What can we learn from experiences in general practice during the COVID-19 pandemic? A qualitative study.

BACKGROUND: Experiences with organizational changes in daytime general practices and out-of-hours (OOH) services during the COVID-19 pandemic may help to address the challenges in general practice care that were already a concern before the crisis. This study aimed to describe these experiences and the potential usefulness of the organizational changes for future general practice care and any future pandemics. METHODS: Semi-structured interviews were performed among 11 directors of OOH services, and 19 (locum) general practitioners (GPs) or practice managers, who were purposively sampled. Video or telephone interviews were performed in two rounds: between November 2020 and January 2021 and between May 2021 and August 2021. The data were analyzed using thematic analysis methods. RESULTS: Three themes emerged from the data: (1) Changes in the triage procedures; in GP practices and OOH services, stricter triage criteria were implemented, and GPs were more actively involved in the triage process. These measures helped to reduce the number of 'low urgency' face-to-face consultations. (2) Changes in GP care; there was a shift towards video and telephone consultations, allowing GPs to spend more time with patients during the remaining face-to-face consultations. For chronic patients, the shift towards telemonitoring appeared to encourage self-care, and postponing face-to-face consultations for regular checkups appeared to be unproblematic for stable patients. (3) Coordination of GP care and information communication flow during the COVID-19 pandemic; OOH directors perceived a lack of consistency in the information from various governmental and non-governmental parties on containment measures and guidelines related to COVID-19, making it difficult to act on them. The COVID-19 pandemic intensified collaboration between GPs, OOH services, and other healthcare professionals. CONCLUSIONS: The results of this study indicate that some of the organizational changes, such as stricter triage, remote consultations, and changes in managed care of chronic patients, may help in tackling the pre-existing challenges in GP care from before the COVID-19 pandemic. However, more extensive research and continuous monitoring are necessary to establish the effects on patients and their health outcomes. To navigate future pandemics, the intensified collaboration between health professionals should be maintained, while there is considerable room for improvement in the provision of unambiguous information.

The use of out-of-hours primary care during the first year of the COVID-19 pandemic.

BACKGROUND: In the Netherlands, General Practitioners (GP) are usually the first point of contact with a health professional for most health problems. Out-of-hours (OOH) primary care is provided by regional OOH services. Changes in consultation rates at OOH services may be regarded as a warning system for failures elsewhere in the healthcare system. Therefore in this study, we investigated how the COVID-19 pandemic changed the use of primary care OOH services during the first year of the pandemic. METHODS: Routine electronic health records data were used from 60% of OOH services in the Netherlands, collected by the Nivel Primary Care Database. We compared consultation rates per week (2020) for COVID-19-like symptoms and other health problems (e.g. small traumas, urinary tract infections), for different age groups, the proportion of remote consultations, and different levels of urgency during the pandemic compared to the same period in 2019. RESULTS: The number of consultations for COVID-19-like symptoms peaked at the start of the COVID-19 pandemic, while consultations for other health problems decreased. These changes in consultation rates differed between age groups. Remote consultations took place more frequently for all health problems, while the proportion of non-urgent health problems increased. CONCLUSION: There were significant changes in the number of consultations and the proportion that were remote for COVID-19-like symptoms and other health problems. Especially care for babies and young children decreased, while the number of consultations for older adults remained stable. The continued use of OOH services by older adults suggests there were unmet care needs elsewhere in our healthcare system.

Lessons learned from participatory research to enhance client participation in long-term care research: a multiple case study.

BACKGROUND: Although participatory research is known to have advantages, it is unclear how participatory research can best be performed. This study aims to report on lessons learned in collaboration with service users involved as co-researchers in three participatory teams in long-term care. METHODS: A multiple case study design was chosen to explore the collaboration in three teams, each covering one specific client group receiving long-term care: physically or mentally frail elderly people, people with mental health problems or people with intellectual disabilities. RESULTS: A good working environment and a good collaboration were found to be crucial requirements for participatory research. A good working environment was developed by discussing reasons for engagement and wishes, formulating basic rules, organizing training sessions, offering financial appreciation, and the availability of the researcher to give travel support. The actual collaboration was established by developing a bond and equal positioning, deciding on the role division, holding on to transparency and a clear structure, and have sufficient time for the collaboration. Moreover, the motivations and unique contributions of the co-researchers and differences between the teams were reported. The motivations of co-researchers ranged from individual goals - such as personal development, creating a new social identity and belonging to a social group - to more external goals, such as being valuable for other service users and increasing the quality of care. An inclusive collaboration required valuing the individual contributions of co-researchers and adjustment to team differences. CONCLUSIONS: The results showed the importance of developing a good working environment and establishing a good collaboration for participatory research. Furthermore, the study shows that individual and team differences should be taken into account. These results can be used by researchers for designing and shaping future research projects in long-term care in collaboration with co-researchers.

Psychometric evaluation of patient-reported experience measures: is it valid?

Multiple published studies and reviews have advocated the application of psychometric methods to the validation of patient experience measurement. Some such methods depend on measurement assumptions that may not be appropriate for patient experience. Rather than being the default approach for the validation of patient experience measurement, we argue that psychometric methods should be reviewed critically to determine their fit to the measurement application, and alternative approaches explored, so that the most appropriate validation methods can be identified.

Qualitative instruments involving clients as co-researchers to assess and improve the quality of care relationships in long-term care: an evaluation of instruments to enhance client participation in quality research.

OBJECTIVES: Enhancing the active involvement of clients as co-researchers is seen as a promising innovation in quality research. The aim of this study was to assess the feasibility and usability of five qualitative instruments used by co-researchers for assessing the quality of care relationships in long-term care. DESIGN AND SETTING: A qualitative evaluation was performed in three care organisations each focused on one of the following three client groups: frail older adults, people with mental health problems and people with intellectual disabilities. A total of 140 respondents participated in this study. The data comprised observations by researchers and experiences from co-researchers, clients and professionals. RESULTS: Two instruments scored best on feasibility and usability and can therefore both be used by co-researchers to monitor the quality of care relationships from the client perspective in long-term care. CONCLUSIONS: The selected instruments let co-researchers interview other clients about their experiences with care relationships. The study findings are useful for long-term care organisations and client councils who are willing to give clients an active role in quality improvement.

Correction to: Determinants of the quality of care relationships in long-term care - a systematic review.

In the original publication of this article [1], there is a layout mistake in the column "McCloughen et al. (2011)" of Table 2.

Determinants of the quality of care relationships in long-term care - a participatory study.

BACKGROUND: The quality of the care relationship between a client and a professional is important in long-term care, as most clients depend on support for a lengthy period. The three largest client groups who receive long-term care in the Netherlands are older adults who are physically or mentally frail, people with mental health problems and people with intellectual disabilities. There is little clarity about how generic and variable the determinants of the quality of care relationships are across these client groups. The aim of this study is to explore and compare the determinants of the quality of care relationships in these three client groups in long-term care. METHODS: This participatory study involving clients as co-researchers was held in three healthcare organizations, each providing long-term care to one client group. The research was conducted by three teams consisting of researchers and co-researchers. We interviewed clients individually and professionals in focus groups. The focus was on care relationships with professionals where there is weekly recurring contact for at least 3 months. Clients and professionals were selected using a convenience sample. The interviews were coded in open, axial and selective coding. The outcomes were compared between the client groups. RESULTS: The study sample consisted of 30 clients and 29 professionals. Determinants were categorized into four levels: client, professional, between client and professional, and context. The findings show that the majority of the determinants apply to the care relationships within all three client groups. At the professional level, eleven generic determinants were found. Eight determinants emerged at the client level of which two were found in two client groups only. At the level between a client and a professional, six determinants were found of which one applied to mental healthcare and disability care only. Five determinants were found at the contextual level of which two were specific for two client groups. CONCLUSIONS: The study yielded a variety of determinants that came to the fore in all three client groups in long-term care. This suggests that including a homogenous client group from a single care setting is not necessary when studying the quality of long-term care relationships.

Developing quality criteria for patient-directed knowledge tools related to clinical practice guidelines. A development and consensus study.

BACKGROUND: Patient-directed knowledge tools such as patient versions of guidelines and patient decision aids are increasingly developed to facilitate shared decision making. In this paper, we report how consensus was reached within the Netherlands on quality criteria for development, content and governance of these tools. METHOD: A 12-month development and consensus study. The consortium worked on four work packages: (a) reviewing existing criteria; (b) drafting the quality criteria; (c) safe-guarding the acceptability and feasibility of the draft criteria by participatory research in on-going tool development projects; and (d) gaining formal support from national stakeholders on the quality criteria. RESULTS: We reached consensus on a 8-step guidance; describing minimal quality criteria for (a) the team composition; (b) setting the scope; (c) identifying needs; (d) the content and format; (e) testing the draft; (f) finalizing and approval; (g) dissemination and application, and (h) ownership and revision. The participants of the on-going tool development projects were positive about the quality criteria in general, but divided as to the degree of detail. Whereas some expressed a clear desire for procedural standards, others felt that it would be sufficient to provide only general directions. Despite the different views as to the degree of detail, consensus was reached in three stakeholder meetings. DISCUSSION: We successfully collaborated with all stakeholders and achieved formal support from national stakeholders on a set of minimum criteria for the development process, content and governance of patient-directed knowledge tools.

Protocol for a participatory study for developing qualitative instruments measuring the quality of long-term care relationships.

INTRODUCTION: In long-term care (LTC), it is unclear which qualitative instruments are most effective and useful for monitoring the quality of the care relationship from the client's perspective. In this paper, we describe the research design for a study aimed at finding and optimising the most suitable and useful qualitative instruments for monitoring the care relationship in LTC. METHODS AND ANALYSIS: The study will be performed in three organisations providing care to the following client groups: physically or mentally frail elderly, people with mental health problems and people with intellectual disabilities. Using a participatory research method, we will determine which determinants influence the quality of a care relationship and we will evaluate up to six instruments in cooperation with client-researchers. We will also determine whether the instruments (or parts thereof) can be applied across different LTC settings. ETHICS AND DISSEMINATION: This study protocol describes a participatory research design for evaluating the quality of the care relationship in LTC. The Medical Ethics Committee of the Radboud University Nijmegen Medical Centre decided that formal approval was not needed under the Dutch Medical Research Involving Human Subjects Act. This research project will result in a toolbox and implementation plan, which can be used by clients and care professionals to measure and improve the care relationship from the client's perspective. The results will also be published in international peer-reviewed journals.

Determinants of the quality of care relationships in long-term care - a systematic review.

BACKGROUND: The quality of a care relationship between a client and a care professional is seen as fundamental if high-quality care is to be delivered. This study reviews studies about the determinants of the quality of the client-professional relationship in long-term care. METHODS: A systematic review was performed using the electronic databases of Medline, Psycinfo, CINAHL and Embase. The review focused on three client groups receiving long-term care: physically or mentally frail elderly, people with mental health problems and people with physical or intellectual disabilities. Included studies concern clients receiving inpatient or outpatient care and care professionals who provided recurring physical and supporting care for a long period of time. The studies we included contained primary empirical data, were written in English and were published in peer-reviewed journals. Data extraction was carried out by two researchers independently. RESULTS: Thirty-two studies out of 11,339 initial hits met the inclusion criteria. In total, 27 determinants were revealed, six at the client level, twelve at the professional level, six between the client and care professional levels and three at the contextual level. The data analysis showed that most determinants were relevant in more than one client group. CONCLUSIONS: This is the first review that looked at determinants of the quality of the care relationship for three large client groups receiving long-term care. It suggests that the current client group-specific focus in research and quality improvement initiatives for care relationships might not be needed. Care organisations can use the findings of this review as guidance on determinants to look for when mapping the quality of a care relationship in order to get a picture of specific points of attention for quality improvement.

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.

Waiting in the Accident and Emergency Department: Exploring Problematic Experiences.

OBJECTIVES: To investigate the relation between perceived waiting times and patients' overall ratings of accident and emergency departments (A&Es) and to explore which patients view waiting times as problematic. METHODS: A cross-sectional survey was held in 21 A&Es in the Netherlands. From each A&E, a random sample of patients was investigated. Patients younger than 18 years and patients who had arrived by ambulance were excluded. Respondents' perceived waiting times and overall quality ratings of their A&E visit were collected and correlated. Respondents were divided into a "no problem" or "problem" group on the basis of the perceived waiting time before treatment. Logistic regression analyses were performed to explore factors potentially related to problematic waiting experiences, such as the amount of information received while waiting and perceived pain and acuity. RESULTS: The study included 3483 patients. Longer perceived waiting time was associated with a decrease in overall rating and increased reports of problematic experiences. Multivariate analysis showed that problematic waiting experiences were significantly associated with perceived pain (odds ratio [OR] 1.1), higher perceived acuity (emergency/urgent/nonurgent ORs: 2.7/2.2/1.0) and limited information before treatment. The OR for patients who did not receive any information about what to expect during a visit to the A&E versus patients who were completely informed was 3.3. For uninformed versus completely informed patients, the OR for information about how quickly patients needed to be helped with their health problem was 3.4. CONCLUSIONS: Providing information before treatment, controlling the perception of pain, and managing perceived acuity not only reduced problematic experiences concerning perceived waiting time but also improved experienced quality of care.

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 accident and emergency department questionnaire: a measure for patients' experiences in the accident and emergency department.

BACKGROUND: The National Health Service National Patient Survey Programme systematically gathers patients' experiences about the care they have recently received. Prioritising quality improvement activities in the accident and emergency (A&E) department requires that survey outcomes are meaningful and reliable. We aimed to determine which method of obtaining summary scores for the A&E department questionnaire optimally combined good interpretability with robust psychometric characteristics. METHODS: A&E department questionnaire data from 151 hospital trusts were analysed, covering 49 646 patients. Three methods of grouping and summarising items of the questionnaire were compared: principal components analysis (PCA); Department of Health dimensions; sections according to the patient's journey through the A&E department. The patient-level reliability of summary scores was determined by Cronbach's α coefficients (threshold: α>0.70), construct validity by Pearson's correlation coefficients, and the discriminative capacity by intra-class correlation coefficients (ICCs) and reliability of A&E-level mean scores. RESULTS: The PCA provided the best score reliability on six clear and interpretable composites: waiting time; doctors and nurses; your care and treatment; hygiene; information before discharge; overall. The discriminative power of the concepts was comparable for the three methods, with ICCs between 0.010 and 0.061. A&E sample sizes were adequate to obtain good to excellent reliability of A&E-level mean scores. CONCLUSIONS: The A&E department questionnaire is a valid and reliable questionnaire to assess patients' experiences with the A&E. The discriminative power of six summary scores offers a reliable comparison of healthcare performance between A&Es to increase patient centredness and quality of care.

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.

Large head metal-on-metal cementless total hip arthroplasty versus 28 mm metal-on-polyethylene cementless total hip arthroplasty: design of a randomized controlled trial.

BACKGROUND: Osteoarthritis of the hip is successfully treated by total hip arthroplasty with metal-on-polyethylene articulation. Polyethylene wear debris can however lead to osteolysis, aseptic loosening and failure of the implant. Large head metal-on-metal total hip arthroplasty may overcome polyethylene wear induced prosthetic failure, but can increase systemic cobalt and chromium ion concentrations. The objective of this study is to compare two cementless total hip arthroplasties: a conventional 28 mm metal-on-polyethylene articulation and a large head metal-on-metal articulation. We hypothesize that the latter arthroplasties show less bone density loss and higher serum metal ion concentrations. We expect equal functional scores, greater range of motion, fewer dislocations, fewer periprosthetic radiolucencies and increased prosthetic survival with the metal-on-metal articulation. METHODS: A randomized controlled trial will be conducted. Patients to be included suffer from non-inflammatory degenerative joint disease of the hip, are aged between 18 and 80 and are admitted for primary cementless unilateral total hip arthroplasty. Patients in the metal-on-metal group will receive a cementless titanium alloy acetabular component with a cobalt-chromium liner and a cobalt-chromium femoral head varying from 38 to 60 mm. Patients in the metal-on-polyethylene group will receive a cementless titanium alloy acetabular component with a polyethylene liner and a 28 mm cobalt-chromium femoral head. We will assess acetabular bone mineral density by dual energy x-ray absorptiometry (DEXA), serum ion concentrations of cobalt, chromium and titanium, self reported functional status (Oxford hip score), physician reported functional status and range of motion (Harris hip score), number of dislocations and prosthetic survival. Measurements will take place preoperatively, perioperatively, and postoperatively (6 weeks, 1 year, 5 years and 10 years). DISCUSSION: Superior results of large head metal-on-metal total hip arthroplasty over conventional hip arthroplasty have been put forward by experts, case series and the industry, but to our knowledge there is no randomized controlled evidence. CONCLUSION: This randomized controlled study has been designed to test whether large head metal-on-metal cementless total hip arthroplasty leads to less periprosthetic bone density loss and higher serum metal ion concentrations compared to 28 mm metal-on-polyethylene cementless total hip arthroplasty. TRIAL REGISTRATION: Netherlands Trial Registry NTR1399.