[Indicators for quality of care: who profits: patients or managers?]. / Indicatoren voor kwaliteit van zorg. wie worden er wijzer van, de patiënten of de managers?

In the Netherlands and abroad detailed indicators are developed to measure quality of care for a variety of treatments and care systems. These days the development of quality indicators is a profession and business in itself. The significance of these indicators is often not related to the primary care process, but based on (administrative) data for 'quality management'. The consequence is a gap between 'real' and 'measured' quality of care. Improvement in quality of care is therefore problematic. There is a need to return to the essence of care, i.e. the patient and the care professional, to develop appropriate indicators for quality of care.

The stability of lifestyle behaviour.

BACKGROUND: The stability of lifestyle behaviour has been studied over a 4-year period in a sample of 1400 men in The Netherlands. The influence of both socioeconomic status and age was studied in relation to lifestyle behaviour change. METHODS: Lifestyle behaviour was analysed by means of index scores, each covering one of four domains: smoking, alcohol consumption, physical activity and dietary habits. Changes in lifestyle behaviour were analysed at individual and group level, using different statistical methods. RESULTS: Smoking behaviour remained highly constant, whereas alcohol consumption had only moderate stability. Physical activity and dietary habits had greater variability over this time period. Age and socioeconomic status are related to the prevalence of lifestyle behaviour, whereas only age is related to the stability of lifestyle behaviour. Socioeconomic status did not relate to changes in lifestyle behaviour. CONCLUSIONS: The four lifestyle behaviours differed in the degree of variation over a 4-year period. Only a small group (11%) changed two or more lifestyle behaviours. This implies that lifestyle behaviour is not a unified concept and should not be treated in that way in public health campaigns.

Measuring morbidity of children in the community: a comparison of interview and diary data.

BACKGROUND: Little is known about the validity of estimates of morbidity experienced at home. METHODS: In the Dutch National Survey of Morbidity and Interventions in General Practice mothers of 1630 children answered a health interview and kept a health diary for 3 weeks (only the first 2 weeks were used). Children's symptoms were recorded during the interview using a check list and monitored in the health diary through open-ended questions. RESULTS: In the interview parents reported symptoms for 65% of their children and in the diary for 54% of children. Ear problems, colds, fever and weakness and anxiety were reported more often in the interview. Mother's mental health was assessed by the General Health Questionnaire; those scoring >4 were assessed as having impaired mental health and these parents reported symptoms for more children in the interview (81%) than in the diary (65%). For similar reference periods, the least educated mothers reported fewer children with symptoms in the diary (45%) than in the interview (66%). More highly educated mothers reported similarly in the diary (67%) and the interview (70%). CONCLUSION: Both data collection methods yield different estimates of community morbidity. Explanations such as telescoping, the seriousness of the symptoms, the amount of psychological distress of the respondent, forgetfulness and literacy limitations are discussed. We recommend that diaries should not be used in less educated populations.

A comparison of nursing minimal data sets.

It is often argued that Nursing Minimal Data Sets (NMDSs) have advantages for the nursing profession. The NMDSs that have been developed and applied in some countries have many features in common, but there are differences in purpose, content, sampling, collection approach, and developmental stage as well. This paper examines the advantages and disadvantages of data sets of nursing practice, and the differences and similarities of five national and international NMDS systems. The purpose is to apply this information toward an NMDS initiative in the Netherlands. Future initiatives in NMDS development should include international coordination.

Distressed or relieved? Psychological side effects of breast cancer screening in The Netherlands.

STUDY OBJECTIVES: To assess the psychological impact of mammographic screening on women with non-malignant outcomes after attending the Netherlands' National Breast Cancer Screening Programme. DESIGN: During one year all women with false positive test results (95) in a screening area were invited for the study. Each false positive was matched with two women with normal mammograms with respect to age and municipality. A random reference group of 400 was drawn from the female population in an area not yet included in the screening programme. Experiences with screening and psychological status of subjects were assessed 8-10 weeks after screening (T1) and again after six months (T2), by interviews as well as questionnaires. References completed two questionnaires with a six months' interval. PARTICIPANTS: 74 (78%) women with false positive outcomes and 113 (59%) women with negative outcomes participated at T1, of these 65 (88%) and 105 (93%) at T2, respectively; 238 references returned questionnaires at T1 (59%), of these 143 (60%) at T2. MAIN RESULTS: At 8-10 weeks after the screening, the women who received false positive test results scored higher on most of the variables indicating psychological disfunctioning than women with normal mammograms, but did not notably differ on the same variables from the non-screened reference group. Women with normal mammograms had the lowest scores on all the variables in the study at both assessments. The same situation was observed six months later. Although 61% of the women who received false positive mammograms reported that they had experienced the "false alarm" as a stressful event, this experience had apparently no adverse effects on their psychological functioning, as assessed 8-10 weeks after screening. CONCLUSIONS: Overall, breast screening is not likely to generate adverse psychological effects in "healthy" women, even if the outcome is false positive. Differences in psychological functioning between false positives and negatives are more likely ascribable to feelings of relief in the negative group than to raised anxiety and distress in the false positive group.

Validity and accuracy of interview and diary data on children's medical utilisation in The Netherlands.

STUDY OBJECTIVE: To assess the validity and accuracy of children's medical utilisation estimates from a health interview and diary and the possible consequences for morbidity estimates. The influence of recall bias and respondent characteristics on the reporting levels was also investigated. DESIGN: Validity study, with the medical record of the general practitioner (GP) as gold standard. In a health interview and three week diary estimates of medical utilisation of children were asked and compared with a GP's medical record. SETTING: General community and primary care centre in the Netherlands. PARTICIPANTS: Parents of 1,805 children and 161 GPs. MAIN RESULTS: The sensitivity of the interview (0.84) is higher than the diary (0.72), while specificity and kappa are higher in the diary (0.96; 0.64) than in the interview (0.91; 0.5-8). Recall bias, expressed as telescoping and heaping, is present in the interview data. Prevalence estimates of all morbidity are much higher in the interview, except for skin problems. Compared with a parental diary more consultations are reported exclusively by the GP for children from ethnic minorities (OR 1.6), jobless (OR 2.3), and less educated mothers (OR 2.6). CONCLUSIONS: Estimates of medical utilisation rates of children are critically influenced by the method of data collection used. Interviews are prone to introduce recall bias, while diaries should only be used in populations with an adequate level of literacy. It is recommended that medical records are used, as they produce most consistent estimates.

Socioeconomic inequity in health care: a study of services utilization in Curaçao.

The aim of this study is to examine whether there is socioeconomic equity in health care utilization in Curaçao, Netherlands Antilles. We explore how educational level is related to utilization of GPs, specialists, hospitals; dentists and physiotherapists, taking into account the effects of sex, age and inequalities in health. The study also examines whether these relationships vary according to the unit of analysis: probability (or incidence) of services use versus overall volume of contacts. The data were derived from the Curaçao Health Study, a health interview survey among a random sample (N = 2248) of the non-institutionalized population aged 18 and over. The results indicate that there is socioeconomic inequity in the probability of health care utilization in Curaçao. People with a higher educational level are more likely to consult a specialist, dentist or physiotherapist, and are also more likely to be hospitalized. This is not only the case when the mediating effects of socioeconomic inequalities in health (need) are taken into account, but also before adjustment for health inequalities. In other words: there appears to be both vertical inequity (i.e. greater needs for services are not met by greater use) and horizontal inequity (i.e. similar needs for care are not met by similar levels of services use). The observed inequalities in use of specialists and hospitals contrast with findings from international research. The volume of health services use (i.e. the numbers of consultations) appears to be hardly connected with a person's position in the SES hierarchy; only dental services are used more extensively by higher educated individuals.

Socio-economic differences in health risk behavior in adolescence: do they exist?

Socio-economic differences in risk behaviors in adolescence can be seen as a prelude to the re-emergence of socio economic health differences in adulthood. We studied whether or not socio-economic differences in health risk behaviors are present in male and female adolescents in The Netherlands. The relation between socio-economic status (SES) and health risk behaviors was examined, by testing both the main and interaction effects of SES and gender on separate health risk behaviors on one hand, and on the behaviors cumulatively on the other. The data were derived from 1984 adolescents in the four northern provinces of The Netherlands. SES was measured by means of the educational level and the occupational status of both parents. Four health risk behaviors were included in this study: smoking, alcohol consumption, soft drug use, and (no) physical exercise. We found that the relationships between SES and health risk behaviors are not as linear as is often found in adulthood. Our findings can be characterised overall by an absence of relationship between SES and health risk behaviors. The only exception applies to sport, which is linearly related to SES. Adolescents in the lower SES groups engage in sport less than adolescents in the higher SES groups. There was an irregular relationship between the father's occupational status and the adolescents' smoking and drinking. Adolescents in the highest, lowest and middle of the six SES groups have the highest rates of health risk behaviors. All observed relationships are similar for both male and female adolescents. A relationship between gender and the separate health risk behaviors was found only for alcohol consumption and drug use. For both male adolescents showed higher rates of risk behavior. Males also scored higher on the cumulative health risk behaviors than their female counterparts. The findings of this study do not support the hypothesis of latent differences in adolescence.

The measurement of social support in the 'European Research on Incapacitating Diseases and Social Support': the development of the Social Support Questionnaire for Transactions (SSQT).

Social support is supposed to have a beneficial effect on the health and wellbeing of people. It is a central concept in the 'EUropean Research on Incapacitating DIseases and Social Support' (EURIDISS). In general, two main distinctions concerning social support are made in the literature, providing four basic dimensions or types of social support: a social-emotional vs an instrumental type of social support, and a 'crisis' or 'problem-oriented' vs 'everyday' or 'daily' type of social support. Based on these types of social support, a series of items were formulated to measure actual supportive interactions or exchanges of resources. The items were spread over five scales. The social-emotional type of social support comprised three scales: daily emotional support; problem-oriented emotional support; and social companionship, while the instrumental type of social support consisted of two scales: the daily instrumental support and the problem-oriented instrumental support. Together, these items and scales constitute the so-called 'Social Support Questionnaire for Transactions' (SSQT). The main objective of this paper is to investigate whether one and the same instrument, i.e. the SSQT, allows for meaningful comparisons between patients with rheumatoid arthritis from different countries. More specifically, the dimensionality and invariance of the dimensions across countries of the SSQT are explored. To this end, patients from four different European countries (France, Norway, The Netherlands and Sweden) were asked to fill in the SSQT. The analysis of the data using principal component analysis (PCA) and simultaneous component analysis (SCA), did yield the intended scales, although the internal consistency of one of them, the daily instrumental support scale, is questionable.(ABSTRACT TRUNCATED AT 250 WORDS)

The social experiences of cancer patients under treatment: a comparative study.

As part of a larger study on the quality of life of cancer patients under treatment, the positive and negative experiences in social interaction have been examined as compared to those of a control group (nonpatients, n = 201). Two patient groups were included: 109 patients who had recently undergone surgery and 108 patients receiving chemotherapy. The respondents returned a mailed questionnaire. Contrary to the assumptions based on a review from the literature, cancer patients appear to have more positive and fewer negative social experiences than a random sample from the 'normal' population. Even under more severe medical circumstances (a poor prognosis or heavy chemotherapy, a large number of chemotherapy cycles, poor progress after surgery) the poorer the patients, medically speaking, the more help and support they perceive. The results of this study do not support the idea of stigmatization. The personality characteristics, neuroticism and self-esteem are especially important for the having of positive and negative experiences in social interaction. Positive social experiences show a relationship with self-esteem and negative social experiences show a relationship with neuroticism.

Compliance after 17 years of breast cancer screening.

OBJECTIVE: To investigate changes in attendance over the course of a population based breast screening programme. DESIGN: Longitudinal; analysis of registered data over nine screening rounds. SETTING: Subjects belong to the screening population of the Nijmegen experimental breast screening programme (1975-1990). SUBJECTS: A cohort of 6898 women who were enrolled in 1975 at the age of 50-69 years and who were invited to nine subsequent screening rounds, irrespective of their attendance at previous rounds. RESULTS: Attendance of women aged 50-53 years at entry was high at the initial screening (88%), decreased in the course of the programme, but remained well over 60% until round 8; 39% completed nine rounds and 24% completed seven to eight rounds. Attendance of women who were older at entry was somewhat lower at the initial screening (87%-82%) and declined more strongly. Regular compliance was also lower. Specific compliance patterns are found that can be relevant for further research. CONCLUSIONS: A substantial proportion of eligible women can be committed to mammography every two years, possibly even after reaching the age of 70, if the age at entry is around 50 and the screening programme is well established in the community. Starting a screening programme in older women seems ineffective.

Everyday symptoms in childhood: occurrence and general practitioner consultation rates.

BACKGROUND: Fewer than 20% of all illnesses that occur in the home require the attention of a general practitioner (GP). Whether specific illnesses in children are more likely to need the attention of a GP is poorly understood, as is the influence of various other factors. Health diaries are the most suitable method of collecting comprehensive information about children's health problems at home and in general practice simultaneously. AIM: To investigate the occurrence of, and consultation rates for, specific symptoms in childhood in relation to age, sex, birth order, and place of residence of the child, and season of the year. METHOD: The parents of 1805 children kept a health diary over three weeks and recorded symptoms and consultation behaviour. The symptoms were later combined into illness episodes. RESULTS: Over three weeks, colds/flu (157/1000 children) and respiratory symptoms (114/1000 children) occurred most frequently. More young children (0-4 years) suffered from illness generally. Eleven per cent of all illness episodes required the attention of a GP. Consultation rates differed greatly according to symptoms. A GP was consulted most often for ear (36%) and skin (28%) problems, and least often for headaches (2%) and tiredness (1%). Regardless of symptoms, young children (0-4 years) were taken to a GP twice as often as older children (10-14 years). CONCLUSIONS: This study emphasizes the enormous amount of illness that occurs in children and the fact that more than 80% of all illnesses are dealt with by parents without reference to the professional health care system.

Sociocultural variations in help-seeking behavior for everyday symptoms and chronic disorders.

In this study, we test the assumption that sociocultural differences in use of health services will only occur below a certain level of illness severity. Data are derived from the Curaçao Health Study (n = 2248). Subjects' educational level and degree of proto-professionalization are used as indicators of their sociocultural background. Differences in the likelihood of seeking professional care for several common health problems are analyzed, and are compared with the help-seeking behavior for chronic disorders. As hypothesized, higher educated and proto-professionalized people are less likely to seek care for everyday symptoms. In addition, proto-professionalization is accompanied by a greater likelihood of using over the counter medication. Increasing empowerment of patients appears to lead to increased self care for everyday symptoms. When conditions reach a more serious stage, the differences in help-seeking behavior disappear: for most of the chronic conditions studied, the higher educated and more proto-professionalized individuals are just as likely to seek professional treatment as the less advantaged groups. However, there is a difference as to the type of professional consulted for chronic health problems. Proto-professionalized individuals more often receive specialist treatment, probably because they are better equipped to persuade GPs to refer. The adverse side of patient empowerment may be increasing consumerism: a situation in which patient demands, not medical necessity, determine the care delivered.

Utilisation of medical technology assessment in health policy.

OBJECTIVE: To assess the contribution of medical technology assessment (MTA) to health policy decision making, the question has to be answered whether MTA is actually being used in decision-making processes and what factors are related to its utilisation. DESIGN: We investigated recent Dutch policy decision making concerning four cases, i.e., breast cancer screening, serum alphaprotein (AFP) screening, in vitro fertilisation (IVF) and lung transplantation. METHODS: A search of the international literature yielded 351 articles that reported MTA results concerning the four cases studied. Policy documents, advisory reports and parliamentary discussions were analysed to identify the utilisation of existing MTA knowledge in The Netherlands. Additionally, 23 structured interviews with experts in the field of MTA and/or policy decision-making were conducted. RESULTS: Numerous articles report results of MTA studies of breast cancer screening and in vitro fertilisation. In both cases the Dutch government commissioned MTA studies, but the outcomes of these studies did not substantially affect the decision-making process. MTA knowledge about AFP screening is more limited and studies dealing with lung transplantation are scarce. Nevertheless, policy decisions were made. CONCLUSION: Policy decisions concerning the introduction of (new) technologies in health care are not based on the results of MTA studies. Political arguments and interest groups decide the outcomes. At best, MTA results are used to implement (new) technologies more effectively.

Opinions on changes in the Romanian health care system from people's point of view: a descriptive study.

After 10 years of changes, the Romanian people were asked to assess the consequences of the reforms that were carried out through the health care system in the last decennium. This article studies the opinion of changes among individuals and socio-economic-demographic groups living in Dolj region. Such surveys are rare in Romania. People show to have different opinions on quality of care, accessibility and on attitudes of politicians to health care comparing the present state of affaires with the past one. Overall the people judge the actual situation preferable to the past. The elderly, the chronically ill and the people who believe that people were happier 10 years ago have a more critical view on the changes especially in terms of accessibility. The higher educated people have a more positive opinion on the consequences of the reforms. The results may help to improve the communication between policy makers and the population. It is suggested that the involvement of the citizens in the health care reforms may realize a better implementation of Romanian health care reforms. This involvement is lacking.

How to validate clinically important change in health-related functional status. Is the magnitude of the effect size consistently related to magnitude of change as indicated by a global question rating?

Some clinical trials perform repeated measurement over time and estimate clinically relevant change in an instrument's score with global ratings of perceived change or so-called transition questions. The conceptual and methodological difficulties in estimating the magnitude of clinically relevant change over time in health-related functional status (HRFS) are discussed. This paper investigates the concordance between the amount of serially assessed change with effect size estimates (the researcher's perspective) and global ratings of perceived change (the patient's perspective). A total of 217 patients who were scheduled for diagnostic examination were included, and the Minnesota Living with Heart Failure Questionnaire, extended with MOS-20 items, was assessed before and after medical intervention (percutaneous transluminal coronary angioplasty, coronary artery bypass grafting or pharmaco-therapy). Global questions were applied to assess perceived change over time for every item from domains of physical and emotional functioning and used as the external criterion of relevant change in the analysis of items. Global questions corresponding with overall change in these domains were used in the comparison of change in physical and emotional functioning scales. Two effect size indices were used: (i) ES (mean change/SDpooled) and (ii) ES (mean change/SDchange). A method is described to calculate a value indicating the extent of discordance between the researcher's interpretation of magnitude of change and the external criterion (the patient's perspective). Findings suggest that effect size (ES) (mean change/SDpooled) was in keeping with the magnitude of change indicated by patients' judgements, or their category of subjective meaning, for all scales. Furthermore, in cases in which the magnitude of change estimated with the SRM (mean change/SDchange) was not confirmed empirically by the external criterion ratings, the discordance could be interpreted as a trivial discordance.

Can we solve current problems with nursing information systems?

Dutch nurses are confronted with health care information systems quite often. However, they do not take full advantage of electronic support for their care activities and professional development. The nursing process is often considered the core of nursing care delivery and guides the documentation of care. Currently, this process can be supported electronically. However, the actual use of nursing information systems (NISs) in the Netherlands is limited to a few sites. Therefore, it is timely to analyse the problems that exist in the development and use of NISs and to look for solutions to solve them. This paper proposes both the nursing information reference model (NIRM), and structured discussions for a proper course of action in the development and use of NISs.

Factors related to fatigue; priority of interventions to reduce or eliminate fatigue and the exploration of a multidisciplinary research model for further study of fatigue.

A growing interest in the health problem presented by fatigue, both in clinical practice and research, coupled with a decreasing number of reported studies on fatigue in the last decade, make an updated and systematic review of factors related to fatigue necessary. A search of the literature, comprising 53 studies, was therefore undertaken to explore the following research questions: Which significantly social-demographic, cure-related, and care-related factors are significantly correlated with fatigue? And which nursing interventions need priority in experimental research to reduce or eliminate fatigue? Reported factors related to fatigue in analysed studies show that the correlations between the specific cure- and care-related factors and fatigue are similar among the various investigated (patient) populations. This result supports the concept of the non-specific character of fatigue. The intervention of primary effectiveness most suggested in this study is 'energy management'. Interventions of secondary importance which emerge are those of 'emotional support', 'activity therapy' and 'coping enhancement'. This study makes clear that the exploration of a research model for fatigue, with social-demographic, cure- and care-related factors is useful and that care-related factors have their own effects on fatigue not necessarily dependent upon the presence of medical diseases or cure-related factors. In general, multi-related factors could be assessed. Implications and relevant questions for further research on fatigue are also given.

Using the nursing minimum data set for the Netherlands (NMDSN) to illustrate differences in patient populations and variations in nursing activities.

RATIONALE: A nursing minimum data set (NMDS) provides data that are useful to legitimate nurses' contribution to healthcare. In Belgium and the US, such NMDS are operational, other countries are developing it, among which is the Netherlands. OBJECTIVE: To evaluate whether the nursing minimum data set for the Netherlands (NMDSN) is suitable to describe the diversity of patient populations and the variability of nursing care. METHODOLOGY: Using the NMDSN data collection forms, patient data were collected from 15 different hospital wards. During one week, nurses manually completed the NMDSN list for every patient. The data analysis methodology from the Belgian MVG was used, including ridit analysis and graphs. RESULTS: The NMDSN includes items related to hospital, patient demographics, medical condition, nursing process, nursing phenomena, nursing interventions, outcomes of nursing care, and complexity of care. There were 686 individual patients in the study, while for the data analysis their 2090 patient days in the hospital were used. Frequencies of nursing phenomena, nursing activities and results of care were calculated, transformed into ridit scores, and presented graphically as 'fingerprints'. CONCLUSION: The set of NMDSN items allows illustrating the diversity of patient populations, and variation in nursing care by means of 'fingerprints'.