Quantifying reciprocal relationships between poverty and health: combining a causal loop diagram with longitudinal structural equation modelling.

BACKGROUND: This study takes on the challenge of quantifying a complex causal loop diagram describing how poverty and health affect each other, and does so using longitudinal data from The Netherlands. Furthermore, this paper elaborates on its methodological approach in order to facilitate replication and methodological advancement. METHODS: After adapting a causal loop diagram that was built by stakeholders, a longitudinal structural equation modelling approach was used. A cross-lagged panel model with nine endogenous variables, of which two latent variables, and three time-invariant exogenous variables was constructed. With this model, directional effects are estimated in a Granger-causal manner, using data from 2015 to 2019. Both the direct effects (with a one-year lag) and total effects over multiple (up to eight) years were calculated. Five sensitivity analyses were conducted. Two of these focus on lower-income and lower-wealth individuals. The other three each added one exogenous variable: work status, level of education, and home ownership. RESULTS: The effects of income and financial wealth on health are present, but are relatively weak for the overall population. Sensitivity analyses show that these effects are stronger for those with lower incomes or wealth. Physical capability does seem to have strong positive effects on both income and financial wealth. There are a number of other results as well, as the estimated models are extensive. Many of the estimated effects only become substantial after several years. CONCLUSIONS: Income and financial wealth appear to have limited effects on the health of the overall population of The Netherlands. However, there are indications that these effects may be stronger for individuals who are closer to the poverty threshold. Since the estimated effects of physical capability on income and financial wealth are more substantial, a broad recommendation would be that including physical capability in efforts that are aimed at improving income and financial wealth could be useful and effective. The methodological approach described in this paper could also be applied to other research settings or topics.

Two sides of the same coin? Absolute income and perceived income inadequacy as social determinants of health.

BACKGROUND: Absolute income is commonly used in studies of health inequalities, however it does not reflect spending patterns, debts, or expectations. These aspects are reflected in measures concerning perceived income inadequacy. While health inequities by absolute income or perceived income inadequacy are well established, few studies have explored the interplay of absolute income and perceived income inadequacy in relation to health. METHODS: Multiple data sources were linked into a nationally representative dataset (n = 445,748) of Dutch adults (18 +). The association between absolute income, perceived income inadequacy and health (self-reported health, chronic disease and psychological distress) was tested using logistic and Poisson regressions, controlling for various potential confounders (demographics, education) and mastery. Interactions were tested to check the association between perceived income inadequacy and health for different absolute income groups. RESULTS: Perceived income inadequacy was reported at every absolute income group (with 42% of individuals in the lowest income group and 5% of individuals in the highest income group). Both absolute income and perceived income inadequacy were independently associated with health. The adjusted relative risk (RR) for lowest absolute income group is 1.11 (1.08-1.1.14) and 1.28 (1.24-1.32) for chronic disease and self-reported health respectively, and the Odds Ratio (OR) for psychological distress is 1.28 (1.16-1.42). For perceived income inadequacy the RR's were 1.41 (1.37-1.46) and 1.49 (1.44-1.54) and the OR for psychological distress is 3.14 (2.81-3.51). Mastery appeared to be an important mediator for the relationship between perceived income inadequacy, poor self-rated health and psychological distress. CONCLUSIONS: Absolute income and perceived income inadequacy reflect conceptually different aspects of income and are independently associated with health outcomes. Perceived income inadequacy may be accounted for in health inequality studies, alongside measures of absolute income. In policy-making, targeting perceived income inadequacy might have potential to reduce health inequalities.

Use it or lose it? Identifying reasons for the low use of psychosocial support by hospital staff.

BACKGROUND: Psychosocial support programs are a way for hospitals to support the mental health of their staff. However, while support is needed, utilization of support by hospital staff remains low. This study aims to identify reasons for non-use and elements that are important to consider when offering psychosocial support. METHODS: This mixed-method, multiple case study used survey data and in-depth interviews to assess the extent of psychosocial support use, reasons for non-use and perceived important elements regarding the offering of psychosocial support among Dutch hospital staff. The study focused on a time of especially high need, namely the COVID-19 pandemic. Descriptive statistics were used to assess frequency of use among 1514 staff. The constant comparative method was used to analyze answers provided to two open-ended survey questions (n = 274 respondents) and in-depth interviews (n = 37 interviewees). RESULTS: The use of psychosocial support decreased from 8.4% in December 2020 to 3.6% by September 2021. We identified four main reasons for non-use of support: deeming support unnecessary, deeming support unsuitable, being unaware of the availability, or feeling undeserving of support. Furthermore, we uncovered four important elements: offer support structurally after the crisis, adjust support to diverse needs, ensure accessibility and awareness, and an active role for supervisors. CONCLUSIONS: Our results show that the low use of psychosocial support by hospital staff is shaped by individual, organizational, and support-specific factors. These factors can be targeted to increase use of psychosocial support, whereby it is important to also focus on the wider hospital workforce in addition to frontline staff.

Supporting professionals to implement integrated, person-centered care for people with chronic conditions: the TARGET pilot study.

OBJECTIVE: The TARGET program for integrated, person-centered care for people with chronic conditions offers primary care (PC) professionals a set of tools and trainings to actively engage in population segmentation and person-centered needs assessments (PCNAs). A pilot study was conducted to gain insight into the program's feasibility and acceptability, and identify preconditions for successful implementation. DESIGN AND SETTING: Seven Dutch PC practices participated in a half-year pilot study starting in August 2020. We performed a review of the population segmentation tool, observed four training sessions and 15 PCNAs, and interviewed 15 professionals and 12 patients. RESULTS: Regarding feasibility and acceptability, we found that the tools and trainings provided professionals with skills to use the segmentation tool and take a more coaching role in the well-appreciated PCNAs. Concerning implementation preconditions, we found that team commitment and network connections need improvement, although work pleasure increased and professionals generally wanted the program to continue. CONCLUSIONS: While the content of the TARGET program is supported by its users, the implementation process, for instance team commitment to the program, needs more attention in future upscaling efforts.

Key PointsTo implement integrated care in practice, primary care professionals (PCPs) need concrete tools, skills and confidence.PCPs consider the tools and trainings of the TARGET program as feasible and acceptable to organize integrated careTARGET's success depends on commitment from professionals to its implementation and the strength of ties with professionals in other domains.Based on qualitative insights, TARGET improves work pleasure and patient experience, but it takes time to decrease work pressure effectively.

Through the looking glass: Confronting health care management's biggest challenges in the wake of a crisis.

BACKGROUND: The challenges brought on by the pandemic triggered a renewed scholarly focus on managing during crises. Now, 3 years on, having covered the initial crisis response, it is important to reevaluate what the crisis has taught us about health care management more generally. In particular, it is useful to consider the persistent challenges that continue to face health care organizations in the wake of a crisis. PURPOSE: The present article aims to identify the biggest challenges that currently face health care managers in order to formulate a postcrisis research agenda. METHODOLOGY/APPROACH: We employ an exploratory qualitative study, utilizing in-depth interviews with hospital executives and management to explore the persistent challenges facing managers in practice. RESULTS: Our qualitative inquiry reveals three key challenges that extend beyond the crisis and are salient for health care managers and organizations in the years to come. Specifically, we identify the centrality of human resource constraints (amidst increasing demand), the necessity of collaboration (amidst competition), and a need to reconsider the approach to leadership (utility of humility). CONCLUSION: We conclude by drawing upon relevant theories such as paradox theory to formulate a research agenda for health care management scholars that can support the creation of novel solutions and approaches to persistent challenges in practice. PRACTICE IMPLICATIONS: We identify several implications for organizations and health systems, including the need to eliminate competition and the importance of building human resource management capacities within organizations. In highlighting areas for future research, we provide organizations and managers with useful and actionable insights to address their most persistent challenges in practice.

First Things First: How to Elicit the Initial Program Theory for a Realist Evaluation of Complex Integrated Care Programs.

Policy Points Realist evaluation (RE) is an emerging and promising research approach for evaluating integrated care, addressing what works, how, for whom, and in what circumstances. The rich philosophical foundation of RE, critical realism, can help to systematically unravel an integrated care program's initial theory prior to implementation, as a first step within RE. RE can be considered a robust methodological asset in integrated care research by facilitating a deeper level of insight into program functioning than traditional forms of evaluation do and by shaping a realist-informed monitoring and evaluation process. CONTEXT: The complexity of integrated care and the need for transferable evaluation insights ask for a suitable evaluation paradigm. Realist evaluation (RE), underpinned by the philosophy of critical realism, is a theory-driven approach that addresses what works, how, for whom, and in what circumstances. The current study illustrates the process needed for RE's first step: eliciting the initial program theory (IPT). The TARGET program, a Dutch primary care initiative to facilitate more integrated care for chronically ill patients, i.e., care that is efficient, tailored, and holistic,  was taken as a real-world case. METHODS: An RE approach informed the phased IPT elicitation: (1) identifying an abstract theory framework; (2) formulating the preliminary IPT, building on the abstract theory and informed by previous scientific studies that underpin TARGET; and (3) refining the preliminary IPT, informed by RE expert interviews (n = 7). An RE heuristic tool, specifying the interplay between intervention-context-actors-mechanisms-outcomes (ICAMO) and retroductive reasoning, was applied to synthesize the underlying theory of individual TARGET components into TARGET's IPT. FINDINGS: Separate but related IPTs were identified for the two main types of actors involved in TARGET: primary care professionals (PCPs) and patients. For both actors, two sorts of mechanisms are assumed to be activated by TARGET, which-via instrumental outcomes-contribute to long-term quadruple aim targets. The first is confidence to enhance PCPs' person-centered conversational skills and to increase patients' active engagement in TARGET. The second is mutual trust, between PCPs and patients and between PCPs and their network partners. A supportive context is assumed crucial for activating these mechanisms-for example, sufficient resources to invest in integrated care. CONCLUSIONS: Although the IPT elicitation process is time intensive and requires a mind shift, it facilitates a deeper insight into program functioning than accommodated by the prevailing experimental designs in integrated care. Furthermore, the design of a realist-informed evaluation process can be informed by the IPT.

Qualitative modelling of social determinants of health using group model building: the case of debt, poverty, and health.

BACKGROUND: Social determinants of health (SDoH) are known to have a large impact on health outcomes, but their effects are difficult to make visible. They are part of complex systems of variables largely indirect effects on multiple levels, constituting so-called wicked problems. This study describes a participatory approach using group model building (GMB) with stakeholders, in order to develop a qualitative causal model of the health effects of SDoH, taking poverty and debt in the Dutch city of Utrecht as a case study. METHODS: With GMB we utilised the perspective of stakeholders who are directly involved in policy and practice regarding poverty, debt, and/or health. This was done using system dynamic modelling, in three interactive sessions lasting three hours each. In these sessions, they constructed a model, resulting in a system of variables with causal relationships and feedback loops. Subsequently, the results of these GMB sessions were compared to scientific literature and reviewed by a panel of researchers with extensive experience in relevant scientific fields. RESULTS: The resulting model contains 71 causal relationships between 39 variables, 29 of which are present in feedback loops. The variables of participation in society, stress, shame, social contacts and use of services/provisions appear to hold prominent roles in the model's mechanisms. Most of the relationships in the model are supported by scientific literature. The researchers reviewing the model in the scientific meeting agreed that the vast majority of relationships would concur with scientific knowledge, but that the model constructed by the stakeholders consists mostly of individual-level factors, while important conditions usually relate to systemic variables. CONCLUSIONS: Building a model with GMB helps grasp the complex situation of a wicked problem, for which it is unlikely that its interrelationships result in a fully intuitive understanding with linear mechanisms. Using this approach, effects of SDoH can be made visible and the body of evidence expanded. Importantly, it elicits stakeholders' perspectives on a complex reality and offers a non-arbitrary way of formulating the model structure. This qualitative model is also well suited to serve as conceptual input for a quantitative model, which can be used to test and estimate the relationships.

Identifying client characteristics to predict homecare use more accurately: a Delphi-study involving nurses and homecare purchasing specialists.

BACKGROUND: Case-mix based prospective payment of homecare is being implemented in several countries to work towards more efficient and client-centred homecare. However, existing models can only explain a limited part of variance in homecare use, due to their reliance on health- and function-related client data. It is unclear which predictors could improve predictive power of existing case-mix models. The aim of this study was therefore to identify relevant predictors of homecare use by utilizing the expertise of district nurses and health insurers. METHODS: We conducted a two-round Delphi-study according to the RAND/UCLA Appropriateness Method. In the first round, participants assessed the relevance of eleven client characteristics that are commonly included in existing case-mix models for predicting homecare use, using a 9-Point Likert scale. Furthermore, participants were also allowed to suggest missing characteristics that they considered relevant. These items were grouped and a selection of the most relevant items was made. In the second round, after an expert panel meeting, participants re-assessed relevance of pre-existing characteristics that were assessed uncertain and of eleven suggested client characteristics. In both rounds, median and inter-quartile ranges were calculated to determine relevance. RESULTS: Twenty-two participants (16 district nurses and 6 insurers) suggested 53 unique client characteristics (grouped from 142 characteristics initially). In the second round, relevance of the client characteristics was assessed by 12 nurses and 5 health insurers. Of a total of 22 characteristics, 10 client characteristics were assessed as being relevant and 12 as uncertain. None was found irrelevant for predicting homecare use. Most of the client characteristics from the category 'Daily functioning' were assessed as uncertain. Client characteristics in other categories - i.e. 'Physical health status', 'Mental health status and behaviour', 'Health literacy', 'Social environment and network', and 'Other' - were more frequently considered relevant. CONCLUSION: According to district nurses and health insurers, homecare use could be predicted better by including other more holistic predictors in case-mix classification, such as on mental functioning and social network. The challenge remains, however, to operationalize the new characteristics and keep stakeholders on board when developing and implementing case-mix classification for homecare prospective payment.

Economic Evaluation of New Models of Care: Does the Decision Change Between Cost-Utility Analysis and Multi-Criteria Decision Analysis?

OBJECTIVES: To experiment with new approaches of collaboration in healthcare delivery, local authorities implement new models of care. Regarding the local decision context of these models, multi-criteria decision analysis (MCDA) may be of added value to cost-utility analysis (CUA), because it covers a wider range of outcomes. This study compares the 2 methods using a side-by-side application. METHODS: A new Dutch model of care, Primary Care Plus (PC+), was used as a case study to compare the results of CUA and MCDA. Data of patients referred to PC+ or care-as-usual were retrieved by questionnaires and administrative databases with a 3-month follow-up. Propensity score matching together with generalized linear regression models was used to reduce confounding. Univariate and probabilistic sensitivity analyses were performed to explore uncertainty in the results. RESULTS: Although both methods indicated PC+ as the dominant alternative, complementary differences were observed. MCDA provided additional evidence that PC+ improved access to care (standardized performance score of 0.742 vs 0.670) and that improvement in health-related quality of life was driven by the psychological well-being component (standardized performance score of 0.710 vs 0.704). Furthermore, MCDA estimated the budget required for PC+ to be affordable in addition to preferable (€521.42 per patient). Additionally, MCDA was less sensitive to the utility measures used. CONCLUSIONS: MCDA may facilitate an auditable and transparent evaluation of new models of care by providing additional information on a wider range of outcomes and incorporating affordability. However, more effort is needed to increase the usability of MCDA among local decision makers.

The (cost-)effectiveness and cost-utility of a novel integrative care initiative for patients with chronic musculoskeletal pain: the pragmatic trial protocol of Network Pain Rehabilitation Limburg.

BACKGROUND: Rehabilitation care for patients with chronic musculoskeletal pain (CMP) is not optimally organized. The Network Pain Rehabilitation Limburg 2.0 (NPRL2.0) provides integrated care with a biopsychosocial approach and strives to improve the Quadruple Aim outcomes: pain-related disability of patients with CMP; experiences of care of patients with CMP; meaning in the work of healthcare professionals; and healthcare costs. Firstly, in this study, the effectiveness (with regard to the functioning and participation of patients) of primary care for patients with CMP will be assessed, comparing care organized following the NPRL2.0 procedure with usual care. Secondly, the cost-effectiveness and cost-utility with regard to health-related quality of life and healthcare costs will be assessed. And thirdly, the effect of duration of participation in a local network in primary care will be studied. METHODS: In this pragmatic study, it is expected that two local networks with 105 patients will participate in the prospective cohort study and six local networks with 184 patients in the stepped-wedge based design. Healthcare professionals in the local networks will recruit patients. INCLUSION CRITERIA: age ≥ 18 years; having CMP; willing to improve functioning despite pain; and adequate Dutch literacy. EXCLUSION CRITERIA: pregnancy; and having a treatable medical or psychiatric disease. Patients will complete questionnaires at baseline (T1), 3 months (T2), 6 months (T3), and 9 months (T4). Questionnaires at T1 and T4 will include the Pain Disability Index and Short Form Health Survey. Questionnaires at T1, T2, T3, and T4 will include the EQ-5D-5L, and iMTA Medical Consumption and Productivity Cost Questionnaires. Outcomes will be compared using linear mixed-model analysis and costs will be compared using bootstrapping methods. DISCUSSION: NPRL2.0 is a multidimensional, complex intervention, executed in daily practice, and therefore needing a pragmatic study design. The current study will assess NPRL2.0 with respect to the Quadruple Aim outcomes: patient health and costs. This will provide more information on the (cost-) effectiveness of the organization of care in a network structure regarding patients with CMP. The other two Quadruple Aim outcomes will be examined alongside this study. Trial registration Netherlands Trial Register: NL7643. https://www.trialregister.nl/trial/7643 .

Identifying integration and differentiation in a Hospital's logistical system: a social network analysis of a case study.

BACKGROUND: Integration, the coordination and alignment of tasks, has been promoted widely in order to improve the performance of hospitals. Both organization theory and social network analysis offer perspectives on integration. This exploratory study research aims to understand how a hospital's logistical system works, and in particular to what extent there is integration and differentiation. More specifically, it first describes how a hospital organizes logistical processes; second, it identifies the agents and the interactions for organizing logistical processes, and, third, it establishes the extent to which tasks are segmented into subsystems, which is referred to as differentiation, and whether these tasks are coordinated and aligned, thus achieving integration. METHODS: The study is based on case study research carried out in a hospital in the Netherlands. All logistical tasks that are executed for surgery patients were studied. Using a mixed method, data were collected from the Hospital Information System (HIS), documentation, observations and interviews. These data were used to perform a social network analysis and calculate the network metrics of the hospital network. RESULTS: This paper shows that 23 tasks are executed by 635 different agents who interact through 31,499 interaction links. The social network of the hospital demonstrates both integration and differentiation. The network appears to function differently from what is assumed in literature, as the network does not reflect the formal organizational structure of the hospital, and tasks are mainly executed across functional silos. Nurses and physicians perform integrative tasks and two agents who mainly coordinate the tasks in the network, have no hierarchical position towards other agents. The HIS does not seem to fulfill the interactional needs of agents. CONCLUSIONS: This exploratory study reveals the network structure of a hospital. The cross-functional collaboration, the integration found, and position of managers, coordinators, nurses and doctors suggests a possible gap between organizational perspectives on hospitals and reality. This research sets a basis for further research that should focus on the relation between network structure and performance, on how integration is achieved and in what way organization theory concepts and social network analysis could be used in conjunction with one another.

Reorganising dermatology care: predictors of the substitution of secondary care with primary care.

BACKGROUND: The substitution of healthcare is a way to control rising healthcare costs. The Primary Care Plus (PC+) intervention of the Dutch 'Blue Care' pioneer site aims to achieve this feat by facilitating consultations with medical specialists in the primary care setting. One of the specialties involved is dermatology. This study explores referral decisions following dermatology care in PC+ and the influence of predictive patient and consultation characteristics on this decision. METHODS: This retrospective study used clinical data of patients who received dermatology care in PC+ between January 2015 and March 2017. The referral decision following PC+, (i.e., referral back to the general practitioner (GP) or referral to outpatient hospital care) was the primary outcome. Stepwise logistic regression modelling was used to describe variations in the referral decisions following PC+, with patient age and gender, number of PC+ consultations, patient diagnosis and treatment specialist as the predicting factors. RESULTS: A total of 2952 patients visited PC+ for dermatology care. Of those patients with a registered referral, 80.2% (N = 2254) were referred back to the GP, and 19.8% (N = 558) were referred to outpatient hospital care. In the multivariable model, only the treating specialist and patient's diagnosis independently influenced the referral decisions following PC+. CONCLUSION: The aim of PC+ is to reduce the number of referrals to outpatient hospital care. According to the results, the treating specialist and patient diagnosis influence referral decisions. Therefore, the results of this study can be used to discuss and improve specialist and patient profiles for PC+ to further optimise the effectiveness of the initiative.

Person-centred and efficient care delivery for high-need, high-cost patients: primary care professionals' experiences.

BACKGROUND: High-need, high-cost (HNHC) patients, who typically have complex and long-term care demands, contribute considerably to the high work pressure of primary care professionals (PCPs). To improve patient as well as provider experiences, it is crucial to take into account the PCPs' perspective in designing health care strategies for HNHC patients. Therefore, this study aimed to create insight into PCPs' experienced barriers and possible solutions with regards to person-centred, efficient care delivery to HNHC patients. METHODS: We conducted a qualitative study using focus group interviews with PCPs at a Dutch primary care group. A semi-structured interview guide was developed for the interviews. Qualitative content analysis was employed deductively by means of a categorisation matrix. The matrix was based on the components retrieved from the SELFIE framework for integrated care for multi-morbidity. RESULTS: Forty-two PCPs participated in five focus group interviews. Discussed barriers and solutions were related to the core of the SELFIE framework (i.e. the individual and environment), and particularly four of the six health system components in the framework: service delivery, leadership & governance, workforce, and technologies & medical products. Many discussed barriers revolved around the complex biopsychosocial needs of HNHC patients: PCPs reported a lack of time (service delivery), insufficiently skilled PCPs (workforce), and inefficient patient information retrieval and sharing (technologies & medical products) as barriers to adequately meet the biopsychosocial needs of HNHC patients. CONCLUSIONS: This qualitative study suggests that primary care is currently insufficiently equipped to accommodate the complex biopsychosocial needs of HNHC patients. Therefore, it is firstly important to strengthen primary care internally, taking into account the experienced lack of time, the insufficient number of equipped PCPs and lack of inter-professional information retrieval and sharing. Secondly, PCPs should be supported in cooperating and communicating more efficiently with health services outside primary care to adequately deliver person-centred, efficient care. As a prerequisite, it is crucial to direct policy efforts at the design of a strong system of social and community services. In terms of future research, it is important to assess the feasibility and effects of re-designing primary care based on the provided recommendations.

Relevant patient characteristics for estimating healthcare needs according to healthcare providers and people with type 2 diabetes: a Delphi survey.

BACKGROUND: Recently, there has been growing interest in providing more tailored, patient-centered care for the treatment of type 2 diabetes mellitus (T2DM). Yet it remains unclear which patient characteristics should be determined to guide such an approach. Therefore, the opinions of healthcare providers (HCP) and people with T2DM about relevant patient characteristics for estimating healthcare needs of people with T2DM were assessed and compared. METHODS: Two separate online Delphi studies were conducted according to the RAND-UCLA Appropriateness Method: one with HCPs (n = 22) from Dutch primary and secondary care and one with people with T2DM treated in Dutch primary care (n = 46). The relevance of patient characteristics for estimating healthcare needs, defined as the number of yearly consultations, was assessed on a 5-point Likert scale. Characteristics with a median of 4 or 5 and an interquartile range ≤ 1.5 were considered relevant with consensus. Participants were also asked to select the top 5 of most relevant patient characteristics. To determine the overall top 5, the mean relative importance score of each characteristic was calculated. RESULTS: In two Delphi rounds, 28 and 15 patient characteristics were rated by HCPs and people with T2DM, respectively. Both HCPs and people with T2DM found health-related characteristics relevant for estimating healthcare needs of people with T2DM. However, HCPs preferred to estimate healthcare needs using person- and context-related characteristics. They ranked self-efficacy as the most relevant estimator. In contrast, people with T2DM were more in favor of health-related characteristics and ranked HbA1c as the most relevant estimator. CONCLUSIONS: The findings show that there is discrepancy in opinions on relevant patient characteristics for estimating healthcare needs between HCPs and people with T2DM. To achieve more tailored, patient-centered care, it is important that both groups agree on the topics to be discussed during patient consultations.

Substitution of hospital care with Primary Care Plus: differences in referral patterns according to specialty, specialist and diagnosis group.

BACKGROUND: Primary Care Plus (PC+) is an intervention where patients consult specialists in a primary care setting outside the hospital. Two facilities have been founded in the city of Maastricht, the Netherlands. Main aim is to achieve substitution of hospital care with primary care and hence reduce costs. The objective of this study is to evaluate referral patterns per specialty, specialist and diagnosis group, as input for deliberations to optimise substitution. METHODS: Prospectively collected referral data after PC+ consultations between November 2014 and March 2016 was analysed for eight participating specialties. Primary outcomes were differences in referral patterns per specialty, specialist and diagnosis group. Absolute counts and percentages were recorded for categorical variables, means and standard deviations for continuous variables. Statistical analyses were performed using IBM SPSS Statistics 23 (SPSS Inc., Chicago, IL). RESULTS: In total 4536 patients were seen in PC+; 3132 (69.0%) were referred back to the general practitioner (GP), whereas 1275 (28.1%) were referred to secondary care. Referral information of 130 (2.9%) patients was unknown. Large differences in referral numbers to secondary care after PC+ consultation were found between specialties (from 8.6% (gynaecology) to 43.8% (orthopaedic surgery)), specialists (14.5 to 65.2%) and diagnosis groups (11.1 to 93.4%). CONCLUSIONS: Wide variation in referral numbers to secondary care between specialties, specialists and diagnosis groups exists after PC+ consultations. This data indicates that deliberation and further research is needed in order to optimize substitution initiatives like PC+.

Does the implementation of a care pathway for patients with hip or knee osteoarthritis lead to fewer diagnostic imaging and referrals by general practitioners? A pre-post-implementation study of claims data.

BACKGROUND: The Dutch care for hip and knee osteoarthritis (OA) is of good quality, but there is room for improvement regarding the efficient use of diagnostic imaging and conservative treatment. Therefore a stepped-care approach, in the shape of the care pathway 'Better exercise in osteoarthritis', was implemented to reduce the number of diagnostic imaging requested by GPs and referrals of GPs to orthopaedic care. METHODS: In 2015, the pathway is implemented with the use of educational meetings, distributing guidelines and incorporating reminders in the GPs' referral application. To evaluate the effect of the pathway on the diagnostic and referral behaviour of GPs, hip and knee related health insurance claims are used together with claims of other joints and of a control region for comparison. The average number of claims and the percentage change in the post-implementation period are described. Binary logistic regression analysis is used to examine the interaction between region (intervention and control) and period (pre- and post-implementation). Using random sampling of patient records, information about the practical application of the pathway and the number of hip or knee arthroplasties is added. RESULTS: In both regions, the number of diagnostic imaging decreased and the number of initial orthopaedic consultations increased during the post-implementation period. Significant interaction effects were found in knee-related diagnostics (p ≤ 0.001) and diagnostics of other joints (p = 0.039). No significant interaction effects were found in hip-related diagnostics (p = 0.060) and in initial orthopaedic consultation claims of hip (p = 0.979), knee (p = 0.281), and other joints (p = 0.464). Being referred according to the pathway had no significant effect on the probability of undergoing arthroplasty. CONCLUSION: The implementation of the pathway had a positive effect on GPs diagnostic behaviour related to the knee, but not to the hip. The referral behaviour of GPs to orthopaedic care needs attention for future interventions and research, since an increase (instead of a desired decrease) in the number of initial orthopaedic consultations was found. Focusing on the entire width of care for hip and knee OA could be helpful.

A risk score including body mass index, glycated haemoglobin and triglycerides predicts future glycaemic control in people with type 2 diabetes.

AIM: To identify, predict and validate distinct glycaemic trajectories among patients with newly diagnosed type 2 diabetes treated in primary care, as a first step towards more effective patient-centred care. METHODS: We conducted a retrospective study in two cohorts, using routinely collected individual patient data from primary care practices obtained from two large Dutch diabetes patient registries. Participants included adult patients newly diagnosed with type 2 diabetes between January 2006 and December 2014 (development cohort, n = 10 528; validation cohort, n = 3777). Latent growth mixture modelling identified distinct glycaemic 5-year trajectories. Machine learning models were built to predict the trajectories using easily obtainable patient characteristics in daily clinical practice. RESULTS: Three different glycaemic trajectories were identified: (1) stable, adequate glycaemic control (76.5% of patients); (2) improved glycaemic control (21.3% of patients); and (3) deteriorated glycaemic control (2.2% of patients). Similar trajectories could be discerned in the validation cohort. Body mass index and glycated haemoglobin and triglyceride levels were the most important predictors of trajectory membership. The predictive model, trained on the development cohort, had a receiver-operating characteristic area under the curve of 0.96 in the validation cohort, indicating excellent accuracy. CONCLUSIONS: The developed model can effectively explain heterogeneity in future glycaemic response of patients with type 2 diabetes. It can therefore be used in clinical practice as a quick and easy tool to provide tailored diabetes care.

Comparative institutional analysis for public health: governing voluntary collaborative agreements for public health in England and the Netherlands.

Democratic institutions and state-society relations shape governance arrangements and expectations between public and private stakeholders about public health impact. We illustrate this with a comparison between the English Public Health Responsibility Deal (RD) and the Dutch 'All About Health…' (AaH) programme. As manifestations of a Whole-of-Society approach, in which governments, civil society and business take responsibility for the co-production of economic utility and good health, these programmes are two recent collaborative platforms based on voluntary agreements to improve public health. Using a 'most similar cases' design, we conducted a comparative secondary analysis of data from the evaluations of the two programmes. The underlying rationale of both programmes was that voluntary agreements would be better suited than regulation to encourage business and civil society to take more responsibility for improving health. Differences between the two included: expectations of an enforcing versus facilitative role for government; hierarchical versus horizontal coordination; big business versus civil society participants; top-down versus bottom-up formulation of voluntary pledges and progress monitoring for accountability versus for learning and adaptation. Despite the attempt in both programmes to base voluntary commitments on trust, the English 'shadow of hierarchy' and adversarial state-society relationships conditioned non-governmental parties to see the pledges as controlling, quasi-contractual agreements that were only partially lived up to. The Dutch consensual political tradition enabled a civil society-based understanding and gradual acceptance of the pledges as the internalization by partner organizations of public health values within their operations. We conclude that there are institutional limitations to the implementation of generic trust-building and learning-based models of change 'Whole-of-Society' approaches.

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).