Retention in substance dependence treatment: the relevance of in-treatment factors.

In addition to "fixed" patient demographic and background variables, treatment process constructs play an important role in the prediction of treatment retention in substance dependence treatment. The objective of this paper is to analyze the predictive role of repeated measures of treatment readiness and behavioral intention, and of patients' perception of the therapeutic alliance, while controlling for fixed patient-oriented variables. Ninety-three patients, both alcohol and drug dependents, enrolled in this study, which was conducted in an inpatient treatment setting. Patients completed questionnaires shortly after admission (t=0) and approximately 2 weeks later (t=1). Using these measures, 35% of variance of a length of stay in treatment of up to 30 days could be explained. Fixed patient-oriented variables accounted for 21% of variance. Of the cognitive factors, helping alliance was the most important, accounting for an additional 8% of variance. The implications of these results are discussed.

Experts' opinions on the profile of optimal care for patients with diabetes mellitus type 2 in the Netherlands.

BACKGROUND: The St. Vincent Declaration has resulted in discussions and initiatives on optimal diabetes care during recent years. Both are based on two sources of knowledge: evidence and experience. We wanted to reveal the experience based knowledge in the Netherlands to identify essential elements or prerequisites for high quality type 2 diabetes care. METHODS: A group of 56 experts on diabetes care were invited to fill in a questionnaire. This included a ranking of 18 elements on the organization of diabetes care and 9 on patient education. RESULTS: The response rate was 87.5%. With regard to the organization of care 'active patient participation', 'protocolized care' and 'patient education' were evaluated as the most important. The integration in daily diabetes care was seen as the most important aspect of patient education. Optimal diabetes patient education would include five sessions (range: 1-10) of 1 h (range: 0.25-3) with active follow-up. The most appropriate disciplines for patient education are the diabetes nurse (chosen by 93% of the experts) and the dietician (77%). CONCLUSIONS: Optimal care for diabetes mellitus type 2 consists of structured care with integrated patient education. The majority of the experts indicated that this is not optimally organized within the Netherlands.

Measuring disability in nursing home residents: validity and reliability of a newly developed instrument.

A 24-item multidimensional nurse-administered Nursing Home Disabilities Instrument (NHDI) was developed to measure disabilities in nursing home residents. We present the psychometric features and value of this instrument, with the following domains assessed: Mobility, Activities of Daily Living (ADLs), Alertness, Resistance to Nursing Assistance, Incontinence, Cognition, and PERCEPTION: Test-retest and interrater reliability was assessed using the Spearman correlation coefficient. Internal consistency was examined by Cronbach's alpha. Criterion validity tests were performed by comparing the scales with scales of the Elderly Residents Rating Scale (BOP). Test-retest reliability correlation coefficients ranged from 0.63 to 0.94. Interrater reliability was high for the scales Cognition, Mobility, ADL, and Incontinence (0.79 to 0.93), moderate for Resistance (0.51), and low for Perception (0.33). Cronbach's alpha of the scales was high, ranging from 0.78 (Alertness) to 0.93 (Mobility); only Perception showed a low alpha: 0.54. Criterion validity was high for Cognition, ADL, and Mobility (0.75 to 0.78), and moderate for Alertness (0.59). The NHDI appears to be a valid and efficient multidimensional instrument for measuring disabilities in nursing home residents. These findings imply that the NHDI is a useful instrument for nursing homes to achieve a reliable assessment of cognitively impaired elders.

Education integrated into structured general practice care for Type 2 diabetic patients results in sustained improvement of disease knowledge and self-care.

AIMS: The objective of this study was to study the effectiveness of structured care with and without integrated education with regard to patients' knowledge, self-care behaviour and disease perception. METHODS: Four diabetes care programmes implemented in a daily primary care setting were compared, two based on structured care and two on education integrated into structured care. Measurements were taken at baseline and after 6 and 12 months. RESULTS: The study included 243 patients with Type 2 diabetes mellitus treated by a general practitioner (mean age 64.0 years; diabetes duration 7.1 years). The level of patients' disease knowledge increased in all programmes, was preserved at follow-up and differed between programmes with a specific educational component (37%) on one hand and the non-educational programmes (11%) on the other (P < 0.001). The percentage of patients performing self-care behaviour increased in all programmes, but more so in the programmes with an educational component. In addition, an increase in the frequency of self-care behaviour was observed, whereas no change in disease perception was found. In cross sectional analyses disease knowledge and self-care behaviour were positively related (partial correlation coefficient: 0.35; P < 0.001 adjusted for age, sex, level of education and duration of diabetes). CONCLUSIONS: The results indicate that primary care programmes which integrated education into structured care are able to improve both Type 2 diabetic patients' disease knowledge and their self-care behaviour. These improvements endured after the completion of the programmes, which suggests that they initiate lasting changes in the way patients handle their disease.

The Helping Alliance Questionnaire: psychometric properties in patients with substance dependence.

Psychometric properties of the Helping Alliance Questionnaire (HAQ) are analyzed in a population of 340 substance-dependent patients of an addiction clinic in the Netherlands. Factor analysis yields a two-factor structure: Cooperation and Helpfulness. The scales show fair correlations with three out of seven scales from the Barrett-Lennard Relationship Inventory. Length of Stay in Detox is predicted by scores on the Helpfulness scale and noncompliance by scores on the Cooperation scale. Besides this, intermediate outcome measures are correlated with HAQ scores. The HAQ seems to be a "quick scan" instrument to give a quick and global impression of the patients' perception of the quality of the working alliance with the therapist.

Cost-effectiveness of implantable defibrillator as first-choice therapy versus electrophysiologically guided, tiered strategy in postinfarct sudden death survivors. A randomized study.

BACKGROUND: Rising costs of health care, partly as a result of costly therapeutic innovations, are of concern to both the medical profession and healthcare authorities. The implantable cardioverter-defibrillator (ICD) is still not remunerated by Dutch healthcare insurers. The aim of this study was to evaluate the cost-effectiveness of early implantation of the ICD in postinfarct sudden death survivors. METHODS AND RESULTS: Sixty consecutive postinfarct survivors of cardiac arrest caused by ventricular tachycardia or fibrillation were randomly assigned either ICD as first choice (n = 29) or a tiered therapy starting with antiarrhythmic drugs and guided by electrophysiological (EP) testing (n = 31). Median follow-up was 729 days (range, 3 to 1675 days). Fifteen patients died, 4 in the early ICD group and 11 in the EP-guided strategy group (P = .07). For quantitative assessment, the cost-effectiveness ratio was calculated for both groups and expressed as median total costs per patient per day alive. Because effectiveness aspects other than mortality are not incorporated in this ratio, other factors related to quality of life were used as qualitative measures of cost-effectiveness. The cost-effectiveness ratios were $63 and $94 for the early ICD and EP-guided strategy groups, respectively, per patient per day alive. This amounts to a net cost-effectiveness of $11,315 per patient per year alive saved by early ICD implantation. Costs in the early ICD group were higher only during the first 3 months of follow-up, but as a result of the high proportion of therapy changes, including arrhythmia surgery and late ICD implantation, costs in the EP-guided strategy group became higher after that. Patients discharged with antiarrhythmic drugs as sole therapy had the lowest total costs. This subset, however, showed extremely high mortality, resulting in a poor cost-effectiveness ratio ($196 per day). Invasive therapies and hospitalization were the major contributors to costs. If quality-of-life measures are taken into account, the cost-effectiveness of early ICD implantation was even more favorable. Recurrent cardiac arrest and cardiac transplantation occurred in the EP-guided strategy group only, whereas exercise tolerance, total hospitalization duration, number of invasive procedures, and antiarrhythmic therapy changes were significantly in favor of early ICD implantation. CONCLUSIONS: In terms of cost-effectiveness, early ICD implantation is superior to the EP-guided therapeutic strategy in postinfarct sudden death survivors.

Quality, costs and cultural beliefs in outpatient treatment with parenteral antibiotics: a comment.

The introduction of outpatient parenteral antibiotic therapy (OPAT) will change the concepts of a hospital and of primary health care. When it is guaranteed by a number of general quality conditions, and short-term transformation costs are left aside, it has a good chance of developing in cities where distances between patient's homes and hospitals are shorter. Cultural beliefs of health care providers in hospitals and in primary health care are an important barrier for the introduction of OPAT. Perhaps countries with hospital-oriented health care systems (Germany, Sweden, USA) will start earlier with OPAT than countries with a strong and independent primary health-care system (the UK, Finland and The Netherlands). On the other hand, the last three countries are better equipped to integrate OPAT into other types of home health service.

Regional health budgeting in Western Europe.

This article distinguishes in the first section three characteristics of regional budgeting in health care systems: geographical division of budgets, regional financial limits, and policy freedom for regional authorities. Following these and more general elements of regional budgeting systems sections 2 to 5 describe the situation in the U.K., Sweden, The Netherlands, and some other European countries. The first two countries have a developed regional budgeting system for health services paid by taxation. Other European countries are developing regional budgeting models which are to be combined with a social insurance system. Of these countries, the Netherlands are discussed in some detail. Based on the experiences with regional budgeting in different countries three hypotheses are generated which require further empirical research. They are: (1) One management tier on a regional level--or municipal or provincial level--is a condition for a regional budgeting system which contributes more to an integration of health services than a two-tier system. (2) Countries with a regional budgeting system with a regional financial limit superimposed by the state seem to spend a smaller percentage of their gross national product than other countries. (3) Countries with policy freedom on a local level show a faster growth rate for primary care than for hospital care.