[Quality improvement as a joint task]. / Kwaliteitsverbetering als een gezamenlijke opgave: Evaluatie van een kwaliteitsinstrument in de verpleeghuiszorg.

This article presents the key elements of the quality measure included in the Dignity and Pride program of the Dutch Ministry of Health, Welfare and Sport in cooperation with Vilans, the national centre of expertise for long-term care in the Netherlands. Nursing homes take part in the quality measure at the start of the program to investigate where they stand with respect to the nursing home quality framework.

Improving the quality of care in nursing home organizations with urgent quality issues: design and effectiveness of a Dutch government-funded support programme.

BACKGROUND: Various societal developments are currently challenging the ability of European nursing home organizations to meet quality standards. To support nursing home organizations throughout the Netherlands in quality improvement (QI), the Dutch government launched a nationwide programme in 2016 entitled 'Dignity and pride' (D&p). As part of this programme, participating nursing home organizations followed a tailored trajectory centred around intensive, on-site support from external expert coaches. For this study, we evaluated to what extent quality improvements were realized in the programme, paying particular attention to the role of the expert coaches. METHODS: Thirty-six nursing home organizations were included. At the start of D&p, the majority of these organizations (78%) had major quality issues as determined by the Health Care Inspectorate. Information on quality of care at the start versus end of the programme was obtained from improvement plans and final evaluation reports. Quality of person-centred care (PCC) and resident safety were quantified using a standardized assessment tool based on national guidelines, with improvements analysed using two-sided paired-sample T-tests. In addition, semi-structured interviews were conducted with 14 coaches and 29 healthcare professionals, focusing on the greatest benefits of programme participation and on the added value of the expert coaches. RESULTS: After completion of the programme, 60% of the organizations scored a 4 (= good) on PCC and resident safety, and none scored a 2 or less (average improvement on a 5-point scale for both themes: 1.9 points, p < 0.001). Interviewees confirmed that the quality of care had both improved and become more person-centred. The expert coaches were credited with substantially contributing to the QI process by offering an outsider's perspective, bringing in experience and expertise, and helping the organization stay committed and focused. CONCLUSIONS: Our study results suggest that the D&p programme was associated with improved quality of care in nursing home organizations with urgent quality issues. However, offering on-site tailored support through a nationally coordinated, government-funded programme is both time- and labour-intensive, and therefore not feasible in every healthcare setting. Nevertheless, the findings provide valuable insights for future QI support strategies.

Quality evaluation questionnaires - nursing homes (QEQ-NH); validation of questionnaires for measuring quality of care in nursing homes from various perspectives.

BACKGROUND: This study aims to describe the validation and optimization of a new instrument designed to comprehensively measure and evaluate the quality of care in nursing homes; the Quality Evaluation Questionnaires for Nursing Homes (QEQ-NH). This instrument comprises several questionnaires on the perceived quality of care for various perspectives (e.g. clients, family and professional caregivers) and covers eight themes of the national quality framework for nursing home care in the Netherlands. METHODS: Data were collected in six nursing homes between September 2017 and June 2018, among 359 residents, 48 family caregivers and 648 professional caregivers who completed a subgroup-specific questionnaire of the QEQ-NH. Construct and criterion validity of the three questionnaires were tested with item- and scale analyses. Content validity of the questionnaires was tested in cognitive interviews with 20 participants (7 residents, 5 family caregivers and 8 professional caregivers). RESULTS: Psychometric analyses confirmed the multidimensionality and reliability of the three questionnaires, and the cognitive interviews showed various possibilities for further optimization of the instrument. Construct, criterion and content validity of the three questionnaires ranged from acceptable to good. Cronbach's alphas were > .70 for almost all scales. More than half of the items were candidate for optimization according to the cognitive interviews, mainly due to clarity or knowledge problems, and the questionnaires of the QEQ-NH were optimized accordingly. CONCLUSIONS: The Quality Evaluation Questionnaires for Nursing Homes (QEQ-NH) provide a solid basis to measure the quality of nursing home care, by covering the national quality themes and by integrating the various perspectives of all parties involved. With real-time feedback, the instrument provides the management and care teams with information to select possibilities or areas for improvement and to continuously monitor the effects of quality improvement in nursing homes.

Disaster exposure as a risk factor for mental health problems, eighteen months, four and ten years post-disaster--a longitudinal study.

BACKGROUND: Disaster experiences have been associated with higher prevalence rates of (mental) health problems. The objective of this study was to examine the independent relation between a series of single disaster experiences versus the independent predictive value of a accumulation of disaster experiences, i.e. a sum score of experiences and symptoms of distress and post-traumatic stress disorder (PTSD). METHODS: Survivors of a fireworks disaster participated in a longitudinal study and completed a questionnaire three weeks (wave 1), eighteen months (wave 2) and four years post-disaster (wave 3). Ten years post-disaster (wave 4) the respondents consisted of native Dutch survivors only. Main outcome measures were general distress and symptoms of PTSD. RESULTS: Degree of disaster exposure (sum score) and some disaster-related experiences (such as house destroyed, injured, confusion) were related to distress at waves 2 and 3. This relation was mediated by distress at an earlier point in time. None of the individual disaster-related experiences was independently related to symptoms of distress. The association between the degree of disaster exposure and symptoms of PTSD at waves 2 and 3 was still statistically significant after controlling for symptoms of distress and PTSD at earlier point in time. The variable 'house destroyed' was the only factor that was independently related to symptoms of PTSD at wave 2. Ten years after the disaster, disaster exposure was mediated by symptoms of PTSD at waves 2 and 3. Disaster exposure was not independently related to symptoms of PTSD ten years post-disaster. CONCLUSIONS: Until 4 years after the disaster, degree of exposure (a sum score) was a risk factor for PTSD symptoms while none of the individual disaster experiences could be identified as an independent risk factor. Ten years post-disaster, disaster exposure was no longer an independent risk factor for symptoms of PTSD. Since symptoms of PTSD and distress at earlier waves perpetuate the symptoms at later waves, health care workers should aim their resources at those who still have symptoms after one and a half year post-disaster, to prevent health problems at medium and long-term.

Risk factors for unexplained symptoms after a disaster: a five-year longitudinal study in general practice.

BACKGROUND: Medically unexplained symptoms (MUS) are a common reason to seek medical care. When presented to the general practitioner (GP), more than three-quarters of symptoms such as stomach ache, headache, and pain in bones and muscles cannot be explained by a medical disorder. OBJECTIVE: The authors examined the course of MUS presented to the GP in the 1 year before the disaster and in the 4 years after a disaster in order to study the risk factors for MUS. METHOD: Data were extracted from the electronic medical records of survivors and from a questionnaire (N=1,216). RESULTS: Although the mean number of MUS was significantly increased statistically in the first 2 years post-disaster, the increase was not clinically significant. CONCLUSION: The authors identified several important risk factors, such as immigrant status and psychological problems, that are easy for GPs to recognize. Despite this, the sensitivity of the regression model was relatively low.

The public health dimension of disasters--health outcome assessment of disasters.

A broad range of health problems are related to disasters. Insight into these health problems is needed for targeted disaster management. Disaster health outcome assessment can provide insight into the health effects of disasters. During the 15th World Congress on Disaster and Emergency Medicine in Amsterdam (2007), experts in the field of disaster epidemiology discussed important aspects of disaster health outcome assessment, such as: (1) what is meant by disaster health outcome assessment?; (2) why should one conduct a disaster health outcome assessment, and what are the objectives?, and (3) who benefits from the information obtained by a disaster health outcome assessment? A disaster health outcome assessment can be defined as a systematic assessment of the current and potential health problems in a population affected by a disaster. Different methods can be used to examine these health problems such as: (1) rapid assessment of health needs; (2) (longitudinal) epidemiological studies using questionnaires; (3) continuous surveillance of health problems using existing registration systems; (4) assessment of the use and distribution of health services; and (5) research into the etiology of the health effects of disasters. The public health impact of a disaster may not be immediately evident. Disaster health outcome assessment provides insight into the health related consequences of disasters. The information that is obtained by performing a disaster health outcome assessment can be used to initiate and adapt the provision of health care. Besides information for policymakers, disaster health outcome assessments can contribute to the knowledge and evidence base of disaster health outcomes (scientific objective). Finally, disaster health outcome assessment might serve as a signal of recognition of the problems of the survivors. Several stakeholders may benefit from the information obtained from a disaster health outcome assessment. Disaster decision-makers and the public health community benefit from performing a disaster health outcome assessment, since it provides information that is useful for the different aspects of disaster management. Also, by providing information about the nature, prevalence, and course of health problems, (mental) health care workers can anticipate the health needs and requirements in the affected population. It is important to realize that the disaster is not over when the acute care has been provided. Instead, disasters will cause many other health problems and concerns such as infectious diseases and mental health problems. Disaster health outcome assessments provide insight into the public health impact of disasters.

Are physical symptoms among survivors of a disaster presented to the general practitioner? A comparison between self-reports and GP data.

BACKGROUND: Most studies examining medically unexplained symptoms (MUS) have been performed in primary or secondary care and have examined symptoms for which patients sought medical attention. Disasters are often described as precipitating factors for MUS. However, health consequences of disasters are typically measured by means of questionnaires, and it is not known whether these self-reported physical symptoms are presented to the GP. It is also not known if the self-reported symptoms are related to a medical disorder or if they remain medically unexplained. In the present study, three research questions were addressed. Firstly, were self-reported symptoms among survivors presented to the GP? Secondly, were the symptoms presented to the GP associated with a high level of functional impairment and distress? Thirdly, what was the GP's clinical judgment of the presented symptoms, i.e. were the symptoms related to a medical diagnosis or could they be labeled MUS? METHODS: Survivors of a man-made disaster (N = 887) completed a questionnaire 3 weeks (T1) and 18 months (T2) post-disaster. This longitudinal health survey was combined with an ongoing surveillance program of health problems registered by GPs. RESULTS: The majority of self-reported symptoms was not presented to the GP and survivors were most likely to present persistent symptoms to the GP. For example, survivors with stomachache at both T1 and T2 were more likely to report stomachache to their GP (28%) than survivors with stomachache at only T1 (6%) or only T2 (13%). Presentation of individual symptoms to the GP was not consistently associated with functional impairment and distress. 56 - 91% of symptoms were labeled as MUS after clinical examination. CONCLUSION: These results indicate that the majority of self-reported symptoms among survivors of a disaster are not presented to the GP and that the decision to consult with a GP for an individual symptom is not dependent on the level of impairment and distress. Also, self-reported physical symptoms such as headache, back pain and shortness of breath are likely to remain medically unexplained after the clinical judgment of a GP.

Selective attrition and bias in a longitudinal health survey among survivors of a disaster.

BACKGROUND: Little is known about the response mechanisms among survivors of disasters. We studied the selective attrition and possible bias in a longitudinal study among survivors of a fireworks disaster. METHODS: Survivors completed a questionnaire three weeks (wave 1), 18 months (wave 2) and four years post-disaster (wave 3). Demographic characteristics, disaster-related factors and health problems at wave 1 were compared between respondents and non-respondents at the follow-up surveys. Possible bias as a result of selective response was examined by comparing prevalence estimates resulting from multiple imputation and from complete case analysis. Analysis were stratified according to ethnic background (native Dutch and immigrant survivors). RESULTS: Among both native Dutch and immigrant survivors, female survivors and survivors in the age categories 25-44 and 45-64 years old were more likely to respond to the follow-up surveys. In general, disasters exposure did not differ between respondents and non-respondents at follow-up. Response at follow-up differed between native Dutch and non-western immigrant survivors. For example, native Dutch who responded only to wave 1 reported more depressive feelings at wave 1 (59.7%; 95% CI 51.2-68.2) than Dutch survivors who responded to all three waves (45.4%; 95% CI 41.6-49.2, p < 0.05). Immigrants who responded only to wave 1 had fewer health problems three weeks post-disaster such as depressive feelings (M = 69.3%; 95% CI 60.9-77.6) and intrusions and avoidance reactions (82.7%; 95% CI 75.8-89.5) than immigrants who responded to all three waves (respectively 89.9%; 95% CI 83.4-96.9 and 96.3%; 95% CI 92.3-100, p < .01). Among Dutch survivors, the imputed prevalence estimates of wave 3 health problems tended to be higher than the complete case estimates. The imputed prevalence estimates of wave 3 health problems among immigrants were either unaffected or somewhat lower than the complete case estimates. CONCLUSION: Our results indicate that despite selective response, the complete case prevalence estimates were only somewhat biased. Future studies, both among survivors of disasters and among the general population, should not only examine selective response, but should also investigate whether selective response has biased the complete case prevalence estimates of health problems by using statistical techniques such as multiple imputation.

Health-related quality of life and mental health problems after a disaster: are chronically ill survivors more vulnerable to health problems?

Studies have shown that the chronically ill are at higher risk for reduced health-related quality of life (HRQL) and for mental health problems. A combination with traumatic events might increase this risk. This longitudinal study among 1216 survivors of a disaster examines whether chronically ill survivors had a different course of HRQL and mental health problems compared to survivors without chronic diseases. HRQL and mental health problems were measured 3 weeks, 18 months and 4 years post-disaster. Data on pre-disaster chronic diseases was obtained from the electronic medical records of general practitioners. Random coefficient analyses showed significant interaction effects for social functioning, bodily pain and emotional role limitations at T2 only. Chronically ill survivors did not consistently have a different course of general health, physical role limitations, and mental health problems. In conclusion, chronic diseases were not an important risk factor for impaired HRQL and mental health problems among survivors.

Symptoms and related functioning in a traumatized community.

BACKGROUND: Traumatic events are described as precipitating factors for medically unexplained symptoms. The aim of this study was to examine the prevalence and course of symptoms reported by disaster survivors and to assess whether the symptoms have features similar to those of medically unexplained symptoms. METHODS: A 3-wave longitudinal study was performed after an explosion of a fireworks depot. As a result of the explosion, 23 people were killed, more than 900 people were injured, and about 500 homes were damaged or destroyed. Respondents completed a set of validated questionnaires measuring their health problems 3 weeks (wave 1), 18 months (wave 2), and 4 years (wave 3) after the disaster. A comparison group was included at waves 2 and 3. RESULTS: The study population included 815 survivors who participated in the 3 waves. The mean number of symptoms was higher among survivors compared with control subjects at wave 2 (7.5 vs 5.8 symptoms) and at wave 3 (6.1 vs 4.9 symptoms) (P < .001 for both). Survivors and control subjects with more symptoms reported significantly lower mean scores on all scales of the Dutch version of the RAND 36-item health survey. Illness behavior and depression and anxiety were associated with the number of symptoms. For example, more than 60% of survivors with 10 or more symptoms reported depression and anxiety, compared with 2.4% of survivors with 0 to 1 symptoms (P < .001). CONCLUSIONS: Up to 4 years after the disaster, symptoms were more prevalent among survivors than controls. Although medical disorders cannot be excluded, the reported symptoms showed several features similar to those of medically unexplained symptoms in the general population.