'They need to ask me first'. Community engagement with low-income citizens. A realist qualitative case-study.

BACKGROUND: Community engagement is seen as key to citizen-centred and sustainable healthcare systems as involving citizens in the designing, implementation and improvement of services and policies is thought to tailor these more closely to communities' own needs and experiences. Organizations have struggled to reach out to and involve disadvantaged citizens. This paper examines how if, why, and when low-income citizens wish to be involved. METHODS: For this qualitative realist case-study, 19 interviews (one dyad) were held with (20) low-income citizens in two Dutch municipalities. Additionally, the results were discussed with a reference panel consisting of professionals and citizens to enrich the results and to ensure the results had face validity. RESULTS: The results showed four different ways in which low-income citizens wished to be involved: (a) in a practical/volunteer way; (b) as a buddy; (c) as a lay expert; (d) not involved at all. The factors affecting citizens' interest and capacity to participate include citizens' own experiences of the services they access and their personal situations, e.g. their mental or physical health, extent of financial crisis, family situation, home environment. None of the interviewees was currently involved, but all had ideas for improving health(care) services and policies. Citizens' experiences of the services they accessed acted as a motivator for some to be involved as they wanted to ensure others would not have the same struggles, while for others their own needs and an apathetic system remained too high a barrier. To enable involvement, citizens need continued support for their own health(care) and financial situation, better communication and accessibility from services, practical support (e.g., training and bus passes) and recognition for their input (e.g., monetary compensation). CONCLUSION: The study shows that citizens' experiences of the services they accessed influenced if and how they wanted to be involved with health and care services. Despite the fact that all participants had shared solid ideas for improving services and policies, they were hindered by a bureaucratic, impersonal and inaccessible system. Organizations seem to underestimate the required investments to reach out to low-income citizens and the support required to ensure their involvement. PATIENT AND PUBLIC INVOLVEMENT (PPI) IN STUDY: Citizens as well as PPI organizations were members of the reference panel who helped formulate the research questions and recruitment strategy. The local reference panel also helped to interpret and refine the initial findings.

How staff characteristics influence residential care facility staff's attitude toward person-centered care and informal care.

BACKGROUND: Staff members, and their attitudes, are crucial for providing person-centered care in residential care facilities for people with dementia. However, the literature on the attitudes of nursing staff regarding person-centered care is limited. The objective of this study is to explore the association between staff characteristics (age, education level, years of work experience and function, i.e., care or welfare) and staff attitudes toward perceived person-centered care provision and including informal caregivers in the caregiving process in residential care facilities. METHODS: A convenience sample of 68 care staff - nurses and nurse assistants - welfare staff members - activity counselors, hostesses, and living room caretakers - of two residential care facilities filled out a questionnaire. Staff attitudes regarding perceived person-centered care were measured with the Person-centered Care Assessment Tool (P-CAT). Staff attitudes regarding informal care provision were measured with the Attitudes Toward Families Checklist (AFC). Multiple linear regression analysis explored the association between variables age, work experience, education, and function (care or welfare). RESULTS: A higher age of staff was associated with a more negative attitude toward perceived person-centered care and informal care provision. Welfare staff had a more negative attitude toward the inclusion of informal caregivers than care staff. The perceived person-centered care provision of the care and welfare staff was both positive. Work experience and education were not associated with perceived person-centered care provision or informal care provision. CONCLUSION: This study is one of the first to provide insight into the association between staff characteristics and their attitude toward their perceived person-centered care provision and informal care provision. A higher age of both the care and welfare staff was associated with a more negative attitude toward their perceived person-centered care and informal care provision. Welfare staff had a less positive attitude toward informal care provision. Additionally, future studies, also observational studies and interview studies, are necessary to collect evidence on the reasons for negative attitudes of older staff members towards PCC and informal care giving, to be able to adequately target these reasons by implementing interventions that eliminate or reduce these negative attitudes.

Addressing safety risks in integrated care programs for older people living at home: a scoping review.

BACKGROUND: Many older people live at home, often with complex and chronic health and social care needs. Integrated care programs are increasingly being implemented as a way to better address these needs. To support older people living at home, it is also essential to maintain their safety. Integrated care programs have the potential to address a wide range of risks and problems that could undermine older people's ability to live independently at home. The aim of this scoping review is to provide insight into how integrated care programs address safety risks faced by older people living at home - an area that is rather underexplored. METHODS: Safety was conceptualised as preventing or reducing the risk of problems, associated with individual functioning and behaviour, social and physical environments, and health and social care management, which could undermine older people's ability to live independently at home. For this scoping review a systematic literature search was performed to identify papers describing integrated care programs where at least one intervention component addressed safety risks. Data were extracted on the programs' characteristics, safety risks addressed, and the activities and interventions used to address them. RESULTS: None of the 11 programs included in this review explicitly mentioned safety in their goals. Nevertheless, following the principles of our conceptual framework, the programs appeared to address risks in multiple domains. Most attention was paid to risks related to older people's functioning, behaviour, and the health and social care they receive. Risks related to people's physical and social environments received less attention. CONCLUSION: Even though prevention of safety risks is not an explicit goal of integrated care programs, the programs address a wide range of risks on multiple domains. The need to address social and environmental risks is becoming increasingly important given the growing number of people receiving care and support at home. Prioritising a multidimensional approach to safety in integrated care programs could enhance the ability of health and social care systems to support older people to live safely at home.

Advancing integrated care evaluation in shifting contexts: blending implementation research with case study design in project SUSTAIN.

BACKGROUND: Despite many studies evaluating the effectiveness of integrated care, evidence remains inconsistent. There is increasing commentary pointing out the mismatch between the ability to capture the somewhat 'illusive' impact of integrated care initiatives and programmes, and the most appropriate way to do this. Focusing on methodology, this paper describes and critically reviews the experiences of SUSTAIN, a Horizon 2020 funded project (2015-2019) with the purpose of advancing knowledge and understanding of cross-European integrated care evaluation. SUSTAIN sought to improve integrated care initiatives for older people in seven countries, and to maximise the potential for knowledge transfer and application across Europe. The methods approach drew from implementation research, employing the participative Evidence Integration Triangle (EIT) and incorporating a mixed method, multiple embedded case study design. A core set of qualitative and quantitative indicators, alongside context and process data, were created and tested within four key project domains (person-centredness, prevention-orientation, safety and efficiency). The paper critically discusses the overall approach, highlighting the value of the EIT and case study design, and signalling the challenges of data collection with frail older people and stakeholder involvement at the sites, as well as difficulties developing the core set of indicators. CONCLUSIONS: Lessons learned and recommendations for advancing integrated care evaluation are put forward that focus on the status of integrated care as a complex intervention and a process. The use of implementation research methods and case study design are recommended as an additional evaluation approach for researchers to consider, alongside suggested ways of improving methods of data collection with frail populations and cost analysis.

How executives' expectations and experiences shape population health management strategies.

BACKGROUND: Within Population Health Management (PHM) initiatives, stakeholders from various sectors apply PHM strategies, via which services are reorganised and integrated in order to improve population health and quality of care while reducing cost growth. This study unravelled how stakeholders' expectations and prior experiences influenced stakeholders intended PHM strategies. METHODS: This study used realist principles. Nine Dutch PHM initiatives participated. Seventy stakeholders (mainly executive level) from seven different stakeholder groups (healthcare insurers, hospitals, primary care groups, municipalities, patient representative organisations, regional businesses and program managers of the PHM initiatives) were interviewed. Associations between expectations, prior experiences and intended strategies of the various stakeholder groups were identified through analyses of the interviews. RESULTS: Stakeholders' expectations, their underlying explanations and intended strategies could be categorized into four themes: 1. Regional collaboration; 2. Governance structures and stakeholder roles; 3. Regional learning environments, and 4. Financial and regulative conditions. Stakeholders agreed on the long-term expectations of PHM development. Differences in short- and middle-term expectations, and prior experiences were identified between stakeholder groups and within the stakeholder group healthcare insurers. These differences influenced stakeholders' intended strategies. For instance, healthcare insurers that intended to stay close to the business of care had encountered barriers in pushing PHM e.g. lack of data insight, and expected that staying in control of the purchasing process was the best way to achieve value for money. Healthcare insurers that were more keen to invest in experiments with data-technology, new forms of payment and accountability had encountered positive experiences in establishing regional responsibility and expected this to be a strong driver for establishing improvements in regional health and a vital and economic competitive region. CONCLUSION: This is the first study that revealed insight into the differences and similarities between stakeholder groups' expectations, experiences and intended strategies. These insights can be used to improve the pivotal cooperation within and between stakeholder groups for PHM.

Unraveling the drivers of regional variation in healthcare spending by analyzing prevalent chronic diseases.

BACKGROUND: To indicate inefficiencies in health systems, previous studies examined regional variation in healthcare spending by analyzing the entire population. As a result, population heterogeneity is taken into account to a limited extent only. Furthermore, it clouds a detailed interpretation which could be used to inform regional budget allocation decisions to improve quality of care of one chronic disease over another. Therefore, we aimed to gain insight into the drivers of regional variation in healthcare spending by studying prevalent chronic diseases. METHODS: We used 2012 secondary health survey data linked with claims data, healthcare supply data and demographics at the individual level for 18 Dutch regions. We studied patients with diabetes (n = 10,767) and depression (n = 3,735), in addition to the general population (n = 44,694). For all samples, we estimated the cross-sectional relationship between spending, supply and demand variables and region effects using linear mixed models. RESULTS: Regions with above (below) average spending for the general population mostly showed above (below) average spending for diabetes and depression as well. Less than 1% of the a-priori total variation in spending was attributed to the regions. For all samples, we found that individual-level demand variables explained 62-63% of the total variance. Self-reported health status was the most prominent predictor (28%) of healthcare spending. Supply variables also explained, although a small part, of regional variation in spending in the general population and depression. Demand variables explained nearly 100% of regional variation in spending for depression and 88% for diabetes, leaving 12% of the regional variation left unexplained indicating differences between regions due to inefficiencies. CONCLUSIONS: The extent to which regional variation in healthcare spending can be considered as inefficiency may differ between regions and disease-groups. Therefore, analyzing chronic diseases, in addition to the traditional approach where the general population is studied, provides more insight into the causes of regional variation in healthcare spending, and identifies potential areas for efficiency improvement and budget allocation decisions.

Harvesting the wisdom of the crowd: using online ratings to explore care experiences in regions.

BACKGROUND: Regional population health management (PHM) initiatives need an understanding of regional patient experiences to improve their services. Websites that gather patient ratings have become common and could be a helpful tool in this effort. Therefore, this study explores whether unsolicited online ratings can provide insight into (differences in) patient's experiences at a (regional) population level. METHODS: Unsolicited online ratings from the Dutch website Zorgkaart Nederland (year = 2008-2017) were used. Patients rated their care providers on six dimensions from 1 to 10 and these ratings were geographically aggregated based on nine PHM regions. Distributions were explored between regions. Multilevel analyses per provider category, which produced Intraclass Correlation Coefficients (ICC), were performed to determine clustering of ratings of providers located within regions. If ratings were clustered, then this would indicate that differences found between regions could be attributed to regional characteristics (e.g. demographics or regional policy). RESULTS: In the nine regions, 70,889 ratings covering 4100 care providers were available. Overall, average regional scores (range = 8.3-8.6) showed significant albeit small differences. Multilevel analyses indicated little clustering between unsolicited provider ratings within regions, as the regional level ICCs were low (ICC pioneer site < 0.01). At the provider level, all ICCs were above 0.11, which showed that ratings were clustered. CONCLUSIONS: Unsolicited online provider-based ratings are able to discern (small) differences between regions, similar to solicited data. However, these differences could not be attributed to the regional level, making unsolicited ratings not useful for overall regional policy evaluations. At the provider level, ratings can be used by regions to identify under-performing providers within their regions.

Shifting hospital care to primary care: An evaluation of cardiology care in a primary care setting in the Netherlands.

BACKGROUND: In an attempt to deal with the pressures on the healthcare system and to guarantee sustainability, changes are needed. This study is focused on a cardiology Primary Care Plus intervention in which cardiologists provide consultations with patients in a primary care setting in order to prevent unnecessary referrals to the hospital. This study explores which patients with non-acute and low-complexity cardiology-related health complaints should be excluded from Primary Care Plus and referred directly to specialist care in the hospital. METHODS: This is a retrospective observational study based on quantitative data. Data collected between January 1 and December 31, 2015 were extracted from the electronic medical record system. Logistic regression analyses were used to select patient groups that should be excluded from referral to Primary Care Plus. RESULTS: In total, 1525 patients were included in the analyses. Results showed that male patients, older patients, those with the referral indication 'Stable Angina Pectoris' or 'Dyspnoea' and patients whose reason for referral was 'To confirm disease' or 'Screening of unclear pathology' had a significantly higher probability of being referred to hospital care after Primary Care Plus. CONCLUSIONS: To achieve efficiency one should exclude patient groups with a significantly higher probability of being referred to hospital care after Primary Care Plus. TRIAL REGISTRATION NUMBER: NTR6629 (Data registered: 25-08-2017) (registered retrospectively).

Does an in-house internist at a GP practice result in reduced referrals to hospital-based specialist care?

OBJECTIVE: Consistent evidence on the effects of specialist services in the primary care setting is lacking. Therefore, this study evaluated the effects of an in-house internist at a GP practice on the number of referrals to specialist care in the hospital setting. Additionally, the involved GPs and internist were asked to share their experiences with the intervention. DESIGN: A retrospective interrupted times series study. SETTING: Two multidisciplinary general practitioner (GP) practices. INTERVENTION: An internist provided in-house patient consultations in two GP practices and participated in the multidisciplinary meetings. SUBJECTS: The referral data extracted from the electronic medical record system of the GP practices, including all referral letters from the GPs to specialist care in the hospital setting. MAIN OUTCOME MEASURES: The number of referrals to internal medicine in the hospital setting. This study used an autoregressive integrated moving average model to estimate the effect of the intervention taking account of a time trend and autocorrelation among the observations, comparing the pre-intervention period with the intervention period. RESULTS: It was found that the referrals to internal medicine did not statistically significant decrease during the intervention period. CONCLUSIONS: This small explorative study did not find any clues to support that an in-house internist at a primary care setting results in a decrease of referrals to internal medicine in the hospital setting. Key Points An in-house internist at a primary care setting did not result in a significant decrease of referrals to specialist care in the hospital setting. The GPs and internist experience a learning-effect, i.e. an increase of knowledge about internal medicine issues.

Improving early detection initiatives: a qualitative study exploring perspectives of older people and professionals.

BACKGROUND: A wide range of initiatives on early detection and intervention have been developed to proactively identify problems related to health and wellbeing in (frail) older people, with the aim of supporting them to live independently for as long as possible. Nevertheless, it remains unclear what the best way is to design such initiatives and how older people's needs and preferences can be best addressed. This study aimed to address this gap in the literature by exploring: 1) older people's perspectives on health and living environment in relation to living independently at home; 2) older people's needs and preferences in relation to initiating and receiving care and support; and 3) professionals' views on what would be necessary to enable the alignment of early detection initiatives with older people's own needs and preferences. METHODS: In this qualitative study, we conducted semi-structured interviews with 36 older people and 19 professionals in proactive elderly care. Data were analysed using the framework analysis method. RESULTS: From the interviews with older people important themes in relation to health and living environment emerged, such as maintaining independence, appropriate housing, social relationships, a supporting network and a sense of purpose and autonomy. Older people preferred to remain self-sufficient, and they would rather not ask for help for psychological or social problems. However, the interviews also highlighted that they were not always able or willing to anticipate future needs, which can hinder early detection or early intervention. At the same time, professionals indicated that older people tend to over-estimate their self-reliance and therefore advocated for early detection and intervention, including social and psychological issues. CONCLUSION: Older people have a broad range of needs in different domains of life. Discrepancies exist between older people and professionals with regard to their views on timing and scope of early detection initiatives. This study aimed to reveal starting-points for better alignment between initiatives and older people's needs and preferences. Such starting points may support policy makers and care professionals involved in early detection initiatives to make more informed decisions.

Evaluating a Dutch cardiology primary care plus intervention on the Triple Aim outcomes: study design of a practice-based quantitative and qualitative research.

BACKGROUND: In an attempt to deal with the pressures on the health-care system and to guarantee sustainability, changes are needed. This study focuses on a cardiology primary care plus intervention. Primary care plus (PC+) is a new health-care delivery model focused on substitution of specialist care in the hospital setting with specialist care in the primary care setting. The intervention consists of a cardiology PC+ centre in which cardiologists, supported by other health-care professionals, provide consultations in a primary care setting. The PC+ centre aims to improve the health of the population and quality of care as experienced by patients, and reduce the number of referrals to hospital-based outpatient specialist care in order to reduce health-care costs. These aims reflect the Triple Aim principle. Hence, the objectives of the study are to evaluate the cardiology PC+ centre in terms of the Triple Aim outcomes and to evaluate the process of the introduction of PC+. METHODS/DESIGN: The study is a practice-based, quantitative study with a longitudinal observational design, and an additional qualitative study to supplement, interpret and improve the quantitative study. The study population of the quantitative part will consist of adult patients (≥18 years) with non-acute and low-complexity cardiology-related health complaints, who will be referred to the cardiology PC+ centre (intervention group) or hospital-based outpatient cardiology care (control group). All eligible patients will be asked to complete questionnaires at three different time points consisting of questions about their demographics, health status and experience of care. Additionally, quantitative data will be collected about health-care utilization and related health-care costs at the PC+ centre and the hospital. The qualitative part, consisting of semi-structured interviews, focus groups, and observations, is designed to evaluate the process as well as to amplify, clarify and explain quantitative results. CONCLUSIONS: This study will evaluate a cardiology PC+ centre using quantitative and supplementary qualitative methods. The findings of both sub-studies will fill a gap in knowledge about the effects of PC+ and in particular whether PC+ is able to pursue the Triple Aim outcomes. TRIAL REGISTRATION: NTR6629 (Data registered: 25-08-2017) (registered retrospectively).

The impact of comorbid chronic conditions on quality of life in type 2 diabetes patients.

OBJECTIVE: To study the prevalence, impact and dose-response relationship of comorbid chronic conditions on quality of life of type 2 diabetes patients. RESEARCH DESIGN AND METHODS: Cross-sectional data of 1676 type 2 diabetes patients, aged 31-96 years, and treated in primary care, were analyzed. Quality of life (QoL) was measured using the mental component summary (MCS) and the physical component summary (PCS) scores of the Short Form-12. Diagnosis of type 2 diabetes was obtained from medical records and comorbidities from self-reports. RESULTS: Only 361 (21.5%) of the patients reported no comorbidities. Diabetes patients with comorbidities showed significantly lower mean difference in PCS [-8.5; 95% confidence interval (CI) -9.8 to -7.3] and MCS scores (-1.9; 95% CI -3.0 to -0.9), compared to diabetes patients without. Additional adjustments did not substantially change these associations. Both MCS and PCS scores decrease significantly with the number of comorbid conditions, yet most pronounced regarding physical QoL. Comorbidities that reduced physical QoL most significantly were retinopathy, heart diseases, atherosclerosis in abdomen or legs, lung diseases, incontinence, back, neck and shoulder disorder, osteoarthritis and chronic rheumatoid arthritis, using the backwards stepwise regression procedure. CONCLUSION: Comorbidities are highly prevalent among type 2 diabetes patients and have a negative impact on the patient's QoL. A strong dose-response relationship between comorbidities and physical QoL was found. Reduced physical QoL is mainly determined by musculoskeletal and cardiovascular disorders.

Are low-value care measures up to the task? A systematic review of the literature.

BACKGROUND: Reducing low-value care is a core component of healthcare reforms in many Western countries. A comprehensive and sound set of low-value care measures is needed in order to monitor low-value care use in general and in provider-payer contracts. Our objective was to review the scientific literature on low-value care measurement, aiming to assess the scope and quality of current measures. METHODS: A systematic review was performed for the period 2010-2015. We assessed the scope of low-value care recommendations and measures by categorizing them according to the Classification of Health Care Functions. Additionally, we assessed the quality of the measures by 1) analysing their development process and the level of evidence underlying the measures, and 2) analysing the evidence regarding the validity of a selected subset of the measures. RESULTS: Our search yielded 292 potentially relevant articles. After screening, we selected 23 articles eligible for review. We obtained 115 low-value care measures, of which 87 were concentrated in the cure sector, 25 in prevention and 3 in long-term care. No measures were found in rehabilitative care and health promotion. We found 62 measures from articles that translated low-value care recommendations into measures, while 53 measures were previously developed by institutions as the National Quality Forum. Three measures were assigned the highest level of evidence, as they were underpinned by both guidelines and literature evidence. Our search yielded no information on coding/criterion validity and construct validity for the included measures. Despite this, most measures were already used in practice. CONCLUSION: This systematic review provides insight into the current state of low-value care measures. It shows that more attention is needed for the evidential underpinning and quality of these measures. Clear information about the level of evidence and validity helps to identify measures that truly represent low-value care and are sufficiently qualified to fulfil their aims through quality monitoring and in innovative payer-provider contracts. This will contribute to creating and maintaining the support of providers, payers, policy makers and citizens, who are all aiming to improve value in health care.

Initiatives on early detection and intervention to proactively identify health and social problems in older people: experiences from the Netherlands.

BACKGROUND: Over the last years, several initiatives on early detection and intervention have been put in place to proactively identify health and social problems in (frail) older people. An overview of the initiatives currently available in the Netherlands is lacking, and it is unknown whether they meet the preferences and needs of older people. Therefore, the objectives of this study were threefold: 1. To identify initiatives on early detection and intervention for older people in the Netherlands and compare their characteristics; 2. To explore the experiences of professionals with these initiatives; and 3. To explore to what extent existing initiatives meet the preferences and needs of older people. METHODS: We performed a qualitative descriptive study in which we conducted semi-structured interviews with seventeen experts in preventive elderly care and three group interviews with volunteer elderly advisors. Data were analysed using the framework analysis method. RESULTS: We identified eight categories of initiatives based on the setting (e.g. general practitioner practice, hospital, municipality) in which they were offered. Initiatives differed in their aims and target groups. The utilization of peers to identify problems and risks, as was done by some initiatives, was seen as a strength. Difficulties were experienced with identifying the target group that would benefit from proactive delivery of care and support most, and with addressing prevalent issues among older people (e.g. psychosocial issues, self-reliance issues). CONCLUSION: Although there is a broad array of initiatives available, there is a discrepancy between supply and demand. Current initiatives insufficiently address needs of (frail) older people. More insight is needed in "what should be done by whom, for which target group and at what moment", in order to improve current practice in preventive elderly care.

Peer support to decrease diabetes-related distress in patients with type 2 diabetes mellitus: design of a randomised controlled trial.

BACKGROUND: Many type 2 diabetes mellitus patients face difficulties self-managing their illness, which can lead to high levels of diabetes-related distress. Diabetes distress may be decreased by peer support, as peers understand and have dealt with similar problems, and can help motivate each other. A recent systematic review concluded that evidence of benefits of peer support in patients with type 2 diabetes mellitus is too inconsistent due to weak theoretical foundation of the interventions. This study describes the design of a trial evaluating the effectiveness of a group-based, peer support programme with a strong theoretical foundation on diabetes-related distress in type 2 diabetes patients. METHODS: This is a parallel group randomised controlled trial of a six session group-based peer support intervention, delivered by peer leaders and group psychotherapists, compared with one educational meeting on diabetes. At least 152 patients with a type 2 diabetes duration of three years or more and between 50 and 70 years of age, recruited via their general practitioner, will be randomised to receive the peer support intervention or one educational meeting. The intervention is developed in line with three key stages of research development of the Medical Research Council framework. The primary outcome measure for this study is diabetes-related distress. Secondary outcomes include self-management behaviour, well-being and health-related quality of life. Perceived social support is a process measure. Outcomes will be measured one month before, and 6, and 12 months after the intervention by means of self-reported questionnaires. Analysis will be on an intention-to-treat basis. DISCUSSION: This article contains a description of the design of a study that will investigate the effect of a group-based, peer support intervention on diabetes-related distress in type 2 diabetes patients. The intervention was developed in recognition of the limited evidence, and the importance of a theoretical foundation and its implementation. Findings will contribute to knowledge in the field of peer support and patient-important outcomes in type 2 diabetes patients. TRIAL REGISTRATION: Dutch Trial Registry: NTR3474.

Environmental interventions in low-SES neighbourhoods to promote healthy behaviour: enhancing and impeding factors.

BACKGROUND: Social and physical environments are important drivers of socioeconomic inequalities in health behaviour. Although many interventions aiming to improve such environments are being implemented in underprivileged neighbourhoods, implementation processes are rarely studied. Acquiring insight into successful implementation may improve future interventions. The present study aimed to investigate factors influencing the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of social and physical environmental interventions aimed at promoting healthy behaviour in underprivileged neighbourhoods in The Netherlands. METHODS: A large set of theory-based factors of successful implementation was assessed for 18 implemented interventions in three underprivileged neighbourhoods. Expert and target group panels scored the RE-AIM dimensions for each intervention. We analyzed the statistical significance of associations between theory-based factors and the actual RE-AIM in a statistical model, to identify factors associated with increased RE-AIM. RESULTS: Six factors were identified: effectiveness and implementation success were higher when the target group was involved in the planning process, whereas maintenance increased in the absence of competition with other projects. If the current situation was inventoried during intervention development, the effectiveness, adoption and implementation were higher. These dimensions were also higher when the target group was informed before implementation. Involvement of the target group during implementation resulted in higher reach, effectiveness and adoption. Finally, lack of intervention staff worsened the reach. DISCUSSION: This study contributes to the evidence base for effective implementation of environmental measures aimed at promoting healthy behaviours. In particular, interventions in which the target group was involved in the implementation process were associated with higher RE-AIM outcomes.

Resource use and costs of type 2 diabetes patients receiving managed or protocolized primary care: a controlled clinical trial.

BACKGROUND: The increasing prevalence of diabetes is associated with increased health care use and costs. Innovations to improve the quality of care, manage the increasing demand for health care and control the growth of health care costs are needed. The aim of this study is to evaluate the care process and costs of managed, protocolized and usual care for type 2 diabetes patients from a societal perspective. METHODS: In two distinct regions of the Netherlands, both managed and protocolized diabetes care were implemented. Managed care was characterized by centralized organization, coordination, responsibility and centralized annual assessment. Protocolized care had a partly centralized organizational structure. Usual care was characterized by a decentralized organizational structure. Using a quasi-experimental control group pretest-posttest design, the care process (guideline adherence) and costs were compared between managed (n = 253), protocolized (n = 197), and usual care (n = 333). We made a distinction between direct health care costs, direct non-health care costs and indirect costs. Multivariate regression models were used to estimate differences in costs adjusted for confounding factors. Because of the skewed distribution of the costs, bootstrapping methods (5000 replications) with a bias-corrected and accelerated approach were used to estimate 95% confidence intervals (CI) around the differences in costs. RESULTS: Compared to usual and protocolized care, in managed care more patients were treated according to diabetes guidelines. Secondary health care use was higher in patients under usual care compared to managed and protocolized care. Compared to usual care, direct costs were significantly lower in managed care (€-1.181 (95% CI: -2.597 to -334)) while indirect costs were higher (€ 758 (95% CI: -353 to 2.701), although not significant. Direct, indirect and total costs were lower in protocolized care compared to usual care (though not significantly). CONCLUSIONS: Compared to usual care, managed care was significantly associated with better process in terms of diabetes care, fewer secondary care consultations and lower health care costs. The same trends were seen for protocolized care, however they were not statistically significant. TRIAL REGISTRATION: Current Controlled trials: ISRCTN66124817.

Multimorbidity of chronic diseases and health care utilization in general practice.

BACKGROUND: Multimorbidity is common among ageing populations and it affects the demand for health services. The objective of this study was to examine the relationship between multimorbidity (i.e. the number of diseases and specific combinations of diseases) and the use of general practice services in the Dutch population of 55 years and older. METHODS: Data on diagnosed chronic diseases, contacts (including face-to-face consultations, phone contacts, and home visits), drug prescription rates, and referral rates to specialised care were derived from the Netherlands Information Network of General Practice (LINH), limited to patients whose data were available from 2006 to 2008 (N=32,583). Multimorbidity was defined as having two or more out of 28 chronic diseases. Multilevel analyses adjusted for age, gender, and clustering of patients in general practices were used to assess the association between multimorbidity and service utilization in 2008. RESULTS: Patients diagnosed with multiple chronic diseases had on average 18.3 contacts (95% CI 16.8 19.9) per year. This was significantly higher than patients with one chronic disease (11.7 contacts (10.8 12.6)) or without any (6.1 contacts (5.6 6.6)). A higher number of chronic diseases was associated with more contacts, more prescriptions, and more referrals to specialized care. However, the number of contacts per disease decreased with an increasing number of diseases; patients with a single disease had between 9 to 17 contacts a year and patients with five or more diseases had 5 or 6 contacts per disease per year. Contact rates for specific combinations of diseases were lower than what would be expected on the basis of contact rates of the separate diseases. CONCLUSION: Multimorbidity is associated with increased health care utilization in general practice, yet the increase declines per additional disease. Still, with the expected rise in multimorbidity in the coming decades more extensive health resources are required.

Associations among health literacy, diabetes knowledge, and self-management behavior in adults with diabetes: results of a dutch cross-sectional study.

Various studies have examined the association between health literacy and self-management behavior, but few have explored ways through which this occurs. The present study examines to what extent health literacy is associated with diabetes self-management behavior and to what extent diabetes knowledge is a mechanism in this association. The study was based on cross-sectional data retrieved from patient registrations and questionnaires completed in 2010. The sample included 1,714 predominantly type 2 diabetes patients, with a mean age of 67 years. Diabetes self-management was indicated by HbA1c level, glucose self-control and self-reported monitoring of glucose levels, physical activity, and smoking. Multilevel analyses were applied based on multiple imputed data. Lower health literacy was significantly associated with less diabetes knowledge, higher HbA1c level, less self-control of glucose level, and less physical activity. Participants with more diabetes knowledge were less likely to smoke and more likely to control glucose levels. Diabetes knowledge was a mediator in the association between health literacy and glucose self-control and between health literacy and smoking. This study indicates that higher health literacy may contribute to participation in certain self-management activities, in some cases through diabetes knowledge. Diabetes knowledge and health literacy skills may be important targets for interventions promoting diabetes self-management.

Tracking the Development of Community Engagement Over Time: Realist Qualitative Study.

BACKGROUND: A growing interest in engaging communities in the development of health care services and communities has not automatically led to progress or consensus as to how to engage communities successfully, despite the evidence base showing how to leverage enablers and alleviate barriers. OBJECTIVE: To bridge the gap between the evidence base and which community engagement (CE) approaches have actually been applied in practice over time, this study aims to investigate how CE approaches have changed over the past 4 years in 6 different regions in the Netherlands and citizens' and professionals' experiences underlying these changes. METHODS: For the last stage of a multiple case study following the development of CE approaches in 6 different regions in the Netherlands, a realist qualitative case study was conducted. To investigate how CE approaches had changed over the past 4 years, data from the entire 4 years of the study were used, including documents, interview transcripts, and observations. To examine citizens' and professionals' experiences underlying these changes, new interviews were conducted. The latest interview results were discussed with a panel to ensure the results had face validity. RESULTS: The regions had implemented different types of CE approaches over the past 4 years and were adapting these approaches over time. Many of the (remaining) approaches may be operating on a smaller scale. The study identified the following overarching themes along which CE had been adapted: fewer region-wide approaches and more community-focused approaches, more focus on building relationships with (already engaged) citizens and community-led initiatives, and more focus on practical and tangible health promotion and social cohesion activities and less focus on complex "abstract" programs. The study identified a further 4 overarching themes highlighting citizens' and professionals' experiences underlying these changes in the CE approaches: a lack of engagement environment, need for facilitative leadership from organizations, need for a clear and shared vision underscoring the importance of CE, and misalignment between citizens' and professionals' perspectives and motivations for CE. All participants had experienced the engagement environment as insufficient. To support CE, professionals experienced the need to develop and receive more facilitative leadership and to develop approaches better equipped to involve citizens in the decision-making process. Citizens experienced the need to better align citizens' and professionals' motivations and aims for CE approaches and to receive longer-term financial support for their community-led initiatives. CONCLUSIONS: This study suggests that CE has not yet been embedded within organizational cultures. This has arguably meant that the (remaining) CE approaches are operating on a smaller scale. To enable the further development of CE approaches, an investment in the engagement environment and a shared vision is required. Only then could CE within the regions move beyond the more seemingly smaller-scale CE approaches.