Quality and safety of care provided by emergency care practitioners.

BACKGROUND: The emergency care practitioner (ECP) role in the UK health service involves paramedic and nurse practitioners with advanced training to assess and treat minor illness and injury. Available evidence suggests that the introduction of this role has been advantageous in terms of managing an increased demand for emergency care, but there is little evidence regarding the quality and safety implications of ECP schemes. OBJECTIVES: The objectives were to compare the quality and safety of care provided by ECPs with non-ECP (eg, paramedic, nurse practitioner) care across three different types of emergency care settings: static services (emergency department, walk-in-centre, minor injury unit); ambulance/care home services (mobile); primary care out of hours services. METHODS: A retrospective patient case note review was conducted to compare the quality and safety of care provided by ECPs and non-ECPs across matched sites in three types of emergency care settings. Retrospective assessment of care provided was conducted by experienced clinicians. The study was part of a larger trial evaluating ECP schemes (http://www.controlled-trials.com/ISRCTN22085282). RESULTS: Care provided by ECPs was rated significantly higher than that of non-ECPs across some aspects of care. The differences detected, although statistically significant, are small and may not reflect clinical significance. On other aspects of care, ECPs were rated as equal to their non-ECP counterparts. CONCLUSIONS: As a minimum, care provided should meet the standards of existing service models and the findings from the study suggest that this is true of ECPs regardless of the service they are operational in.

The breadth of primary care: a systematic literature review of its core dimensions.

BACKGROUND: Even though there is general agreement that primary care is the linchpin of effective health care delivery, to date no efforts have been made to systematically review the scientific evidence supporting this supposition. The aim of this study was to examine the breadth of primary care by identifying its core dimensions and to assess the evidence for their interrelations and their relevance to outcomes at (primary) health system level. METHODS: A systematic review of the primary care literature was carried out, restricted to English language journals reporting original research or systematic reviews. Studies published between 2003 and July 2008 were searched in MEDLINE, Embase, Cochrane Library, CINAHL, King's Fund Database, IDEAS Database, and EconLit. RESULTS: Eighty-five studies were identified. This review was able to provide insight in the complexity of primary care as a multidimensional system, by identifying ten core dimensions that constitute a primary care system. The structure of a primary care system consists of three dimensions: 1. governance; 2. economic conditions; and 3. workforce development. The primary care process is determined by four dimensions: 4. access; 5. continuity of care; 6. coordination of care; and 7. comprehensiveness of care. The outcome of a primary care system includes three dimensions: 8. quality of care; 9. efficiency care; and 10. equity in health. There is a considerable evidence base showing that primary care contributes through its dimensions to overall health system performance and health. CONCLUSIONS: A primary care system can be defined and approached as a multidimensional system contributing to overall health system performance and health.

The European primary care monitor: structure, process and outcome indicators.

BACKGROUND: Scientific research has provided evidence on benefits of well developed primary care systems. The relevance of some of this research for the European situation is limited.There is currently a lack of up to date comprehensive and comparable information on variation in development of primary care, and a lack of knowledge of structures and strategies conducive to strengthening primary care in Europe. The EC funded project Primary Health Care Activity Monitor for Europe (PHAMEU) aims to fill this gap by developing a Primary Care Monitoring System (PC Monitor) for application in 31 European countries. This article describes the development of the indicators of the PC Monitor, which will make it possible to create an alternative model for holistic analyses of primary care. METHODS: A systematic review of the primary care literature published between 2003 and July 2008 was carried out. This resulted in an overview of: (1) the dimensions of primary care and their relevance to outcomes at (primary) health system level; (2) essential features per dimension; (3) applied indicators to measure the features of primary care dimensions. The indicators were evaluated by the project team against criteria of relevance, precision, flexibility, and discriminating power. The resulting indicator set was evaluated on its suitability for Europe-wide comparison of primary care systems by a panel of primary care experts from various European countries (representing a variety of primary care systems). RESULTS: The developed PC Monitor approaches primary care in Europe as a multidimensional concept. It describes the key dimensions of primary care systems at three levels: structure, process, and outcome level. On structure level, it includes indicators for governance, economic conditions, and workforce development. On process level, indicators describe access, comprehensiveness, continuity, and coordination of primary care services. On outcome level, indicators reflect the quality, and efficiency of primary care. CONCLUSIONS: A standardized instrument for describing and comparing primary care systems has been developed based on scientific evidence and consensus among an international panel of experts, which will be tested to all configurations of primary care in Europe, intended for producing comparable information. Widespread use of the instrument has the potential to improve the understanding of primary care delivery in different national contexts and thus to create opportunities for better decision making.

The systematic guideline review: method, rationale, and test on chronic heart failure.

BACKGROUND: Evidence-based guidelines have the potential to improve healthcare. However, their de-novo-development requires substantial resources -- especially for complex conditions, and adaptation may be biased by contextually influenced recommendations in source guidelines. In this paper we describe a new approach to guideline development -- the systematic guideline review method (SGR), and its application in the development of an evidence-based guideline for family physicians on chronic heart failure (CHF). METHODS: A systematic search for guidelines was carried out. Evidence-based guidelines on CHF management in adults in ambulatory care published in English or German between the years 2000 and 2004 were included. Guidelines on acute or right heart failure were excluded. Eligibility was assessed by two reviewers, methodological quality of selected guidelines was appraised using the AGREE instrument, and a framework of relevant clinical questions for diagnostics and treatment was derived. Data were extracted into evidence tables, systematically compared by means of a consistency analysis and synthesized in a preliminary draft. Most relevant primary sources were re-assessed to verify the cited evidence. Evidence and recommendations were summarized in a draft guideline. RESULTS: Of 16 included guidelines five were of good quality. A total of 35 recommendations were systematically compared: 25/35 were consistent, 9/35 inconsistent, and 1/35 un-rateable (derived from a single guideline). Of the 25 consistencies, 14 were based on consensus, seven on evidence and four differed in grading. Major inconsistencies were found in 3/9 of the inconsistent recommendations. We re-evaluated the evidence for 17 recommendations (evidence-based, differing evidence levels and minor inconsistencies) - the majority was congruent. Incongruity was found where the stated evidence could not be verified in the cited primary sources, or where the evaluation in the source guidelines focused on treatment benefits and underestimated the risks. The draft guideline was completed in 8.5 man-months. The main limitation to this study was the lack of a second reviewer. CONCLUSION: The systematic guideline review including framework development, consistency analysis and validation is an effective, valid, and resource saving-approach to the development of evidence-based guidelines.

Stakeholders' views of UK nurse and pharmacist supplementary prescribing.

OBJECTIVES: Supplementary prescribing (SP) by pharmacists and nurses in the UK represents a unique approach to improving patients' access to medicines and better utilizing health care professionals' skills. Study aims were to explore the views of stakeholders involved in SP policy, training and practice, focusing upon issues such as SP benefits, facilitators, challenges, safety and costs, thereby informing future practice and policy. METHOD: Qualitative, semi-structured interviews were conducted with 43 purposively sampled UK stakeholders, including pharmacist and nurse supplementary prescribers, doctors, patient groups representatives, academics and policy developers. Analysis of transcribed interviews was undertaken using a process of constant comparison and framework analysis, with coding of emergent themes. RESULTS: Stakeholders generally viewed SP positively and perceived benefits in terms of improved access to medicines and fewer delays, along with a range of facilitators and barriers to the implementation of this form of non-medical prescribing. Stakeholders' views on the economic impact of SP varied, but safety concerns were not considered significant. Future challenges and implications for policy included SP being potentially superseded by independent nurse and pharmacist prescribing, and the need to improve awareness of SP. Several potential tensions emerged including nurses' versus pharmacists' existing skills and training needs, supplementary versus independent prescribing, SP theory versus practice and prescribers versus non-prescribing peers. CONCLUSION: SP appeared to be broadly welcomed by stakeholders and was perceived to offer patient benefits. Several years after its introduction in the UK, stakeholders still perceived several implementation barriers and challenges and these, together with various tensions identified, might affect the success of supplementary and other forms of non-medical prescribing.

Modelling the expected net benefits of interventions to reduce the burden of medication errors.

OBJECTIVES: The aim of this study is to estimate the potential costs and benefits of three key interventions (computerized physician order entry [CPOE], additional ward pharmacists and bar coding) to help prioritize research to reduce medication errors. METHODS: A generic model structure was developed to describe the incidence and impacts of medication errors in hospitals. The model follows pathways from medication error points at alternative stages of the medication pathway through to the outcomes of undetected errors. The model was populated from a systematic review of the medication errors literature combined with novel probabilistic calibration methods. Cost ranges were applied to the interventions, the treatment of preventable adverse drug events (pADEs), and the value of the health lost as a result of an ADE. RESULTS: The model predicts annual health service costs of between pound 0.3 million and pound 1 million for the treatment of pADEs in a 400-bed acute hospital in the UK. Including only health service costs, it is uncertain whether any of the three interventions will produce positive net benefits, particularly if high intervention costs are assumed. When the monetary value of lost health is included, all three interventions have a high probability of producing positive net benefits with a mean estimate of around pound 31.5 million for CPOE over a five-year time horizon. CONCLUSIONS: The results identify the potential cost-effectiveness of interventions aimed at medication errors, as well as identifying key drivers of cost-effectiveness that should be specifically addressed in the design of primary evaluations of medication error interventions.

Nonmedical prescribing in the United kingdom: developments and stakeholder interests.

This article reflects upon the introduction of nonmedical prescribing in the United Kingdom and describes the historical developments within the National Health Service over the last 2 decades, together with an assessment of the impact of this prescribing for various stakeholders, drawing upon relevant research. We argue that a number of issues are associated with the introduction and development of nonmedical prescribing, including benefits to patients, the promise of increased autonomy for professions such as nursing and pharmacy, explicit and implicit government objectives, and threats to medical dominance and autonomy.

Nurse and pharmacist supplementary prescribing in the UK--a thematic review of the literature.

OBJECTIVES: Supplementary prescribing (SP) represents a recent development in non-medical prescribing in the UK, involving a tripartite agreement between independent medical prescriber, dependent prescriber and patient, enabling the dependent prescriber to prescribe in accordance with a patient-specific clinical management plan (CMP). The aim in this paper is to review, thematically, the literature on nurse and pharmacist SP, to inform further research, policy and education. METHODS: A review of the nursing and pharmacy SP literature from 1997 to 2007 was undertaken using searches of electronic databases, grey literature and journal hand searches. RESULTS: Nurses and pharmacists were positive about SP but the medical profession were more critical and lacked awareness/understanding, according to the identified literature. SP was identified in many clinical settings but implementation barriers emerged from the empirical and anecdotal literature, including funding problems, delays in practicing and obtaining prescription pads, encumbering clinical management plans and access to records. Empirical studies were often methodological weaknesses and under-evaluation of safety, economic analysis and patients' experiences were identified in empirical studies. There was a perception that nurse and pharmacist independent prescribing may supersede supplementary prescribing. CONCLUSIONS: There is a need for additional research regarding SP and despite nurses' and pharmacists' enthusiasm, implementation issues, medical apathy and independent prescribing potentially undermine the success of SP.

Learning to prescribe - pharmacists' experiences of supplementary prescribing training in England.

BACKGROUND: The introduction of non-medical prescribing for professions such as pharmacy and nursing in recent years offers additional responsibilities and opportunities but attendant training issues. In the UK and in contrast to some international models, becoming a non-medical prescriber involves the completion of an accredited training course offered by many higher education institutions, where the skills and knowledge necessary for prescribing are learnt. AIMS: to explore pharmacists' perceptions and experiences of learning to prescribe on supplementary prescribing (SP) courses, particularly in relation to inter-professional learning, course content and subsequent use of prescribing in practice. METHODS: A postal questionnaire survey was sent to all 808 SP registered pharmacists in England in April 2007, exploring demographic, training, prescribing, safety culture and general perceptions of SP. RESULTS: After one follow-up, 411 (51%) of pharmacists responded. 82% agreed SP training was useful, 58% agreed courses provided appropriate knowledge and 62% agreed that the necessary prescribing skills were gained. Clinical examination, consultation skills training and practical experience with doctors were valued highly; pharmacology training and some aspects of course delivery were criticised. Mixed views on inter-professional learning were reported - insights into other professions being valued but knowledge and skills differences considered problematic. 67% believed SP and recent independent prescribing (IP) should be taught together, with more diagnostic training wanted; few pharmacists trained in IP, but many were training or intending to train. There was no association between pharmacists' attitudes towards prescribing training and when they undertook training between 2004 and 2007 but earlier cohorts were more likely to be using supplementary prescribing in practice. CONCLUSION: Pharmacists appeared to value their SP training and suggested improvements that could inform future courses. The benefits of inter-professional learning, however, may conflict with providing profession-specific training. SP training may be perceived to be an instrumental 'stepping stone' in pharmacists' professional project of gaining full IP status.

Using a multi-method, user centred, prospective hazard analysis to assess care quality and patient safety in a care pathway.

BACKGROUND: Care pathways can be complex, often involving multiple care providers and as such are recognised as containing multiple opportunities for error. Prospective hazard analysis methods may be useful for evaluating care provided across primary and secondary care pathway boundaries. These methods take into account the views of users (staff and patients) when determining where potential hazards may lie. The aim of this study is to evaluate the feasibility of prospective hazard analysis methods when assessing quality and safety in care pathways that lie across primary and secondary care boundaries. METHODS: Development of a process map of the care pathway for patients entering into a Chronic Obstructive Pulmonary Disease (COPD) supported discharge programme. Triangulation of information from: care process mapping, semi-structured interviews with COPD patients, semi-structured interviews with COPD staff, two round modified Delphi study and review of prioritised quality and safety challenges by health care staff. RESULTS: Interview themes emerged under the headings of quality of care and patient safety. Quality and safety concerns were mostly raised in relation to communication, for example, communication with other hospital teams. The three highest ranked safety concerns from the modified Delphi review were: difficulties in accessing hospital records, information transfer to primary care and failure to communicate medication changes to primary care. CONCLUSION: This study has demonstrated the feasibility of using mixed methods to review the quality and safety of care in a care pathway. By using multiple research methods it was possible to get a clear picture of service quality variations and also to demonstrate which points in the care pathway had real potential for patient safety incidents or system failures to occur. By using these methods to analyse one condition specific care pathway it was possible to uncover a number of hospital level problems. A number of safety challenges were systems related; these were therefore difficult to improve at care team level. Study results were used by National Health Service (NHS) stakeholders to implement solutions to problems identified in the review.

How the philosophies, styles, and methods of family medicine affect the research agenda.

Family physicians provide person-centered, continuous, comprehensive care that is accessible and available at the time of need. Although this core philosophy is shared around the world, its translation into actual practice can vary greatly with time and from place to place as family physicians adapt to local constraints and conditions. Factors driving these local variations include entrenched habits and patterns of care, funding systems, patient expectations, public policy, and the availability and quality of other critical health system components. This diversity provides both an opportunity and a challenge for family medicine research. The potential for fruitful comparisons and contrasts arising from natural experiments may require investigators to use multiple research methods capable of evaluating complex interventions and comparisons. Family medicine has the capacity to be an excellent laboratory in which research in representative populations can offer the pragmatic answers needed by practicing physicians. The nature of the research questions and interventions require the involvement of clinicians in the formulation of research questions and evaluation of the applicability of research results. The variations in implementation of the family medicine philosophy can be a potential asset because of the research opportunities they provide.

Developing primary care review criteria from evidence-based guidelines: coronary heart disease as a model.

BACKGROUND: National Health Service (NHS) initiatives such as Clinical Governance, National Service Frameworks and the National Institute of Clinical Excellence (NICE) clinical guidelines programme create demand for tools to enable performance review by healthcare professionals. Ideally such tools should enable clinical teams to assess quality of care and highlight areas of good practice or where improvement is needed. They should also be able to be used to demonstrate progress towards goals and promote quality, while not unnecessarily increasing demand on limited resources or weakening professional control. AIM: To formulate and evaluate a method for developing, from clinical guidelines, evidence-based review criteria that are proritised, useful and relevant to general practices assessing quality of care for the primary care management of coronary heart disease (CHD). DESIGN OF STUDY: A two-stage study comprising, first, a review of available evidence-based guidelines for CHD and, second, the definition and prioritization of associated review criteria from the most highly rated guidelines. SETTING: Primary healthcare teams in England. METHODS: Using structured methods, evidence-based clinical guidelines for CHD were identified and appraised to ensure their suitability as the basis for developing review criteria. Recommendations common to a number of guidelines were priortszid by a panel of general practitioners to develop review criteria suitable for use in primary care. RESULTS: A standardised method has been developed for constructing evidence-based review criteria from clinical guidelines. A limited, prioritized set of review criteria was developed for the primary care management of CHD. This was distributed around the NHS through the Royal College of General Practitioners for use by primary care teams across the United Kingdom. CONCLUSION: Developing useful, evidence-based review criteria is not a straightforward process, partly because of a lack of consistency and clarity in guidelines currently available. A method was developed which accommodated these limitations and which can be applied to the development and evaluation of review criteria from guidelines for other conditions.

Managing care in the community for patients with type 2 diabetes.

Jean Peters and colleagues researched the perceptions of 97 practice nurses and 69 diabetes specialist nurses regarding their current and future role in the management of people with type 2 diabetes in the community. Issues of concern that were identified included patients, resources, training and professional responsibilities.

A structured judgement method to enhance mortality case note review: development and evaluation.

BACKGROUND: Case note review remains a prime means of retrospectively assessing quality of care. This study examines a new implicit judgement method, combining structured reviewer comments with quality of care scores, to assess care of people who die in hospital. METHODS: Using 1566 case notes from 20 English hospitals, 40 physicians each reviewed 30-40 case notes, writing structured judgement-based comments on care provided within three phases of care, and on care overall, and scoring quality of care from 1 (unsatisfactory) to 6 (very best care). Quality of care comments on 119 people who died (7.6% of the cohort) were analysed independently by two researchers to investigate how well reviewers provided structured short judgement notes on quality of care, together with appropriate care scores. Consistency between explanatory textual data and related scores was explored, using overall care score to group cases. RESULTS: Physician reviewers made informative, clinical judgement-based comments across all phases of care and usually provided a coherent quality of care score relating to each phase. The majority of comments (83%) were explicit judgements. About a fifth of patients were considered to have received less than satisfactory care, often experiencing a series of adverse events. CONCLUSIONS: A combination of implicit judgement, explicit explanatory comment and related quality of care scores can be used effectively to review the spectrum of care provided for people who die in hospital. The method can be used to quickly evaluate deaths so that lessons can be learned about both poor and high quality care.

The strength of primary care in Europe: an international comparative study.

BACKGROUND: A suitable definition of primary care to capture the variety of prevailing international organisation and service-delivery models is lacking. AIM: Evaluation of strength of primary care in Europe. DESIGN AND SETTING: International comparative cross-sectional study performed in 2009-2010, involving 27 EU member states, plus Iceland, Norway, Switzerland, and Turkey. METHOD: Outcome measures covered three dimensions of primary care structure: primary care governance, economic conditions of primary care, and primary care workforce development; and four dimensions of primary care service-delivery process: accessibility, comprehensiveness, continuity, and coordination of primary care. The primary care dimensions were operationalised by a total of 77 indicators for which data were collected in 31 countries. Data sources included national and international literature, governmental publications, statistical databases, and experts' consultations. RESULTS: Countries with relatively strong primary care are Belgium, Denmark, Estonia, Finland, Lithuania, the Netherlands, Portugal, Slovenia, Spain, and the UK. Countries either have many primary care policies and regulations in place, combined with good financial coverage and resources, and adequate primary care workforce conditions, or have consistently only few of these primary care structures in place. There is no correlation between the access, continuity, coordination, and comprehensiveness of primary care of countries. CONCLUSION: Variation is shown in the strength of primary care across Europe, indicating a discrepancy in the responsibility given to primary care in national and international policy initiatives and the needed investments in primary care to solve, for example, future shortages of workforce. Countries are consistent in their primary care focus on all important structure dimensions. Countries need to improve their primary care information infrastructure to facilitate primary care performance management.

Further challenges to medical dominance? The case of nurse and pharmacist supplementary prescribing.

Doctors have traditionally been viewed as the dominant healthcare profession, with the authority to prescribe medicines, but recent non-medical prescribing initiatives have been viewed as possible challenges to such dominance. Using the example of the introduction of supplementary prescribing in the UK, this study sought to explore whether such initiatives represent a challenge to medical authority. Ten case study sites in England involving primary and secondary care and a range of clinical areas were used to undertake a total of 77 observations of supplementary prescribing consultations and interviews with 28 patients, 11 doctors and nurse and pharmacist prescribers at each site. Supplementary prescribing was viewed positively by all participants but several doctors and patients appeared to lack awareness and understanding of supplementary prescribing. Continued medical authority was supported empirically in five areas: patients' and supplementary prescribers' perception of doctors as being hierarchically superior; doctors legitimation of nurses' and pharmacists' prescribing initially; doctors' belief that they could control (particularly nurses') access to prescribing training; supplementary prescribers' frequent recourse to use doctors' advice, coupled with doctors' encouragement of such 'knock on door' prescribing advice policies; doctors' denigration of most routine prescribing but claims that diagnosis was more skilled and key to medicine. Supplementary prescribing appeared to be successfully accomplished in practice in a range of clinical settings and was acceptable to all involved but did not ultimately challenge medical dominance. However, more recent nurse and pharmacist independent prescribing (involving diagnosis) may represent a more significant threat.

The National Programme for IT in England: clinicians' views on the impact of the Choose and Book service.

In England, the Choose and Book service, a main component of the England National Programme for IT (NPfIT), aims at empowering patients. Little research has been performed to evaluate clinicians' perceptions of, and satisfaction with, the Choose and Book service. The aim of the research was to examine clinicians' perceptions of, and satisfaction with, the Choose and Book service. A qualitative approach, using in-depth, semi-structured interviews, was used to collect data. Framework analysis was used to analyse the data. Twenty clinicians were interviewed, including 14 general practitioners (GPs) and six hospital consultants. Although clinicians were positive about the benefits of the Choose and Book service, they were concerned about the adverse impact of the electronic referral process on their job. Paying attention to the impact of the service on clinicians' jobs, at both ends of the process, could help to improve the referral process and the use of the system.

Организация первичной помощи в условиях меняющейся Европы

Для многих граждан первичное звено медико-санитарной помощи – это первая точка соприкосновения с системой медицинского обслуживания, где люди получают большую часть необходимой им помощи, но также могут быть направлены на другие уровни системы. Таким образом, первичное звено оказывает огромное влияние на то, как пациенты оценивают систему здравоохранения с точки зрения ее соответствия своим нуждам и ожиданиям. Авторы книги анализируют особенности организации и оказания первичной медико-санитарной помощи в странах Европейского региона с точки зрения руководства, финансирования, кадрового обеспечения и спектра услуг. В книге описаны особенности доступа к первичному звену и преемственности и координации его услуг в различных странах. Сопоставляя эти различия с конечными показателями здоровья населения, авторы предлагают приоритетные шаги для сокращения разрыва между идеальной системой и реальностью. Помимо этого, авторы проанализировали накопленные данные о дополнительных преимуществах, которые крепкое первичное звено дает для общей эффективности системы здравоохранения, а также то, как на первичное звено влияют финансовые трудности, новые угрозы для здоровья и структура заболеваемости, динамика кадровых ресурсов и новые возможности, которые открывает технологический прогресс. Во втором томе публикации, с которым можно ознакомиться в интернете, приводятся структурированные сводные обзоры состояния первичной медико-санитарной помощи в 31 стране Европейского региона. В них описан контекст, в котором работает первичное звено в каждой из этих стран; особенности стратегического руководства и экономическая ситуация; динамика в отношении кадровых ресурсов для первичного звена; специфика оказания первичной медико-санитарной помощи; качество и эффективность системы первичной медико-санитарной помощи. В основе настоящей публикации лежит проект "Мониторинг первичной медико-санитарной помощи в Европе" (PHAMEU), который проводился под руководством Нидерландского института исследований служб здравоохранения (NIVEL) на средства ЕС и Европейской комиссии (Генеральный директорат по здравоохранению и защите прав потребителей).

Building primary care in a changing Europe: case studies

This new volume consists of structured case studies summarizing the state of primary care in 31 European countries. It complements the previous study, Building primary care in a changing Europe, in which we provided an overview of the state of primary care across the continent, including aspects of governance, financing, workforce and details of service profiles. These case studies establish the context of primary care in each country; the key governance and economic conditions; the development of the primary care workforce; how primary care services are delivered; and an assessment of the quality and efficiency of the primary-care system. The studies exemplify the broad national variations in accessibility, continuity and coordination of primary care in Europe today, something which complicates the assessment of primary care's role in contributing to the overall performance of the health system despite growing evidence of the added value of a strong primary care sector. This book builds on the EU-funded project 'Primary Health Care Activity Monitor for Europe' (PHAMEU) that was led by the Netherlands Institute for Health Services Research (NIVEL) and co-funded by the European Commission (Directorate General Health & Consumers).