[Caring for confused community dwelling seniors]. / Zorgverlening aan thuiswonende ouderen met verward gedrag.

A qualitative research focused on contributing and obstructing factors for healthcare assistants in district nursing Older people with confused behavior have behavioral problems due to dementia, mental problems or social problems. For the Healthcare Assistant (HA) in district nursing, it is a daily challenge to care for older people with confused behavior. Aim of this research is to achieve an insight in the strategies the HA uses to deal with the daily care for older people with confused behavior. It is also the aim to have insight in factors which contribute to the daily care in a positive or negative way. Method: a qualitative explorative research. 17 HA's in district nursing participated in semi-structured interviews. All respondents had experience with caring for older people with confused behavior. The most important influencing factors are the experienced relationship between HA and the client and the experienced support by the team. Particularly behavioral problems due to mental problems can impede a relationship with the client. Further research is recommended to study the level of knowledge and competences of all levels of employees in district nursing.

[Evaluation by case managers dementia : An explorative practice based study on types and content]. / Evaluatie door casemanagers dementie : Een explorerende praktijkstudie naar vormen en inhoud.

BACKGROUND: This practice based explorative study aims to provide insight into the ways in which case managers shape and fill up the evaluation phase of their support of the informal care network of persons with dementia. METHOD: A combination of quantitative and qualitative research methods were used. A group of 57 case managers of persons with dementia in three different organisational networks took part in this study. RESULTS: Results from the quantitative and qualitative data are organized into four themes: (1) attitude towards evaluation, (2) forms of evaluation, (3) implementation of evaluation and (4) content of evaluation. There are different ways in shaping evaluation and the content of it. The importance of interim and final evaluation is recognized, but is difficult to realize in a methodical way. Barriers experienced by the case managers include various factors associated both with clients as professionals. CONCLUSION: Case managers evaluate continuously and in an informal way to assess whether the extent of their assistance is meeting the needs of the client and informal network. Case managers do not use systematic evaluation to measure the quality of care they offer to persons with dementia and their caregivers. The findings demand a discussion on the level of clients, as well as on the professional and societal level about the way case managers should evaluate their support.

Patients' expectations of variation in quality of care relates to their search for comparative performance information.

BACKGROUND: Choice of hospital based on comparative performance information (CPI) was introduced for Dutch healthcare consumers at least 5 years ago, but CPI use has not yet become commonplace. Our aim was to assess the role of patients' expectations regarding variation in the quality of hospital care in determining whether they search for CPI. METHODS: A questionnaire (for a cross-sectional survey) was distributed to 475 orthopaedic patients in a consecutive sample, who underwent primary hip or knee replacement in a university, teaching, or community hospital between September 2009 and July 2010. RESULTS: Of the 302 patients (63%) who responded, 13% reported searching for CPI to help them choose a hospital. People who expected quality differences between hospitals (67%) were more likely to search for CPI (OR =3.18 [95% CI: 1.02-9.89]; p <0.04) than those who did not. Quality differences were most often expected in hospital reputation, distance, and accessibility. Patients who did not search for CPI stated that they felt no need for this type of information. CONCLUSION: Patients' expectations regarding variation in quality of care are positively related to their reported search for CPI. To increase the relevance of CPI for patients, future studies should explore the underlying reasoning of patients about meaningful quality-of-care variation between hospitals.

Comparative performance information plays no role in the referral behaviour of GPs.

BACKGROUND: Comparative performance information (CPI) about the quality of hospital care is information used to identify high-quality hospitals and providers. As the gatekeeper to secondary care, the general practitioner (GP) can use CPI to reflect on the pros and cons of the available options with the patient and choose a provider best fitted to the patient's needs. We investigated how GPs view their role in using CPI to choose providers and support patients. METHOD: We used a mixed-method, sequential, exploratory design to conduct explorative interviews with 15 GPs about their referral routines, methods of referral consideration, patient involvement, and the role of CPI. Then we quantified the qualitative results by sending a survey questionnaire to 81 GPs affiliated with a representative national research network. RESULTS: Seventy GPs (86% response rate) filled out the questionnaire. Most GPs did not know where to find CPI (87%) and had never searched for it (94%). The GPs reported that they were not motivated to use CPI due to doubts about its role as support information, uncertainty about the effect of using CPI, lack of faith in better outcomes, and uncertainty about CPI content and validity. Nonetheless, most GPs believed that patients would like to be informed about quality-of-care differences (62%), and about half the GPs discussed quality-of-care differences with their patients (46%), though these discussions were not based on CPI. CONCLUSION: Decisions about referrals to hospital care are not based on CPI exchanges during GP consultations. As a gatekeeper, the GP is in a good position to guide patients through the enormous amount of quality information that is available. Nevertheless, it is unclear how and whether the GP's role in using information about quality of care in the referral process can grow, as patients hardly ever initiate a discussion based on CPI, though they seem to be increasingly more critical about differences in quality of care. Future research should address the conditions needed to support GPs' ability and willingness to use CPI to guide their patients in the referral process.

Exploring consumer values of comparative performance information for hospital choice.

BACKGROUND: In many countries, market orientation in healthcare has resulted in the publication of comparative performance information (CPI). Most of the research in this field is oriented towards the content and the presentation format of CPI while little is known about how consumers value CPI and the use of this information. AIM: The aim of this study was to clarify the perceived value that CPI brings for consumers of healthcare. Methods Qualitative research using six focus group interviews. Twenty-seven healthcare consumers were recruited using a mailing list and by personal invitation. Data from focus group interviews were transcribed and thematic analysis undertaken. RESULTS: Most participants were unaware of CPI, and valued alternative sources of information more than CPI. Through discussion with other consumers and by means of examples of CPI, respondents were able to express the values and perceived effects of CPI. Numerous underlying values hindered consumers' use of CPI, and therefore clarification of consumer values gave insights into the current non-usage of CPI. CONCLUSIONS: CPI is marginally valued, partly because of conflicting values expressed by consumers and, as such, it does not yet provide a useful information source on hospital choice beyond consumers' current selection routines in healthcare. Future research should be more focused on the values of consumers and their impact on the use of CPI.

Recognition of physiotherapists' expertise in Parkinson's disease.

BACKGROUND: Publicly available information comparing performance across quality and costs has proliferated in recent years, both about individual healthcare professionals and hospitals. This type of information is now becoming increasingly available for physiotherapists with expertise in Parkinson's disease (PD). Our study aimed to explore the ability of people with Parkinson's disease to recognise expertise, and to what extent respondents selectively choose such expert physiotherapists. METHODS: We used claim data from the period 2009-2010 to select customers with PD who claimed physiotherapy. A random sample of 500 eligible respondents received a paper-based survey. We used descriptive statistics to compare the respondent characteristics, a qualitative programme to analyse the qualitative items, and univariate and multivariate regression. RESULTS: Most respondents (89%) took their referring physician's advice when selecting a physiotherapist, although this advice rarely was supported with arguments. The remaining respondents (11%) searched for comparative performance information about physiotherapists. Respondents who recognised the added value of PD expertise among physiotherapists were 3.28 times as likely to search for comparative performance information as those who did not understand. Respondents were willing to switch to an expert physiotherapist (68%), and this willingness increased if they recognised the value of PD expertise (p < .001). CONCLUSION: The participants were able to recognise certain aspects of expertise. Though they showed relatively few signs of selectively choice behaviour for expert physiotherapists. Both respondents and referring professionals need more understanding about the added value of an expert physiotherapist, to foster selective provider choice.

Performance measurements in diabetes care: the complex task of selecting quality indicators.

PURPOSE: To review the literature on the content and development of the sets of quality indicators used in studies on the quality of diabetes care in primary care settings. DATA SOURCES: The MEDLINE (Ovid), PubMed, PsychINFO, Embase and CINAHL databases were searched for relevant articles published up to January 2011. STUDY SELECTION: and data extraction We included studies on the quality of adult diabetes care, using quality indicators. We excluded studies focusing on the hospital setting, patient subgroups, specific components of diabetes care and specific outcomes. In total, 102 studies (including 102 sets and 1494 indicators) were analyzed by two independent reviewers, using the criteria of the National Quality Measures Clearinghouse and international guidelines to document the content and selection of the identified indicators. RESULTS OF DATA SYNTHESIS: Sets varied greatly in number, content and definitions of quality indicators. Most of the indicators concerned HbA1C, lipids, blood pressure, eye and foot examination and urinalysis. Few sets included indicators on lifestyle counseling, patient experiences, healthcare structure or access to healthcare providers. Seventy sets did not specify explicit selection criteria, and 19 of these did not report the sources of the indicators. CONCLUSIONS: Sets of quality indicators are diverse in number, content and definitions. This diversity reflects a lack of uniformity in the concept of diabetes care quality and hinders the interpretation of and comparison between quality assessments. Methodology regarding defining constructs such as the quality of diabetes care and indicator selection procedures is available and should be used more rigorously.

Public release of performance data in changing the behaviour of healthcare consumers, professionals or organisations.

BACKGROUND: It is becoming increasingly common to release information about the performance of hospitals, health professionals or providers, and healthcare organisations into the public domain. However, we do not know how this information is used and to what extent such reporting leads to quality improvement by changing the behaviour of healthcare consumers, providers and purchasers, or to what extent the performance of professionals and providers can be affected. OBJECTIVES: To determine the effectiveness of the public release of performance data in changing the behaviour of healthcare consumers, professionals and organisations. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, MEDLINE Ovid (from 1966), EMBASE Ovid (from 1979), CINAHL, PsycINFO Ovid (from 1806) and DARE up to 2011. SELECTION CRITERIA: We searched for randomised or quasi-randomised trials, interrupted time series and controlled before-after studies of the effects of publicly releasing data regarding any aspect of the performance of healthcare organisations or individuals. The papers had to report at least one main outcome related to selecting or changing care. Other outcome measures were awareness, attitude, views and knowledge of performance data and costs. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies for eligibility and extracted data. For each study, we extracted data about the target groups (healthcare consumers, healthcare providers and healthcare purchasers), performance data, main outcomes (choice of healthcare provider and improvement by means of changes in care) and other outcomes (awareness, attitude, views, knowledge of performance data and costs). MAIN RESULTS: We included four studies containing more than 35,000 consumers, and 1560 hospitals. Three studies were conducted in the USA and examined consumer behaviour after the public release of performance data. Two studies found no effect of Consumer Assessment of Healthcare Providers and Systems information on health plan choice in a Medicaid population. One interrupted time series study found a small positive effect of the publishing of data on patient volumes for coronary bypass surgery and low-complication outliers for lumbar discectomy, but these effects did not persist longer than two months after each public release. No effects on patient volumes for acute myocardial infarction were found.One cluster-randomised controlled trial, conducted in Canada, studied improvement changes in care after the public release of performance data for patients with acute myocardial infarction and congestive heart failure. No effects for the composite process-of-care indicators for either condition were found, but there were some improvements in the individual process-of-care indicators. There was an effect on the mortality rates for acute myocardial infarction. More quality improvement activities were initiated in response to the publicly-released report cards. No secondary outcomes were reported. AUTHORS' CONCLUSIONS: The small body of evidence available provides no consistent evidence that the public release of performance data changes consumer behaviour or improves care. Evidence that the public release of performance data may have an impact on the behaviour of healthcare professionals or organisations is lacking.

How to promote healthy behaviours in patients? An overview of evidence for behaviour change techniques.

To identify the evidence for the effectiveness of behaviour change techniques, when used by health-care professionals, in accomplishing health-promoting behaviours in patients. Reviews were used to extract data at a study level. A taxonomy was used to classify behaviour change techniques. We included 23 systematic reviews: 14 on smoking cessation, 6 on physical exercise, and 2 on healthy diets and 1 on both exercise and diets. None of the behaviour change techniques demonstrated clear effects in a convincing majority of the studies in which they were evaluated. Techniques targeting knowledge (n = 210 studies) and facilitation of behaviour (n = 172) were evaluated most frequently. However, self-monitoring of behaviour (positive effects in 56% of the studies), risk communication (52%) and use of social support (50%) were most often identified as effective. Insufficient insight into appropriateness of technique choice and quality of technique delivery hinder precise conclusions. Relatively, however, self-monitoring of behaviour, risk communication and use of social support are most effective. Health professionals should avoid thinking that providing knowledge, materials and professional support will be sufficient for patients to accomplish change and consider alternative strategies which may be more effective.