The governance of quality management in dutch health care: new developments and strategic challenges.

This article gives a brief sketch of quality management in Dutch health care. Our focus is upon the governance of guideline development and quality measurement. Governance is conceptualized as the structure and process of steering of quality management. The governance structure of guideline development in the Netherlands can be conceptualized as a network without central coordination. Much depends upon the self-initiative of stakeholders. A similar picture can be found in quality measurement. Special attention is given to the development of care standards for chronic disease. Care standards have a broader scope than guidelines and take an explicit patient perspective. They not only contain evidence-based and up-to-date guidelines for the care pathway but also contain standards for self-management. Furthermore, they comprise a set of indicators for measuring the quality of care of the entire pathway covered by the standard. The final part of the article discusses the mission, tasks and strategic challenges of the newly established National Health Care Institute (Zorginstituut Nederland), which is scheduled to be operative in 2013.

Bottom-up implementation of disease-management programmes: results of a multisite comparison.

OBJECTIVES: To evaluate the implementation of three regional disease-management programmes on chronic obstructive pulmonary disease (COPD) based on bottlenecks experienced in professional practice. METHODS: The authors performed a multisite comparison of three Dutch regional disease-management programmes combining patient-related, professional-directed and organisational interventions. Process (Assessing Chronic Illness Care survey) and outcome (disease specific quality of life (clinical COPD questionnaire (CCQ); chronic respiratory questionnaire (CRQ)), Medical Research Council dyspnoea and patients' experiences) data were collected for 370 COPD patients and their care providers. RESULTS: Bottlenecks in region A were mostly related to patient involvement, in region B to organisational issues and in region C to both. Selected interventions related to identified bottlenecks were implemented in all programmes, except for patient-related interventions in programme A. Within programmes, significant improvements were found on dyspnoea and patients' experiences with practice nurses. Outcomes on quality of life differed between programmes: programme A did not show any significant improvements; programme B did show any significant improvements on CCQ total (p<0.001), functional (p=0.011) and symptom (p<0.001), CRQ fatigue (p<0.001) and emotional scales (p<0.001); in programme C, CCQ symptom (p<0.001) improved significantly, whereas CCQ mental score (p<0.001) deteriorated significantly. Regression analyses showed that programmes with better implementation of selected interventions resulted in relatively larger improvements in quality of life (CCQ). CONCLUSIONS: Bottom-up implementation of COPD disease-management programmes is a feasible approach, which in multiple settings leads to significant improvements in outcomes of care. Programmes with a better fit between implemented interventions and bottlenecks showed more positive changes in outcomes.

The use of social services by community-dwelling older persons who are at risk of institutionalization: a survey.

The use of community-based social services additionally to regular home help services to support older persons at risk of institutionalization was studied. Structured interviews were held with 292 persons, who specifically pointed out that they prefer to remain independently at home. Bivariate and multivariate logistic regression models were developed to study the association between social service use and personal, health-related and wellbeing characteristics. 195 respondents indicated that they made use of at least one social service (68%). Only three services (individual care, social-cultural activities and restaurant facilities), out of nine, were used regularly. Those who lived in a sheltered environment or were supported by informal caregivers or who visited day care had a significantly higher probability of using these services. More attention should be given to the nature and accessibility of community-based social services in order to have distinctive added value in enabling older persons to age in place.

The role of nurses in euthanasia and physician-assisted suicide in The Netherlands.

BACKGROUND: Issues concerning legislation and regulation with respect to the role of nurses in euthanasia and physician-assisted suicide gave the Minister for Health reason to commission a study of the role of nurses in medical end-of-life decisions in hospitals, home care and nursing homes. AIM: This paper reports the findings of a study of the role of nurses in euthanasia and physician-assisted suicide, conducted as part of a study of the role of nurses in medical end-of-life decisions. The findings for hospitals, home care and nursing homes are described and compared. METHOD: A questionnaire was sent to 1509 nurses, employed in 73 hospitals, 55 home care organisations and 63 nursing homes. 1179 responses (78.1%) were suitable for analysis. The questionnaire was pilot-tested among 106 nurses, with a response rate of 85%. RESULTS: In 37.0% of cases, the nurse was the first person with whom patients discussed their request for euthanasia or physician-assisted suicide. Consultation between physicians and nurses during the decision-making process took place quite often in hospitals (78.8%) and nursing homes (81.3%) and less frequently in home care situations (41.2%). In some cases (12.2%), nurses administered the euthanatics. CONCLUSIONS: The results show substantial differences between the intramural sector (hospitals and nursing homes) and the extramural sector (home care), which are probably linked to the organisational structure of the institutions. Consultation between physicians and nurses during the decision-making process needs improvement, particularly in home care. Some nurses had administered euthanatics, although this task is by law exclusively reserved to physicians.

The use of community-based social services by elderly people at risk of institutionalization: an evaluation.

OBJECTIVE: To examine the use of community-based social services by elderly people at risk of institutionalization, who prefer to remain at home. METHODS: A study with a longitudinal design (measurements at two points in time) was conducted. RESULTS: One hundred and thirty-four elderly people (mean age=82 years) were interviewed twice. At baseline, 81 respondents indicated that they made use of at least one social service (60.4%). After 1 year the use of these services did not increase significantly (64.2%, p=0.53). Only two services (socio-cultural activities and restaurant facility) out of five services were used frequently. The respondents reported more autonomy and fewer feelings of loneliness after 1 year. These positive changes cannot be related to an increased use of services. DISCUSSION: Overall, the use of social services remained moderate. This raises questions about the need for these services, the possible barriers and the ability of these social services to contribute to de-institutionalization.

Transfer of care for outpatients with stable chronic obstructive pulmonary disease from respiratory care physician to respiratory nurse--a randomized controlled study.

OBJECTIVES: To assess effects on patient outcomes when care for patients with stable chronic obstructive pulmonary disease (COPD) is transferred from respiratory care physician to respiratory nurse. METHODS: A randomized controlled trial was used with a follow-up period of 9 months. Of 720 patients from the respiratory outpatient clinic of the general and teaching hospital in Alkmaar (The Netherlands), 187 were eligible for randomization and gave informed consent. Ninety-three patients received care from the nurse, and 87 received usual care. Outcomes measured were: clinical parameters, health status, self-care behaviour (including knowledge), patient satisfaction, and consultations with key care providers. RESULTS: The respiratory nurse reported more consultations than the respiratory care physician [mean (standard deviation)]: number of consultations 3.1 (0.7) by nurse and 2.0 (0.9) by physician (p = 0.007). Patients cared for by the nurse showed worsening in mean forced vital capacity [-5.5% (13.3%) v. +2.9% (18.2%) with physician; p = 0.004], and no difference in self-assessed condition, while improvements were found for subjective knowledge (p = 0.017), self-assessed rate for coping with COPD (p = 0.045), overall satisfaction (p = 0.003), and the majority of individual indicators of satisfaction. Groups showed no differences for forced expiratory volume in 1 s, body mass index, smoking status, health status, objective knowledge, other items of self-care behaviour, and consultations with key care providers. DISCUSSION: Assignment of care for outpatients with stable COPD to the respiratory nurse, working under a protocol, seems to be justified in terms of patient outcomes.

A disease management programme for patients with diabetes mellitus is associated with improved quality of care within existing budgets.

AIM: To assess the impact of a disease management programme for patients with diabetes mellitus (Type 1 and Type 2) on cost-effectiveness, quality of life and patient self-management. By organizing care in accordance with the principles of disease management, it is aimed to increase quality of care within existing budgets. METHODS: Single-group, pre-post design with 2-year follow-up in 473 patients. RESULTS: Substantial significant improvements in glycaemic control, health-related quality of life (HRQL) and patient self-management were found. No significant changes were detected in total costs of care. The probability that the disease management programme is cost-effective compared with usual care amounts to 74%, expressed in an average saving of 117 per additional life year at 5% improved HRQL. CONCLUSION: Introduction of a disease management programme for patients with diabetes is associated with improved intermediate outcomes within existing budgets. Further research should focus on long-term cost-effectiveness, including diabetic complications and mortality, in a controlled setting or by using decision-analytic modelling techniques.

Demand of elderly people for residential care: an exploratory study.

BACKGROUND: Because of the rapid aging population, the demand for residential care exceeds availability. This paper presents the results of a study that focuses on the demand of elderly people for residential care and determinants (elderly people's personal characteristics, needs and resources) that are associated with this demand. Furthermore, the accuracy of the waiting list as a reflection of this demand has been examined. METHODS: 67 elderly people waiting for admission into a home for the elderly, are subjected to semi-structured interviews. The data are analyzed by using multivariate statistics. RESULTS: Elderly people who indicate that they would refuse an offer of admission into a home for the elderly feel healthier (p = 0.02), have greater self-care agency (p = 0.02) and perceive less necessity of admission (p < 0.01), compared to those who would accept such an offer. Especially the inability to manage everyday activities and the lack of a social network are highly associated with the elderly people's demand for residential care. Furthermore, it is evident that waiting lists for homes for the elderly do not accurately reflect the demand for residential care, since 35% of the elderly people on a waiting list did not actually experience an immediate demand for residential care and stated that they would not accept an offer of admission. Quite a lot of respondents just registered out of a sense of precaution; a strategic decision dictated by current shortages in care provision and a vulnerable health status. CONCLUSION: The results contribute to the understanding of waiting lists and the demand for residential care. It became apparent that not everybody who asks for admission into a home for the elderly, really needed it. The importance of elderly people's resources like social networks and the ability to manage everyday activities in relation to the demand for care became clear. These findings are important because they indicate that resources also play a role in predicting elderly people's demand and as a result can guide the development and the (re)design of adequate health care services.

The Health Technology Assessment-disease management instrument reliably measured methodologic quality of health technology assessments of disease management.

OBJECTIVE: Systematic reviews aim to summarize the evidence in a particular topic area, giving attention to the identified methodologic quality of published research. Because research in a specific area may be susceptible to specific biases, it is assumed that the methodologic quality of Health Technology Assessment (HTA) of disease management cannot properly be measured with the existing methodologic quality assessment instruments. The purpose of this study was to describe to what extent existing instruments are useful in assessing the methodologic quality of HTA of disease management. STUDY DESIGN AND SETTING: An inventory was made of the problems that arise when assessing the methodologic quality of six HTAs of disease management with three different instruments. Based on these findings, a new instrument is proposed and validated. RESULTS: Problems mainly concern the items related to the study design, criteria for selection and restriction of patients, baseline and outcome measures, blinding of patients and providers, and the description of (co)-interventions. CONCLUSION: With its more specific characteristics, the HTA-DM addresses the problems mentioned. The HTA-DM is a reliable instrument for methodologic quality assessment of HTA of disease management in comparison with the other three instruments.

Applying low disease activity criteria using the DAS28 to assess stability in patients with rheumatoid arthritis.

OBJECTIVES: To examine whether low disease activity criteria using the disease activity score (DAS28) can be applied to identify a reasonably large number of patients with stable low disease activity of rheumatoid arthritis (RA) over a six month period, with the ultimate intention of including these patients in a substitution based, shared care model. Additionally, to assess the reliability of the DAS28 for selecting patients with stable disease from an outpatient population. METHODS: Patients regularly seen at the rheumatology outpatient department of the university hospital Maastricht, were invited for assessment of the stability of their RA. The shared care model was intended to provide care to patients with stable, low disease activity of RA by nurse specialists. For this, patients underwent assessments using the DAS28 criteria at entry and three and six months later. Test-retest reliability was assessed for composing measures as well as for the DAS28. RESULTS: Of the 97 outpatients included, one third (31 patients) did not complete the study. Patients with missing data were older and assessed their disease activity as greater than patients with complete data. Applying the low disease activity criteria to assess stability over a period of six months (DAS28(T0)

['Knowledge Infrastructure for Public Health': an advisory report from the Advisory Council on Health Research]. / 'Kennisinfrastructuur Public Health'; een advies van de Raad voor Gezondheidsonderzoek.

Social, scientific and technological developments are forcing health care systems to shift the focus from disease to health and from cure to prevention. The Advisory Council on Health Research (RGO) has published an advisory report about the knowledge infrastructure serving the needs of public health in the Netherlands. The Council's concept of public health also includes aspects such as policy and health management. The Council concludes that more research is needed on the following determinants of health: environmental issues, social factors, unhealthy behaviour and genetic factors. Intervention research must focus on health protection, health promotion and disease prevention. The public health infrastructure can be improved by amalgamating research groups, establishing departments of public health at every academic medical centre, and linking service, education and research.

The nurse specialist as main care-provider for patients with type 2 diabetes in a primary care setting: effects on patient outcomes.

A solution to safeguard high quality diabetes care may be to allocate care to the nurse specialist. By using a one group pretest-posttest design with additional comparisons, this study evaluated effects on patient outcomes of a shared care model with the diabetes nurse as main care-provider for patients with type 2 diabetes in a primary care setting. The shared care model resulted in an improved glycaemic control, additional consultations and other outcomes being equivalent to diabetes care before introduction, with the general practitioner as main care-provider. Assignment of care for patients with type 2 diabetes to nurse specialists seems to be justified.

Participation of general practitioners in disease management: experiences from The Netherlands.

OBJECTIVE: To investigate the extent to which GPs in The Netherlands participate in disease management and how personal opinions, impeding and promoting incentives as well as physician characteristics influence their attitude towards disease management. METHODS: The attitude-model of Fishbein and Ajzen was used to describe the attitude of GPs towards disease management and main influencing factors. After interviewing seventeen representatives of the GPs and testing a questionnaire, the final questionnaire was sent to all GPs in The Netherlands (7680 GPs) barring those involved in the testing of the questionnaire. RESULTS: At least 10.4% of all Dutch GPs are active in disease management. The main factors predicting a positive attitude towards disease management are the following: GPs' opinion that they are improving quality and efficiency of care when executing disease management, presence of a good quality network between actors involved prior to the start of disease management, working in a health centre, and performing sideline activities besides their daily activities as GPs. The main factors predicting a negative attitude are: GPs' opinion that the investment-time is too high, lack of reimbursement for disease management activities, working in a solo practice, and not performing any sideline activities beside their daily activities as GP. CONCLUSIONS: The factors predicting a negative attitude of Dutch GPs towards disease management dominate the factors predicting a positive attitude. The arguments in favour of disease management are matters of belief, for example concerning improvements in the quality of care, while arguments against are more concrete barriers e.g. high workload and financial reimbursement. Placed on the innovation timeline, the 10.4% participation might be taken to represent the start of a trend.

Substitution model with central role for nurse specialist is justified in the care for stable type 2 diabetic outpatients.

AIM OF THE STUDY: Assessment of effects on quality of care, in terms of patient outcomes, when tasks in the care for outpatients with stable type 2 diabetes are transferred from internist to nurse specialist and from outpatient clinic to general practice. BACKGROUND: For the management of chronic diseases with a high prevalence and requiring current monitoring, it is suggested that substitution of care may be an appropriate solution to safeguard high quality care. DESIGN AND METHODS: A 12-month nonequivalent control group design was used. General practitioners (GPs) referring diabetes patients to the University Hospital Maastricht were asked to choose for the traditional model or the nurse specialist model. Informed consent was obtained from patients with stable diabetes type 2 attending these practices. All patients received care according to the model chosen by their GP. Identified outcomes were: clinical status, health status, self-care behaviour, knowledge of diabetes, patient satisfaction, and consultation with care-providers. RESULTS: In the control group (n=47) no patients were treated with oral hypoglycaemic agents (OHA) only. The control group was compared with an intervention subgroup (n=52) also without patients receiving OHA only. Clinical data were available for all patients. Patients without complete data from questionnaires had better mean concentration of HbA1c than patients with complete data (P=0.004). The traditional care model and the nurse specialist model achieved equal outcomes, while glycaemic control of patients in the nurse specialist model improved (from 8.6% to 8.3%) but deteriorated in the traditional model (from 8.6% to 8.8%; P-value between groups=0.001). CONCLUSIONS: The model with nurse specialists taking on roles and tasks beyond those traditionally regarded as their remit as well as new ones, is effective for the care of stable diabetic outpatients.

How to manage the implementation of shared care: a discussion of the role of power, culture and structure in the development of shared care arrangements.

The Dutch health care sector has become familiar with innovation of care delivery in order to meet the changing demand of the steadily ageing population, in need of complex care. Innovations often concern the implementation of shared care models, implying collaboration and substitution of care. Whereas ageing is a European-wide phenomenon, the development of such new care arrangements can be observed not only in The Netherlands, but also in the UK, Scandinavia, Italy and other countries. In this article we discuss the implementation of shared care, with the help of three concepts: power, culture and structure. We discuss the role of these factors from the view that shared care can be considered as inter-professional working within a network context. The central question is how structure, culture and power can offer change managers a starting-point for improving their innovative capacity. To illuminate our discussion we make use of a number of event-descriptions from five Dutch shared care projects. Also, we give some practical recommendations for change managers.

Integration of care in The Netherlands: the development of transmural care since 1994.

BACKGROUND: integration of primary and hospital services has been the subject of health policy in The Netherlands in the 1990s. A bottom-up facilitating approach was chosen to stimulate development of 'transmural care' between traditionally separate sectors. Transmural care has been defined as, care, attuned to the needs of the patient, provided on the basis of co-operation and co-ordination between general and specialised caregivers with shared overall responsibility and the specification of delegated responsibilities'. We conducted a national survey to determine the success of the bottom-up policy and the extent of the development of transmural care. METHODS: a written questionnaire was distributed among members of two national networks of transmural care executives and project coordinators, which are representative for hospitals and home care organisations in The Netherlands. A total of 271 facilities were included in the study representing 71% of hospitals and 63% of the home care organisations in The Netherlands. The questionnaire covered topics as; type of care provided, participants, population, goals and type of evaluation. RESULTS: all hospitals in The Netherlands provide one or more of the seven types of transmural care, however, there is a great variation in the number of facilities per organisation. Most facilities cater to one or more groups of chronically ill patients. Project coordinators experience difficulties finding adequate financing options for the facilities. Evidence on the effects of transmural care on quality and efficiency is lacking. CONCLUSION: the bottom-up approach towards the development of transmural care has been successful but needs to be followed by top-down measures to insure adequate evaluation and encourage wide-spread implementation.

From shared care to disease management: key-influencing factors.

BACKGROUND: In order to improve the quality of care of chronically ill patients the traditional boundaries between primary and secondary care are questioned. To demolish these boundaries so-called 'shared care' projects have been initiated in which different ways of substitution of care are applied. When these projects end, disease management may offer a solution to expand the achieved co-operation between primary and secondary care. OBJECTIVE: Answering the question: What key factors influence the development and implementation of shared care projects from a management perspective and how are they linked? THEORY: The theoretical framework is based on the concept of the learning organisation. DESIGN: Reference point is a multiple case study that finally becomes a single case study. Data are collected by means of triangulation. The studied cases concern two interrelated Dutch shared care projects for type 2 diabetic patients, that in the end proceed as one disease management project. RESULTS: In these cases the predominant key-influencing factors appear to be the project management, commitment and local context, respectively. The factor project management directly links the latter two, albeit managing both appear prerequisites to its success. In practice this implies managing the factors' interdependency by the application of change strategies and tactics in a committed and skillful way. CONCLUSION: Project management, as the most important and active key factor, is advised to cope with the interrelationships of the influencing factors in a gradually more fundamental way by using strategies and tactics that enable learning processes. Then small-scale shared care projects may change into a disease management network at a large scale, which may yield the future blueprint to proceed.

Effects on quality of care for patients with NIDDM or COPD when the specialised nurse has a central role: a literature review.

Chronic care has to be organised in a way that care from any one caregiver is linked up to that provided by others so that disturbing gaps, contradictions and overlaps are avoided. In the search for the most effective and efficient combination of health professionals to deliver care to chronic patients, the role of the specialised nurse has become important. This article reviews a Medline search for publications about the effects of models of care for patients with NIDDM or COPD in which the specialised nurse has a central role. Main features of the models are identified and related to expected and statistically significant effects. In this young domain of effect evaluation ten publications met our criteria. Depending on the division of tasks between care providers, improvements are seen in self-care, quality of life and patient satisfaction, as well as increased medical consumption. More methodologically suitable evaluations with the use of only valid measures are needed.