[Indicators for quality of care: who profits: patients or managers?]. / Indicatoren voor kwaliteit van zorg. wie worden er wijzer van, de patiënten of de managers?

In the Netherlands and abroad detailed indicators are developed to measure quality of care for a variety of treatments and care systems. These days the development of quality indicators is a profession and business in itself. The significance of these indicators is often not related to the primary care process, but based on (administrative) data for 'quality management'. The consequence is a gap between 'real' and 'measured' quality of care. Improvement in quality of care is therefore problematic. There is a need to return to the essence of care, i.e. the patient and the care professional, to develop appropriate indicators for quality of care.

Transfer effects of a cognitive strategy training for stroke patients with apraxia.

The objective of this study was to evaluate transfer effects of cognitive strategy training for stroke patients with apraxia. During 8 weeks, 29 apraxic patients received cognitive strategy training to teach them how to perform activities of daily living (ADL) as independently as possible. ADL functioning was assessed at the rehabilitation centre at baseline and after 8 weeks of training. In addition, assessment took place at the patients' own homes after 8 weeks of training and 5 months after the start of the training. The performance of both trained and nontrained tasks was observed. Patients performed trained tasks and nontrained tasks at the same level of independency at the rehabilitation centre as well as at home, indicating transfer of training effects. These effects turned out to be stable over time.

Comparison of two Dutch follow-up care models for spinal cord-injured patients and their impact on health problems, re-admissions and quality of care.

OBJECTIVE: To evaluate whether transmural care for people with spinal cord injury living in the community has more impact on health outcomes than traditional follow-up care within the Netherlands. DESIGN: Quasi-experiment with 12 months of follow-up. SETTING: Eight Dutch rehabilitation centres. SUBJECTS: Thirty-one patients who received transmural care in two ;experimental' rehabilitation centres were compared with a matched sample of 31 patients having received ;usual follow-up care' in six other rehabilitation centres. INTERVENTION: The core component of the transmural care consists of a transmural nurse, who 'liaises' between former patients living in the community, primary care professionals and the rehabilitation team. The transmural care model provides activities to support patients and their family/partners and activities to promote continuity of care. MAIN MEASURES: The prevalence of pressure sores and urinary tract infections; the number and duration of re-admissions to hospital and rehabilitation centre due to pressure sores, bladder and bowel problems; and the experienced quality of follow-up care. RESULTS: The transmural care, as implemented, did not influence the health outcomes. The prevalence of pressure sores, urinary tract infections and the number of re-admissions (due to pressure sores, bladder and bowel problems) was respectively 13, 13 and 4 in the intervention group versus 14, 15 and 6 in the usual follow-up care group. Since the transmural care had been incompletely implemented and there were methodological and practical limitations, we formulated no final conclusions regarding its effectiveness. CONCLUSION: Implementing the transmural care model strictly according to protocol may improve its effectiveness.

Health behaviour of persons with spinal cord injury.

STUDY DESIGN: Postal survey. OBJECTIVE: To describe the health behaviour of persons with spinal cord injury (SCI) living in the community and the relationships between health behaviour, respondent/injury characteristics, and health-related variables: the presence and number of secondary impairments, readmissions in rehabilitation centre and hospital, and perceived health. SETTING: Members of the Dutch Association of Patients with SCI. METHODS: The frequency of health behaviours, that delay or prevent secondary impairments, was assessed by means of a 22-item, self-report questionnaire. The questionnaire was also focused on 13 secondary impairments. RESULTS: The frequency of engaging in health behaviour varied considerably between the respondents. Variance was observed between and within the health behaviours measured. The respondents did not frequently engage in pressure relief methods when sitting/driving in their wheelchair. Almost no statistical differences were observed between health behaviour of subgroups of respondents based on respondent/injury characteristics. However, the total health behaviour scores increased significantly with increasing age and pressure sore prevention was significantly more applied in persons with a complete lesion. Health behaviour was significantly more applied in respondents who had one or more secondary impairments. CONCLUSION: As secondary impairments are prevalent among persons with SCI and education on a healthy lifestyle is a core component of every rehabilitation programme, it is of great importance to rigorously test the efficacy of health behaviours promoted during rehabilitation. Therefore, longitudinal research is recommended.

Transmural care in the rehabilitation sector: implementation experiences with a transmural care model for people with spinal cord injury.

PURPOSES: The purpose of this article is first to describe the development and content of a transmural care model in the rehabilitation sector, which aims to reduce the number and severity of health problems of people with spinal cord injury (SCI) and improve the continuity of care. Second, the purpose is to describe the applicability and implementation experiences of a transmural care model in the rehabilitation sector. METHODS: The transmural care model was developed in cooperation with the Dutch Association of Spinal Cord Injured Patients, community nurses, general practitioners, rehabilitation nurses, rehabilitation managers, physiatrists and researchers. The core component of the care model consists of a transmural nurse, who 'liaises' between people with SCI living in the community, professional primary care professionals and the rehabilitation centre. The transmural care model provides a job description containing activities to support people with SCI and their family/partners and activities to promote continuity of care. The transmural care model was implemented in two Dutch rehabilitation centres. The following three aspects, as experienced by the transmural nurses, were evaluated: the extent to which the care model was implemented; enabling factors and barriers for implementation; strength and weakness of the care model. RESULTS: The transmural care model was not implemented in all its details, with a clear difference between the two rehabilitation centres. Enabling factors and barriers for implementation were found at three levels: 1. the level of the individual professional (e.g. competencies, attitude and motivation), 2. the organisational and financing level (e.g. availability of facilities and finances), and 3. the social context (the opinion of colleagues, managers and other professionals involved with the care). The most important weakness experienced was that there was not enough time to put all the activities into practice. The strength of the care model lies in the combination of support of patients after discharge, support of and cooperation with primary care professionals, and feedback of experiences to the clinical rehabilitation teams. CONCLUSION: We recommend further improving and implementing the care model and encourage other care professionals and researchers to share their implementation experiences of follow-up care innovations for people with SCI.

Are there more than cross-sectional relationships of social support and support networks with functional limitations and psychological distress in early rheumatoid arthritis? the European Research on Incapacitating Diseases and Social Support Longitudinal Study.

OBJECTIVE: To investigate whether greater social support and support network are cross-sectionally associated with less functional limitations and psychological distress in patients with early rheumatoid arthritis (RA); whether this association is constant over time; and whether increases in social support or support network are associated with less functional limitations and psychological distress. METHODS: Subjects were from the European Research on Incapacitating Diseases and Social Support cohort and had early RA. Social support, support network, functional limitations (Health Assessment Questionnaire), and psychological distress (General Health Questionnaire) were assessed annually. Variance and covariance analyses with repeated measures were performed. RESULTS: A total of 542 subjects were assessed for 3 years. On average, patients with a greater amount of specific social support or a stronger specific support network experienced less functional limitation and less psychological distress. Changes in a given subject's functional limitations and psychological distress did not depend on his or her baseline social support or support network. Neither social support nor support network change over time. CONCLUSION: There may be a cross-sectional link between specific social support or support network and functional limitations and psychological distress, but no longitudinal association could be evidenced.

Functional ability, social support, and depression in rheumatoid arthritis.

OBJECTIVE: First, to investigate the patterns of functional ability, depressive feelings, and social support in early stage rheumatoid arthritis (RA) patients. Second, to demonstrate the stress buffering effect of social support. Social support is thought to reduce the impact of chronic stress on psychological well-being; for patients without social support the impact of functional ability on depressive feelings will be stronger. METHODS: In 4 waves with an intervening period of 1 year, longitudinal data was collected of 264 Dutch RA patients, of which 65% was female. At T1, the mean age of these patients was 53 years, while their mean disease duration was 22 months. In an interview at the patients' homes, data was collected on functional ability, social support en psychological well-being. The buffering effect of social support was examined by testing the significance of the (computed) stressor by social support interaction term in a regression analysis on depressive feelings. RESULTS: Although large differences between subjects existed, the mean scores on functional ability, social support, and depressive feelings barely changed from year to year. Patients who deteriorated in functional ability during one year had the best chances to improve next year, and visa versa. Furthermore, the stress by support interaction terms had no significant effect on depressive feelings in a regression analysis. CONCLUSIONS: This study demonstrated clearly the fluctuating pattern of RA in the first years after onset. The patients' level of depressive feelings was linearly related to the level of functional ability. Like many other studies, also this study could not provide evidence for the stress buffering effect of social support.

Effectiveness of provision of outdoor mobility services and devices in The Netherlands.

OBJECTIVE: To answer the following questions: What are the problems encountered by people with outdoor mobility disabilities? What solutions are being offered to them in The Netherlands? How effective are these solutions? How responsive is the IPPA instrument (Individually Prioritized Problem Assessment)? DESIGN: Analysing the results of a follow-up study using the IPPA instrument. SETTING: The Dutch Service for the Disabled Act (SDA, in Dutch: WVG) provision system. This act is responsible for the provision of mobility aids and home adaptations. SUBJECTS: Fifty-nine people with outdoor mobility disabilities. INTERVENTIONS: The provision of outdoor mobility service and devices. MAIN OUTCOME MEASURES: Effectiveness of provisions as measured using IPPA (i.e., the degree to which activities have become less difficult to perform), effect size of IPPA with this intervention. RESULTS: Problems identified by clients are very diverse and specific but can be classified fairly well on the basis of the International Classification of Functioning, Disability and Health (ICF); in the main, the solutions they are provided with are very similar and generic. Effectiveness is excellent at a group level, but insufficient for some at an individual level. The IPPA instrument is highly responsive in this setting. Most mobility problems respondents identified, although very individual and specific, were related to shopping, social visits or leisure activities. These specific sets of problems were solved using 'standard', generic solutions. CONCLUSIONS: The Dutch provision system should be more 'demand oriented' and less 'supply oriented'. IPPA turns out to be a useful, structured and individual-oriented method to evaluate service delivery.

Opinions on changes in the Romanian health care system from people's point of view: a descriptive study.

After 10 years of changes, the Romanian people were asked to assess the consequences of the reforms that were carried out through the health care system in the last decennium. This article studies the opinion of changes among individuals and socio-economic-demographic groups living in Dolj region. Such surveys are rare in Romania. People show to have different opinions on quality of care, accessibility and on attitudes of politicians to health care comparing the present state of affaires with the past one. Overall the people judge the actual situation preferable to the past. The elderly, the chronically ill and the people who believe that people were happier 10 years ago have a more critical view on the changes especially in terms of accessibility. The higher educated people have a more positive opinion on the consequences of the reforms. The results may help to improve the communication between policy makers and the population. It is suggested that the involvement of the citizens in the health care reforms may realize a better implementation of Romanian health care reforms. This involvement is lacking.

How to validate clinically important change in health-related functional status. Is the magnitude of the effect size consistently related to magnitude of change as indicated by a global question rating?

Some clinical trials perform repeated measurement over time and estimate clinically relevant change in an instrument's score with global ratings of perceived change or so-called transition questions. The conceptual and methodological difficulties in estimating the magnitude of clinically relevant change over time in health-related functional status (HRFS) are discussed. This paper investigates the concordance between the amount of serially assessed change with effect size estimates (the researcher's perspective) and global ratings of perceived change (the patient's perspective). A total of 217 patients who were scheduled for diagnostic examination were included, and the Minnesota Living with Heart Failure Questionnaire, extended with MOS-20 items, was assessed before and after medical intervention (percutaneous transluminal coronary angioplasty, coronary artery bypass grafting or pharmaco-therapy). Global questions were applied to assess perceived change over time for every item from domains of physical and emotional functioning and used as the external criterion of relevant change in the analysis of items. Global questions corresponding with overall change in these domains were used in the comparison of change in physical and emotional functioning scales. Two effect size indices were used: (i) ES (mean change/SDpooled) and (ii) ES (mean change/SDchange). A method is described to calculate a value indicating the extent of discordance between the researcher's interpretation of magnitude of change and the external criterion (the patient's perspective). Findings suggest that effect size (ES) (mean change/SDpooled) was in keeping with the magnitude of change indicated by patients' judgements, or their category of subjective meaning, for all scales. Furthermore, in cases in which the magnitude of change estimated with the SRM (mean change/SDchange) was not confirmed empirically by the external criterion ratings, the discordance could be interpreted as a trivial discordance.

Quality of life profiles in the first years of rheumatoid arthritis: results from the EURIDISS longitudinal study.

OBJECTIVE: The aim of this study was to examine the quality of life (QoL) profiles of patients with early rheumatoid arthritis (RA) and to relate these to disease and impairment variables as indicated, respectively, by erythrocyte sedimentation rate (ESR) and by tender joint count (Ritchie Articular Index), fatigue, and pain. METHODS: The present study uses part of the European Research on Incapacitating Disease and Social Support data of 573 patients with recently diagnosed RA (268 from the Netherlands, 216 from Norway, and 89 from France). A series of clinical and psychosocial data were collected on 4 (the Netherlands, France) and 3 (Norway) occasions, with 1-year intervals separating the waves of data collection. RESULTS: Of the disease activity (ESR) and impairment variables (tender joint count, fatigue, pain), fatigue was identified as the consequence of disease that differentiated best on a series of QoL aspects such as disability, psychological well-being, social support, and "overall evaluation of health." Next came pain and tender joint count, and ESR showed by far the least differentiating ability. A principal-component analysis on the QoL measures used in this study yielded one general factor measuring "overall QoL." After rotation, two separate factors were encountered, one referring to the physical domain and the other to the psychological and social domains of QoL. Again, the QoL of RA patients experiencing much fatigue appeared to decline the most. CONCLUSIONS: Because of the highly variable nature of RA, impairments, activities of daily living (ADL) and instrumental ADL restrictions, and psychosocial distress can vary erratically. In particular, "fatigue" as measured over a period of 2 to 3 years distinguished best among RA patients as shown by their QoL profiles. Although the physical domain was most affected, the significant effect of RA on the psychosocial domain should not be underestimated.

Using the nursing minimum data set for the Netherlands (NMDSN) to illustrate differences in patient populations and variations in nursing activities.

RATIONALE: A nursing minimum data set (NMDS) provides data that are useful to legitimate nurses' contribution to healthcare. In Belgium and the US, such NMDS are operational, other countries are developing it, among which is the Netherlands. OBJECTIVE: To evaluate whether the nursing minimum data set for the Netherlands (NMDSN) is suitable to describe the diversity of patient populations and the variability of nursing care. METHODOLOGY: Using the NMDSN data collection forms, patient data were collected from 15 different hospital wards. During one week, nurses manually completed the NMDSN list for every patient. The data analysis methodology from the Belgian MVG was used, including ridit analysis and graphs. RESULTS: The NMDSN includes items related to hospital, patient demographics, medical condition, nursing process, nursing phenomena, nursing interventions, outcomes of nursing care, and complexity of care. There were 686 individual patients in the study, while for the data analysis their 2090 patient days in the hospital were used. Frequencies of nursing phenomena, nursing activities and results of care were calculated, transformed into ridit scores, and presented graphically as 'fingerprints'. CONCLUSION: The set of NMDSN items allows illustrating the diversity of patient populations, and variation in nursing care by means of 'fingerprints'.

Drug consumption in the first years of rheumatoid arthritis in France, The Netherlands, and Norway. A longitudinal study in the early nineties.

OBJECTIVE: To analyse drug consumption in the first years of rheumatoid arthritis (RA) in France, the Netherlands, and Norway, in a longitudinal study between 1991 and 1993. PATIENTS AND METHODS: The EURIDISS cohort followed up over three years included 695 RA subjects with less than 5 years disease duration. Clinical and biological parameters, drug consumption according to ATC classification, and use of local treatment were recorded. RESULTS: In the Netherlands consumption of second-line treatment occurred early on, and remained constant over time. In France, it was consumed by half of the subjects and decreased during follow-up (p<0.001). In Norway, 50% of the subjects were on second-line treatment at the outset. NSAIDs rather than corticoids were the most widely consumed. Patients underwent frequently local treatments with decrease frequency of infiltrations over time (p<0.001). CONCLUSION: Second-line treatments were used in the first years of disease development, following varying sequences in the different countries.

Development of the Nursing Minimum Data Set for the Netherlands (NMDSN): identification of categories and items.

Development of the Nursing Minimum Data Set for the Netherlands (NMDSN): identification of categories and items Rationale Currently, there is no systematic collection of nursing care data in the Netherlands, while pressure is growing from the profession, policy-makers and society to justify the contribution of nursing and its costs. A nursing minimum data set can provide data to demonstrate nursing's contribution to health care as it can be used to describe the diversity of different patient populations and the variability of nursing activities, and to calculate the associated nursing workload. Objective To identify categories and items for inclusion in the Nursing Minimum Data Set for the Netherlands. Design A multimethod, exploratory approach was used. This included interviews, document analysis, consensus rounds, seeking validation in the literature, and drawing up lists of most frequently occurring patient problems, interventions and outcomes of care. Eight hospitals, with a total of 16 wards, participated in the study. Results Relevant categories and items emerged after analysis and grouping of the material and included: five hospital-related items, six patient demographics items, seven medical condition items, 10 nursing process items, 24 patient problems, 32 nursing interventions, four outcomes of nursing care, and three complexity of care items. Almost every item could be located in the existing documentation systems, the lists of patient problems, outcomes and interventions, or in the literature. Conclusion A set of categories and items of nursing data has been identified. The content validity of this set is partly supported by its consistency with the literature, findings from practice and the judgement of potential users. Nursing outcomes need further development. The data set will be tested in practice to find out whether the categories and items are useful, and whether they can be minimized.

Factors related to fatigue; priority of interventions to reduce or eliminate fatigue and the exploration of a multidisciplinary research model for further study of fatigue.

A growing interest in the health problem presented by fatigue, both in clinical practice and research, coupled with a decreasing number of reported studies on fatigue in the last decade, make an updated and systematic review of factors related to fatigue necessary. A search of the literature, comprising 53 studies, was therefore undertaken to explore the following research questions: Which significantly social-demographic, cure-related, and care-related factors are significantly correlated with fatigue? And which nursing interventions need priority in experimental research to reduce or eliminate fatigue? Reported factors related to fatigue in analysed studies show that the correlations between the specific cure- and care-related factors and fatigue are similar among the various investigated (patient) populations. This result supports the concept of the non-specific character of fatigue. The intervention of primary effectiveness most suggested in this study is 'energy management'. Interventions of secondary importance which emerge are those of 'emotional support', 'activity therapy' and 'coping enhancement'. This study makes clear that the exploration of a research model for fatigue, with social-demographic, cure- and care-related factors is useful and that care-related factors have their own effects on fatigue not necessarily dependent upon the presence of medical diseases or cure-related factors. In general, multi-related factors could be assessed. Implications and relevant questions for further research on fatigue are also given.

Socio-economic differences in health risk behavior in adolescence: do they exist?

Socio-economic differences in risk behaviors in adolescence can be seen as a prelude to the re-emergence of socio economic health differences in adulthood. We studied whether or not socio-economic differences in health risk behaviors are present in male and female adolescents in The Netherlands. The relation between socio-economic status (SES) and health risk behaviors was examined, by testing both the main and interaction effects of SES and gender on separate health risk behaviors on one hand, and on the behaviors cumulatively on the other. The data were derived from 1984 adolescents in the four northern provinces of The Netherlands. SES was measured by means of the educational level and the occupational status of both parents. Four health risk behaviors were included in this study: smoking, alcohol consumption, soft drug use, and (no) physical exercise. We found that the relationships between SES and health risk behaviors are not as linear as is often found in adulthood. Our findings can be characterised overall by an absence of relationship between SES and health risk behaviors. The only exception applies to sport, which is linearly related to SES. Adolescents in the lower SES groups engage in sport less than adolescents in the higher SES groups. There was an irregular relationship between the father's occupational status and the adolescents' smoking and drinking. Adolescents in the highest, lowest and middle of the six SES groups have the highest rates of health risk behaviors. All observed relationships are similar for both male and female adolescents. A relationship between gender and the separate health risk behaviors was found only for alcohol consumption and drug use. For both male adolescents showed higher rates of risk behavior. Males also scored higher on the cumulative health risk behaviors than their female counterparts. The findings of this study do not support the hypothesis of latent differences in adolescence.