students were almost equally positive. After one year, dental hygiene students demonstrated a significantly more positive attitude toward collaborative learning and teamwork than the dentistry students. Further research should investigate whether the positive attitudes impact behavior in professional practice.

PA and NP general practice employment in the Netherlands.

ABSTRACT: General practitioners (GPs) are the cornerstone of primary healthcare in the Netherlands. As a national strategy, physician associates/assistants (PAs) and NPs were introduced to address growing healthcare demand. In this study, four representative practices were analyzed quantitatively and qualitatively-two solo practices with a PA or NP and two group practices with a PA or NP. A reference group of GPs served as experts. The annual encounters per full-time GP averaged 6,839; for the NPs, 2,636; and the PAs, 4,926. Billable services were 70% to 100%, averaging 71% for NPs and 85% for PAs, and in three of the four practices, the employment of the NP or PA was cost-efficient. The qualitative data show that PAs and NPs contribute to general practice, easing the workload so that the GP has more time for complex patients. PA and NP employment was financially beneficial in 75% of cases.

Perceptions of interprofessional collaboration in education of dentists and dental hygienists and the impact on dental practice in the Netherlands: A qualitative study.

INTRODUCTION: The purpose of this study was to evaluate the perceptions of dentists and dental hygienists regarding their own and each other's roles in interprofessional collaboration following a clinical interprofessional educational programme (CIEP) as part of their graduate programme at Radboud university medical center (Radboudumc) and HAN University of Applied Sciences (HAN UAS), Nijmegen, the Netherlands, respectively. Perceptions were obtained at the end of their study (2014) and two years after their graduation (2016). METHODS: A qualitative study was conducted using a questionnaire with open-ended questions. Sixty-two dentists and thirty-eight dental hygienists were invited. Theory-based analyses were applied in combination with principles of Grounded Theory to analyse and synthesise the collected data from the open-ended questions. RESULTS: At baseline, 100% responded. At follow-up, thirty-two dentists (51.6%) and twenty-six dental hygienists (68.4%) responded; twenty-seven dentists (43.5%) and eighteen dental hygienists (47.4%) were included. Many similarities were found between baseline and follow-up regarding perceptions of each other's expertise and responsibility, learning from and with each other, and the behaviour of students and the "novice" professionals in interprofessional collaboration. Both dentists and dental hygienists experienced the CIEP as useful for interprofessional collaboration. The "novice" dentists and dental hygienists indicated that in dental practices interprofessional collaboration was less common. CONCLUSION: The CIEP resulted in more understanding amongst dentists and dental hygienists with regard to interprofessional roles, but in practice the "novice" dentists and dental hygienists face difficulties in applying the interprofessional roles.

Barriers and facilitators to the implementation of doctor-nurse substitution strategies in primary care: a qualitative evidence synthesis.

BACKGROUND: Having nurses take on tasks that are typically conducted by doctors (doctor-nurse substitution, a form of 'task-shifting') may help to address doctor shortages and reduce doctors' workload and human resource costs. A Cochrane Review of effectiveness studies suggested that nurse-led care probably leads to similar healthcare outcomes as care delivered by doctors. This finding highlights the need to explore the factors that affect the implementation of strategies to substitute doctors with nurses in primary care. In our qualitative evidence synthesis (QES), we focused on studies of nurses taking on tasks that are typically conducted by doctors working in primary care, including substituting doctors with nurses or expanding nurses' roles. OBJECTIVES: (1) To identify factors influencing implementation of interventions to substitute doctors with nurses in primary care. (2) To explore how our synthesis findings related to, and helped to explain, the findings of the Cochrane intervention review of the effectiveness of substituting doctors with nurses. (3) To identify hypotheses for subgroup analyses for future updates of the Cochrane intervention review. SEARCH METHODS: We searched CINAHL and PubMed, contacted experts in the field, scanned the reference lists of relevant studies and conducted forward citation searches for key articles in the Social Science Citation Index and Science Citation Index databases, and 'related article' searches in PubMed. SELECTION CRITERIA: We constructed a maximum variation sample (exploring variables such as country level of development, aspects of care covered and the types of participants) from studies that had collected and analysed qualitative data related to the factors influencing implementation of doctor-nurse substitution and the expansion of nurses' tasks in community or primary care worldwide. We included perspectives of doctors, nurses, patients and their families/carers, policymakers, programme managers, other health workers and any others directly involved in or affected by the substitution. We excluded studies that collected data using qualitative methods but did not analyse the data qualitatively. DATA COLLECTION AND ANALYSIS: We identified factors influencing implementation of doctor-nurse substitution strategies using a framework thematic synthesis approach. Two review authors independently assessed the methodological strengths and limitations of included studies using a modified Critical Appraisal Skills Programme (CASP) tool. We assessed confidence in the evidence for the QES findings using the GRADE-CERQual approach. We integrated our findings with the evidence from the effectiveness review of doctor-nurse substitution using a matrix model. Finally, we identified hypotheses for subgroup analyses for updates of the review of effectiveness. MAIN RESULTS: We included 66 studies (69 papers), 11 from low- or middle-income countries and 55 from high-income countries. These studies found several factors that appeared to influence the implementation of doctor-nurse substitution strategies. The following factors were based on findings that we assessed as moderate or high confidence.Patients in many studies knew little about nurses' roles and the difference between nurse-led and doctor-led care. They also had mixed views about the type of tasks that nurses should deliver. They preferred doctors when the tasks were more 'medical' but accepted nurses for preventive care and follow-ups. Doctors in most studies also preferred that nurses performed only 'non-medical' tasks. Nurses were comfortable with, and believed they were competent to deliver a wide range of tasks, but particularly emphasised tasks that were more health promotive/preventive in nature.Patients in most studies thought that nurses were more easily accessible than doctors. Doctors and nurses also saw nurse-doctor substitution and collaboration as a way of increasing people's access to care, and improving the quality and continuity of care.Nurses thought that close doctor-nurse relationships and doctor's trust in and acceptance of nurses was important for shaping their roles. But nurses working alone sometimes found it difficult to communicate with doctors.Nurses felt they had gained new skills when taking on new tasks. But nurses wanted more and better training. They thought this would increase their skills, job satisfaction and motivation, and would make them more independent.Nurses taking on doctors' tasks saw this as an opportunity to develop personally, to gain more respect and to improve the quality of care they could offer to patients. Better working conditions and financial incentives also motivated nurses to take on new tasks. Doctors valued collaborating with nurses when this reduced their own workload.Doctors and nurses pointed to the importance of having access to resources, such as enough staff, equipment and supplies; good referral systems; experienced leaders; clear roles; and adequate training and supervision. But they often had problems with these issues. They also pointed to the huge number of documents they needed to complete when tasks were moved from doctors to nurses. AUTHORS' CONCLUSIONS: Patients, doctors and nurses may accept the use of nurses to deliver services that are usually delivered by doctors. But this is likely to depend on the type of services. Nurses taking on extra tasks want respect and collaboration from doctors; as well as proper resources; good referral systems; experienced leaders; clear roles; and adequate incentives, training and supervision. However, these needs are not always met.

Skill mix change between physicians, nurse practitioners, physician assistants, and nurses in nursing homes: A qualitative study.

Nursing home physicians face heavy workloads, because of the aging population and rising number of older adults with one or more chronic diseases. Skill mix change, in which professionals perform tasks previously reserved for physicians independently or under supervision, could be an answer to this challenge. The aim of this study was to describe how skill mix change in nursing homes is organized from four monodisciplinary perspectives and the interdisciplinary perspective, what influences it, and what its effects are. The study focused particularly on skill mix change through the substitution of nurse practitioners, physician assistants, or registered nurses for nursing home physicians. Five focus group interviews were conducted in the Netherlands. Variation in tasks and responsibilities was found. Despite this variation, stakeholders reported increased quality of health care, patient centeredness, and support for care teams. A clear vision on skill mix change, acceptance of nurse practitioners, physician assistants, and registered nurses, and a reduction of legal insecurity are needed that might maximize the added value of nurse practitioners, physician assistants, and registered nurses.

Nurses as substitutes for doctors in primary care.

BACKGROUND: Current and expected problems such as ageing, increased prevalence of chronic conditions and multi-morbidity, increased emphasis on healthy lifestyle and prevention, and substitution for care from hospitals by care provided in the community encourage countries worldwide to develop new models of primary care delivery. Owing to the fact that many tasks do not necessarily require the knowledge and skills of a doctor, interest in using nurses to expand the capacity of the primary care workforce is increasing. Substitution of nurses for doctors is one strategy used to improve access, efficiency, and quality of care. This is the first update of the Cochrane review published in 2005. OBJECTIVES: Our aim was to investigate the impact of nurses working as substitutes for primary care doctors on:• patient outcomes;• processes of care; and• utilisation, including volume and cost. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), part of the Cochrane Library (www.cochranelibrary.com), as well as MEDLINE, Ovid, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and EbscoHost (searched 20.01.2015). We searched for grey literature in the Grey Literature Report and OpenGrey (21.02.2017), and we searched the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov trial registries (21.02.2017). We did a cited reference search for relevant studies (searched 27.01 2015) and checked reference lists of all included studies. We reran slightly revised strategies, limited to publication years between 2015 and 2017, for CENTRAL, MEDLINE, and CINAHL, in March 2017, and we have added one trial to 'Studies awaiting classification'. SELECTION CRITERIA: Randomised trials evaluating the outcomes of nurses working as substitutes for doctors. The review is limited to primary healthcare services that provide first contact and ongoing care for patients with all types of health problems, excluding mental health problems. Studies which evaluated nurses supplementing the work of primary care doctors were excluded. DATA COLLECTION AND ANALYSIS: Two review authors independently carried out data extraction and assessment of risk of bias of included studies. When feasible, we combined study results and determined an overall estimate of the effect. We evaluated other outcomes by completing a structured synthesis. MAIN RESULTS: For this review, we identified 18 randomised trials evaluating the impact of nurses working as substitutes for doctors. One study was conducted in a middle-income country, and all other studies in high-income countries. The nursing level was often unclear or varied between and even within studies. The studies looked at nurses involved in first contact care (including urgent care), ongoing care for physical complaints, and follow-up of patients with a particular chronic conditions such as diabetes. In many of the studies, nurses could get additional support or advice from a doctor. Nurse-doctor substitution for preventive services and health education in primary care has been less well studied.Study findings suggest that care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low- or moderate-certainty evidence):• Nurse-led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor-led care. However, the results vary and it is possible that nurse-led primary care makes little or no difference to the number of deaths (low-certainty evidence).• Blood pressure outcomes are probably slightly improved in nurse-led primary care. Other clinical or health status outcomes are probably similar (moderate-certainty evidence).• Patient satisfaction is probably slightly higher in nurse-led primary care (moderate-certainty evidence). Quality of life may be slightly higher (low-certainty evidence).We are uncertain of the effects of nurse-led care on process of care because the certainty of this evidence was assessed as very low.The effect of nurse-led care on utilisation of care is mixed and depends on the type of outcome. Consultations are probably longer in nurse-led primary care (moderate-certainty evidence), and numbers of attended return visits are slightly higher for nurses than for doctors (high-certainty evidence). We found little or no difference between nurses and doctors in the number of prescriptions and attendance at accident and emergency units (high-certainty evidence). There may be little or no difference in the number of tests and investigations, hospital referrals and hospital admissions between nurses and doctors (low-certainty evidence).We are uncertain of the effects of nurse-led care on the costs of care because the certainty of this evidence was assessed as very low. AUTHORS' CONCLUSIONS: This review shows that for some ongoing and urgent physical complaints and for chronic conditions, trained nurses, such as nurse practitioners, practice nurses, and registered nurses, probably provide equal or possibly even better quality of care compared to primary care doctors, and probably achieve equal or better health outcomes for patients. Nurses probably achieve higher levels of patient satisfaction, compared to primary care doctors. Furthermore, consultation length is probably longer when nurses deliver care and the frequency of attended return visits is probably slightly higher for nurses, compared to doctors. Other utilisation outcomes are probably the same. The effects of nurse-led care on process of care and the costs of care are uncertain, and we also cannot ascertain what level of nursing education leads to the best outcomes when nurses are substituted for doctors.

Skill mix change between general practitioners, nurse practitioners, physician assistants and nurses in primary healthcare for older people: a qualitative study.

BACKGROUND: More and more older adults desire to and are enabled to grow old in their own home, regardless of their physical and mental capabilities. This change, together with the growing number of older adults, increases the demand for general practitioners (GPs). However, care for older people lacks prestige among medical students and few medical students are interested in a career in care for older people. Innovative solutions are needed to reduce the demand for GPs, to guarantee quality of healthcare and to contain costs. A solution might be found in skill mix change by introducing nurse practitioners (NPs), physician assistants (PAs) or registered nurses (RNs). The aim of this study was to describe how skill mix change is organised in daily practice, what influences it and what the effects are of introducing NPs, PAs or RNs into primary healthcare for older people. METHODS: In total, 34 care providers working in primary healthcare in the Netherlands were interviewed: GPs (n = 9), NPs (n = 10), PAs (n = 5) and RNs (n = 10). Five focus groups and 14 individual interviews were conducted. Analysis consisted of open coding, creating categories and abstraction. RESULTS: In most cases, healthcare for older people was only a small part of the tasks of NPs, PAs and RNs; they did not solely focus on older people. The tasks they performed and their responsibilities in healthcare for older people differed between, as well as within, professions. Although the interviewees debated the usefulness of proactive structural screening on frailty in the older population, when implemented, it was also unclear who should perform the geriatric assessment. Interviewees considered NPs, PAs and RNs an added value, and it was stated that the role of the GP changed with the introduction of NPs, PAs or RNs. CONCLUSIONS: The roles and responsibilities of NPs, PAs and RNs for the care of older people living at home are still not established. Nonetheless, these examples show the potential of these professionals. The establishment of a clear vision on primary healthcare for older people, including the organisation of proactive healthcare, is necessary to optimise the impact of skill mix change.

Collaboration in teams with nurse practitioners and general practitioners during out-of-hours and implications for patient care; a qualitative study.

BACKGROUND: Increasingly, nurse practitioners (NPs) are deployed in teams along with general practitioners (GPs) to help meet the demand for out-of-hours care. The purpose of this study was to explore factors influencing collaboration between GPs and NPs in teams working out-of-hours. METHODS: A descriptive qualitative study was done using a total of 27 semi-structured interviews and two focus group discussions. Data was collected between June, 2014 and October, 2015 at an out-of-hours primary care organisation in the Netherlands. Overall, 38 health professionals (GPs, NPs, and support staff) participated in the study. The interviews were audio-taped and transcribed verbatim. Two researchers conducted an inductive content analysis, involving the identification of relevant items in a first phase and clustering into themes in a second phase. RESULTS: The following four themes emerged from the data: clarity of NP role and regulation, shared caseload and use of skills, communication concerning professional roles, trust and support in NP practice. Main factors influencing collaboration between GPs and NPs included a lack of knowledge regarding the NPs' scope of practice and regulations governing NP role; differences in teams in sharing caseload and using each other's skills effectively; varying support of GPs for the NP role; and limited communication between GPs and NPs regarding professional roles during the shift. Lack of collaboration was perceived to result in an increased risk of delay for patients who needed treatment from a GP, especially in teams with more NPs. Collaboration was not perceived to improve over time as teams varied across shifts. CONCLUSION: In out-of-hours primary care teams constantly change and team members are often unfamiliar with each other or other's competences. In this environment, knowledge and communication about team members' roles is continuously at stake. Especially in teams with more NPs, team members need to use each other's skills to deliver care to all patients on time.

Factors influencing decision of general practitioners and managers to train and employ a nurse practitioner or physician assistant in primary care: a qualitative study.

BACKGROUND: Due to the increasing demand on primary care, it is not only debated whether there are enough general practitioners (GPs) to comply with these demands but also whether specific tasks can be performed by other care providers. Although changing the workforce skill mix care by employing Physician Assistants (PAs) and Nurse Practitioners (NPs) has proven to be both effective and safe, the implementation of those professionals differs widely between and within countries. To support policy making regarding PAs/NPs in primary care, the aim of this study is to provide insight into factors influencing the decision of GPs and managers to train and employ a PA/NP within their organisation. METHODS: A qualitative study was conducted in 2014 in which 7 managers of out-of-hours primary care services and 32 GPs who owned a general practice were interviewed. Three main topic areas were covered in the interviews: the decision-making process in the organisation, considerations and arguments to train and employ a PA/NP, and the tasks and responsibilities of a PA/NP. RESULTS: Employment of PAs/NPs in out-of-hours services was intended to substitute care for minor ailments in order to decrease GPs' caseload or to increase service capacity. Mangers formulated long-term planning and role definitions when changing workforce skill mix. Lastly, out-of-hours services experienced difficulties with creating team support among their members regarding the employment of PAs/NPs. In general practices during office hours, GPs indented both substitution and supplementation for minor ailments and/or target populations through changing the skill mix. Supplementation was aimed at improving quality of care and extending the range of services to patients. The decision-making in general practices was accompanied with little planning and role definition. The willingness to employ PAs/NPs was highly influenced by an employees' motivation to start the master's programme and GPs' prior experience with PAs/NPs. Knowledge about the PA/NP profession and legislations was often lacking. CONCLUSIONS: Role standardisations, long-term political planning and support from professional associations are needed to support policy makers in implementing skill mix in primary care.

Effects of substituting nurse practitioners, physician assistants or nurses for physicians concerning healthcare for the ageing population: a systematic literature review.

AIMS: To evaluate the effects of substituting nurse practitioners, physician assistants or nurses for physicians in long-term care facilities and primary healthcare for the ageing population (primary aim) and to describe what influences the implementation (secondary aim). BACKGROUND: Healthcare for the ageing population is undergoing major changes and physicians face heavy workloads. A solution to guarantee quality and contain costs might be to substitute nurse practitioners, physician assistants or nurses for physicians. DESIGN: A systematic literature review. DATA SOURCES: PubMed, EMBASE, CINAHL, PsycINFO, CENTRAL, Web of Science; searched January 1995-August 2015. REVIEW METHODS: Study selection, data extraction and quality appraisal were conducted independently by two reviewers. Outcomes collected: patient outcomes, care provider outcomes, process of care outcomes, resource use outcomes, costs and descriptions of the implementation. Data synthesis consisted of a narrative summary. RESULTS: Two studies used a randomized design and eight studies used other comparative designs. The evidence of the two randomized controlled trials showed no effect on approximately half of the outcomes and a positive effect on the other half of the outcomes. Results of eight other comparative study designs point towards the same direction. The implementation was influenced by factors on a social, organizational and individual level. CONCLUSION: Physician substitution in healthcare for the ageing population may achieve at least as good patient outcomes and process of care outcomes compared with care provided by physicians. Evidence about resource use and costs is too limited to draw conclusions.

Cost-effectiveness of a nurse-led intervention to optimise implementation of guideline-concordant continence care: Study protocol of the COCON study.

BACKGROUND: Guidelines on urinary incontinence recommend that absorbent products are only used as a coping strategy pending definitive treatment, as an adjunct to ongoing therapy, or for long-term management after all treatment options have been explored. However, these criteria are rarely met and a significant share of long-term product users could still benefit from therapeutic interventions recommended in guidelines for urinary incontinence. Better implementation of these guidelines can potentially result in both health benefits for women and long-term cost savings for society. The aim of the COCON study is to evaluate the (cost-)effectiveness of a nurse-led intervention to optimise implementation of guideline-concordant continence care in comparison with usual care for urinary incontinent women aged 55 years and over who use absorbent products. METHODS: This randomised clinical trial compares usual care with a nurse-led intervention to optimise implementation of guideline-concordant continence care. Women (anticipated N = 160) are recruited in 12 community pharmacies in three Dutch regions, and are eligible for trial entry when they are 55 years and over, community-dwelling and long-term users of absorbent products (≥4 months) reimbursed by health insurance. Measurements are administered at baseline, 3, 6 and 12 months. Primary outcome is severity of urinary incontinence (ICIQ-UI SF); other outcomes include health related quality of life (EQ-5D-5 L), use of absorbent products (in accordance with the recommended criteria in guidelines) (yes/no), and societal costs. Mixed model analysis will be performed to compare (the course) of outcomes between groups. The economic evaluation will be performed from a societal perspective. The implementation process is investigated using the Tailored Implementation for Chronic Diseases (TICD) framework. DISCUSSION: Results will add to current knowledge of the (cost-)effectiveness of nurse-led primary healthcare to improve guideline-concordant care for older women with urinary incontinence. In addition, the results will provide more insight into care needs and health service utilization of this group of women, as well as into use of absorbent products in accordance with the recommended criteria in guidelines. Finally, results will increase our understanding of the intervention's uptake and could provide useful insights for future dissemination and sustenance. TRIAL REGISTRATION: Dutch Trial Register NTR4396, registered 13-January-2014.

Are gynaecological and pregnancy-associated conditions in family practice indicators of intimate partner violence?

BACKGROUND: Some gynaecological and pregnancy-associated conditions are more common in abused women than in non-abused women, but this has not been examined in family practice. OBJECTIVE: We aimed to investigate intimate partner violence (IPV) prevalence in family practice and to investigate whether gynaecological and pregnancy-associated conditions are more common in abused women than in non-abused women. METHODS: We conducted a cross-sectional waiting room survey in 12 family practices in the Netherlands in 2012. Women were eligible if they were of 18 years or older. Questionnaires measured IPV and gynaecological and pregnancy-associated conditions. Chi-square tests were used to assess the differences in gynaecological and pregnancy-associated conditions between abused women and non-abused women. RESULTS: The response rate was 86% (262 of 306 women). The past-year prevalence of IPV in women who had had an intimate relationship in the past year and were not accompanied by their partner was 8.7% (n = 195). Lifetime prevalence of women who had ever had an intimate relationship, but not in the past year, was 17.6% (n = 51). Sexually transmitted infections (STIs) [odds ratio (OR) = 4.6, 95% confidence interval [CI] = 1.7-12.5, n = 240], menstrual disorders (OR = 3.7, 95% CI = 1.2-11.2, n = 143), sexual problems (OR = 3.3, 95% CI = 1.2-9.3, n = 229), miscarriages (OR = 2.5, 95% CI = 1.062-5.8, n = 202) and induced abortions (OR = 2.7, 95% CI = 1.028-7.3, n = 202) were significantly more common in abused women than in non-abused women. CONCLUSION: Family physicians should ask about IPV when women present with STIs, menstrual disorders, sexual problems, miscarriages or induced abortions. To improve the recognition of IPV, future research needs to investigate whether a combination of symptoms offers improved prediction of IPV.

The impact of substituting general practitioners with nurse practitioners on resource use, production and health-care costs during out-of-hours: a quasi-experimental study.

BACKGROUND: The pressure in out-of-hours primary care is high due to an increasing demand for care and rising health-care costs. During the daytime, substituting general practitioners (GPs) with nurse practitioners (NPs) shows positive results to contribute to these challenges. However, there is a lack of knowledge about the impact during out-of-hours. The current study aims to provide an insight into the impact of substitution on resource use, production and direct health-care costs during out-of-hours. METHODS: At a general practitioner cooperative (GPC) in the south-east of the Netherlands, experimental teams with four GPs and one NP were compared with control teams with five GPs. In a secondary analysis, GP care versus NP care was also examined. During a 15-month period all patients visiting the GPC on weekend days were included. The primary outcome was resource use including X-rays, drug prescriptions and referrals to the Emergency Department (ED). We used logistic regression to adjust for potential confounders. Secondary outcomes were production per hour and direct health-care costs using a cost-minimization analysis. RESULTS: We analysed 6,040 patients in the experimental team (NPs: 987, GPs: 5,053) and 6,052 patients in the control team. There were no significant differences in outcomes between the teams. In the secondary analysis, in the experimental team NP care was associated with fewer drug prescriptions (NPs 37.1 %, GPs 43 %, p < .001) and fewer referrals to the ED (NPs 5.1 %, GPs 11.3 %, p = .001) than GP care. The mean production per hour was 3.0 consultations for GPs and 2.4 consultations for NPs (p < .001). The cost of a consultation with an NP was €3.34 less than a consultation with a GP (p = .02). CONCLUSIONS: These results indicated no overall differences between the teams. Nonetheless, a comparison of type of provider showed that NP care resulted in lower resource use and cost savings than GP care. To find the optimal balance between GPs and NPs in out-of-hours primary care, more research is needed on the impact of increasing the ratio of NPs in a team with GPs on resource use and health-care costs. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT01388374 .

Substitution of general practitioners by nurse practitioners in out-of-hours primary care: a quasi-experimental study.

AIM: To provide insight into the impact of substituting general practitioners with nurse practitioners in out-of-hours services on: (1) the number of patients; and (2) general practitioners' caseload (patient characteristics, urgency levels, types of complaints). BACKGROUND: General practitioners' workload during out-of-hours care is high, and the number of hours they work out-of-hours has increased, which raises concerns about maintaining quality of care. One response to these challenges is shifting care to nurse practitioners. DESIGN: Quasi-experimental study comparing differences between and within out-of-hours teams: experimental, one nurse practitioner and four general practitioners; control, five general practitioners. METHODS: Data of 12,092 patients from one general practitioners cooperative were extracted from medical records between April 2011 and July 2012. RESULTS: The number of patients was similar in the two study arms. In the experimental arm, the nurse practitioner saw on average 16·3% of the patients and each general practitioner on average 20·9% of the patients. General practitioners treated more older patients; higher urgency levels; and digestive, cardiovascular and neurological complaints. Nurse practitioners treated more patients with skin and respiratory complaints. Substitution did not lead to a meaningful increase of general practitioners' caseload. CONCLUSION: The results show that nurse practitioners can make a valuable contribution to patient care during out-of-hours. The patients managed and care provided by them is roughly the same as general practitioners. In areas with a shortage of general practitioners, administrators could consider employing nurses who are competent to independently treat patients with a broad range of complaints to offer timely care to patients with acute problems.

Professional's Attitudes Do Not Influence Screening and Brief Interventions Rates for Hazardous and Harmful Drinkers: Results from ODHIN Study.

AIMS: To determine the relation between existing levels of alcohol screening and brief intervention rates in five European jurisdictions and role security and therapeutic commitment by the participating primary healthcare professionals. METHODS: Health care professionals consisting of, 409 GPs, 282 nurses and 55 other staff including psychologists, social workers and nurse aids from 120 primary health care centres participated in a cross-sectional 4-week survey. The participants registered all screening and brief intervention activities as part of their normal routine. The participants also completed the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ), which measure role security and therapeutic commitment. RESULTS: The only significant but small relationship was found between role security and screening rate in a multilevel logistic regression analysis adjusted for occupation of the provider, number of eligible patients and the random effects of jurisdictions and primary health care units (PHCU). No significant relationship was found between role security and brief intervention rate nor between therapeutic commitment and screening rate/brief intervention rate. The proportion of patients screened varied across jurisdictions between 2 and 10%. CONCLUSION: The findings show that the studied factors (role security and therapeutic commitment) are not of great importance for alcohol screening and BI rates. Given the fact that screening and brief intervention implementation rate has not changed much in the last decade in spite of increased policy emphasis, training initiatives and more research being published, this raises a question about what else is needed to enhance implementation.

Pulling out all the stops: what motivates 65+ year olds with depressive symptoms to participate in an outreaching preference-led intervention programme?

OBJECTIVES: Many older adults have significant depressive symptoms but few people access care for these. This study explores which personal, clinical and need factors facilitate or hinder acceptance of a new outreaching preference-led intervention programme. METHODS: From a sample of 9661 community-dwelling 65+ year olds, 244 persons with depressive symptoms according to the Patient Health Questionnaire-9 were included. Data on programme effectiveness in terms of care utilisation were collected. Associations between programme acceptance and personal, clinical and need factors were studied using quantitative (logistic regression analyses) and qualitative methods (semi-structured interviews with 26 subjects, who accepted (n = 20) or declined (n = 6) the programme). RESULTS: Fifty-six per cent (n = 137) took part in the interventions. Quantitative logistic regression analyses showed that participants were more often female, suffered from more severe depressive symptoms and perceived more loneliness. Qualitative analyses revealed that people accepting the intervention programme felt that medical terms as having a depressed mood were applicable to their situation, more often perceived their symptoms as hindering, felt lonely and more often perceived a need for care. They were more often advised by their general practitioner to participate than individuals who refused the interventions. Many participating individuals did not see a match between the intervention programme and their needs, especially with respect to meeting new people. CONCLUSION: Many older persons with depressive symptoms did not feel the need to take part in the programme. Providing support in alleviating loneliness and further adaptation to older adults' illness representations and perceptions when discussing depressive symptoms might enhance care utilisation.

Physician substitution by mid-level providers in primary healthcare for older people and long-term care facilities: protocol for a systematic literature review.

AIM: This protocol describes a systematic review that evaluates the effects of physician substitution by mid-level providers (nurse practitioners, physician assistants or nurses) in primary healthcare for older people and long-term care facilities. The secondary aim is to describe facilitators and barriers to the implementation of physician substitution in these settings. BACKGROUND: Healthcare for older people is undergoing major changes, due to population ageing and reforms that shift care to the community. Besides, relatively few medical students are pursuing careers in healthcare for older people. Innovative solutions are needed to guarantee the quality of healthcare and to contain costs. A solution might be shifting care from physicians to mid-level providers. To date, no systematic review on this topic exits to guide policymaking. DESIGN: A quantitative systematic literature review using Cochrane methods. METHODS: The following databases will be searched for original research studies that quantitatively compare care provided by a physician to the same care provided by a mid-level provider: PubMed, EMBASE, CINAHL, PsycINFO, CENTRAL and Web of Science. Study selection, data extraction and quality appraisal will be conducted independently by two reviewers. Data synthesis will consist of a qualitative analysis of the data. Funding of the review was confirmed in August 2013 by the Ministry of Health, Welfare and Sport of the Netherlands. DISCUSSION: This review will contribute to the knowledge on effects of physician substitution in healthcare for older people and factors that influence the outcomes. This knowledge will guide professionals and policy administrators in their decisions to optimize healthcare for older people.