Early-stage health technology assessment of fractional flow reserve coronary computed tomography versus standard diagnostics in patients with stable chest pain in The Netherlands.

OBJECTIVES: The aim of this early-stage Health Technology Assessment (HTA) was to assess the difference in healthcare costs and effects of fractional flow reserve derived from coronary computed tomography (FFRct) compared to standard diagnostics in patients with stable chest pain in The Netherlands. METHODS: A decision-tree model was developed to assess the difference in total costs from the hospital perspective, probability of correct diagnoses, and risk of major adverse cardiovascular events at one year follow-up. One-way sensitivity analyses were conducted to determine the main drivers of the cost difference between the strategies. A threshold analysis on the added price of FFRct analysis (computational analysis only) was conducted. RESULTS: The mean one-year costs were €2,680 per patient for FFRct and €2,915 per patient for standard diagnostics. The one-year probability of correct diagnoses was 0.78 and 0.61, and the probability of major adverse cardiovascular events was 1.92x10-5 and 0.01, respectively. The probability and costs of revascularization and the specificity of coronary computed tomography angiography had the greatest effect on the difference in costs between the strategies. The added price of FFRct analysis should be below €935 per patient to be considered the least costly option. CONCLUSIONS: The early-stage HTA findings suggest that FFRct may reduce total healthcare spending, probability of incorrect diagnoses, and major adverse cardiovascular events compared to current diagnostics for patients with stable chest pain in the Dutch healthcare setting over one year. Future cost-effectiveness studies should determine a value-based pricing for FFRct and quantify the economic value of the anticipated therapeutic impact.

Trust in and Acceptance of Artificial Intelligence Applications in Medicine: Mixed Methods Study.

BACKGROUND: Artificial intelligence (AI)-powered technologies are being increasingly used in almost all fields, including medicine. However, to successfully implement medical AI applications, ensuring trust and acceptance toward such technologies is crucial for their successful spread and timely adoption worldwide. Although AI applications in medicine provide advantages to the current health care system, there are also various associated challenges regarding, for instance, data privacy, accountability, and equity and fairness, which could hinder medical AI application implementation. OBJECTIVE: The aim of this study was to identify factors related to trust in and acceptance of novel AI-powered medical technologies and to assess the relevance of those factors among relevant stakeholders. METHODS: This study used a mixed methods design. First, a rapid review of the existing literature was conducted, aiming to identify various factors related to trust in and acceptance of novel AI applications in medicine. Next, an electronic survey including the rapid review-derived factors was disseminated among key stakeholder groups. Participants (N=22) were asked to assess on a 5-point Likert scale (1=irrelevant to 5=relevant) to what extent they thought the various factors (N=19) were relevant to trust in and acceptance of novel AI applications in medicine. RESULTS: The rapid review (N=32 papers) yielded 110 factors related to trust and 77 factors related to acceptance toward AI technology in medicine. Closely related factors were assigned to 1 of the 19 overarching umbrella factors, which were further grouped into 4 categories: human-related (ie, the type of institution AI professionals originate from), technology-related (ie, the explainability and transparency of AI application processes and outcomes), ethical and legal (ie, data use transparency), and additional factors (ie, AI applications being environment friendly). The categorized 19 umbrella factors were presented as survey statements, which were evaluated by relevant stakeholders. Survey participants (N=22) represented researchers (n=18, 82%), technology providers (n=5, 23%), hospital staff (n=3, 14%), and policy makers (n=3, 14%). Of the 19 factors, 16 (84%) human-related, technology-related, ethical and legal, and additional factors were considered to be of high relevance to trust in and acceptance of novel AI applications in medicine. The patient's gender, age, and education level were found to be of low relevance (3/19, 16%). CONCLUSIONS: The results of this study could help the implementers of medical AI applications to understand what drives trust and acceptance toward AI-powered technologies among key stakeholders in medicine. Consequently, this would allow the implementers to identify strategies that facilitate trust in and acceptance of medical AI applications among key stakeholders and potential users.

Early modelling of the effects and healthcare costs of the Dutch citizen-rescuer system for out-of-hospital cardiac arrests.

OBJECTIVES: 1) to analyse the total average healthcare costs of a patient with an out-of-hospital cardiac arrest (OHCA), as well as estimating the operational costs of the citizen-rescuer system (CRS); 2) to conduct an early modelling of the effects and healthcare costs of the Dutch CRS in comparison to no CRS. METHODS: A health economic modelling study was conducted. Adult patients with OHCA from cardiac causes in the province of Limburg (the Netherlands) were included. The time horizon was from OHCA occurrence up to one year after hospital discharge. First, the total average healthcare costs of OHCA patients were analysed as well as the yearly operating costs of the CRS. Second, an early modelling was conducted to compare from the healthcare perspective the healthcare costs of OHCA patients with the CRS being activated but no responders attended (CRS-NV) versus the CRS being activated with attendance of ≥1 responder(s) (CRS-V). RESULTS: The total average healthcare costs per patient are €42,533. The yearly operating costs for the CRS are approximately €1.5 million per year in the Netherlands. The early modelling of costs and effects showed that the incremental healthcare costs per patient thus were €4,131 in the CRS-V versus the CRS-NV group (€25,184 in the CRS-V group and €21,053 in the CRS-NV group). Incremental quality-adjusted life years (QALYs) was 5 per 100 patients (16 per 100 patients in the CRS-V group versus 11 per 100 patients in the CRS-NV group). The incremental cost-effectiveness ratio (ICER) was €79,662 per QALY for the CRS-V group. CONCLUSION: This study shows that patients in the CSR-V group had additional health care costs of €4,131 per patient compared to patients in the CRS-NV group. This increase is caused by patients surviving more often, who then continue to utilise health services, which results in a (logic) increase in healthcare costs. For future research, accurate and up-to-date data on effectiveness and costs of the CRS needs to be collected.

Person-centred care in the Dutch primary care setting: Refinement of middle-range theory by patients and professionals.

In a previous rapid realist review (RRR) of international literature insight was provided into how, why, and under what circumstances person-centred care (PCC) in primary care works (or not) among others for people with low health literacy skills and for people with a diverse ethnic and socioeconomic background, by establishing a middle-range programme theory (PT), which describes the relationship between context items, mechanisms, and outcomes. Since the application of PCC in primary care in the Dutch setting is expected to differ from other countries, the objective of this study is to validate the items (face validity) resulting from the RRR for the Dutch setting by assessing consensus on the relevance of items. Four focus group discussions with patient representatives and patients with limited health literacy skills (n = 14), and primary care professionals (n = 11) were held partly combined with a Delphi-study. Items were added to refine the middle-range PT for the Dutch primary care setting. These items indicated that in order to optimally align care to the patient tailored supporting material that is developed together with the target group is important, next to providing tailored communication. Healthcare providers (HCPs) and patients need to have a shared vision and set up goals and action plans together. HCPs should stimulate patient's self-efficacy, need to be aware of the patient's (social) circumstances and work in a culturally sensitive way. Better integration between information and communications technology systems, flexible payment models, and patients access to documents, and recorded consultations should be in place. This may result in better alignment of care to the needs of patients, improved accessibility to care, improved patient's self-efficacy, and improved health-related quality of life. On the long-term higher cost-effectiveness and a higher quality of healthcare can be realised. In conclusion, this study shows that for PCC to be effective in Dutch primary care, the PT based on international literature was refined by leaving out items and adding new items for which insufficient or sufficient consensus, respectively, was found.

New Heat and Moisture Exchangers for Laryngectomized Patients in Germany: Mixed Methods Study on the Expected Effectiveness.

BACKGROUND: Notwithstanding the benefits of heat and moisture exchangers (HMEs) in both clinical research and practice, a gap exists between the optimal physiological humidification created through the nasal function and the humidification capacity of HMEs for patients after total laryngectomy. In this study, 5 new HMEs (Provox Life) specialized for situational use with improved humidification capacities were evaluated. OBJECTIVE: This study aims to evaluate the effectiveness of the existing HMEs, assess the potential effectiveness of the new HMEs, and elicit expert judgments on the new HMEs' expected effectiveness and impact on health care use. METHODS: First, a rapid literature review (RLR) was performed to identify evidence on the clinical outcomes, health outcomes, and complications of HMEs in patients who underwent laryngectomy. Second, semistructured interviews with German experts (n=4) were conducted to validate the findings of the RLR and identify reasonable expectations regarding the potential of the new HMEs. Third, a structured expert elicitation among German experts (n=19) was used to generate quantitative evidence on the expected effectiveness of the new HMEs in clinical and health outcomes. RESULTS: The RLR (n=10) demonstrated that HME use by patients has advantages compared with no HME use concerning breathing resistance, tracheal dryness and irritation, mucus production and plugging, frequency of cough and forced expectorations, sleep quality, voice quality, use of physiotherapy, tracheobronchitis or pneumonia episodes, quality of life, and patient satisfaction. From the expert interviews and structured expert elicitation, it was found that, on average, experts expect that compared with the second-generation HMEs, the new HMEs will lead to a decrease in tracheal dryness or irritation (51%, SD 24%, of patients), mucus plug events (33%, SD 32%, of patients), mucus production (53%, SD 22%, of patients), physiotherapy (0.74, SD 0.70, days) and pulmonary infections (34%, SD 32%) and an increase or improvement in speech quality (25%, SD 23%, of patients), social contacts (13%, SD 18%), quality of life (33%, SD 30%), and patient satisfaction (44%, SD 30%). An improvement in breathing (53%, SD 28%, of patients) and shortness of breath (48%, SD 25%, of patients) was expected. The average number of daily cough periods and forced expectorations was expected to be 2.95 (SD 1.61) and 2.46 (SD 1.42), respectively. Experts expect that, on average, less than half of the patients will experience sleeping problems (48%, SD 22%) and psychosocial problems (24%, SD 20%). CONCLUSIONS: According to German experts, it is expected that the new HMEs with improved humidification levels will lead to additional (clinical) effectiveness on pulmonary health and an improved overall quality of life of patients compared with the currently available HMEs.

Person-centred care in primary care: What works for whom, how and in what circumstances?

This rapid realist review aims to explain how and why person-centred care (PCC) in primary care works (or not) among others for people with low health literacy skills and for people with a diverse ethnic and socioeconomic background, and to construct a middle-range programme theory (PT). Peered reviewed- and non-peer-reviewed literature (Jan 2013-Feb 2021) reporting on PCC in primary care was included. Selection and appraisal of documents were based on relevance and rigour according to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) criteria. Data on context, mechanisms and outcomes (CMO) were extracted. Based on the extracted data, CMO configurations were identified per source publication. Configurations containing all three constructs (CMO) were included in the PT. The middle-range PT demonstrates that healthcare professionals (HCPs) should be trained and equipped with the knowledge and skills to communicate effectively (i.e. in easy-to-understand words, emphatically, checking whether the patient understands everything, listening attentively) tailored to the wishes, needs and possibilities of the patient, which may lead to higher satisfaction. This way the patient will be more involved in the care process and in the shared decision-making process, which may result in improved concordance, and an improved treatment approach. A respectful and empathic attitude of the HCP plays an important role in establishing a strong therapeutic relationship and improved health (system) outcomes. Together with a good accessibility of care for patients, setting up a personalised care plan with all involved parties may positively affect the self-management skills of patients. Good collaboration within the team and between different domains is desirable to ensure good care coordination. The coherence of items related to PCC in primary care should be considered to better understand its effectiveness.

Cost-effectiveness analysis of implementing screening on preterm pre-eclampsia at first trimester of pregnancy in Germany and Switzerland.

OBJECTIVE: To assess the cost-effectiveness of preterm preeclampsia (PE) screening versus routine screening based on maternal characteristics in Germany and Switzerland. METHODS: A health economic model was used to analyse the cost-effectiveness of PE screening versus routine screening based on maternal characteristics. The analysis was conducted from the healthcare perspective with a time horizon of one year from the start of pregnancy. The main outcome measures were incremental health care costs and incremental costs per PE case averted. RESULTS: The incremental health care costs for PE screening versus routine screening per woman were €14 in Germany, and -CHF42 in Switzerland, the latter representing cost savings. In Germany, the incremental costs per PE case averted were €3,795. In Switzerland, PE screening was dominant. The most influential parameter in the one-way sensitivity analysis was the cost of PE screening (Germany) and the probability of preterm PE in routine screening (Switzerland). In Germany, at a willingness-to-pay for one PE case avoided of €4,200, PE screening had a probability of more than 50% of being cost-effective compared to routine screening. In Switzerland, at a willingness-to-pay of CHF0, PE screening had a 78% probability of being the most cost-effective screening strategy. CONCLUSION: For Switzerland, PE screening is expected to be cost saving in comparison to routine screening. For Germany, the additional health care costs per woman were expected to be €14. Future cost-effectiveness studies should be conducted with a longer time horizon.

Patient perspectives of the Self-management and Educational Technology tool for Atrial Fibrillation (SETAF): A mixed-methods study in Singapore.

BACKGROUND: Atrial fibrillation (AF) is the most common arrythmia and is associated with costly morbidity such as stroke and heart failure. Mobile health (mHealth) has potential to help bridge the gaps of traditional healthcare models that may be poorly suited to the sporadic nature of AF. The Self-management and Educational technology support Tool for AF patients (SETAF) was designed based on the preferences and needs of AF patients but more study is required to assess the acceptance of this novel tool. OBJECTIVE: Explore the usability and acceptance of SETAF among AF patients in Singapore. METHODS: A mixed methods study was conducted with AF patients who were purposively sampled from an outpatient cardiology clinic in Singapore. After 6 weeks of using SETAF, semi-structured interviews were performed, and data were analyzed inductively following a thematic analysis approach. Results from a short 4-item survey and application usage data were also analyzed descriptively. Both qualitative and quantitative results were organized and presented following the Technology Acceptance Model (TAM) framework. RESULTS: A total of 37 patients participated in the study and 19 were interviewed. Participants perceived SETAF as useful for improving AF knowledge, self-management and access to healthcare providers and was easy to use due to the guided tutorial and user-friendly interface. They also identified the need for better personalization of content, psychosocial support features and reduction of language barriers. Application usage data revealed preference for AF related content and decreased interaction with the motivational message component of SETAF over time. Overall, most of the participants would continue using SETAF and were willing to pay for it. CONCLUSIONS: AF patients in Singapore found SETAF useful and acceptable as a tool for AF management. The insights from this study not only support the potential of mHealth but may also inform the design and implementation of future mHealth tools for AF patients.

Optimising Integrated Stroke Care in Regional Networks: A Nationwide Self-Assessment Study in 2012, 2015 and 2019.

BACKGROUND: To help enhance the quality of integrated stroke care delivery, regional stroke services networks in the Netherlands participated in a self-assessment study in 2012, 2015 and 2019. METHODS: Coordinators of the regional stroke services networks filled out an online self-assessment questionnaire in 2012, 2015 and 2019. The questionnaire, which was based on the Development Model for Integrated Care, consisted of 97 questions in nine clusters (themes). Cluster scores were calculated as proportions of the activities implemented. Associations between clusters and features of stroke services were assessed by regression analysis. RESULTS: The response rate varied from 93.1% (2012) to 85.5% (2019). Over the years, the regional stroke services networks increased in 'size': the median number of organisations involved and the volume of patients per network increased (7 and 499 in 2019, compared to 5 and 364 in 2012). At the same time, fewer coordinators were appointed for more than 1 day a week in 2019 (35.1%) compared to 2012 (45.9%). Between 2012 and 2019, there were statistically significantly more elements implemented in four out of nine clusters: 'Transparent entrepreneurship' (MD = 18.0% F(1) = 10.693, p = 0.001), 'Roles and tasks' (MD = 14.0% F(1) = 9.255, p = 0.003), 'Patient-centeredness' (MD = 12.9% F(1) = 9.255, p = 0.003), and 'Commitment' (MD = 11.2%, F(1) = 4.982, p = 0.028). A statistically significant positive correlation was found for all clusters between implementation of activities and age of the network. In addition, the number of involved organisations is associated with better execution of implemented activities for 'Transparent entrepreneurship', 'Result-focused learning' and 'Quality of care'. Conversely, there are small but negative associations between the volume of patients and implementation rates for 'Interprofessional teamwork' and 'Patient-centredness'. CONCLUSION: This long-term analyses of stroke service development in the Netherlands, showed that between 2012 and 2019, integrated care activities within the regional stroke networks increased. Experience in collaboration between organisations within a network benefits the uptake of integrated care activities.

Untangling the inter-relatedness within integrated care programmes for community-dwelling frail older people: a rapid realist review.

OBJECTIVE: To identify the relationships between the context in which integrated care programmes (ICPs) for community-dwelling frail older people are applied, the mechanisms by which the programmes do (not) work and the outcomes resulting from this interaction by establishing a programme theory. DESIGN: Rapid realist review. INCLUSION CRITERIA: Reviews and meta-analyses (January 2013-January 2019) and non-peer-reviewed literature (January 2013-December 2019) reporting on integrated care for community-dwelling frail older people (≥60 years). ANALYSIS: Selection and appraisal of documents was based on relevance and rigour according to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards criteria. Data on context, mechanisms, programme activities and outcomes were extracted. Factors were categorised into the five strategies of the WHO framework of integrated people-centred health services (IPCHS). RESULTS: 27 papers were included. The following programme theory was developed: it is essential to establish multidisciplinary teams of competent healthcare providers (HCPs) providing person-centred care, closely working together and communicating effectively with other stakeholders. Older people and informal caregivers should be involved in the care process. Financial support, efficient use of information technology and organisational alignment are also essential. ICPs demonstrate positive effects on the functionality of older people, satisfaction of older people, informal caregivers and HCPs, and a delayed placement in a nursing home. Heterogeneous effects were found for hospital-related outcomes, quality of life, healthcare costs and use of healthcare services. The two most prevalent WHO-IPCHS strategies as part of ICPs are 'creating an enabling environment', followed by 'strengthening governance and accountability'. CONCLUSION: Currently, most ICPs do not address all WHO-IPCHS strategies. In order to optimise ICPs for frail older people the interaction between context items, mechanisms, programme activities and the outcomes should be taken into account from different perspectives (system, organisation, service delivery, HCP and patient).

Mixed-method evaluation of CARITAS: a hospital-to-community model of integrated care for dementia.

OBJECTIVES: The capability and capacity of the primary and community care (PCC) sector for dementia in Singapore may be enhanced through better integration. Through a partnership involving a tertiary hospital and PCC providers, an integrated dementia care network (CARITAS: comprehensive, accessible, responsive, individualised, transdisciplinary, accountable and seamless) was implemented. The study evaluated the process and extent of integration within CARITAS. DESIGN: Triangulation mixed-methods design and analyses were employed to understand factors underpinning network mechanisms. SETTING: The study was conducted at a tertiary hospital in the northern region of Singapore. PARTICIPANTS: We recruited participants who were involved in the conceptualisation, design, development and implementation of the CARITAS Programme from a tertiary hospital and PCC providers. INTERVENTION: We used the Rainbow Model of Integrated Care-Measurement Tool (RMIC-MT) to assess integration from managerial perspectives. RMIC-MT comprises eight dimensions that play interconnected roles on a macro-level, meso-level and micro-level. We administered RMIC-MT to healthcare providers and conducted in-depth interviews with key CARITAS stakeholders. PRIMARY AND SECONDARY OUTCOME MEASURES: We assessed integration scores across eight dimensions of the RMIC-MT and factors underpinning network mechanisms. RESULTS: Compared with other dimensions, functional integration (mechanisms by which information and management modalities are linked) achieved the lowest mean score of 55. Other dimensions (eg, clinical, professional and organisational integration) scored about 70. Presence of inspiring clinical leaders and tacit interdependencies among partners strengthened the network. However, the lack of structured documentation and a shared information-technology platform hindered functional integration. CONCLUSION: CARITAS has reached maturity in micro-levels and meso-levels of integration, while macro-integration needs further development. Integration can be enhanced by assessing service gaps, increasing engagement with stakeholders and providing a shared communication system.

Promoting BioPsychoSocial health of older adults using a Community for Successful Ageing program (ComSA) in Singapore: A mixed-methods evaluation.

BioPsychoSocial health promotion is increasingly emphasized for Successful Ageing. Few programs are known to target BioPsychoSocial health of older adults and their community. The Community for Successful Ageing: Community Development program (ComSA CD) was developed in Singapore for this purpose. This study assessed program effects on BioPsychoSocial health and civic engagement behaviours of participants. ComSA CD offered self-care healthy lifestyle education (Bio-physical), guided autobiography (Psychological) and a civic engagement component which galvanized participants to solve community issues (Social). Recruitment occurred through self-care or guided autobiography; following which participants were funnelled into the civic engagement component. A mixed-methods quasi-experimental evaluation was conducted, using a pre-post one-year survey (N=232) with those exposed and unexposed (rejected) to ComSA CD. Using a generalized linear model, associations between post one-year BioPsychoSocial outcomes and exposure group were quantified using percentage change, adjusting for baseline outcome and group differences. Concurrently, program effects were explored through six focus groups with program implementers and participants using thematic analysis. The program had multiple positive effects. Participants recruited via self-care also taking part in civic engagement reported 31% higher frequency of self-care (95% CI=21% to 68%) post one-year compared to unexposed participants. Qualitative findings illustrated how the civic engagement component stimulated agency of participants to push for neighborhood changes and civic engagement initiatives. The quantitative survey highlighted that this effect was strongest among those funnelled from guided-autobiography (92% higher frequency of civic engagement at post one-year than unexposed; 95%CI=41% to 178%) compared to those funnelled from self-care (53% higher than unexposed, 95%CI=17% to 114%). It was found qualitatively that guided-autobiography enabled more meaningful bonding and communication than the self-care component, explaining quantitative effects on social support only present among guided autobiography participants (36% higher than unexposed; 95%CI=11% to 68%). Findings highlighted the importance of improving group dynamics for collective action.

Assessment of the implementation fidelity of a strategy to scale up integrated care in five European regions: a multimethod study.

OBJECTIVE: The SCaling IntegRated Care in COntext (SCIROCCO) project tested a step-based scaling up strategy to explore what and how to scale up integrated care initiatives in five European regions. To gain a profound understanding of which factors influence the implementation of this strategy, the objective of this study was to assess the extent to which the SCIROCCO strategy was implemented as planned. DESIGN: Multimethod study. METHODS: The extended version of the conceptual framework for implementation fidelity was used to evaluate what factors influence the implementation of the scaling up strategy. Data were collected in the five participating European regions during the intervention period. Data collection methods included: key informant interviews, focus groups, questionnaire studies and project documents. RESULTS: All three main steps of the scaling up strategy were implemented with acceptable fidelity. Variations were observed in the duration of implementing the steps in the regions. Also, variations were observed in the coverage of experts to participate in the steps of the strategy. Several factors were observed to influence the implementation: facilitation conditions (ie, good coordination for implementation) and participant responsiveness (ie, a positive experience of participants in the organised study visits). Factors that may have moderated adherence to the original plan of the strategy were found in facilitating conditions (ie, in the flexible approach), participant recruitment factors (ie, adaptions of the procedure by the regions) and contextual factors (ie, the level of development of integrated care). CONCLUSION: This was the first study to assess implementation fidelity of a European project that used a step-based scaling up strategy in five European regions. Similar European projects that are based on collaboration between several European regions can learn from the lessons captured in SCIROCCO and can become more aware of the facilitating factors and pitfalls of implementing such projects.

Exploring the implementation of the Community for Successful Ageing (ComSA)program in Singapore: lessons learnt on program delivery for improving BioPsychoSocial health.

BACKGROUND: The Community for Successful Ageing (ComSA) program has implemented overlapping BioPsychoSocial (BPS) components as part of a Community Development (CD) grassroots and volunteer-led initiative. Implementation of such multi-component programming is influenced by known program characteristics including novelty, complexity and observability as well as related organizational factors. As such, we explored ComSA CD's implementation from the organizational perspective, seeking to inform program improvements. METHODS: We conducted four focus groups with program staff, partners and trainers (total N = 21 participants). Findings were analysed using an interpretative approach and synthesized into a line of argument informing lessons learnt. RESULTS: An implementation framework was identified. It is guided by considering the influence of known program characteristics across major themes, representing three core implementation stages. These and supporting sub-themes are elaborated in turn: 1) Creating commitment toward the program was challenged by novelty and at times a lack of shared understanding of ComSA CD, particularly relating to the S component. Overall, cohesion within organizational contexts and having a strong rapport with the community (ability to engage) were needed to persuade volunteers and participants to commit to the program. 2) Coordination and resource allocation were influenced by the complexity of interconnecting BPS components - requiring aligning communication between partners and adapting the BPS sequence, given the separated management structure of program trainers. Efficiency of resource utilization was constrained by the ability to pool and match resources given the limited manpower and community partners who worked-in-silo due to a KPI-centric culture. 3) Collaborative program monitoring and appraisal increased observability of the program's benefits, but depended on partners' prior commitment. Despite appreciating its holistic BPS programming, dropout rate was used as a way to gauge program success, which has limited interpretability. Occasional uncertainty about the program value contributed to concerns about duplicating existing ageing programs, particularly those related to the B component. CONCLUSION: Lessons learnt for improving BPS programming include (1) eliciting better participants' buy-in and shared program vision, (2) increasing adaptability of BPS sequence and building a culture of shared values for working together (3) and developing comprehensive monitoring systems for program appraisal.

Theory and Design of the Community for successful ageing (ComSA) program in Singapore: connecting BioPsychoSocial health and quality of life experiences of older adults.

BACKGROUND: Despite the emphasis on holistic health promotion in community programs for older people, few studies explicitly consider how BioPsychoSocial (BPS) health elements are interconnected and function to improve Quality of Life (QoL). The Community for Successful Ageing (ComSA) program in Singapore focuses on Community Development (CD) initiatives for older people, accounting for BPS theory in its design and content. Biological (B) health is conceived as physiological and cognitive functioning and related biological self-care; Psychological (P) health as feelings of life satisfaction, and Social health (S) as perceived social support and civic engagement. Furthermore, three overlapping sub-constructs are theorized to connect these elements. Namely Bio-Psychological (BP) health in terms of self-perceptions of ageing; the Psycho-Social (PS) aspects of interpersonal communication; and the Socio-Communal (SC) health in terms of civic engagement. BPS health is conceived as distinct from QoL, defined as composed of control, autonomy, self-realisation and pleasure (measured by CASP-19) of the older person. We examined 1) interconnections of BPS constructs and related sub-constructs and 2) their associations with QoL to inform a practical, applied program theory. METHODS: A baseline survey (n = 321) of program participants (Mean = 70 years, SD = 8.73). All continuous variables were binarized as 'high' if the scores were above the median. Multivariate logistic regression was used to assess 1) the adjusted effect of each BPS construct on CASP-19, and 2) the odds of scoring high on one BPS construct with the odds of scoring high on a related sub-construct (e.g. B and BP health). RESULTS: The strongest relationship with QoL was markedly with BP self-perceptions of ageing (OR = 4.07, 95%CI = 2.21-7.49), followed by P life satisfaction (OR = 3.66, 95%CI = 2.04-6.57), PS interpersonal communication (OR = 2.42, 95%CI = 1.23-4.77), SC civic engagement (OR = 1.94, 95%CI = 1.05-3.57), and S social support (OR = 1.89, 95%CI = 1.06-3.38). Core B, P and S health were closely associated with their sub-constructs. CONCLUSION: ComSA CD is tightly coupled to its proposed program theory. It offers classes to improve B self-care and BP self-perceptions of ageing, group-based guided autobiography to improve P life-satisfaction and PS interpersonal communication, and community initiatives that encourage seniors to solve community issues. This holistic approach is likely to enhance ageing experiences and QoL.

Validation of the Rainbow Model of Integrated Care Measurement Tools (RMIC-MTs) in renal care for patient and care providers.

INTRODUCTION: Integrated service delivery is considered to be an essential condition for improving the management and health outcomes of people with chronic kidney disease (CKD). However, research on the assessment of integrated care by patients and care providers is hindered by the absence of brief, reliable, and valid measurement tools. OBJECTIVE: The aim of this study was to develop survey instruments for healthcare professionals and patients based on the Rainbow Model of Integrated Care (RMIC), and to evaluate their psychometric properties. DESIGN: The development process was based on the US Food and Drug Administration guidelines. This included item generation from systematic reviews of existing tools and expert opinion on clarity and content validity, involving renal care providers and chronic kidney patients. A cross-sectional, multi-centre design was used to test for internal consistency and construct validity. SETTING: Outpatient clinics in a large renal network. PARTICIPANTS: A sample of 30.788 CKD patients, and 8.914 renal care providers. METHODS AND ANALYSIS: Both survey instruments were developed using previous qualitative work and published literature. A multidisciplinary expert panel assessed the face and content validity of both instruments and following a pilot study, the psychometric properties of both instruments were explored. Exploratory factor analysis with principal axis factoring and with promax rotation was used to assess the underlying dimensions of both instruments; Cronbach's alpha was used to determine the internal constancy reliability. RESULTS: 17.512 patients (response rate: 56.9%) and 8.849 care providers (response rate: 69.5%) responded to the questionnaires. Factor analysis of the patient questionnaire yielded three internally consistent (Cronbach's alpha > 0.7) factors: person-centeredness, clinical coordination, and professional coordination. Factor analysis of the provider questionnaire produced eight internally consistent (Cronbach's alpha > 0.7) factors: person-centeredness, community centeredness, clinical coordination, professional coordination, organisational coordination, system coordination, technical and cultural competence. As hypothesised, care coordination patient and providers scores significantly correlated with questions about quality of care, treatment involvement, reported health, clinics' organisational readiness, and external care coordination capacity. CONCLUSION: This study provides evidence for the reliability and validity of the RMIC patient and provider questionnaires as generic tools to assess the experience with or perception of integrated renal care delivery. The instruments are recommended in future applications testing test-retest reliability, convergent and predictive validity, and responsiveness.

Facilitators and barriers to implementing task shifting: Expanding the scope of practice of clinical technologists in the Netherlands.

Despite recent studies confirming task shifting is both safe and effective, its implementation has proven difficult in practice. So too in the Netherlands, where legal barriers enforcing strict professional boundaries have historically limited task shifting. In recent years, Dutch policymakers have experimented with temporary expanded scopes of practice (ESP) for several professional groups, with the aim to facilitate task shifting in order to increase the overall effectiveness and efficiency of health care. The Clinical Technologist (CT), is an emerging new professional group that has received such a temporary ESP pending an evaluation. This paper reports the qualitative findings of the implementation process of providing CTs with an temporary ESP. Data collection consisted of 69 semi-structured interviews, 3 focus group interviews and 9 participant observations, conducted between September 2015 and October 2017. Analysis was conducted through an 'editing analysis style' whereby data were categorized using the conceptual framework of Grol & Wensing's implementation model. The study suggests that social features are of great importance when implementing task shifting. In situations with few social barriers, organizational and administrative barriers seem to be less dominant, thereby expediting the overall implementation process. Consequently, we recommend that policymakers should prioritize social features over organizational features when implementing task shifting.

Integrated specialized atrial fibrillation clinics reduce all-cause mortality: post hoc analysis of a randomized clinical trial.

AIMS: An integrated chronic care programme in terms of a specialized outpatient clinic for patients with atrial fibrillation (AF), has demonstrated improved clinical outcomes. The aim of this study is to assess all-cause mortality in patients in whom AF management was delivered through a specialized outpatient clinic offering an integrated chronic care programme. METHODS AND RESULTS: Post hoc analysis of a Prospective Randomized Open Blinded Endpoint Clinical trial to assess all-cause mortality in AF patients. The study included 712 patients with newly diagnosed AF, who were referred for AF management to the outpatient service of a University hospital. In the specialized outpatient clinic (AF-Clinic), comprehensive, multidisciplinary, and patient-centred AF care was provided, i.e. nurse-driven, physician supervised AF treatment guided by software based on the latest guidelines. The control group received usual care by a cardiologist in the regular outpatient setting.After a mean follow-up of 22 months, all-cause mortality amounted 3.7% (13 patients) in the AF-Clinic arm and 8.1% (29 patients) in usual care [hazard ratio (HR) 0.44, 95% confidence interval (CI) 0.23-0.85; P = 0.014]. This included cardiovascular mortality in 4 AF-Clinic patients (1.1%) and 14 patients (3.9%) in usual care (HR 0.28; 95% CI 0.09-0.85; P = 0.025). Further, 9 patients (2.5%) died in the AF-Clinic arm due to a non-cardiovascular reason and 15 patients (4.2%) in the usual care arm (HR 0.59; 95% CI 0.26-1.34; P = 0.206). CONCLUSION: An integrated specialized AF-Clinic reduces all-cause mortality compared with usual care. These findings provide compelling evidence that an integrated approach should be widely implemented in AF management.

Value of information analysis in telehealth for chronic heart failure management.

OBJECTIVES: Value of information (VOI) analysis provides information on opportunity cost of a decision in healthcare by estimating the cost of reducing parametric uncertainty and quantifying the value of generating additional evidence. This study is an application of the VOI methodology to the problem of choosing between home telemonitoring and nurse telephone support over usual care in chronic heart failure management in the Netherlands. METHODS: The expected value of perfect information (EVPI) and the expected value of partially perfect information (EVPPI) analyses were based on an informal threshold of €20K per quality-adjusted life-year. These VOI-analyses were applied to a probabilistic Markov model comparing the 20-year costs and effects in three interventions. The EVPPI explored the value of decision uncertainty caused by the following group of parameters: treatment-specific transition probabilities between New York Heart Association (NYHA) defined disease states, utilities associated with the disease states, number of hospitalizations and ER visits, health state specific costs, and the distribution of patients per NYHA group. We performed the analysis for two population sizes in the Netherlands-patients in all NYHA classes of severity, and patients in NYHA IV class only. RESULTS: The population EVPI for an effective population of 2,841,567 CHF patients in All NYHA classes of severity over the next 20 years is more than €4.5B, implying that further research is highly cost-effective. In the NYHA IV only analysis, for the effective population of 208,003 patients over next 20 years, the population EVPI at the same informal threshold is approx. €590M. The EVPPI analysis showed that the only relevant group of parameters that contribute to the overall decision uncertainty are transition probabilities, in both All NYHA and NYHA IV analyses. CONCLUSIONS: Results of our VOI exercise show that the cost of uncertainty regarding the decision on reimbursement of telehealth interventions for chronic heart failure patients is high in the Netherlands, and that future research is needed, mainly on the transition probabilities.

Cost-Effectiveness Analysis in Telehealth: A Comparison between Home Telemonitoring, Nurse Telephone Support, and Usual Care in Chronic Heart Failure Management.

OBJECTIVES: To assess the cost effectiveness of home telemonitoring (HTM) and nurse telephone support (NTS) compared with usual care (UC) in the management of patients with chronic heart failure, from a third-party payer's perspective. METHODS: We developed a Markov model with a 20-year time horizon to analyze the cost effectiveness using the original study (Trans-European Network-Home-Care Management System) and various data sources. A probabilistic sensitivity analysis was performed to assess the decision uncertainty in our model. RESULTS: In the original scenario (which concerned the cost inputs at the time of the original study), HTM and NTS interventions yielded a difference in quality-adjusted life-years (QALYs) gained compared with UC: 2.93 and 3.07, respectively, versus 1.91. An incremental net monetary benefit analysis showed €7,697 and €13,589 in HTM and NTS versus UC at a willingness-to-pay (WTP) threshold of €20,000, and €69,100 and €83,100 at a WTP threshold of €80,000, respectively. The incremental cost-effectiveness ratios were €12,479 for HTM versus UC and €8,270 for NTS versus UC. The current scenario (including telenurse cost inputs in NTS) yielded results that were slightly different from those for the original scenario, when comparing all New York Heart Association (NYHA) classes of severity. NTS dominated HTM, compared with UC, in all NYHA classes except NYHA IV. CONCLUSIONS: This modeling study demonstrated that HTM and NTS are viable solutions to support patients with chronic heart failure. NTS is cost-effective in comparison with UC at a WTP of €9000/QALY or higher. Like NTS, HTM improves the survival of patients in all NYHA classes and is cost-effective in comparison with UC at a WTP of €14,000/QALY or higher.