Using PROMs during routine medical consultations: The perspectives of people with Parkinson's disease and their health professionals.

BACKGROUND: The use of patient-reported outcomes measures (PROMs), such as quality of life or symptoms like pain or fatigue, is increasingly embraced within patient-centred care and shared decision making. OBJECTIVES: To investigate: (a) how patients and health professionals think about using PROMs during routine medical consultations; (b) for which purpose(s), patients and health professionals want to use PROMs during those consultations; and (c) how patients interpret PROMs information presented in various formats. People with Parkinson's disease and their health professionals served as case example. METHODS: We performed semi-structured interviews with patients (N = 13) and professionals (N = 7 neurologists; N = 7 physiotherapists). We also used a survey in which patients (N = 115) were shown six figures displaying different information types. Presentation formats of this information varied (line/bar graphs). Interpretation by patients, perceived usefulness of information, attitude towards using information during routine medical consultations and (hypothetical) decisions were assessed. FINDINGS: Patients and professionals were generally positive about using PROMs during medical consultations. Professionals stressed the opportunity to monitor changes in individual PROMs over time. Patients were primarily positive about aggregated PROMs to make treatment decisions. This information was also most often interpreted correctly, especially when presented through a line graph (90.1% correct). Professionals thought patients should take the initiative in discussing PROMs, whereas patients thought professionals should do so. CONCLUSION/DISCUSSION: When used in routine medical consultations, PROMs seem to have potential to support shared decision making and facilitate patient-professional communication. However, training seems needed for both patients and professionals to facilitate actual discussion and proper interpretation.

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.

A three-goal model for patients with multimorbidity: A qualitative approach.

BACKGROUND: To meet the challenge of multimorbidity in decision making, a switch from a disease-oriented to a goal-oriented approach could be beneficial for patients and clinicians. More insight about the concept and the implementation of this approach in clinical practice is needed. OBJECTIVE: This study aimed to develop conceptual descriptions of goal-oriented care by examining the perspectives of general practitioners (GPs) and clinical geriatricians (CGs), and how the concept relates to collaborative communication and shared decision making with elderly patients with multimorbidity. METHOD: Qualitative interviews with GPs and CGs were conducted and analyzed using thematic analysis. RESULTS: Clinicians distinguished disease- or symptom-specific goals, functional goals and a new type of goals, which we labelled as fundamental goals. "Fundamental goals" are goals specifying patient's priorities in life, related to their values and core relationships. These fundamental goals can be considered implicitly or explicitly in decision making or can be ignored. Reasons to explicate goals are the potential mismatch between medical standards and patient preferences and the need to know individual patient values in case of multimorbidity, including the management in acute situations. CONCLUSION: Based on the perspectives of clinicians, we expanded the concept of goal-oriented care by identifying a three-level goal hierarchy. This model could facilitate collaborative goal-setting for patients with multiple long-term conditions in clinical practice. Future research is needed to refine and validate this model and to provide specific guidance for medical training and practice.

Building a patient-centered and interprofessional training program with patients, students and care professionals: study protocol of a participatory design and evaluation study.

BACKGROUND: A common approach to enhance patient-centered care is training care professionals. Additional training of patients has been shown to significantly improve patient-centeredness of care. In this participatory design and evaluation study, patient education and medical education will be combined by co-creating a patient-centered and interprofessional training program, wherein patients, students and care professionals learn together to improve patient-centeredness of care. METHODS: In the design phase, scientific literature regarding interventions and effects of student-run patient education will be synthesized in a scoping review. In addition, focus group studies will be performed on the preferences of patients, students, care professionals and education professionals regarding the structure and content of the training program. Subsequently, an intervention plan of the training program will be constructed by combining these building blocks. In the evaluation phase, patients with a chronic disease, that is rheumatoid arthritis, diabetes and hypertension, and patients with an oncologic condition, that is colonic cancer and breast cancer, will learn together with medical students, nursing students and care professionals in training program cycles of three months. Process and effect evaluation will be performed using the plan-do-study-act (PDSA) method to evaluate and optimize the training program in care practice and medical education. A modified control design will be used in PDSA-cycles to ensure that students who act as control will also benefit from participating in the program. DISCUSSION: Our participatory design and evaluation study provides an innovative approach in designing and evaluating an intervention by involving participants in all stages of the design and evaluation process. The approach is expected to enhance the effectiveness of the training program by assessing and meeting participants' needs and preferences. Moreover, by using fast PDSA cycles and a modified control design in evaluating the training program, the training program is expected to be efficiently and rapidly implemented into and adjusted to care practice and medical education.

Assessment of goals and priorities in patients with a chronic condition: a secondary quantitative analysis of determinants across 11 countries.

OBJECTIVE: To assess the impact of patient characteristics, patient-professional engagement, communication and context on the probability that healthcare professionals will discuss goals or priorities with older patients. DESIGN: Secondary analysis of cross-sectional data from the 2014 Commonwealth Fund International Health Policy Survey of Older Adults. SETTING: 11 western countries. SUBJECTS: Community-dwelling adults, aged 55 or older. MAIN OUTCOME MEASURE: Assessment of goals and priorities. RESULTS: The final sample size consisted of 17,222 respondents, 54% of whom reported an assessment of their goals and priorities (AGP) by healthcare professionals. In logistic regression model 1, which was used to analyse the entire population, the determinants found to have moderate to large effects on the likelihood of AGP were information exchange on stress, diet or exercise, or both. Country (living in Sweden) and continuity of care (no regular professional or organisation) had moderate to large negative effects on the likelihood of AGP. In model 2, which focussed on respondents who experienced continuity of care, country and information exchange on stress and lifestyle were the main determinants of AGP, with comparable odds ratios to model 1. Furthermore, a professional asking questions also increased the likelihood of AGP. CONCLUSIONS: Continuity of care and information exchange is associated with a higher probability of AGP, while people living in Sweden are less likely to experience these assessments. Further study is required to determine whether increasing information exchange and professionals asking more questions may improve goal setting with older patients. Key points A patient goal-oriented approach can be beneficial for older patients with chronic conditions or multimorbidity; however, discussing goals with these patients is not a common practice. The likelihood of discussing goals varies by country, occurring most commonly in the USA, and least often in Sweden. Country-level differences in continuity of care and questions asked by a regularly visited professional affect the goal discussion probability. Patient characteristics, including age, have less impact than expected on the likelihood of sharing goals.

Automated Quality Control for Sensor Based Symptom Measurement Performed Outside the Lab.

The use of wearable sensing technology for objective, non-invasive and remote clinimetric testing of symptoms has considerable potential. However, the accuracy achievable with such technology is highly reliant on separating the useful from irrelevant sensor data. Monitoring patient symptoms using digital sensors outside of controlled, clinical lab settings creates a variety of practical challenges, such as recording unexpected user behaviors. These behaviors often violate the assumptions of clinimetric testing protocols, where these protocols are designed to probe for specific symptoms. Such violations are frequent outside the lab and affect the accuracy of the subsequent data analysis and scientific conclusions. To address these problems, we report on a unified algorithmic framework for automated sensor data quality control, which can identify those parts of the sensor data that are sufficiently reliable for further analysis. Combining both parametric and nonparametric signal processing and machine learning techniques, we demonstrate that across 100 subjects and 300 clinimetric tests from three different types of behavioral clinimetric protocols, the system shows an average segmentation accuracy of around 90%. By extracting reliable sensor data, it is possible to strip the data of confounding factors in the environment that may threaten reproducibility and replicability.

Implementation of Patient Engagement in the Netherlands: A Stimulating Environment within a Large Academic Medical Centre.

Patients are the official third party of the Dutch healthcare system, apart from healthcare providers and insurers. Radboud university medical center (Radboudumc) is a regional centre for specialized secondary care in the Netherlands. Here innovation is recognized as a decisive factor when it comes to the implementation of patient engagement. Therefore, all employees are invited to innovate, experiment, fail and implement promising innovations into practice. In this paper, we demonstrate how this stimulating environment led to a rich collection of patient engagement activities in organizational (re-)design and in educational programs for students and employees.

Involving Medical Students in Providing Patient Education for Real Patients: A Scoping Review.

BACKGROUND: Studies suggest that involving students in patient education can contribute to the quality of care and medical education. Interventions and outcomes in this field, however, have not yet been systematically reviewed. The authors examined the scientific literature for studies on interventions and outcomes of student-provided patient education. METHODS: Four databases (MEDLINE, EMBASE, ERIC, PsycINFO) were searched for studies reporting patient education, undergraduate medical students, and outcomes of patient education, published between January 1990 and October 2015. Facilitators of and barriers to educational interventions were assessed using the Learning Transfer System Inventory. The learning yield, impact on quality of care, and practical feasibility of the interventions were rated by patients, care professionals, researchers, and education professionals. RESULTS: The search resulted in 4991 hits. Eighteen studies were included in the final synthesis. Studies suggested that student-provided patient education improved patients' health knowledge, attitude, and behavior (nine studies), disease management (three studies), medication adherence (one study), and shared decision-making (one study). In addition, involving students in patient education was reported to enhance students' patient education self-efficacy (four studies), skills (two studies), and behavior (one study), their relationships with patients (two studies), and communication skills (two studies). DISCUSSION: Our findings suggest that student-provided patient education-specifically, student-run patient education clinics, student-provided outreach programs, student health coaching, and clerkships on patient education-has the potential to improve quality of care and medical education. To enhance the learning effectiveness and quality of student-provided patient education, factors including professional roles for students, training preparation, constructive supervision, peer support on organizational and individual levels, and learning aids should be taken into account. Future research should focus on further investigating the effects found in this study with high-level evidence.

Collaborative goal setting with elderly patients with chronic disease or multimorbidity: a systematic review.

BACKGROUND: It is challenging to use shared decision-making with patients who have a chronic health condition or, especially, multimorbidity. A patient-goal-oriented approach can thus be beneficial. This study aims to identify and evaluate studies on the effects of interventions that support collaborative goal setting or health priority setting compared to usual care for elderly people with a chronic health condition or multimorbidity. METHODS: This systematic review was based on EPOC, PRISMA and MOOSE guidelines. Pubmed, PsychInfo, CINAHL, Web of Science, Embase and the Cochrane Central Register of Controlled Trials were searched systematically. The following eligibility criteria were applied: 1. Randomised (cluster) controlled trials, non-randomised controlled trials, controlled before-after studies, interrupted time series or repeated measures study design; 2. Single intervention directed specifically at collaborative goal setting or health priority setting or a multifactorial intervention including these elements; 3. Study population of patients with multimorbidity or at least one chronic disease (mean age ± standard deviation (SD) incl. age 65). 4. Studies reporting on outcome measures reducible to outcomes for collaborative goal setting or health priority setting. RESULTS: A narrative analysis was performed. Eight articles describing five unique interventions, including four cluster randomised controlled trials and one randomised controlled trial, were identified. Four intervention studies, representing 904, 183, 387 and 1921 patients respectively, were multifactorial and showed statistically significant effects on the application of goal setting (Patient Assessment of Chronic Illness Care (PACIC) goal setting subscale), the number of advance directives or the inclusion of goals in care plans. Explicit attention for goal setting or priority setting by a professional was a common element in these multifactorial interventions. One study, which implemented a single-factor intervention on 322 patients, did not have significant effects on doctor-patient agreement. All the studies had methodological concerns in varying degrees. CONCLUSIONS: Collaborative goal setting and/or priority setting can probably best be integrated in complex care interventions. Further research should determine the mix of essential elements in a multifactorial intervention to provide recommendations for daily practice. In addition, the necessity of methodological innovation and the application of mixed evaluation models must be highlighted to deal with the complexity of goal setting and/or priority setting intervention studies.

Moving Parkinson care to the home.

In many ways, the care of individuals with Parkinson disease does not meet their needs. Despite the documented benefits of receiving care from clinicians with Parkinson disease expertise, many patients (if not most) do not. Moreover, current care models frequently require older individuals with impaired mobility, cognition, and driving ability to be driven by overburdened caregivers to large, complex urban medical centers. Moving care to the patient's home would make Parkinson disease care more patient-centered. Demographic factors, including aging populations, and social factors, such as the splintering of the extended family, will increase the need for home-based care. Technological advances, especially the ability to assess and deliver care remotely, will enable the transition of care back to the home. However, despite its promise, this next generation of home-based care will have to overcome barriers, including outdated insurance models and a technological divide. Once these barriers are addressed, home-based care will increase access to high quality care for the growing number of individuals with Parkinson disease. © 2016 International Parkinson and Movement Disorder Society.

Trends towards stronger primary care in three western European countries; 2006-2012.

BACKGROUND: Strong primary care systems are believed to have an important role in dealing with healthcare challenges. Strengthening primary care systems is therefore a common policy goal for many countries. This study aims to investigate whether the Netherlands, the UK and Germany have strengthened their primary care systems in 2006-2012. METHOD: For this cross-sectional study, data from the International Health Policy surveys of the Commonwealth Fund in 2006, 2009 and 2012 were used. The surveys represent the experiences and perspectives of primary care physicians with their primary care system. The changes over time were researched in three areas: organization of primary care processes, use of IT in primary care and use of benchmarking and financial incentives for performance improvement. RESULTS: Regarding organization of primary care processes, in all countries the use of supporting personnel in general practice increased, but at the same time practice accessibility decreased. IT services were most advanced in the UK. The UK and the Netherlands showed increased use of performance feedback information. German GPs were least satisfied with how their system works across the 2006-2012 timeframe. CONCLUSION: All three countries show trends towards stronger primary care systems, although in different areas. Coordination and comprehensive care through the assignment of assisting personnel and use of disease management programs improved in all countries. In the Netherlands and the UK, informational continuity is in part ensured through better IT services. All countries showed increasing difficulties upholding primary care accessibility.

The impact of primary care organization on avoidable hospital admissions for diabetes in 23 countries.

OBJECTIVE: Diabetes is a so-called ambulatory care sensitive condition. It is assumed that by appropriate and timely primary care, hospital admissions for complications of such conditions can be avoided. This study examines whether differences between countries in diabetes-related hospitalization rates can be attributed to differences in the organization of primary care in these countries. DESIGN: Data on characteristics of primary care systems were obtained from the QUALICOPC study that includes surveys held among general practitioners and their patients in 34 countries. Data on avoidable hospitalizations were obtained from the OECD Health Care Quality Indicator project. Negative binomial regressions were carried out to investigate the association between characteristics of primary care and diabetes-related hospitalizations. SETTING: A total of 23 countries. SUBJECTS: General practitioners and patients. MAIN OUTCOME MEASURES: Diabetes-related avoidable hospitalizations. RESULTS: Continuity of care was associated with lower rates of diabetes-related hospitalization. Broader task profiles for general practitioners and more medical equipment in general practice were associated with higher rates of admissions for uncontrolled diabetes. Countries where patients perceive better access to care had higher rates of hospital admissions for long-term diabetes complications. There was no association between disease management programmes and rates of diabetes-related hospitalization. Hospital bed supply was strongly associated with admission rates for uncontrolled diabetes and long-term complications. CONCLUSIONS: Countries with elements of strong primary care do not necessarily have lower rates of diabetes-related hospitalizations. Hospital bed supply appeared to be a very important factor in this relationship. Apparently, it takes more than strong primary care to avoid hospitalizations. KEY POINTS: Countries with elements of strong primary care do not necessarily have lower rates of diabetes-related avoidable hospitalization. Hospital bed supply is strongly associated with admission rates for uncontrolled diabetes and long-term complications. Continuity of care was associated with lower rates of diabetes-related hospitalization. Better access to care, broader task profiles for general practitioners, and more medical equipment in general practice was associated with higher rates of admissions for diabetes.

Personal health communities: a phenomenological study of a new health-care concept.

CONTEXT: Fragmentation of care, complexity of diseases and the need to involve patients actively in their individual health care led to the development of the personal health community (PHC). In a PHC, patients can -regardless of the nature of their condition- invite all professionals that are involved in their health care process. Once gathered, the patient and health care team can exchange information about the patient's health and communicate through several functionalities, in a secured environment. OBJECTIVES: Exploring the use, first experiences and potential consequences of using PHCs in health care. DESIGN: Qualitative phenomenological study. PARTICIPANTS: Eighteen respondents, consisting of women experiencing infertility (n = 5), persons with Parkinson's disease (n = 6), a gynaecologist, a fertility doctor, a fertility nurse, three Parkinson's specialist nurses and a neurologist. RESULTS: First experiences with PHCs showed that patients use their PHC differently, dependending on their condition and people involved. Various (potential) advantages for future health care were mentioned relating to both organizational aspects of care (e.g. continuity of care) and the human side of care (e.g. personal care). Patient involvement in care was facilitated. Disadvantages were the amount of work that it took and technological issues. CONCLUSIONS: Using PHCs leads to promising improvements in both the organization of care and care experience, according to the participants in this study. They indicate that patients with different diseases and in different circumstances can benefit from these improvements. The PHC seem to be an online tool that can be applied in a personalized way. When (technically) well facilitated, it could stimulate active involvement of patients in their own health and health care. It warrants further research to study its effect on concrete health outcomes.

Propensity to seek healthcare in different healthcare systems: analysis of patient data in 34 countries.

BACKGROUND: Some people have a lower threshold to seek care for certain symptoms than others. This study aims to investigate what factors are associated with patients' propensity to seek care. In addition, this study explores whether patients' propensity to seek care is associated with their actual health care utilization. We hypothesized that higher scores for propensity to seek care will lead to more general practitioners (GP) consultations, but to lower rates of avoidable hospitalization. METHODS: Propensity to seek care and GP utilization were measured by the Patient Experience Questionnaire of the QUALICOPC study, a survey among 61,931 patients that recently visited GP services in 34 countries. Propensity to seek care was estimated by two questions: one question focusing on health care seeking behavior for serious symptoms and the other question focused minor complaints. Data on country level rates of avoidable hospitalization for CHF, COPD, asthma and diabetes were obtained from the OECD health care quality indicators project. RESULTS: Beside patient characteristics, various organizational factors, such as better accessible and continuous primary care, and better experienced communication between patient and GPs was associated with a higher propensity to seek care for both severe and minor complaints. A higher propensity to seek care was associated with a slightly higher health care utilization in terms of GP visits, with no differences between the severity of the experienced symptoms (OR 1.08 for severe complaints and OR 1.05 for minor complaints). At country level, no association was found between propensity to seek care and rates of avoidable hospitalization for CHF, COPD, asthma and diabetes, possibly due to low statistical power at country level. CONCLUSIONS: The organization of primary care and patients' perceived communication with their GP were found to be highly correlated with patients' decision to seek health care for minor or severe complaints, suggesting that characteristics of healthcare systems directly influence patients' care seeking behavior, potentially leading to overuse or underuse of health services. However, we also observed that patients' propensity to seek care is only weakly associated with more GP use.

Organizational aspects of primary care related to avoidable hospitalization: a systematic review.

BACKGROUND: Often used indicators for the quality of primary care are hospital admissions rates for conditions which are potentially avoidable by well-functioning primary care. Such hospitalizations are frequently termed as ambulatory care sensitive conditions (ACSCs). OBJECTIVE: We aim to investigate which characteristics of primary care organization influence avoidable hospitalization for chronic ACSCs. METHODS: MEDLINE, Embase and SciSearch were searched for publications on avoidable hospitalization and primary care. Studies were included if peer reviewed, written in English, published between January 1997 and November 2013, conducted in high income countries, identified hospitalization for ACSC as outcome measures and researched organization characteristics of primary care. A risk of bias assessment was performed to assess the quality of the articles. FINDINGS: A total of 1778 publications were reviewed, of which 49 met inclusion criteria. Twenty-two primary care factors were found. Factors were clustered into four primary care clusters: system-level characteristics, accessibility, structural and organizational characteristics and organization of the care process. Adequate physician supply and better longitudinal continuity of care reduced avoidable hospitalizations. Furthermore, inconsistent results were found on the effectiveness of various disease management programs in reducing hospitalization rates. CONCLUSIONS: Available evidence suggests that strong primary care in terms of adequate primary care physician supply and long-term relationships between primary care physicians and patients reduces hospitalizations for chronic ACSCs. There is a lack of evidence for the positive effects of many other organizational primary care aspects, such as specific disease management programs.

Is the role as gatekeeper still feasible? A survey among Dutch general practitioners.

INTRODUCTION: In the 2012 International Health Policy Survey by the Commonwealth Fund, 57% of Dutch GPs indicated that Dutch patients receive too much health care. This is an unexpected finding, given the clear gatekeeper role of Dutch GPs and recent efforts strengthening this role. OBJECTIVES: The study aims to explore where perceived overuse of care prevails and to identify factors associated with too much care at the entry point of Dutch health care. METHOD: An American survey exploring perceptions of the amount of care among primary care providers was modified for relevance to the Dutch health system. We further included additional factors possibly related to overuse based on 12 interviews with Dutch GPs. The survey was sent to a random sample of 600 GPs. RESULTS: Dutch GPs (N = 157; response rate 26.2%) indicated that patients receive (much) too much care in general hospitals, primary care, GP cooperatives as well as private clinics. The Dutch responding GPs showed a relatively demand-satisfying attitude, which contributed to the delivery of too much care, often leading to deviation from guidelines and professional norms. The increasing availability of diagnostic facilities was identified as an additional factor contributing to the provision of unnecessary care. Finally, funding gaps between primary care and hospitals impede cooperation and coordination, provoking unnecessary care. CONCLUSION: Our results--most notably regarding the demand-satisfying attitude of responding GPs--call into question the classical view of the guidance and gatekeeper role of GPs in the Dutch health care system.

Patients' expectations of variation in quality of care relates to their search for comparative performance information.

BACKGROUND: Choice of hospital based on comparative performance information (CPI) was introduced for Dutch healthcare consumers at least 5 years ago, but CPI use has not yet become commonplace. Our aim was to assess the role of patients' expectations regarding variation in the quality of hospital care in determining whether they search for CPI. METHODS: A questionnaire (for a cross-sectional survey) was distributed to 475 orthopaedic patients in a consecutive sample, who underwent primary hip or knee replacement in a university, teaching, or community hospital between September 2009 and July 2010. RESULTS: Of the 302 patients (63%) who responded, 13% reported searching for CPI to help them choose a hospital. People who expected quality differences between hospitals (67%) were more likely to search for CPI (OR =3.18 [95% CI: 1.02-9.89]; p <0.04) than those who did not. Quality differences were most often expected in hospital reputation, distance, and accessibility. Patients who did not search for CPI stated that they felt no need for this type of information. CONCLUSION: Patients' expectations regarding variation in quality of care are positively related to their reported search for CPI. To increase the relevance of CPI for patients, future studies should explore the underlying reasoning of patients about meaningful quality-of-care variation between hospitals.

Comparative performance information plays no role in the referral behaviour of GPs.

BACKGROUND: Comparative performance information (CPI) about the quality of hospital care is information used to identify high-quality hospitals and providers. As the gatekeeper to secondary care, the general practitioner (GP) can use CPI to reflect on the pros and cons of the available options with the patient and choose a provider best fitted to the patient's needs. We investigated how GPs view their role in using CPI to choose providers and support patients. METHOD: We used a mixed-method, sequential, exploratory design to conduct explorative interviews with 15 GPs about their referral routines, methods of referral consideration, patient involvement, and the role of CPI. Then we quantified the qualitative results by sending a survey questionnaire to 81 GPs affiliated with a representative national research network. RESULTS: Seventy GPs (86% response rate) filled out the questionnaire. Most GPs did not know where to find CPI (87%) and had never searched for it (94%). The GPs reported that they were not motivated to use CPI due to doubts about its role as support information, uncertainty about the effect of using CPI, lack of faith in better outcomes, and uncertainty about CPI content and validity. Nonetheless, most GPs believed that patients would like to be informed about quality-of-care differences (62%), and about half the GPs discussed quality-of-care differences with their patients (46%), though these discussions were not based on CPI. CONCLUSION: Decisions about referrals to hospital care are not based on CPI exchanges during GP consultations. As a gatekeeper, the GP is in a good position to guide patients through the enormous amount of quality information that is available. Nevertheless, it is unclear how and whether the GP's role in using information about quality of care in the referral process can grow, as patients hardly ever initiate a discussion based on CPI, though they seem to be increasingly more critical about differences in quality of care. Future research should address the conditions needed to support GPs' ability and willingness to use CPI to guide their patients in the referral process.

Exploring consumer values of comparative performance information for hospital choice.

BACKGROUND: In many countries, market orientation in healthcare has resulted in the publication of comparative performance information (CPI). Most of the research in this field is oriented towards the content and the presentation format of CPI while little is known about how consumers value CPI and the use of this information. AIM: The aim of this study was to clarify the perceived value that CPI brings for consumers of healthcare. Methods Qualitative research using six focus group interviews. Twenty-seven healthcare consumers were recruited using a mailing list and by personal invitation. Data from focus group interviews were transcribed and thematic analysis undertaken. RESULTS: Most participants were unaware of CPI, and valued alternative sources of information more than CPI. Through discussion with other consumers and by means of examples of CPI, respondents were able to express the values and perceived effects of CPI. Numerous underlying values hindered consumers' use of CPI, and therefore clarification of consumer values gave insights into the current non-usage of CPI. CONCLUSIONS: CPI is marginally valued, partly because of conflicting values expressed by consumers and, as such, it does not yet provide a useful information source on hospital choice beyond consumers' current selection routines in healthcare. Future research should be more focused on the values of consumers and their impact on the use of CPI.

Recognition of physiotherapists' expertise in Parkinson's disease.

BACKGROUND: Publicly available information comparing performance across quality and costs has proliferated in recent years, both about individual healthcare professionals and hospitals. This type of information is now becoming increasingly available for physiotherapists with expertise in Parkinson's disease (PD). Our study aimed to explore the ability of people with Parkinson's disease to recognise expertise, and to what extent respondents selectively choose such expert physiotherapists. METHODS: We used claim data from the period 2009-2010 to select customers with PD who claimed physiotherapy. A random sample of 500 eligible respondents received a paper-based survey. We used descriptive statistics to compare the respondent characteristics, a qualitative programme to analyse the qualitative items, and univariate and multivariate regression. RESULTS: Most respondents (89%) took their referring physician's advice when selecting a physiotherapist, although this advice rarely was supported with arguments. The remaining respondents (11%) searched for comparative performance information about physiotherapists. Respondents who recognised the added value of PD expertise among physiotherapists were 3.28 times as likely to search for comparative performance information as those who did not understand. Respondents were willing to switch to an expert physiotherapist (68%), and this willingness increased if they recognised the value of PD expertise (p < .001). CONCLUSION: The participants were able to recognise certain aspects of expertise. Though they showed relatively few signs of selectively choice behaviour for expert physiotherapists. Both respondents and referring professionals need more understanding about the added value of an expert physiotherapist, to foster selective provider choice.