Value-based health care in translation: From global popularity to primary care for Dutch elderly patients.

In this article we examine the fragmented interpretation and implementation of a remarkably popular concept, value-based health care (VBHC). By building on a case study of a project team working on the development of value-based primary care services for elderly patients, we shed new light on the way in which VBHC transitions from theory to practice. The concept of 'translation' is used to theoretically frame our analysis. Between June 2021 and May 2022, we gathered data through participant observation (50 h), semi-structured interviews (n = 20) and document analysis (n = 16). Our findings show how VBHC inspired new ways of working, and that, in line with previous studies, parts of the original concept have been neglected, while others have been modified. We identified three reasons for VBHC's locally varied applications: VBHC transforms to enable a growing support base, the originally radical idea is applied conservatively and the concept tends to get mixed up with other policy objectives. In all, VBHC appears to be successful in catalysing cross-disciplinary interaction aimed at improving value for patients.

Eye for an AI: More-than-seeing, fauxtomation, and the enactment of uncertain data in digital pathology.

Artificial Intelligence (AI) tools are being developed to assist with increasingly complex diagnostic tasks in medicine. This produces epistemic disruption in diagnostic processes, even in the absence of AI itself, through the datafication and digitalization encouraged by the promissory discourses around AI. In this study of the digitization of an academic pathology department, we mobilize Barad's agential realist framework to examine these epistemic disruptions. Narratives and expectations around AI-assisted diagnostics-which are inextricable from material changes-enact specific types of organizational change, and produce epistemic objects that facilitate to the emergence of some epistemic practices and subjects, but hinder others. Agential realism allows us to simultaneously study epistemic, ethical, and ontological changes enacted through digitization efforts, while keeping a close eye on the attendant organizational changes. Based on ethnographic analysis of pathologists' changing work processes, we identify three different types of uncertainty produced by digitization: sensorial, intra-active, and fauxtomated uncertainty. Sensorial and intra-active uncertainty stem from the ontological otherness of digital objects, materialized in their affordances, and result in digital slides' partial illegibility. Fauxtomated uncertainty stems from the quasi-automated digital slide-making, which complicates the question of responsibility for epistemic objects and related knowledge by marginalizing the human.

Diversity in Stakeholder Groups in Generative Co-design for Digital Health: Assembly Procedure and Preliminary Assessment.

BACKGROUND: Diverse knowledge and ways of thinking are claimed to be important when involving stakeholders such as patients, care professionals, and care managers in a generative co-design (GCD) process. However, this claim is rather general and has not been operationalized; therefore, the influence of various stakeholders on the GCD process has not been empirically tested. OBJECTIVE: In this study, we aimed to take the first step in assessing stakeholder diversity by formulating a procedure to assemble a group of diverse stakeholders and test its influence in a GCD process. METHODS: To test the procedure and assess its influence on the GCD process, a case was selected involving a foundation that planned to develop a serious game to help people with cancer return to work. The procedure for assembling a stakeholder group involves snowball sampling and individual interviews, leading to the formation of 2 groups of stakeholders. Thirteen people were identified through snowball sampling, and they were briefly interviewed to assess their knowledge, inference experience, and communication skills. Two diverse stakeholder groups were formed, with one more potent than the other. The influence of both stakeholder groups on the GCD process was qualitatively assessed by comparing the knowledge output and related knowledge processing in 2 identical GCD workshops. RESULTS: Our hypothesis on diverse stakeholders was confirmed, although it also appeared that merely assessing the professional background of stakeholders was not sufficient to reach the full potential of the GCD process. The more potently diverse group had a stronger influence on knowledge output and knowledge processing, resulting in a more comprehensive problem definition and more precisely described solutions. In the less potently diverse group, none of the stakeholders had experience with abduction-2 inferencing, and this did not emerge in the GCD process, suggesting that at least one stakeholder should have previous abduction-2 experience. CONCLUSIONS: A procedure to assemble a stakeholder group with specific criteria to assess the diversity of knowledge, ways of thinking, and communication can improve the potential of the GCD process and the resulting digital health.

Conceptualizing the digitalization of healthcare work: A metaphor-based Critical Interpretive Synthesis.

The digitalization of healthcare work has gained center stage in academic debates spanning disciplines as diverse as medicine, sociology and STS. The different analytical interests and methodological traditions of these three strains of scholarship have, however, resulted in quite diverging approaches to this issue. Points of interest have ranged from the (disattended) promise of increased efficiency of healthcare work, to dynamics of task delegation, (re-)professionalization and (re-)distribution of invisible work, to the disruption of informal organization. Instead of studying these dynamics in practice, in this paper we foreground the potentiality for theory-making inherent in the systematic cross-contamination of different theoretical and disciplinary perspectives. We perform a Critical Interpretive Synthesis (CIS) centering the ways the digitalization of healthcare work has been investigated in recent STS, sociological and medical literature. To open up assumptions and insights intrinsic to each body of literature for scholars and practitioners in other fields, we propose here a metaphor-based variation on CIS approaches. We probe, in turn, what slime molds can teach us about STS's focus on interconnections and materiality, how we can better understand sociological analyses of invisible work exploring them through theatrical performances, and which lessons river engineering offers concerning medical scholarship's discussion of efficiency and proper healthcare work. Thinking through these metaphors, we conceptualize the digitalization of healthcare work as a phenomenon spanning, at once, the directionality of technological innovation trajectories and the open-endedness of situated changes in work practices. Based on our analysis, we propose focusing on technological scripts, and various forms of invisible work and informal organization as entry points into the study of the tension between directionality and open-endedness in the context of the digitalization of healthcare work.

Between "Medical" and "Social" Egg Freezing : A Comparative Analysis of Regulatory Frameworks in Austria, Germany, Israel, and the Netherlands.

Egg freezing has led to heated debates in healthcare policy and bioethics. A crucial issue in this context concerns the distinction between "medical" and "social" egg freezing (MEF and SEF)-contrasting objections to bio-medicalization with claims for oversimplification. Yet such categorization remains a criterion for regulation. This paper aims to explore the "regulatory boundary-work" around the "medical"-"social" distinction in different egg freezing regulations. Based on systematic documents' analysis we present a cross-national comparison of the way the "medical"-"social" differentiation finds expression in regulatory frameworks in Austria, Germany, Israel, and the Netherlands. Findings are organized along two emerging themes: (1) the definition of MEF and its distinctiveness-highlighting regulatory differences in the clarity of the definition and in the medical indications used for creating it (less clear in Austria and Germany, detailed in Israel and the Netherlands); and (2) hierarchy of medical over social motivations reflected in usage and funding regulations. Blurred demarcation lines between "medical" and "social" are further discussed as representing a paradoxical inclusion of SEF while offering new insights into the complexity and normativity of this distinction. Finally, we draw conclusions for policymaking and the bioethical debate, also concerning the related cryopolitical aspects.

Role of Dutch internal policy advisors in a hospital quality improvement programme and their influence on nurses' role development: a qualitative study.

OBJECTIVE: Nurses are vital in providing and improving quality of care. To enhance the quality improvement (QI) competencies of nurses, hospitals in the Netherlands run developmental programmes generally led by internal policy advisors (IPAs). In this study, we identify the roles IPAs play during these programmes to enhance the development of nurses' QI competencies and studied how these roles influenced nurses and management. DESIGN: An exploratory ethnographical study comprising observations, informal conversations, semistructured interviews, focus groups and a strategy evaluation meeting. SETTING: A teaching hospital in an urban region in the Netherlands. PARTICIPANTS: IPAs (n=7) in collaboration with four teams of nurses (n=131), team managers (n=4), senior managers (n=4) and the hospital director (n=1). RESULTS: We identified five distinct advisory roles that IPAs perform in the hospital programme: gatekeeper, connector, converter, reflector and implementer. In describing these roles, we provide insights into how IPAs help nurses to develop QI competencies. The IPA's professional background was a driving force for nurses' QI role development. However, QI development was threatened if IPAs lost sight of different stakeholders' interests and consequently lost their credibility. QI role development among nurses was also threatened if the IPA took on all responsibility instead of delegating it timely to managers and nurses. CONCLUSIONS: We have shown how IPAs' professional background and advisory knowledge connect organisational, managerial and professional aims and interests to enhance professionalisation of nurses.

Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice.

BACKGROUND: Transitions in healthcare delivery, such as the rapidly growing numbers of older people and increasing social and healthcare needs, combined with nursing shortages has sparked renewed interest in differentiations in nursing staff and skill mix. Policy attempts to implement new competency frameworks and job profiles often fails for not serving existing nursing practices. This study is aimed to understand how licensed vocational nurses (VNs) and nurses with a Bachelor of Science degree (BNs) shape distinct nursing roles in daily practice. METHODS: A qualitative study was conducted in four wards (neurology, oncology, pneumatology and surgery) of a Dutch teaching hospital. Various ethnographic methods were used: shadowing nurses in daily practice (65h), observations and participation in relevant meetings (n=56), informal conversations (up to 15 h), 22 semi-structured interviews and member-checking with four focus groups (19 nurses in total). Data was analyzed using thematic analysis. RESULTS: Hospital nurses developed new role distinctions in a series of small-change experiments, based on action and appraisal. Our findings show that: (1) this developmental approach incorporated the nurses' invisible work; (2) nurses' roles evolved through the accumulation of small changes that included embedding the new routines in organizational structures; (3) the experimental approach supported the professionalization of nurses, enabling them to translate national legislation into hospital policies and supporting the nurses' (bottom-up) evolution of practices. The new roles required the special knowledge and skills of Bachelor-trained nurses to support healthcare quality improvement and connect the patients' needs to organizational capacity. CONCLUSIONS: Conducting small-change experiments, anchored by action and appraisal rather than by design, clarified the distinctions between vocational and Bachelor-trained nurses. The process stimulated personal leadership and boosted the responsibility nurses feel for their own development and the nursing profession in general. This study indicates that experimental nursing role development provides opportunities for nursing professionalization and gives nurses, managers and policymakers the opportunity of a 'two-way-window' in nursing role development, aligning policy initiatives with daily nursing practices.

Women's viewpoints on egg freezing in Austria: an online Q-methodology study.

BACKGROUND: Egg freezing has emerged as a technology of assisted reproductive medicine that allows women to plan for the anticipated loss of fertility and hence to preserve the option to conceive with their own eggs. The technology is surrounded by value-conflicts and is subject to ongoing discussions. This study aims at contributing to the empirical-ethical debate by exploring women's viewpoints on egg freezing in Austria, where egg freezing for social reasons is currently not allowed. METHODS: Q-methodology was used to identify prevailing viewpoints on egg freezing. 46 female participants ranked a set of 40 statements onto a 9-column forced choice ranking grid according to the level of agreement. Participants were asked to explain their ranking in a follow-up survey. By-person factor analysis was used to identify distinct viewpoints which were interpreted using both the quantitative and the qualitative data. RESULTS: Three distinct viewpoints were identified: (1) "women should decide for themselves", (2) "we should accept nature but change policy", and (3) "we need an informed societal debate". These viewpoints provide insights into how biomedical innovations such as egg freezing are perceived by women in Austria and illustrate the normative tensions regarding such innovations. CONCLUSIONS: Acknowledging the different prioritizations of values regarding assisted reproductive technologies is important to better understand the underlying normative tensions in a country where egg freezing for social reasons is currently not allowed. The study adds new empirical insights to the ongoing debate by outlining and discussing viewpoints of those directly affected: women. Following up on the lay persons perspective is particularly important in the context of future biomedical innovations that may challenge established norms and create new tensions. It therefore also adds to the societal debate and supports evidence-informed policy making in that regard.

Necessity under construction - societal weighing rationality in the appraisal of health care technologies.

Health care coverage decisions may employ many different considerations, which are brought together across two phases. The assessment phase examines the available scientific evidence, such as the cost-effectiveness, of the technology. The appraisal then contextualises this evidence to arrive at an (advised) coverage decision, but little is known about how this is done.In the Netherlands, the appraisal is set up to achieve a societal weighing and is the primary place where need- and solidarity-related ('necessity') argumentations are used. To elucidate how the Dutch appraisal committee 'constructs necessity', we analysed observations and recordings of two appraisal committee meetings at the National Health Care Institute, the corresponding documents (five), and interviews with committee members and policy makers (13 interviewees in 12 interviews), with attention to specific necessity argumentations.The Dutch appraisal committee constructs necessity in four phases: (1) allowing explicit criteria to steer the process; (2) allowing patient (representative) contributions to challenge the process; (3) bringing new argumentations in from outside and weaving them together; and (4) formulating recommendations to societal stakeholders. We argue that in these ways, the appraisal committee achieves societal weighing rationality, as the committee actively uses argumentations from society and embeds the decision outcome in society.

Who contextualises clinical epidemiological evidence? A political analysis of the problem of evidence-based medicine in the layered Dutch healthcare system.

We critically examine the discussion on the role of evidence-based medicine (EBM) in healthcare governance. We take the institutionally layered Dutch healthcare system as our case study. Here, different actors are involved in the regulation, provision and financing of healthcare services. Over the last decades, these actors have related to EBM to inform their actor specific roles. At the same time, EBM has increasingly been problematised. To better understand this problematisation, we organised focus groups and interviews. We noticed that particularly EBM's reductionist epistemology and its uncritical use by 'professional others' are considered problematic. However, our analysis also reveals that something else seems to be at stake. In fact, all the actors involved underwrite EBM's reductionist epistemology and emphasise that evidence should be contextualised. They however do so in different ways and with different contexts in mind. Moreover, the ways in which some actors contextualise evidence has consequences for the ways in which others can do the same. We therefore emphasise that behind EBM's scientific problematisation lurks a political issue. A dispute over who should contextualise evidence how, in a layered healthcare system with interdependent actors that cater to both individual patients and the public. We urge public administration scholars and policymakers to open-up the political confrontation between healthcare actors and their sometimes irreconcilable, yet evidence-informed perspectives.

Lessons for Employing Participatory Design When Developing Care for Young People with Cancer: A Qualitative Multiple-Case Study.

Purpose: Participatory design (PD) is a collective creative design process involving designers and nondesigners. There is limited reporting on the experience of using PD for adolescent and young adult (AYA) care. This study summarizes lessons from employing PD to develop care for AYAs with cancer. Methods: A qualitative multiple-case study method was conducted of three PD processes addressing food (FfC), intimacy and sexuality (I&S), and integrative medicine (IM) in caring for AYAs with cancer. Results: Local key stakeholders, who were exposed to a problem and had not been successful at solving it individually, were recruited to "dream" together. Through this synergy, a shared understanding of the problem and a joint mission emerged to find a solution. PD tools were used to develop a problem definition. An open mind and explorative research helped to understand the problems, and stakeholders were managed such that idea-sharing and learning were enabled. Designers translated ideas into prototypes. The PD process was prolonged due to the hierarchical hospital environment, business considerations, and additionally required evidence. The FfC program produced an effective new food service for the whole hospital. The I&S initiative developed a podcast, two articles, and a prototype website. The IM project developed a pilot study. Conclusions: For a PD process to successfully develop care for AYAs, one needs to use designers and skilled people, PD tools, and an open-ended approach to visualize and materialize new forms of care. Furthermore, recruitment and facilitation techniques help leverage knowledge and create a synergy in a democratic environment between stakeholders.

Understanding the Uptake of Big Data in Health Care: Protocol for a Multinational Mixed-Methods Study.

BACKGROUND: Despite the high potential of big data, their applications in health care face many organizational, social, financial, and regulatory challenges. The societal dimensions of big data are underrepresented in much medical research. Little is known about integrating big data applications in the corporate routines of hospitals and other care providers. Equally little is understood about embedding big data applications in daily work practices and how they lead to actual improvements for health care actors, such as patients, care professionals, care providers, information technology companies, payers, and the society. OBJECTIVE: This planned study aims to provide an integrated analysis of big data applications, focusing on the interrelations among concrete big data experiments, organizational routines, and relevant systemic and societal dimensions. To understand the similarities and differences between interactions in various contexts, the study covers 12 big data pilot projects in eight European countries, each with its own health care system. Workshops will be held with stakeholders to discuss the findings, our recommendations, and the implementation. Dissemination is supported by visual representations developed to share the knowledge gained. METHODS: This study will utilize a mixed-methods approach that combines performance measurements, interviews, document analysis, and cocreation workshops. Analysis will be structured around the following four key dimensions: performance, embedding, legitimation, and value creation. Data and their interrelations across the dimensions will be synthesized per application and per country. RESULTS: The study was funded in August 2017. Data collection started in April 2018 and will continue until September 2021. The multidisciplinary focus of this study enables us to combine insights from several social sciences (health policy analysis, business administration, innovation studies, organization studies, ethics, and health services research) to advance a holistic understanding of big data value realization. The multinational character enables comparative analysis across the following eight European countries: Austria, France, Germany, Ireland, the Netherlands, Spain, Sweden, and the United Kingdom. Given that national and organizational contexts change over time, it will not be possible to isolate the factors and actors that explain the implementation of big data applications. The visual representations developed for dissemination purposes will help to reduce complexity and clarify the relations between the various dimensions. CONCLUSIONS: This study will develop an integrated approach to big data applications that considers the interrelations among concrete big data experiments, organizational routines, and relevant systemic and societal dimensions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/16779.

The Need for Sustainable Teleconsultation Systems in the Aftermath of the First COVID-19 Wave.

The physical and social distancing measures that have been adopted worldwide because of COVID-19 will probably remain in place for a long time, especially for senior adults, people with chronic conditions, and other at-risk populations. Teleconsultations can be useful in ensuring that patients continue to receive clinical care while reducing physical crowding and avoiding unnecessary exposure of health care staff. Implementation processes that typically take months of planning, budgeting, pilot testing, and education were compressed into days. However, in the urgency to deal with the present crisis, we may be forgetting that the introduction of digital health is not exclusively a technological issue, but part of a complex organizational change problem. This viewpoint offers insight regarding issues that rapidly adopted teleconsultation systems may face in a post-COVID-19 world.

Redefining value: a discourse analysis on value-based health care.

BACKGROUND: Today's remarkable popularity of value-based health care (VBHC) is accompanied by considerable ambiguity concerning the very meaning of the concept. This is evident within academic publications, and mirrored in fragmented and diversified implementation efforts, both within and across countries. METHOD: This article builds on discourse analysis in order to map the ambiguity surrounding VBHC. We conducted a document analysis of publicly accessible, official publications (n = 22) by actors and organizations that monitor and influence the quality of care in the Netherlands. Additionally, between March and July 2019, we conducted a series of semi-structured interviews (n = 23) with national stakeholders. RESULTS: Our research revealed four discourses, each with their own perception regarding the main purpose of VBHC. Firstly, we identified a Patient Empowerment discourse in which VBHC is a framework for strengthening the position of patients regarding their medical decisions. Secondly, in the Governance discourse, VBHC is a toolkit to incentivize providers. Thirdly, within the Professionalism discourse, VBHC is a methodology for healthcare delivery. Fourthly, in the Critique discourse, VBHC is rebuked as a dogma of manufacturability. We also show, however, that these diverging lines of reasoning find common ground: they perceive shared decision-making to be a key component of VBHC. Strikingly, this common perception contrasts with the pioneering literature on VBHC. CONCLUSIONS: The four discourses will profoundly shape the diverse manners in which VBHC moves from an abstract concept to the practical provision and administration of health care. Moreover, our study reveals that VBHC's conceptual ambiguity largely arises from differing and often deeply rooted presuppositions, which underlie these discourses, and which frame different perceptions on value in health care. The meaning of VBHC - including its perceived implications for action - thus depends greatly on the frame of reference an actor or organization brings to bear as they aim for more value for patients. Recognizing this is a vital concern when studying, implementing and evaluating VBHC.

Non-dispensing pharmacist integrated in the primary care team: effect on the quality of physician's prescribing, a non-randomised comparative study.

Background Especially in elderly with polypharmacy, medication can do harm. Clinical pharmacists integrated in primary care teams might improve quality of pharmaceutical care. Objective To assess the effect of non-dispensing clinical pharmacists integrated in primary care teams on general practitioners' prescribing quality. Setting This study was conducted in 25 primary care practices in the Netherlands. Methods Non-randomised, controlled, multi-centre, complex intervention study with pre-post comparison. First, we identified potential prescribing quality indicators from the literature and assessed their feasibility, validity, acceptability, reliability and sensitivity to change. Also, an expert panel assessed the indicators' health impact. Next, using the final set of indicators, we measured the quality of prescribing in practices where non-dispensing pharmacists were integrated in the team (intervention group) compared to usual care (two control groups). Data were extracted anonymously from the healthcare records. Comparisons were made using mixed models correcting for potential confounders. Main outcome measure Quality of prescribing, measured with prescribing quality indicators. Results Of 388 eligible indicators reported in the literature we selected 8. In addition, two more indicators relevant for Dutch general practice were formulated by an expert panel. Scores on all 10 indicators improved in the intervention group after introduction of the non-dispensing pharmacist. However, when compared to control groups, prescribing quality improved solely on the indicator measuring monitoring of the renal function in patients using antihypertensive medication: relative risk of a monitored renal function in the intervention group compared to usual care: 1.03 (95% CI 1.01-1.05, p-value 0.010) and compared to usual care plus: 1.04 (1.01-1.06, p-value 0.004). Conclusion This study did not demonstrate a consistent effect of the introduction of non-dispensing clinical pharmacists in the primary care team on the quality of physician's prescribing.This study is part of the POINT-study, which was registered at The Netherlands National Trial Register with trial registration number NTR-4389.

Around the Tables - Contextual Factors in Healthcare Coverage Decisions Across Western Europe.

BACKGROUND: Across Western Europe, procedures and formalised criteria for taking decisions on the coverage (inclusion in the benefits basket or equivalent) of healthcare technologies vary substantially. In the decision documents, which display the justification of, the rationale for, these decisions, national healthcare institutes may employ 'contextual factors,' defined here as situation-specific considerations. Little is known about how the use of such contextual factors compares across countries. We describe and compare contextual factors as used in coverage decisions generally and 4 decision documents specifically in Belgium, England, Germany, and the Netherlands. METHODS: Four group interviews with 3 experts from the national healthcare institute of each country, document and web site analysis, and a workshop with 1 to 2 of these experts per country were followed by the examination of the documents of 4 specific decisions taken in each of the 4 countries, sampled to vary widely in type of technology and decision outcome. RESULTS: From the available decision documents, we conclude that in every country studied, contextual factors are established 'around the table,' ie, in deliberation. All documents examined feature contextual factors, with similar contextual factor patterns leading to similar decisions in different countries. The Dutch decisions employ the widest variety of factors, with the exception of the societal functioning of the patient, which is relatively common in Belgium, England, and Germany. Half of the final decisions were taken in another setting, with the consequence that no documentation was retrievable for 2 decisions. CONCLUSION: First, we conclude that in these countries, contextual factors are actively integrated in the decision document, and that this is achieved in deliberation. Conceptualising contextual factors as both situation-specific and actively-integrated affords insight into practices of contextualisation and provides an encouragement for exchange between decision-makers on more qualitative aspects of decisions. Second, the decisions that lacked a publicly accessible justification of the final decision document raised questions on the decisions' legitimacy. Further research could address patterning of contextual factors, elucidate why some factors may remain implicit, and how decisions without a publicly available decision document may enable or restrain decision-making practice.

Epistemic virtues and data-driven dreams: On sameness and difference in the epistemic cultures of data science and psychiatry.

Data science and psychiatry have diverse epistemic cultures that come together in data-driven initiatives (e.g., big data, machine learning). The literature on these initiatives seems to either downplay or overemphasize epistemic differences between the fields. In this paper, we study the convergence and divergence of the epistemic cultures of data science and psychiatry. This approach is more likely to capture where and how the cultures differ and gives insights into how practitioners from both fields find ways to work together despite their differences. We introduce the notions of "epistemic virtues" to focus on epistemic differences ethnographically, and "trading zones" to concentrate on how differences are negotiated. This leads us to the following research question: how are epistemic differences negotiated by data science and psychiatry practitioners in a hospital-based data-driven initiative? Our results are based on an ethnographic study in which we observed a Dutch psychiatric hospital department developing prediction models of patient outcomes based on machine learning techniques (September 2017 - February 2018). Many epistemic virtues needed to be negotiated, such as completeness or selectivity in data inclusion. These differences were traded locally and temporarily, stimulated by shared epistemic virtues (such as a systematic approach), boundary objects and socialization processes. Trading became difficult when virtues were too diverse, differences were enlarged by storytelling and parties did not have the time or capacity to learn about the other. In the discussion, we argue that our combined theoretical framework offers a fresh way to study how cooperation between diverse practitioners goes and where it can be improved. We make a call for bringing epistemic differences into the open as this makes a grounded discussion possible about the added value of data-driven initiatives and the role they can play in healthcare.

Generative Participatory Design Methodology to Develop Electronic Health Interventions: Systematic Literature Review.

BACKGROUND: Generative participatory design (PD) may help in developing electronic health (eHealth) interventions. PD is characterized by the involvement of all stakeholders in creative activities. This is different from the traditional user-centered design, where users are less involved. When looking at PD from a research through design perspective, it is important to summarize the reasons for choosing a certain form of generative PD to further develop its methodology. However, the scientific literature is currently unclear about which forms of PD are used to develop eHealth and which arguments are used to substantiate the decision to use a certain form of generative PD. OBJECTIVE: This study aimed to explore the reporting and substantiation of generative PD methodologies in empirical eHealth studies published in scientific journals to further develop PD methodology in the field of eHealth. METHODS: A systematic literature review following the Cochrane guidelines was conducted in several databases (EMBASE, MEDLINE Ovid, Web of Science, and CINAHL EBSCOhost). Data were extracted on the recruitment and management of stakeholders, the use of tools, and the use of outcome measures. RESULTS: Of the 3131 studies initially identified, 69 were selected for qualitative synthesis. The reporting was very variable, depending to a large extent on whether the study stated that reporting on the PD process was a major aim. The different levels of reporting and substantiation of the choices of a recruitment strategy, stakeholder management, and tools and outcome measures are presented. Only a few authors explicitly used arguments directly related to PD guiding principles such as democratic, mutual learning, tacit and latent knowledge, and collective creativity. Even though PD principles were not always explicitly discussed in the method descriptions of the studies, they were implicitly present, mostly in the descriptions of the use of PD tools. The arguments used to substantiate the choices made in stakeholder management, PD tools, and the type of outcome measures adopted point to the involvement of PD principles. CONCLUSIONS: Studies that have used a PD research methodology to develop eHealth primarily substantiate the choice of tools made and much less the use of stakeholders and outcome measures.

How Clinical Integration of Pharmacists in General Practice has Impact on Medication Therapy Management: A Theory-oriented Evaluation.

BACKGROUND: Data on medication-related hospital admissions suggest that there is an opportunity for improved pharmaceutical care. Hence, concerns about medication-related hospital admissions is a driver to extend and integrate the role of community pharmacists in general practice. AIM: The aim of this paper is to give a systematic description of 1) what integrating a non-dispensing pharmacist (NDP) in general practice entails and 2) how this integrated care model is expected to contribute to patients' medication therapy management. METHODS: Based on ethnographic data collected by NDPs in general practices in the Netherlands, we conducted a theory evaluation. RESULTS: The impact of NDPs providing integrated care can be explained by 1) the specific expertise NDPs bring into general practice and the tailored solutions they offer for individual patients, including deviation from medical protocols when necessary, 2) the reconciliation of interprofessional tensions caused by overlapping tasks with practice nurses, which results in a distinct patient population, 3) the conduct of clinical medication reviews aligned to the work processes of the GP practice and 4) the integration of quality management work into clinical work. CONCLUSION: The success of integrated pharmaceutical care is dependent on how NDPs collaborate with GPs and practice nurses. NDPs need to mobilize clinical pharmaceutical expertise into general practice. Yet, integrating quality management into clinical work is key to integrate pharmaceutical care. Paradoxically, full integration requires from NDPs to develop a distinct role in general practice.

Non-dispensing pharmacists' actions and solutions of drug therapy problems among elderly polypharmacy patients in primary care.

OBJECTIVE: To evaluate the process of clinical medication review for elderly patients with polypharmacy performed by non-dispensing pharmacists embedded in general practice. The aim was to identify the number and type of drug therapy problems and to assess how and to what extent drug therapy problems were actually solved. METHOD: An observational cross-sectional study, conducted in nine general practices in the Netherlands between June 2014 and June 2015. On three pre-set dates, the non-dispensing pharmacists completed an online data form about the last 10 patients who completed all stages of clinical medication review. Outcomes were the type and number of drug therapy problems, the extent to which recommendations were implemented and the percentage of drug therapy problems that were eventually solved. Interventions were divided as either preventive (aimed at following prophylactic guidelines) or corrective (aimed at active patient problems). RESULTS: In total, 1292 drug therapy problems were identified among 270 patients, with a median of 5 (interquartile range 3) drug therapy problems per patient, mainly related to overtreatment (24%) and undertreatment (21%). The non-dispensing pharmacists most frequently recommended to stop medication (32%). Overall, 83% of the proposed recommendations were implemented; 57% were preventive, and 35% were corrective interventions (8% could not be assessed). Almost two-third (64%) of the corrective interventions actually solved the drug therapy problem. CONCLUSION: Non-dispensing pharmacists integrated in general practice identified a large number of drug therapy problems and successfully implemented a proportionally high number of recommendations that solved the majority of drug therapy problems.