Assembling a population health management maturity index using a Delphi method.

BACKGROUND: Although local initiatives commonly express a wish to improve population health and wellbeing using a population health management (PHM) approach, implementation is challenging and existing tools have either a narrow focus or lack transparency. This has created demand for practice-oriented guidance concerning the introduction and requirements of PHM. METHODS: Existing knowledge from scientific literature was combined with expert opinion obtained using an adjusted RAND UCLA appropriateness method, which consisted of six Dutch panels in three Delphi rounds, followed by two rounds of validation by an international panel. RESULTS: The Dutch panels identified 36 items relevant to PHM, in addition to the 97 items across six elements of PHM derived from scientific literature. Of these 133 items, 101 were considered important and 32 ambiguous. The international panel awarded similar scores for 128 of 133 items, with only 5 items remaining unvalidated. Combining literature and expert opinion gave extra weight and validity to the items. DISCUSSION: In developing a maturity index to help assess the use and progress of PHM in health regions, input from experts counterbalanced a previous skewedness of item distribution across the PHM elements and the Rainbow Model of Integrated Care (RMIC). Participant expertise also improved our understanding of successful PHM implementation, as well as how the six PHM elements are best constituted in a first iteration of a maturity index. Limitations included the number of participants in some panels and ambiguity of language. Further development should focus on item clarity, adoption in practice and item interconnectedness. CONCLUSION: By employing scientific literature enriched with expert opinion, this study provides new insight for both science and practice concerning the composition of PHM elements that influence PHM implementation. This will help guide practices in their quest to implement PHM.

How to successfully implement population health management: a scoping review.

BACKGROUND: Despite international examples, it is unclear for multisector initiatives which want to sustainably improve the health of a population how to implement Population Health Management (PHM) and where to start. Hence, the main purpose of this research is to explore current literature about the implementation of PHM and organising existing knowledge to better understand what needs to happen on which level to achieve which outcome. METHODS: A scoping review was performed within scientific literature. The data was structured using Context-Mechanism-Outcome, the Rainbow model of integrated care and six elements of PHM as theoretical concepts. RESULTS: The literature search generated 531 articles, of which 11 were included. Structuring the data according to these three concepts provided a framework that shows the skewed distribution of items that influence the implementation of PHM. It highlights that there is a clear focus on normative integration on the organisational level in 'accountable regional organisation'. There is less focus on the normative integration of 'cross domain business model', 'integrated data infrastructure', and 'population health data analytics', and overall the perspective of citizen and professionals, indicating possible gaps of consideration. CONCLUSIONS: A first step is taken towards a practical guide to implement PHM by illustrating the depth of the complexity and showing the partial interrelatedness of the items. Comparing the results with existing literature, the analysis showed certain gaps that are not addressed in practice, but should be according to other frameworks. If initiators follow the current path in literature, they may be missing out on some important components to achieve proper implementation of PHM.

The introduction of a data-driven population health management approach in the Netherlands since 2019: The Extramural LUMC Academic Network data infrastructure.

Improving population health and reducing inequalities through better integrated health and social care services is high up on the agenda of policymakers internationally. In recent years, regional cross-domain partnerships have emerged in several countries, which aim to achieve better population health, quality of care and a reduction in the per capita costs. These cross-domain partnerships aim to have a strong data foundation and are committed to continuous learning in which data plays an essential role. This paper describes our approach towards the development of the regional integrative population-based data infrastructure Extramural LUMC (Leiden University Medical Center) Academic Network (ELAN), in which we linked routinely collected medical, social and public health data at the patient level from the greater The Hague and Leiden area. Furthermore, we discuss the methodological issues of routine care data and the lessons learned about privacy, legislation and reciprocities. The initiative presented in this paper is relevant for international researchers and policy-makers because a unique data infrastructure has been set up that contains data across different domains, providing insights into societal issues and scientific questions that are important for data driven population health management approaches.

Patients' evaluation of quality of care in general practice: what are the cultural and linguistic barriers?

OBJECTIVE: Increased migration implies increased contacts for physicians with patients from diverse cultural backgrounds who have different expectations about healthcare. How satisfied are immigrant patients, and how do they perceive the quality of care? This study investigated which patient characteristics (such as cultural views and language proficiency) are related to patients' satisfaction and perceived quality of care. METHODS: Patients (n=663) from 38 general practices in Rotterdam (The Netherlands) were interviewed. General satisfaction with the general practitioner (GP) was measured by a report mark. Perceived quality of care was measured using the 'Quote-mi' scale (quality of care through the patient's eyes-for migrants), which contains an ethnic-specific subscale and a communication process subscale. Using multilevel regression techniques, the relation between patient characteristics (ethnicity, age, education, Dutch language proficiency, cultural views) and satisfaction and perceived quality of care was analysed. RESULTS: In general, patients seemed fairly satisfied. Non-Western patients perceived less quality of care and were less satisfied than Dutch-born patients. The older the patients and the more modern cultural views they had, the more satisfied they were about the GP in general, as well as about the communication process. However, non-Western patients holding more modern views were the most critical regarding the ethnic-specific quality items. The poorer patients' Dutch language proficiency, the more negative they were about the communication process. CONCLUSION: It is concluded that next to communication aspects, especially when the patient's proficiency in Dutch is poor, physician awareness about the patient's cultural views is very important during the consultation. This holds especially true when the immigrant patient seems to be more or less acculturated. PRACTICE IMPLICATIONS: Medical students and physicians should be trained to become aware of the relevance of patients' different cultural backgrounds. It is also recommended to offer facilities to bridge the language barrier, by making use of interpreters or cultural mediators.

Cultural dissimilarities in general practice: development and validation of a patient's cultural background scale.

Due to increased migration physicians encounter more communication difficulties due to poor language proficiency and different culturally defined views about illness. This study aimed to develop and validate a 'patient's cultural background scale' in order to classify patients based on culturally conditioned norms instead of on ethnicity. A total of 986 patients from 38 multi-ethnic general practices were included. From a list of 36 questions, non-contributing and non-consistent questions were deleted and from the remaining questions the scale was constructed by principal component analysis. Comparing the scale with two other methods of construction assessed internal validity. Comparing the found dimensions with known dimensions from literature assessed the construct validity. Criterion validity was determined by comparing the patient's score with criteria assumed or known to have relationship with cultural background. Criterion validity was reasonably good but poor for income. A valid patient's cultural background scale was developed, for use in large-scale quantitative studies.

Factors associated with hypertension awareness, treatment, and control in Ghana, West Africa.

Hypertension is rapidly becoming a major public health burden in sub-Saharan/Africa but awareness, treatment, and control is lagging behind. We analysed cross-sectional data from Ghana (West-Africa) to examine factors associated with awareness, treatment, and control of hypertension. The overall prevalence of hypertension was 29.4%. Of these, 34% were aware of their condition, 28% were receiving treatment, and 6.2% were controlled below SBP/DBP <140/90 mmHg. Multivariate analysis showed that old age was independently associated with higher hypertension awareness: 35-49-year-olds (odds ratio (OR) = 2.57, 95% (confidence interval) CI: 1.26-5.22), > or =50-year-olds (OR = 6.14, CI: 2.98-12.64) compared with 16-34-year-olds. Old age: > or =50-year-olds (OR: 6.25, 95% CI: 2.87-13.62), trading (OR = 2.46, 95% CI: 1.17-5.17), and overweight (OR = 1.85, 95% CI: 1.02, 3.34) were independently associated with pharmacological treatment of hypertension. Trading (OR = 2.51, 95% CI: 1.03-7.40) was independently associated with adequate blood pressure (BP) control but old age: > or =50-year-olds (OR = 0.11, 95% CI: 0.01-0.60) was independently associated with inadequate BP control. The identified factors provide important information for improving BP control among this population. Given the high cost of hypertension medication relative to income, increasing awareness and simple preventive measures such as promotion of physical activity, normalising body weight and reduction of salt intake, present the best hope for reducing the impact of hypertension on morbidity and mortality.

Prevention of cardiovascular diseases: focus on modifiable cardiovascular risk.

OBJECTIVE: To determine whether the use of a 20% absolute risk threshold for cardiovascular disease as recommended in current guidelines leads to exclusion of patients with a substantial modifiable risk (> or = 5%). METHODS: Data collected within the framework of a randomised controlled trial in three primary health care centres located in deprived neighbourhoods were analysed. The 10 year absolute risk and the modifiable part of risk were calculated by using the Framingham risk equation. Among patients with a modifiable risk reduction of > or = 5% (number needed to treat < or = 20) the characteristics and risk factors of patients with an absolute risk > or = 20% and those with an absolute risk < 20% were compared. RESULTS: 293 patients aged 30-70 years at risk of developing cardiovascular disease were included, of whom 66% were women and 36% were of Dutch origin. Of all patients, 33% had an absolute risk > or = 20% and 61% had a modifiable risk > or = 5%. Of those at > or = 20% absolute risk, a vast majority (98%) had a modifiable risk > or = 5%. Among those with an absolute risk < 20%, 43% had a modifiable risk > or = 5%; this group, who were relatively young and predominantly women, constituted 29% of the entire study population. CONCLUSIONS: Targeting preventive strategies at a 10 year absolute risk > or = 20% leads to exclusion of a large group of relatively young, predominantly female patients. In total, about one quarter had an absolute risk < 20% but a modifiable risk > or = 5% and should therefore benefit from intervention.

Assessment of mutual understanding of physician patient encounters: development and validation of a Mutual Understanding Scale (MUS) in a multicultural general practice setting.

Mutual understanding between physician and patient is essential for good quality of care; however, both parties have different views on health complaints and treatment. This study aimed to develop and validate a measure of mutual understanding (MU) in a multicultural setting. The study included 986 patients from 38 general practices. GPs completed a questionnaire and patients were interviewed after the consultation. To assess mutual understanding the answers from GP and patient to questions about different consultation aspects were compared. An expert panel, using nominal group technique, developed criteria for mutual understanding on consultation aspects and secondly, established a ranking to combine all aspects into an overall consultation judgement. Regarding construct validity, patients' ethnicity, age and language proficiency were the most important predictors for MU. Regarding criterion validity, all GP-related criteria (the GPs perception of his ability to explain to the patient, the patient's ability to explain to the GP, and the patient's understanding of consultation aspects), were well-related to MU. The same can be said of patient's consultation satisfaction and feeling that the GP was considerate. We conclude that the Mutual Understanding Scale is regarded a reliable and valid measure to be used in large-scale quantitative studies.

No clear effect of diabetes education on glycaemic control for Turkish type 2 diabetes patients: a controlled experiment in general practice.

BACKGROUND: In Turkish immigrant diabetics, problems with communication and cultural differences may hinder delivery of diabetes care. METHODS: In a prospective controlled study, the effect of an ethnic-specific diabetes education programme on glycaemic control and cardiovascular risk factors in Turkish type 2 diabetes patients was assessed, by comparing Turkish diabetics who were offered the education programme with Turkish diabetics offered routine care only (control group). From 16 general practices (31 GPs) in Rotterdam, 104 Turkish type 2 diabetes patients were recruited, 85 of whom could be assessed at one-year follow-up. Glycaemic control, lipid concentrations, blood pressure and body mass index were measured. RESULTS: Compared with the control group, mean HbA(1C) in the intervention group decreased by 0.3% (95% CI -0.8 to 0.2). A significant decrease in HbA(1C) was observed in women with HbA(1C) >7% at baseline (-0.9%; 95% CI -1.73 to -0.09) but not in the other subgroups studied. serum lipid concentrations, blood pressure and body mass index remained unchanged in the intervention group. CONCLUSION: Ethnic-specific diabetes education by Turkish female educators has no obvious beneficial effect on glycaemic control or cardiovascular risk profile. More focus on specific patient selection and gender equality between educators/patients may prove worthwhile.

Prevalence of type 2 diabetes mellitus, other cardiovascular risk factors, and cardiovascular disease in Turkish and Moroccan immigrants in North West Europe: a systematic review.

BACKGROUND: The prevalence of diabetes, other cardiovascular risk factors, and cardiovascular morbidity and mortality varies between immigrant groups in Western societies, but epidemiological data on these topics are scarce for Turks and Moroccan immigrant living in North West Europe. METHODS: Medline and Embase were systematically searched for studies containing data on the prevalence of diabetes, cardiovascular risk factors, and cardiovascular morbidity and mortality in Turkish or Moroccan immigrants living in Northwestern European countries. RESULTS: Eighteen studies were identified. Corresponding findings were a high prevalence of type 2 diabetes in Turkish and Moroccan immigrants, a high prevalence of smoking among Turkish men, and a very low prevalence of smoking in Moroccan women compared to the indigenous population. Because of lack of valid studies, no definite conclusions could be drawn for in particular blood pressure and lipids. One German study showed exceptionally lower cardiovascular mortality rates in Turkish immigrants. CONCLUSION: The reviewed studies yielded insufficient evidence for a good quality comparison of the cardiovascular risk profile between Turkish and Moroccan immigrants and indigenous populations. Diabetes mellitus was more prevalent in Turkish and Moroccan immigrants, smoking more prevalent in Turkish males, and very rare in Moroccan females.

Diabetes care in Dutch general practice: differences between Turkish immigrants and Dutch patients.

AIM: To compare the adherence to clinical guidelines by GPs as registered and glycaemic control in Turkish and Dutch type 2 diabetes patients. DESIGN: A retrospective cohort study. Search of general practice medical records for diabetes-related variables of Turkish and Dutch diabetes patients, stratified for age and gender. SETTING: Seventeen general practices (37 GPs) in the inner city of Rotterdam. SUBJECTS: 196 type 2 diabetes patients (106 Turkish and 90 Dutch), known with diabetes for at least 18 months, were followed for two years during the 1992-1997 period. MAIN OUTCOME MEASURES: 1) Level of care as registered in the medical records based on eight quantifiable criteria derived from the national guidelines for GPs; and 2) glycaemic control (fasting and non-fasting blood glucose levels). RESULTS: Turkish patients visited the GP for periodic control more often than Dutch patients. The other seven criteria were followed in an equal number of Turkish and Dutch patients. Turkish patients had a higher mean non-fasting plasma glucose level (12.9 mmol/l) than Dutch patients (10.8) (p=0.001) during the two-year follow-up. CONCLUSIONS: Although adherence to clinical guidelines as registered in Turkish and Dutch type 2 diabetes patients is comparable, Turkish patients have higher mean non-fasting plasma glucose level than their Dutch counterparts.

Ethnic specific recommendations in clinical practice guidelines: a first exploratory comparison between guidelines from the USA, Canada, the UK, and the Netherlands.

OBJECTIVES: To investigate whether clinical practice guidelines in different countries take ethnic differences between patients into consideration and to assess the scientific foundation of such ethnic specific recommendations. DESIGN: Analysis of the primary care sections of clinical practice guidelines. SETTING: Primary care practice guidelines for type 2 diabetes mellitus, hypertension, and asthma developed in the USA, Canada, the UK, and the Netherlands. MAIN OUTCOME MEASURES: Enumeration of the ethnic specific information and recommendations in the guidelines, and the scientific basis and strength of this evidence. RESULTS: Different guidelines do address ethnic differences between patients, but to a varying extent. The USA guidelines contained the most ethnic specific statements and the Dutch guidelines the least. Most ethnic specific statements were backed by scientific evidence, usually arising from descriptive studies or narrative reviews. CONCLUSION: The attention given to ethnic differences between patients in clinical guidelines varies between countries. Guideline developers should be aware of the potential problems of ignoring differences in ethnicity.

[Less ethnic knowledge in the Dutch College of General Practitioner's practice guidelines on type 2 diabetes mellitus, hypertension and asthma in adults than in the supporting literature]. / Minder etnische kennis in de standaarden van het Nederlands Huisartsen Genootschap over diabetes mellitus type 2, hypertensie en over astma bij volwassenen dan in de onderbouwende literatuur.

OBJECTIVE: To assess whether ethnic differences present in the scientific literature used as the basis for the Dutch College of General Practitioner's (NHG) practice guidelines were reflected in the ethnic-specific information the guidelines contained. DESIGN: Analysis of published information. METHOD: The scientific literature used as the basis for the guidelines about type 2 diabetes mellitus, hypertension and asthma in adults was collected and carefully screened. Relevant ethnic-specific information was compared to the content of the guidelines. RESULTS: Several relevant ethnic differences were stated in the scientific literature used as the basis for the guidelines. Differences in prevalence and clinical progress were stated for type 2 diabetes mellitus, differences in lung-volume were stated for asthma and differences in prevalence, onset, complications, response to pharmacological treatment and dietary salt restriction were stated for hypertension. The type 2 diabetes mellitus guideline stated a higher prevalence of diabetes in Hindustani people and recommended earlier screening in this group. The asthma guideline stated that the lung volume is dependent of ethnicity. The hypertension guideline did not state any ethnic-specific information. CONCLUSION: The guidelines on type 2 diabetes mellitus, hypertension and asthma in adults only adopted a limited number of the ethnic differences contained in the scientific literature on which they were based. Possible explanations are that information was only included if there was a clear scientific basis, and that ethnic distinctions were found to be politically and socially undesirable. However, this lack of information might lead to ineffective or sub-optimal care for ethnic minorities.

[General practitioner's workload: objective increase in 9 practices in Rotterdam and surroundings, 1992-1997 and an extrapolation to 2005]. / Werkbelasting van huisartsen: objectieve toename in 9 praktijken in Rotterdam en omgeving, 1992-1997 en een extrapolatie naar 2005.

OBJECTIVE: To assess the change in general practitioners' (GPs') workload during the period 1992-1997, calculated as consult frequency and GP-patient contact time, and to estimate the workload in 2005. DESIGN: Descriptive. METHOD: During the period 1992 to 1997, data from all GP-patient contacts from nine general practices in and around Rotterdam, the Netherlands, were registered and stored in a central database. The yearly GP-patient contact time in 1992 and 1997 was calculated using the measured contact frequencies and known figures from the medical literature on the distribution and average duration of the different contact types (consultation, home visit, telephonic consultation, other). The contact time in 2005 was estimated by extrapolating the contact time for the period 1992 to 1997, whilst bearing in mind the expected population composition in 2005. RESULTS: The number of GP consultations increased from 4.26 in 1992 to 5.16 in 1997 (+21%). Compared with 1992, the yearly GP-patient contact time in 1997 was at least 90 hours higher. Extrapolation to 2005, revealed a further increase in this contact time of 667 (+36%) hours compared to 1997. This predicted increase in the workload could mostly be attributed to an increase in the number of elderly patients and the number of contacts with these patients. CONCLUSION: The number of hours worked by GPs increased by 20% over a six year period and is expected to increase by about a third over the next few years.

Headache in children in Dutch general practice.

AIM: To describe the occurrence of headache in general practice, the diagnoses made in general practice, and the management. METHOD: Data from the Dutch national survey of morbidity and interventions in general practice were used. The practice population (103 practices) comprised 63,753 children aged 0-14 years. RESULTS: In 634 episodes, headache was a reason for encounter. The incidence of headache presented to the general practitioner was 40.2 per 1000 person years. More than half of the episodes were related to an infectious disease, among which upper respiratory tract infections predominated. The incidence rate of the diagnosis idiopathic headache was 7.3 episodes per 1000 person years. The incidence increased with age and was higher in girls than in boys. In only 12% of cases of idiopathic headache were special investigations carried out, mostly blood examinations. Medication was prescribed in 27% of all episodes of idiopathic headache. In the absence of an infectious disease, many headache episodes were associated with psychosocial problems. Family problems and school problems were mentioned most often. CONCLUSION: Headache in children as reason for encounter is a common problem in general practice, often associated with an infectious disease. When confronted with a child with idiopathic headache, the general practitioner should be aware of a possible psychosocial component.

Validity and accuracy of interview and diary data on children's medical utilisation in The Netherlands.

STUDY OBJECTIVE: To assess the validity and accuracy of children's medical utilisation estimates from a health interview and diary and the possible consequences for morbidity estimates. The influence of recall bias and respondent characteristics on the reporting levels was also investigated. DESIGN: Validity study, with the medical record of the general practitioner (GP) as gold standard. In a health interview and three week diary estimates of medical utilisation of children were asked and compared with a GP's medical record. SETTING: General community and primary care centre in the Netherlands. PARTICIPANTS: Parents of 1,805 children and 161 GPs. MAIN RESULTS: The sensitivity of the interview (0.84) is higher than the diary (0.72), while specificity and kappa are higher in the diary (0.96; 0.64) than in the interview (0.91; 0.5-8). Recall bias, expressed as telescoping and heaping, is present in the interview data. Prevalence estimates of all morbidity are much higher in the interview, except for skin problems. Compared with a parental diary more consultations are reported exclusively by the GP for children from ethnic minorities (OR 1.6), jobless (OR 2.3), and less educated mothers (OR 2.6). CONCLUSIONS: Estimates of medical utilisation rates of children are critically influenced by the method of data collection used. Interviews are prone to introduce recall bias, while diaries should only be used in populations with an adequate level of literacy. It is recommended that medical records are used, as they produce most consistent estimates.

Everyday symptoms in childhood: occurrence and general practitioner consultation rates.

BACKGROUND: Fewer than 20% of all illnesses that occur in the home require the attention of a general practitioner (GP). Whether specific illnesses in children are more likely to need the attention of a GP is poorly understood, as is the influence of various other factors. Health diaries are the most suitable method of collecting comprehensive information about children's health problems at home and in general practice simultaneously. AIM: To investigate the occurrence of, and consultation rates for, specific symptoms in childhood in relation to age, sex, birth order, and place of residence of the child, and season of the year. METHOD: The parents of 1805 children kept a health diary over three weeks and recorded symptoms and consultation behaviour. The symptoms were later combined into illness episodes. RESULTS: Over three weeks, colds/flu (157/1000 children) and respiratory symptoms (114/1000 children) occurred most frequently. More young children (0-4 years) suffered from illness generally. Eleven per cent of all illness episodes required the attention of a GP. Consultation rates differed greatly according to symptoms. A GP was consulted most often for ear (36%) and skin (28%) problems, and least often for headaches (2%) and tiredness (1%). Regardless of symptoms, young children (0-4 years) were taken to a GP twice as often as older children (10-14 years). CONCLUSIONS: This study emphasizes the enormous amount of illness that occurs in children and the fact that more than 80% of all illnesses are dealt with by parents without reference to the professional health care system.

Measuring morbidity of children in the community: a comparison of interview and diary data.

BACKGROUND: Little is known about the validity of estimates of morbidity experienced at home. METHODS: In the Dutch National Survey of Morbidity and Interventions in General Practice mothers of 1630 children answered a health interview and kept a health diary for 3 weeks (only the first 2 weeks were used). Children's symptoms were recorded during the interview using a check list and monitored in the health diary through open-ended questions. RESULTS: In the interview parents reported symptoms for 65% of their children and in the diary for 54% of children. Ear problems, colds, fever and weakness and anxiety were reported more often in the interview. Mother's mental health was assessed by the General Health Questionnaire; those scoring >4 were assessed as having impaired mental health and these parents reported symptoms for more children in the interview (81%) than in the diary (65%). For similar reference periods, the least educated mothers reported fewer children with symptoms in the diary (45%) than in the interview (66%). More highly educated mothers reported similarly in the diary (67%) and the interview (70%). CONCLUSION: Both data collection methods yield different estimates of community morbidity. Explanations such as telescoping, the seriousness of the symptoms, the amount of psychological distress of the respondent, forgetfulness and literacy limitations are discussed. We recommend that diaries should not be used in less educated populations.