Development, Testing, and Implementation of the Belgian Patient Reported Experience Measure for Pancreatic Cancer Care (PREPARE) Project: Protocol for a Multi-Method Research Project.

BACKGROUND: Patients with pancreatic cancer do not feel involved in the development of their treatment and care plans. In Belgium, these plans are decided on during multidisciplinary team meetings. However, limited time is spent on the discussion of the preferences of the patient during these meetings. This research project aims to develop a patient-reported experience measure (PREM) for pancreatic cancer and assess if its use can support collaborative treatment decision-making. OBJECTIVE: This paper aims to outline the protocol for a multi-method research project to improve person-centered pancreatic cancer care in Belgium. Three subobjectives are pursued: (1) to develop a PREM to assess the experiences of care-related aspects in pancreatic cancer care, (2) to validate the PREM, and (3) to develop and evaluate an educational intervention to support the use of the PREM's results. METHODS: For the development of the PREM, an exploratory mixed methods study design will be used. The study will start with a survey followed by a telephone interview involving patients with pancreatic cancer and digestive oncology health care professionals. Study two is the testing of the content and construct validity of the PREM. Study three involves the implementation study according to the Medical Research Council framework of a complex intervention introducing the PREM in practice. The effectiveness of the intervention will be investigated using a pragmatic randomized controlled trial study design. RESULTS: The protocol presents the entire structure of the research project. Ethics approval to conduct the exploratory mixed methods study (objective 1) has been obtained, and recruitment has started since January 2022. CONCLUSIONS: The poor prognosis of patients with pancreatic cancer should not be considered a hurdle to not study this patient population group. Involving patients in the research and decision-making processes early on is key. This project aims to realize a scientifically sound research process providing research outputs that can easily and timely be implemented in the care trajectory of patients with pancreatic cancer. This research project will also lead to recommendations on how to involve patients with pancreatic cancer and how the methodology of this research project can be translated to other patient groups. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/29004.

Exploring non-physician care professionals' roles in cancer multidisciplinary team meetings: A qualitative study.

The growing complexity of cancer care necessitates collaboration among different professionals. This interprofessional collaboration improves cancer care delivery and outcomes. Treatment decision-making within the context of a multidisciplinaire team meeting (MDTMs) may be seen as a particular form of interprofessional collaboration. Various studies on cancer MDTMs highlight a pattern of suboptimal information sharing between attendants. To overcome the lack of non-medical, patient-based information, it might be recommended that non-physician care professionals play a key patient advocacy role within cancer MDTMs. This study aims to explore non-physician care professionals' current and aspired role within cancer MDTMs. Additionally, the perceived hindering factors for these non-physician care professionals to fulfil their specific role are identified. The analysis focuses on nurses, specialist nurses, head nurses, psychologists, social workers, a head of social workers and data managers. The results show that non-physician care professionals play a limited role during case discussions in MDTMs. Neither do they actively participate in the decision-making process. Barriers perceived by non-physician care professionals are classified on two main levels: 1) team-related barriers (factors internally related to the team) and 2) external barriers (factors related to healthcare management and policy). A group of non-physician care professionals also belief that their information does not add value in the decision-making proces and as such, they underestimate their own role in MDTMs. To conclude, a change of culture is needed towards an interdisciplinary collaboration in which knowledge and expertise of different professions are equally assimilated into an integrated perspective to guarantee a true patient-centred approach for cancer MDTMs.

Organizational perspectives and diagnostic evaluations for children with neurodevelopmental disorders.

AIM: To clarify organizational perspectives on diagnostic evaluations for children with neurodevelopmental disorders (NDD), with the goal to enhance interorganizational collaboration and improve accessibility. METHOD: Focus groups with expert stakeholders in Flanders, Belgium, were organized. Data were analyzed in a continuous, comparative method with researcher and data triangulation, and a member check validation. RESULTS: Fifty-nine people participated in six focus groups. Organizations had no shared vision on diagnostic evaluations of NDD. An interdisciplinary team approach was considered essential. All stakeholders agreed that a diagnostic evaluation is an iterative process along the trajectory of the child. INTERPRETATION: Diagnostic evaluations of NDD should be conceptualized as an integrated process of the child's care trajectory, differentiating needs-based goals in each phase, and requiring an interdisciplinary team approach. This conceptualization will support a health systems model, allowing interorganizational collaboration to optimize available capacity and increase accessibility.

Understanding the Complexity, Underlying Processes, and Influencing Factors for Optimal Multidisciplinary Teamwork in Hospital-Based Cancer Teams: A Systematic Integrative Review.

BACKGROUND: Multidisciplinary teamwork has become the standard in care for oncological patients and their treatment trajectory when comprehensive, holistic, and high-quality cancer care is needed. Working together from a variety of perspectives is difficult to achieve and has well-known pitfalls, such as miscommunication and poor coordination. OBJECTIVE: To describe and synthesize the factors influencing and the processes underlying optimal multidisciplinary teamwork. METHODS: An integrative review was conducted, guided by the framework of Whittemore and Knafl. The systematic search for literature published since 2010 in 3 databases (PubMed, Web of Science, and Scopus) yielded 49 articles. RESULTS: Eighty-eight percent of the included studies focus on multidisciplinary team meetings, rather than on the wider notion of multidisciplinary teamwork. We identified influencing factors on the basis of structural features of the team, hospital, and health system, as well as process features of multidisciplinary teamwork in multidisciplinary team meetings. CONCLUSION: To improve multidisciplinary teamwork, the focus needs to be on the process of collaboration throughout the cancer care trajectory of the patient. A more integrated, interdisciplinary approach should be aimed for to recognize the role and contribution of all disciplines involved. IMPLICATIONS: A cultural change is needed toward interdisciplinary practice in hospitals to reach partnership between all involved professionals as part of a participatory, collaborative, and coordinated approach.

Key dimensions of collaboration quality in mental health care service networks.

Appropriate care delivery for patients with severe mental illness (SMI) requires a high level of collaboration quality between primary, mental health, and social care services. Few studies have addressed the interpersonal and inter-organizational components of collaboration within one unique study setting and it is unclear how these components contribute to overall collaboration quality. Using a comprehensive model that includes ten key indicators of collaboration in relation to both components, we evaluated how interpersonal and inter-organizational collaboration quality were associated in 19 networks that included 994 services across Belgium. Interpersonal collaboration was significantly higher than inter-organizational collaboration. Despite the internal consistency of the model, analysis showed that respondents perceived a conflict between client-centered care and leadership in the network. Our results reveal two approaches to collaborative service networks, one relying on interpersonal interactions and driven by client needs and another based on formalization and driven by governance procedures. The results reflect a lack of strategy on the part of network leaders for supporting client-centered care and hence, the persistence of the high level of fragmentation that networks were expected to address. Policy-makers should pay more attention to network formalization and governance mechanisms with a view to achieving effective client-centered outcomes.

How multidisciplinary are multidisciplinary team meetings in cancer care? An observational study in oncology departments in Flanders, Belgium.

BACKGROUND: In current cancer care, multidisciplinary team meetings (MDTMs) aim at uniting care professionals from different disciplines to decide upon the best possible treatment plan for the patients based on the available scientific evidence. In Belgium, the multidisciplinary approach is mandatory and formally regulated since 2003. Current research indicates that MDTMs are not always truly multidisciplinary, ie, with a mix of medical as well as paramedical disciplines, and that the medical profession (physicians and medical specialists) tends to dominate the interaction in MDTMs. To ensure that MDTMs can benefit from their diverse membership to achieve their full potential, significant attention should be devoted to the multidisciplinary character of these meetings. The aim of this study is to explore and describe the multidisciplinary character in MDTMs and how it is actually shaped in practice in different Flemish medical oncology departments. METHODS: For this study, we carried out an observational comparative case study. We studied 59 multidisciplinary team meetings at inpatient medical oncology departments in five different Belgian hospitals (academic as well as general) and explored multidisciplinarity and how it is actually shaped in practice. RESULTS: The study is unique in identifying and analyzing three distinct types of MDTMs. The analysis of the three types revealed an inconsistent and, at times, contradictory picture of multidisciplinary team meetings. The findings also align with previous studies arguing that MDTMs in oncology are typically driven by doctors, with limited input of nurses and other nonmedical staff in which decisions are argued on biomedical information and far less consideration of psychosocial aspects. CONCLUSION: The concept of a MDTM should not merely be a group of care professionals who work essentially independently and occasionally liaise with one another. Yet, this study has shown a worryingly low awareness of the true character of multidisciplinarity, particularly among medical disciplines.

Effectiveness of Health and Social Service Networks for Severely Mentally Ill Patients' Outcomes: A Case-Control Study.

Mental health and social care services networks aim to provide patients with continuity of care and support their recovery. There is, however, no conclusive evidence of their effectiveness. Since 2011, Belgium has been implementing a nation-wide reform of mental health care by commissioning service networks. Using a case-control design, we assessed the reform's effectiveness for continuity of care, social integration, quality of life, and re-hospitalization for 1407 patients from 23 networks. Greater reform exposure was associated with a slight improvement in continuity of care, but not with other outcomes. We concluded that service networks alone do not affect patient-level outcomes.

Qualitative assessment of opportunities and challenges to improve evidence-informed health policy-making in Hungary - an EVIPNet situation analysis pilot.

BACKGROUND: In evidence-informed policy-making (EIP), major knowledge gaps remain in understanding the context and possibilities for institutionalisation of knowledge translation. In 2014, the WHO Evidence-informed Policy Network (EVIPNet) Europe initiated a number of pilot countries, with Hungary among them, to engage in a 'situation analysis' (SA) in order to fill some of those gaps. This contribution discusses the results of the SA in Hungary on research-policy interactions, facilitating factors and potential barriers to establish a knowledge translation platform (KTP). METHODS: In line with the EVIPNet Europe SA Manual, a document analysis, 13 interviews, 3 focus group discussions with 21 participants, and an online survey with 31 respondents were carried out from April to October, 2015. A SA aims to assess the context in which EIP takes form and seeks opportunities to establish a KTP, so information was gathered on the current practice of EIP and knowledge translation, its relevant actors, enablers and barriers for EIP, and opinions on a future KTP. Methodological and researcher triangulation resulted in a narrative synthesis of data, including a comparison with literature. A stakeholder consultation was organised to validate findings. RESULTS: This study reveals that stakeholders show commitment to produce and use research evidence in Hungarian health policy-making. All stakeholders endorsed the idea of strengthening the systematic use of evidence in decision-making and favoured the idea of establishing a KTP. In line with literature on other countries, some good practices exist on the uptake of evidence in policy-making; however, a systematic approach of developing, translating and using research evidence in health policy processes is lacking. EIP is currently hampered by scattered capacity, coordination problems, high fluctuation in government, an often legalistic and a more 'symbolic' rather than practical support for knowledge translation and EIP. The article summarises recommendations on a Hungarian KTP. CONCLUSIONS: Pragmatic adaptation of the SA Manual to local needs proved to be a useful mechanism to provide insight into the Hungarian EIP field and the establishment of a potential KTP. Despite the success of a KTP pilot, it remains unclear how a KTP in Hungary will be institutionalised in a sustainable way.

Input of Psychosocial Information During Multidisciplinary Team Meetings at Medical Oncology Departments: Protocol for an Observational Study.

BACKGROUND: Multidisciplinary team meetings (MDTMs) have become standard practice in oncology and gained the status of the key decision-making forum for cancer patient management. The current literature provides evidence that MDTMs are achieving their intended objectives but there are also indications to question the positive impact of MDTMs in oncology settings. For cancer management to be patient-centered, it is crucial that medical information as well as psychosocial aspects-such as the patients' living situation, possible family problems, patients' mental state, and patients' perceptions and values or preferences towards treatment or care-are considered and discussed during MDTMs. Previous studies demonstrate that failure to account for patients' psychosocial information has a negative impact on the implementation of the treatment recommendations formulated during MDTMs. Few empirical studies have demonstrated the predominant role of physicians during MDTMs, leading to the phenomenon that medical information is shared almost exclusively at the expense of psychosocial information. However, more in-depth insight on the underlying reasons why MDTMs fail to take into account psychosocial information of cancer patients is needed. OBJECTIVE: This paper presents a research protocol for a cross-sectional observational study that will focus on exploring the barriers to considering psychosocial information during MDTMs at medical oncology departments. METHODS: This protocol encompasses a cross-sectional comparative case study of MDTMs at medical oncology departments in Flanders, Belgium. MDTMs from various oncology subspecialties at inpatient medical oncology departments in multiple hospitals (academic as well as general hospitals) are compared. The observations focus on the "multidisciplinary oncology consultation" (MOC), a formally regulated and financed type of MDTM in Belgian oncology since 2003. Data are collected through nonparticipant observations of MOC-meetings. Observational data are supplemented with semi-structured individual interviews with members of the MOC-meetings. RESULTS: The protocol is part of a larger research project on communication and multidisciplinary collaboration in oncology departments. Results of this study will particularly focus on the input of psychosocial information during MDTMs. CONCLUSIONS: The concept of an MDTM should not merely be a group of care professionals who mostly work independently and occasionally liaise with one another. Interventions aiming to enhance the input of psychosocial information are crucial to ensure that MDTMs can benefit from their diverse membership to achieve their full potential. The findings from this study can be used to design nonclinical and organizational interventions that enhance multidisciplinary decision-making in oncology.

Emergency psychiatric care for children and adolescents: a literature review.

OBJECTIVES: Over the years, increasing numbers of children and adolescents have sought help for acute psychiatric problems. The responses to this treatment-seeking behavior are heterogeneous in different settings and nations. This review aimed to provide an answer to the questions "which care should be offered to children and adolescents presenting with a psychiatric emergency or crisis and how should it be organized." METHODS: We committed a literature review to find out if any recommendations can be made regarding the organization of emergency care for children and adolescents with acute mental health problems. RESULTS: The lack of a clear definition of emergencies or urgencies hampered this review; we note the differences between adult and child or adolescent psychiatry. The theoretical models of care found in the literature are built up from several process and structural components, which we describe in greater detail. Furthermore, we review the main service delivery models that exist for children and adolescents. CONCLUSIONS: Currently, emergency psychiatric care for children and adolescents is practiced within a wide range of care models. There is no consensus on recommended care or recommended setting for this population. More research is needed to make exact recommendations on the standardization of psychiatric care for young people in emergency settings.

Illness trajectory and Internet as a health information and communication channel used by parents of infants admitted to a neonatal intensive care unit.

BACKGROUND: Internet use became an integral part of the healthcare relationship. Literature indicates that the illness trajectory plays a role in the use of Internet as a health information tool. This study focuses on infants admitted to a neonatal intensive care unit. AIM: This study aims to understand how the illness trajectory triggers the use of Internet by parents of infants admitted to a neonatal intensive care unit, using a conceptual framework influenced by Corbin and Strauss' illness trajectory. DESIGN: This study was based on a qualitative longitudinal multiple-case study design. METHODS: From July 2007-August 2008 and from June 2009-May 2010, parents with newborns were prospectively interviewed over a period of 10 months. Parents were recruited in four neonatal intensive care units. The interviews were subject of a thematic content analysis. RESULTS: The multi-layered illness trajectory triggers Internet use. Parents' online health information behaviour interacts with other information channels too (such as interaction with healthcare professionals). Parents accumulate knowledge along the illness trajectory affecting their information needs. The sickness trajectory helps to understand the complexity of the information behaviour. Labels have a major impact on the effectiveness of search strategies. CONCLUSIONS: Nursing and other healthcare professionals should become more aware about the complex relationship between information needs and Internet use along the illness trajectory of an infant. As such, they will be more able to assist parents in finding and evaluating high-quality online information at the right time.

Information behaviour of parents of children admitted to a neonatal intensive care unit: Constructing a conceptual framework.

This article explores the concepts 'information behaviour' and 'illness trajectory' at the neonatal intensive care unit (NICU). On the basis of literature review and exploratory interviews with neonatologists and head nurses of Belgian NICUs a conceptual framework is presented. The 'information behaviour' of parents of infants admitted to a NICU is analytically divided into five dimensions: ways of getting information; interpersonal information sources; time-related issues; location of information transfer; and content of information. The conceptual framework equally takes the 'illness trajectory' into account. Following Corbin and Strauss the illness trajectory at a NICU is analysed in three sub-trajectories: disease course; healthcare trajectory; and sickness trajectory. By combining the respective categories of information behaviour and illness trajectory, an analytical tool is presented under the form of a classification matrix for scrutinizing the mediating role of the illness trajectory on the information behaviour of parents of infants admitted to a NICU.

Using threshold values for cost per quality-adjusted life-year gained in healthcare decisions.

BACKGROUND: In many countries, the incremental cost-effectiveness ratio (ICER) is used to assess whether an intervention is worth its costs. At the same time, policy makers often feel uncomfortable with refusing reimbursement of any intervention purely on the basis of the fact that the ICER exceeds a specific threshold value. Reluctance to define a single threshold value for the ICER seems to have been stronger in social security systems than in national healthcare services systems. This study explores how basic differences between healthcare systems impact upon the potential usefulness of an ICER threshold value. METHODS: This study is a narrative review of literature about the theoretical foundations of the ICER threshold value approach and its practical relevance in different types of healthcare systems. RESULTS: A single ICER threshold value cannot be maintained, defined, or measured and should not be used as a policy-making tool. None of the solutions presented up until now to make the ICER threshold approach a valuable policy-making tool overcome the important weaknesses of the approach. CONCLUSIONS: ICERs and ICER threshold values are insufficient for assessing interventions' value for money. Rather, they should be considered as one element in the decision-making process. Complete rationalization of the decision-making process by means of quantitative decision criteria is undesirable and not feasible. Increasing transparency in the criteria used for a decision and explicitness about the relative importance of each criterion should, therefore, be the major goal.

Variations in follow-up services after inpatient stroke rehabilitation: a multicentre study.

BACKGROUND: Care after discharge from inpatient stroke rehabilitation units varies across Europe. The aim of this study was to compare service delivery after discharge. METHODS: A total of 532 consecutive patients after stroke were recruited from 4 European rehabilitation centres in Germany, Switzerland, Belgium and the UK. At 2-month intervals, clinical assessments and structured interviews were carried out to document functional status and delivery of services after discharge. Significant factors for receiving follow-up services were analysed using a logistic generalized estimating equation model. RESULTS: After controlling for case-mix, the results showed that Belgian patients were most likely to receive physical therapy but least likely to receive occupational therapy. German patients were least likely to receive nursing care. UK patients were less likely to receive medical care from their general practitioner compared with the other patient groups. CONCLUSION: Clinical characteristics did not explain the variations in service delivery after discharge from in-patient stroke rehabilitation. The decision-making processes involved in the provision of follow-up services need to be better documented. To improve our understanding of events post-discharge, the influence of non-clinical factors, such as healthcare regulations, should be explored further.

Information needs of parents of children admitted to a neonatal intensive care unit: a review of the literature (1990-2008).

OBJECTIVE: This literature review focuses on information and communication needs of parents of children admitted to the NICU and on their use of information sources in the illness trajectories at NICU. METHODS: Literature search in 4 electronic databases (Ovid Medline, PsycINFO, CINAHL and Sociological Abstracts), covering 1990-March 2008. RESULTS: The seventy-eight included articles revealed that NICU parents have high information needs. The illness trajectory mediates parental information needs and induces a changing pattern in information use and information needs. Most attention is paid to the prenatal and acute phases, while information behaviour in sudden events and later phases receives limited attention. CONCLUSIONS: In-depth studies on information needs and corresponding use of information sources are lacking. More longitudinal studies are needed, taking the illness trajectory into account and investigating the determinants and outcomes of the information and communication needs of NICU parents. PRACTICE IMPLICATIONS: Healthcare professionals should adapt their information provision along the illness trajectory. The development of guidelines of information provision during the illness trajectory at NICU would support all professionals.

Anxiety and depression in the first six months after stroke. A longitudinal multicentre study.

PURPOSE: To document the prevalence, severity and time course of anxiety and depression in stroke rehabilitation patients in four European countries. METHOD: At two, four and six months post-stroke, the prevalence and severity of anxiety and depression were determined in 532 consecutively recruited patients, using the Hospital Anxiety and Depression Scale. Time course of prevalence and severity was examined, using Cochran-Q and Friedman-tests, respectively. We identified whether the numbers of anxious/depressed patients at each time point comprised the same individuals. RESULTS: Prevalence of anxiety ranged between 22% and 25%; depression between 24% and 30%. Median severity ranged between 4 and 5. No significant differences between centres occurred (p > 0.05). Prevalence of both disorders was not significantly different over time. Severity of anxiety decreased between four and six months; severity of depression remained stable. About 40% of the patients with initial anxiety remained anxious at six months. Some 11% and 7% of those initially not anxious became anxious at four or six months after stroke, respectively. Depression showed a similar pattern. CONCLUSIONS: Despite differences in patient profiles and intensity of rehabilitation, no significant differences occurred between centres in prevalence and severity of both disorders. Anxiety was almost as common as depression and additional patients became anxious/depressed at each time point.

A methodology for shifting the focus of e-health support design onto user needs: a case in the homecare field.

BACKGROUND: Epidemiological shifts, financial pressures and changing policy priorities in healthcare initiate reflections on innovative ways to deliver care. Technologies offer opportunities to change health services delivery. One of the emerging fields is telehomecare-applications. Yet, these applications are not always adapted to the user needs and characteristics of the homecare setting, resulting in "system failure". OBJECTIVES: We describe a generic methodological model to incorporate user perspectives in the design and development process of e-health systems. The model aims at grounding the choice of the technology in a clear understanding of the homecare field, and on interactive reflections with the technology developers. METHODS AND RESULTS: The methodological model develops over three phases. A first phase aims to identify and to select potential patient groups for which the technology will be developed: It holds (a) gathering of epidemiological data; (b) identifying relevant inclusion criteria to select patient groups; (c) qualitative weighting based on the inclusion criteria to include potential patient groups and (d) plenary discussion with the technology developers. In a second phase, the particular needs of the selected patient groups are assessed through literature review, document analysis and explorative interviews with key informants. In the third phase, "social" use cases are developed in which the use of potential technologies is written as virtual storylines. The writing of the use cases is prepared through a semi-structured questionnaire for all partners listing the "visions and expectations on the technology and user context". The use cases are the source documents for a plenary discussion with the technology developers in which priorities are set for functionalities of the e-homecare platform. The methodological approach is illustrated within the Coplintho-project. It is a Flemish initiative developing an e-homecare platform offering a package of services on a dedicated device to support the social integration and 'independent living' of people in their home environment. DISCUSSION: Our methodological approach provides a practical framework for understanding and considering user perspectives. The application of the method within the development of the Coplintho-e-homecare platform demonstrated its usefulness. The experience within the Coplintho-pilot project learned important lessons about the operational use of the method. The methodology is time-consuming and requires scientific input to assess and to document potential user needs, requiring specific means and human resources. The method also requires a very explicit project management of the preparatory phase.

Motor and functional recovery after stroke: a comparison of 4 European rehabilitation centers.

BACKGROUND AND PURPOSE: Outcome after first stroke varies significantly across Europe. This study was designed to compare motor and functional recovery after stroke between four European rehabilitation centers. METHODS: Consecutive stroke patients (532 patients) were recruited. They were assessed on admission and at 2, 4, and 6 months after stroke with the Barthel Index, Rivermead Motor Assessment of Gross Function, Rivermead Motor Assessment of Leg/Trunk, Rivermead Motor Assessment of Arm, and Nottingham Extended Activities of Daily Living (except on admission). Data were analyzed using random effects ordinal logistic models adjusting for case-mix and multiple testing. RESULTS: Patients in the UK center were more likely to stay in lower Rivermead Motor Assessment of Gross Function classes compared with patients in the German center (DeltaOR, 2.4; 95% CI, 1.3 to 4.3). In the Swiss center, patients were less likely to stay in lower Nottingham Extended Activities of Daily Living classes compared with patients in the UK center (DeltaOR, 0.7; 95% CI, 0.5 to 0.9). The latter were less likely to stay in lower Barthel Index classes compared with the patients in the German center (DeltaOR, 0.6; 95%CI, 0.4 to 0.8). Recovery patterns of Rivermead Motor Assessment of Leg/Trunk and Rivermead Motor Assessment of Arm were not significantly different between centers. CONCLUSIONS: Gross motor and functional recovery were better in the German and Swiss centers compared with the UK center, respectively. Personal self-care recovery was better in the UK compared with the German center. Previous studies in the same centers indicated that German and Swiss patients received more therapy per day. This was not the result of more staff but of a more efficient use of human resources. This study indicates potential for improving rehabilitation outcomes in the UK and Belgian centers.

Inpatient stroke rehabilitation: a comparative study of admission criteria to stroke rehabilitation units in four European centres.

OBJECTIVE: To explore the clinical and non-clinical factors involved in decision-making concerning admission to European stroke rehabilitation units. DESIGN: Observational study on case-mix at intake combined with questionnaires and semi-structured interviews with the medical consultants of each European stroke rehabilitation unit. PATIENTS AND SETTINGS: Clinical data on 532 first-ever patients after stroke. Medical consultants from 6 European stroke rehabilitation units in 4 European countries (UK, Belgium, Germany and Switzerland). METHODS: Standardized clinical assessments within 2 days after admission. Questionnaires to each medical consultants followed by a qualitative round of semi-structured interviews. RESULTS: Case-mix of patients after stroke was significantly different between European stroke rehabilitation units. Clinical criteria for admission were seldom explicit and were evaluated differently between the European stroke rehabilitation units. In the UK units, diagnosis of stroke was the only criterion for admission. In the Belgian, German and Swiss units, pre-morbid conditions were taken into account in admission decisions. The likelihood of discharge home was considered highly important in the Swiss units. CONCLUSION: Case-mix differences at intake could be linked to different appraisals of clinical and non-clinical factors of patients after stroke. The findings urge us to be more explicit about decision-making processes at admission in order to provide a more comprehensive insight into the interplay between context and process of care.