Client-centered flexible planning of home-based postpartum care: A randomized controlled trial on the quality of care.

BACKGROUND: Standardization of health systems often hinders client-centered care. This study investigates whether allowing more flexibility in the planning range of the Dutch home-based postpartum care service improves its quality of care, as innovative approach to client-centered care. METHODS: A randomized controlled trial was conducted (2017-2019), in which pregnant women who intended to breastfeed were assigned into two groups (1:1). The intervention group was allowed to receive care up to the 14th-day postpartum, instead of the first 8-10 consecutive days ("usual care"). Primary outcome measure was the proportion of newborns still receiving exclusively breastmilk on final caring day of the service. This so-called successful breastfeeding rate is currently used by the Dutch health sector to measure the quality of care. Secondary outcome measures were self-care experience, overall care experience, and exclusive breastfeeding duration rate. RESULTS: Based on data from 1275 participants, there was no difference in exclusive breastfeeding on final caring day (86,7% intervention group vs. 88,9% control group, RR: 1.03, 95% CI: 0.98-1.07). Both groups showed similar self-care experiences. Women in the intervention group had slightly poorer overall care experience and lower exclusive breastfeeding duration rates. CONCLUSIONS: This study found no effect on the quality of care when allowing more flexibility in the planning range of home-based postpartum care. Women can, therefore, be offered more flexibility to suit them. Given the confusion in interpreting the sector's current main quality indicator, we call for an inclusive dialogue on how to best measure the quality of home-based postpartum care.

The identification of genetic pathways involved in vascular adaptations after physical deconditioning versus exercise training in humans.

Physical inactivity and exercise training result in opposite adaptations of vascular structure. However, the molecular mechanisms behind these adaptations are not completely understood. We used a unique study design to examine both vascular characteristics of the superficial femoral artery (using ultrasound) and gene expression levels (from a muscle biopsy) in human models for physical deconditioning and exercise training. Initially, we compared able-bodied control subjects (n = 6) with spinal cord-injured individuals (n = 8) to assess the effects of long-term deconditioning. Subsequently, able-bodied control subjects underwent short-term lower limb deconditioning using 3 weeks of unilateral limb suspension. Spinal cord-injured individuals were examined before and after 6 weeks of functional electrical stimulation exercise training. Baseline femoral artery diameter and hyperaemic flow were lower after short- and long-term deconditioning and higher after exercise training, whilst intima-media thickness/lumen ratio was increased with short- and long-term deconditioning and decreased with exercise training. Regarding gene expression levels of vasculature-related genes, we found that groups of genes including the vascular endothelial growth factor pathway, transforming growth factor ß1 and extracellular matrix proteins were strongly associated with vascular adaptations in humans. This approach resulted in the identification of important genes that may be involved in vascular adaptations after physical deconditioning and exercise.

Expression of genes involved in fatty acid transport and insulin signaling is altered by physical inactivity and exercise training in human skeletal muscle.

Physical deconditioning is associated with the development of chronic diseases, including type 2 diabetes and cardiovascular disease. Exercise training effectively counteracts these developments, but the underlying mechanisms are largely unknown. To gain more insight into these mechanisms, muscular gene expression levels were assessed after physical deconditioning and after exercise training of the lower limbs in humans by use of gene expression microarrays. To exclude systemic effects, we used human models for local physical inactivity (3 wk of unilateral limb suspension) and for local exercise training (6 wk of functional electrical stimulation exercise of the extremely deconditioned legs of individuals with a spinal cord injury). The most interesting subset of genes, those downregulated after deconditioning as well as upregulated after exercise training, contained 18 genes related to both the "insulin action" and "adipocytokine signaling" pathway. Of these genes, the three with strongest up/downregulation were the muscular fatty acid-binding protein-3 (FABP3), the fatty acid oxidizing enzyme hydroxyacyl-CoA dehydrogenase (HADH), and the mitochondrial fatty acid transporter solute carrier 25 family member A20 (SLC25A20). The expression levels of these genes were confirmed using RT-qPCR. The results of the present study indicate an important role for a decreased transport and metabolism of fatty acids, which provides a link between physical activity levels and insulin signaling.

Mothers' experiences of client-centred flexible planning in home-based postpartum care: A promising tool to meet their diverse and dynamic needs.

OBJECTIVE: To explore mothers' perspectives and experiences when facilitating greater flexibility in the planning range of home-based postpartum care, as an innovative tool to more client-centred care. DESIGN: A qualitative study design with semi-structured in-depth interviews. SETTING: The study was executed in collaboration with a postpartum care organisation in the Netherlands. It was part of a larger research project that studied the health effects of a new way of planning home-based postpartum care. This so-called 'flexible planning' made spreading and pausing of care possible up to the 14th day postpartum instead of the standard care planning up to the 8th day postpartum. PARTICIPANTS: Mothers eligible to be interviewed for this study were participants of the larger research project who were allowed to plan their care according to the flexible planning. Twenty-one mothers were recruited through purposive sampling, of which ten were first-time mothers. FINDINGS: Mothers valued the flexible planning as the timing of care could be tailored to their personal preferences and contexts. Yet, two main challenges were found: 1. mothers experienced difficulties in communicating and translating their dynamic needs into a care planning and 2. they felt discomfort in assigning tasks to care workers. Besides, our findings showed that care workers' practical as well as their emotional support (i.e. 'doing' vs. 'being') are greatly important in responding to mothers' needs. KEY CONCLUSIONS: A flexible planning is a promising tool to facilitate more client-centred care in the postpartum care period. Yet, the hectic and overwhelming nature of the first few postpartum days can complicate the forward planning of care. In addition, not knowing what to expect from the postpartum care period and having a main focus on care workers 'doing' can lead to unclear and undesired working relations. IMPLICATIONS FOR PRACTICE: When planning care in practice, a dialogue should be held between care workers and parents in which both their fields of expertise are respected. Above all, our study elucidated that novel care innovations like ours need to be co-created directly from the start with all involved parties to truly be successful.

Effects of a Personal Health Record in Maternity Care: A Stepped-Wedge Trial.

To improve both the active involvement of pregnant women in their maternal health and multidisciplinary collaboration between maternal care professionals, we introduced a personal health record (PHR) in routine maternity care. We studied the effects of this intervention on the percentage of uncomplicated births, women's perspectives on quality of care, and the collaboration between health care professionals. We performed a stepped-wedge cluster randomized controlled trial with four clusters and 13 maternity health centers (community-based midwife practices and hospitals) in one collaborative area. In total, 7350 pregnant women and 220 health care professionals participated. Uncomplicated births accounted for 51.8% (95% CI 50.1-53.9%) of total births in the control group and 55.0% (CI 53.5-56.5%) of total births in the intervention group (p = 0.289). Estimated means revealed that the differences detected in the stepped-wedge study were due to time and not the intervention. Women's perspectives on quality of care and collaboration between health care professionals revealed no relevant differences between the control and intervention groups. The introduction of the PHR resulted in no significant effect on the chosen measures of quality of maternal care. The suggested positive effect in the raw data was a local trend which was less visible in the national database, and thus might be related to subtle changes toward an improved collaborative culture in the study region.

The unintended consequences of client-centred flexible planning in home-based postpartum care: a shift in care workers' tasks and responsibilities.

OBJECTIVE: To explore care workers' experiences with a flexible planning of home-based postpartum care as an innovative instrument to facilitate more client-centred care. DESIGN: A mixed-methods design with a primarily qualitative approach followed by a quantitative follow-up, according to the Priority-Sequence model. SETTING: This study is part of a larger research project researching the health effects of a flexible planning in postpartum care. The new planning enables clients and care workers to spread and/or pause the care over 14 days postpartum instead of the standard planning of eight to ten consecutive days. PARTICIPANTS: Maternity home care workers who provide care according the flexible planning. Eight care workers were interviewed, another eight care workers participated in the focus group discussion, and 59 care workers filled in the survey. FINDINGS: Two main unintended consequences of the flexible planning were found: 1. care workers experienced an undesirable 'shift in their tasks' along the course of the postpartum period and 2. were heavily worried about 'making enough contracted hours'. Consequently, care workers unwillingly performed much more domiciliary activities compared to the standard planning, especially during the final days of care. KEY CONCLUSIONS: The predominant nursing tasks and responsibilities of care workers appeared insufficient to respond to clients' altering needs. In addition, shorter working days and on-call duties caused an undesired excessive high-level of flexibility among care workers. Consequently, care was paradoxically determined by organisational structures rather than clients' individual needs. IMPLICATIONS FOR PRACTICE: Our study elucidated that co-creation together with health professionals is a prerequisite for successfully implementing innovations as their way of working and personal lives are profoundly affected.

Effect of functional electrostimulation on impaired skin vasodilator responses to local heating in spinal cord injury.

Spinal cord injury (SCI) induces vascular adaptations below the level of the lesion, such as impaired cutaneous vasodilation. However, the mechanisms underlying these differences are unclear. The aim of this study is to examine arm and leg cutaneous vascular conductance (CVC) responses to local heating in 17 able-bodied controls (39 +/- 13 yr) and 18 SCI subjects (42 +/- 8 yr). SCI subjects were counterbalanced for functional electrostimulation (FES) cycling exercise (SCI-EX, n = 9) or control (SCI-C, n = 9) and reanalyzed after 8 wk. Arm and leg skin blood flow were measured by laser-Doppler flowmetry during local heating (42 degrees C), resulting in an axon-reflex mediated first peak, nadir, and a primarily nitric oxide-dependent plateau phase. Data were expressed as a percentage of maximal CVC (44 degrees C). CVC responses to local heating in the paralyzed leg, but also in the forearm of SCI subjects, were lower than in able-bodied controls (P < 0.05 and 0.01, respectively). The 8-wk intervention did not change forearm and leg CVC responses to local heating in SCI-C and SCI-EX, but increased femoral artery diameter in SCI-EX (P < 0.05). Interestingly, findings in skin microvessels contrast with conduit arteries, where physical (in)activity contributes to adaptations in SCI. The lower CVC responses in the paralyzed legs might suggest a role for inactivity in SCI, but the presence of impaired CVC responses in the normally active forearm suggests other mechanisms. This is supported by a lack of adaptation in skin microcirculation after FES cycle training. This might relate to the less frequent and smaller magnitude of skin blood flow responses to heat stimuli, compared with controls, than physical inactivity per se.

Evaluation of the subjective effect of middle ear implantation in hearing-impaired patients with severe external otitis.

The subjective benefit of middle ear implantation was studied in a group of 23 hearing-impaired patients who could not use conventional hearing aids owing to severe chronic external otitis. Changes in hearing disability (Abbreviated Profile of Hearing Aid Benefit [APHAB]) and changes in quality of life (Glasgow Benefit Inventory [GBI]) were determined. Mean benefit value on the APHAB for the subscale Ease of Communication was close to the mean reference value for conventional hearing aids. For the subscales Reverberation and Background Noise, a poorer result was found. Individual analysis of the APHAB scores showed significant benefit in 12 out of the 23 patients. According to the GBI, 16 out of 17 patients reported that middle ear implantation had made a positive impact on their quality of life. It is concluded that middle ear implantation has a positive effect on hearing difficulties and quality of life in hearing-impaired subjects who cannot use conventional devices. The APHAB outcomes were not better than those reported for conventional devices.

Use of social network analysis in maternity care to identify the profession most suited for case manager role.

OBJECTIVE: To improve Dutch maternity care, professionals start working in interdisciplinary patient-centred networks, which includes the patients as a member. The introduction of the case manager is expected to work positively on both the individual and the network level. However, case management is new in Dutch maternity care. The present study aims to define the profession that would be most suitable to fulfil the role of case manager. DESIGN: The maternal care network in the Nijmegen region was determined by using Social Network Analysis (SNA). SNA is a quantitative methodology that measures and analyses patient-related connections between different professionals working in a network. To identify the case manager we focused on the position, reach, and connections in the network of the maternal care professionals. SETTING: Maternity healthcare professionals in a single region of the Netherlands with an average of 4,500 births/year. PARTICIPANTS: The participants were 214 individual healthcare workers from eight different professions. MEASUREMENTS AND FINDINGS: The total network showed 3948 connections between 214 maternity healthcare professionals with a density of 0.08. Each profession had some central individuals in the network. The 52 community-based midwives were responsible for 51% of all measured connections. The youth health doctors and nurses were mostly situated on the periphery and less connected. The betweenness centrality had the highest score in obstetricians and community-based midwives. Only the community-based midwives had connections with all other groups of professions. Almost all professionals in the network could reach other professionals in two steps.

Shared agenda making for quality improvement; towards more synergy in maternity care.

OBJECTIVES: Professionals in maternity care have started working in a network approach. To further enhance the efficacy of this multidisciplinary maternity network, the identification of priorities for improvement is warranted. The aim of this study was to create key recommendations for the improvement agenda, in co-production with patients and professionals. STUDY DESIGN: We conducted a Delphi study to inventory (round 1), prioritize (round 2) and eventually approve (round 3) the improvement agenda for the maternity network. Both patients and professionals joined this study. Initial input for the study consisted of experiences from 397 patients, collected using the ReproQ questionnaire. In round 1, the expert panel, gave improvement recommendations, based on the ReproQ results. This resulted in 11 recommendations. In the second round, the expert panel prioritised these recommendations. In the consensus meeting then finally the concrete improvement agenda was composed. RESULTS: Priority scores differed considerably between patients and professionals in seven items, while four items received similar priority scores from both groups. The four most important improvement activities were: Realise more single bedrooms in hospitals; Create more opportunities for the continued presence of the community midwife during labour; Initiate a digital patient record view system for the network with a view function for patients; and Introduce a case manager for pregnant woman. CONCLUSION: Based on patient experience and the active involvement of patients and professionals, we were able to compose the shared agenda for quality improvement in maternity care.

Estimated cost-effectiveness of active middle-ear implantation in hearing-impaired patients with severe external otitis.

OBJECTIVE: To determine the cost-effectiveness of middle-ear implantations in hearing-impaired patients with severe external otitis in the Netherlands. DESIGN: Cost-effectiveness analysis, using single-subject repeated measures of quality of life and total cost determinations. SETTING: Hospital based. Patients Moderately to severely sensorineurally hearing-impaired patients (n = 21) with severe chronic external otitis, eligible to receive a middle-ear implant. Main Outcome Measure Cost per quality-adjusted life-year (QALY), based on scores of the Medical Outcomes Study Short-Form Health()Survey (SF-36) generic quality of life questionnaire. Only direct costs were included in cost calculation of middle-ear implantation. RESULTS: Mean health utility gain was 0.046 (0.012-0.079) (P = .01) measured at the mental component of the SF-36. With a mean profitable time of 19.4 years and an overall cost of euro 14,354, minimal cost-effectiveness of middle-ear implantation was euro 16,085/QALY. CONCLUSION: Based on the cost per QALY, middle-ear implantation proved to be a cost-effective and justified health care intervention in the Netherlands.

Improving maternity care using a personal health record: study protocol for a stepped-wedge, randomised, controlled trial.

BACKGROUND: A personal health record (PHR) is an online application through which individuals can access, manage, and share their health information in a private, secure, and confidential environment. Personal health records empower patients, facilitate collaboration among healthcare professionals, and improve health outcomes. Given these anticipated positive effects, we want to implement a PHR, named MyPregn@ncy, in a Dutch maternity care setting and to evaluate its effects in routine care. This paper presents the study protocol. METHODS/DESIGN: The effects of implementing a PHR in maternity care on patients and professionals will be identified in a stepped-wedge, cluster-randomised, controlled trial. The study will be performed in the region of Nijmegen, a Dutch area with an average of 4,500 births a year and more than 230 healthcare professionals involved in maternity care. Data analyses will describe the effects of MyPregn@ncy on health outcomes in maternity care, quality of care from the patients' perspectives, and collaboration among healthcare professionals. Additionally, a process evaluation of the implementation of MyPregn@ncy will be performed. Data will be collected using data from the Dutch perinatal registry, questionnaires, interviews, and log data. DISCUSSION: The study is expected to yield new information about the effects, strengths, possibilities, and challenges to the implementation and usage of a PHR in routine maternal care settings. Results may lead to new insights and improvements in the quality of maternal and perinatal care. TRIAL REGISTRATION: Netherlands Trial Register: NTR4063.

Wikis to facilitate patient participation in developing information leaflets: first experiences.

OBJECTIVE: Although patients have gained a wealth of experienced based knowledge they are usually not involved in the development of patient information. We sought to determine the technical feasibility of wikis in generating dynamic patient information leaflets with participation from patients and healthcare professionals and identified barriers and facilitators for wiki use. METHODS: An open wiki for patients receiving intrauterine inseminations and a closed wiki for patients receiving in vitro fertilization at one Dutch university clinic were used. Feasibility was assessed by analyzing logging data, content and users' experiences and expectations. The latter were addressed by means of semi-structured interviews, which were also used to identify barriers and facilitators to wiki use. RESULTS: Both patients and professionals worked on the information simultaneously, not hindered by time or location restrictions. The open IUI wiki was visited by 2957 and the closed IVF wiki by 424 users. About 28 barriers and 14 facilitators for using the wiki were identified. CONCLUSION: Wikis are promising tools to improve patient participation in the creation of patient information. Future projects should aim to increase active use of wikis by testing interventions based on the wide spectrum of barriers and should evaluate the quality of the content produced.

Do infertile women and their partners have equal experiences with fertility care?

OBJECTIVE: To study the possible differences between women and their partners' experiences with patient-centered fertility care. DESIGN: A cross-sectional study. SETTING: Thirty-two Dutch fertility clinics. PATIENT(S): A total of 1,620 infertile women and their partners, under treatment in one of the participating clinics, were randomly selected to participate in this study. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Level of patient-centeredness, measured with the validated Patient-Centeredness Questionnaire-Infertility questionnaire (PCQ-Infertility). RESULT(S): Questionnaires from 696 women and 520 partners were analyzed. No significant difference in PCQ-Infertility total score was found between women and their partners. The partners scored significantly higher on the subscales "respect for patients values" and "staff's competence" compared with the women. CONCLUSION(S): Patients' experiences with fertility care are only slightly different between women and their partners. This can be valuable in the process of improvement of patient-centered fertility care, one of the core dimensions of quality of care.

Improving patient-centeredness of fertility care using a multifaceted approach: study protocol for a randomized controlled trial.

BACKGROUND: Beside traditional outcomes of safety and (cost-)effectiveness, the Institute of Medicine states patient-centeredness as an independent outcome indicator to evaluate the quality of healthcare. Providing patient-centered care is important because patients want to be heard for their ideas and concerns. Healthcare areas associated with high emotions and intensive treatment periods could especially benefit from patient-centered care. How care can become optimally improved in patient-centeredness is unknown. Therefore, we will conduct a study in the context of Dutch fertility care to determine the effects of a multifaceted approach on patient-centeredness, patients' quality of life (QoL) and levels of distress. Our aims are to investigate the effectiveness of a multifaceted approach and to identify determinants of a change in the level of patient-centeredness, patients' QoL and distress levels. This paper presents the study protocol. METHODS/DESIGN: In a cluster-randomized trial in 32 Dutch fertility clinics the effects of a multifaceted approach will be determined on the level of patient-centeredness (Patient-centredness Questionnaire - Infertility), patients' QoL (FertiQoL) and levels of distress (SCREENIVF). The multifaceted approach includes audit and feedback, educational outreach visits and patient-mediated interventions. Potential determinants of a change in patient-centeredness, patients' QoL and levels of distress will be collected by an addendum to the patients' questionnaire and a professionals' questionnaire. The latter includes the Organizational Culture Assessment Instrument about the clinic's culture as a possible determinant of an increase in patient-centered care. DISCUSSION: The study is expected to yield important new evidence about the effects of a multifaceted approach on levels of patient-centeredness, patients' QoL and distress in fertility care. Furthermore, determinants associated with a change in these outcome measures will be studied. With knowledge of these results, patient-centered care and thus the quality of healthcare can be improved. Moreover, the results of this study could be useful for similar initiatives to improve the quality of care delivery. The results of this project are expected at the end of 2013. TRIAL REGISTRATION: Clinicialtrials.gov NCT01481064.

Impact of bed rest on conduit artery remodeling: effect of exercise countermeasures.

Physical inactivity is a potent stimulus for vascular remodeling, leading to a marked decrease in conduit artery diameter. However, little is known about the impact of physical inactivity on artery wall thickness or wall:lumen ratio or the potential of exercise countermeasures to modify artery wall thickness. The purpose of the study was to examine the impact of 60 days of bed rest, with or without exercise countermeasures, on carotid and superficial femoral artery wall thickness. Eighteen men were assigned to bed rest (second Berlin Bed Rest Study) and randomly allocated to control, resistive exercise, or resistive vibration exercise. Both exercise countermeasures were applied 3 times per week while the subjects were in the supine position on the bed. Sonography was used to examine baseline diameter and wall thickness of the carotid and femoral arteries. Bed rest decreased diameter of the superficial femoral artery (P=0.001) but not the carotid artery (P=0.29). Bed rest induced a significant increase in carotid and superficial femoral artery wall thickness (P=0.007 and 0.03) and wall:lumen ratio (P=0.009 and 0.001). Exercise prevented the increase in wall thickness of the carotid artery. In addition, exercise partly prevented the increased wall:lumen ratio in the superficial femoral artery. In conclusion, 8 weeks of bed rest resulted in approximately 20% increase in conduit artery wall thickness. Exercise countermeasures completely (carotid artery) or partly (superficial femoral artery) abolished the increase in wall thickness. These findings suggest that conduit artery wall thickness, a vascular characteristic associated previously with atherosclerosis, can rapidly adapt to physical inactivity and exercise in humans.

Resistive exercise versus resistive vibration exercise to counteract vascular adaptations to bed rest.

Bed rest results in marked vascular adaptations, and resistive vibration exercise (RVE) has been shown to be an effective countermeasure. As vibration exercise has practical and logistical limitations, the use of resistive exercise (RES) alone has the preference under specific circumstances. However, it is unknown if RES is sufficient to prevent vascular adaptations to bed rest. Therefore, the purpose of the present study was to examine the impact of RES and RVE on the vascular function and structure of the superficial femoral artery in young men exposed to 60 days of bed rest. Eighteen healthy men (age: 31 +/- 8 yr) were assigned to bed rest and randomly allocated to control, RES, or RVE groups. Exercise was applied 3 times/wk for 5-7 min/session. Resting diameter, blood flow, flow-mediated dilation (FMD), and dilator capacity of the superficial femoral artery were measured using echo-Doppler ultrasound. Bed rest decreased superficial femoral artery diameter and dilator capacity (P < 0.001), which were significantly attenuated in the RVE group (P < 0.01 and P < 0.05, respectively) but not in the RES group (P = 0.202 and P = 0.696, respectively). Bed rest significantly increased FMD (P < 0.001), an effect that was abolished by RVE (P < 0.005) but not RES (P = 0.078). Resting and hyperemic blood flow did not change in any of the groups. Thus, RVE abolished the marked increase in FMD and decrease in baseline diameter and dilator capacity normally associated with prolonged bed rest. However, the stimulus provided by RES alone was insufficient to counteract the vascular adaptations to bed rest.

The effect of bed rest and an exercise countermeasure on leg venous function.

This study was performed to assess the effect of resistive vibration exercise during bed rest deconditioning on venous vascular dimension and function, as measured with ultrasound in the popliteal vein. Sixteen men were assigned to bed rest (BR-Ctrl) or bed rest with resistive vibration exercise (BR-RVE). Before and at 25 and 52 days of bed rest, popliteal vein diameter was measured at increasing cuff pressures. Venous capacitance and compliance were calculated from the pressure-volume curve. After 52 days of bed rest, BR-Ctrl showed no change in baseline popliteal vein diameter or compliance, while venous capacitance decreased. Resistive vibration exercise had no effect on the response in venous diameter, capacitance or compliance to 52 days of bed rest. The decline in venous capacitance due to long-term bed rest is not effectively counteracted by resistive vibration exercise, indicating that an alternative factor during bed rest deconditioning is responsible for venous changes.