It's your Choice! A Study of Search and Selection Processes, and the Use of Performance Indicators in Different Patient Groups

In the last few years, the Dutch health care system has undergone the most radical changes since the Second World War. Most people are now aware that competition has become one of the leading principles of the new health care system. A tangible expression of this change came when, on 1 January 2006, all Dutch citizens had to choose a health care insurer. Under the new system, citizens are given more freedom of choi

General practitioners' evaluations of optimal timing to initiate advance care planning for patients with cancer, organ failure, or multimorbidity: a health records survey study

Background: Appropriate timing to initiate advance care planning is difficult, especially for individuals with non-malignant disease in community settings. Aim: To identify the optimal moment for, and reasons to initiate advance care planning in different illness trajectories. Design and methods: A health records survey study; health records were presented to 83 GPs with request to indicate and substantiate what they considered optimal advance care planning timing within the 2 years before death. We used quantitative and qualitative analyses. Setting and patients: We selected and anonymized 90 health records of patients who died with cancer, organ failure or multimorbidity, from a regional primary care registration database in the Netherlands. Results: The median optimal advance care planning timing according to the GPs was 228 days before death (interquartile range 392). This moment was closer to death for cancer (87.5 days before death, IQR 302) than for organ failure (266 days before death, IQR 401) and multimorbidity (290 days before death, IQR 389) (p < 0.001). The most frequently mentioned reason for cancer was "receiving a diagnosis" (21.5%), for organ failure it was "after a period of illness" (14.7%), and for multimorbidity it was "age" and "patients" expressed wishes or reflections' (both 12.0%). Conclusion: The optimal advance care planning timing and reasons to initiate advance care planning indicated by GPs differ between patients with cancer and other illnesses, and they also differ between GPs. This suggests that "the" optimal timing for ACP should be seen as a "window of opportunity" for the different disease trajectories.Surgical oncolog

Assessing Quantitative Comparisons of Health and Social Care Between Countries

Contains fulltext : 225549.pdf (Publisher’s version ) (Closed access

Uniform criteria for total hip replacement surgery in patients with hip osteoarthritis: a decision tool to guide treatment decisions

Contains fulltext : 232547.pdf (Publisher’s version ) (Open Access)BACKGROUND: Uniform criteria for performing hip replacement surgery in hip osteoarthritis patients are currently lacking. As a result, variation in surgery and inappropriateness of care may occur. The aim of this study was to develop a consensus-based decision tool to support the decision-making process for hip replacement surgery. METHODS: Patients with a diagnosis of unilateral or bilateral osteoarthritis were included. Consensus rounds with orthopedic surgeons were organized to blindly reassess medical files and to decide whether surgery is indicated or not, based on all available pre-treatment information. We compared the outcomes obtained from the blind reassessment by the consensus group with the actual treatment. Furthermore, prediction models were fitted on the reassessment outcome to identify which set of clinical parameters would be most predictive and uniformly shared in the decision to operate.Two prediction models were fitted, one model without radiologic outcomes and one model where radiologic outcomes were included. RESULTS: In total, 364 medical files of osteoarthritis patients were included and reassessed in the analyses. Key predictors in the prediction model without radiology were age, flexion, internal rotation and the Hip disability and Osteoarthritis Outcome Score-quality of life. The discriminative power was high (Area Under Receiver Operating Curve (AUC) = 0.86). Key predictors in the prediction model with radiology were age, internal rotation and Kellgren and Lawrence severity score (AUC = 0.94). CONCLUSION: The study yielded a decision tool with uniform criteria for hip replacement surgery in osteoarthritis patients. The tool will guide the clinical decision-making process of physicians on whether to perform hip surgery and should be used together with information about patient preferences and social context

Impact of moral case deliberation in healthcare settings: a literature review

Contains fulltext : 200173.pdf (publisher's version ) (Open Access)BACKGROUND: An important and supposedly impactful form of clinical ethics support is moral case deliberation (MCD). Empirical evidence, however, is limited with regard to its actual impact. With this literature review, we aim to investigate the empirical evidence of MCD, thereby a) informing the practice, and b) providing a focus for further research on and development of MCD in healthcare settings. METHODS: A systematic literature search was conducted in the electronic databases PubMed, CINAHL and Web of Science (June 2016). Both the data collection and the qualitative data analysis followed a stepwise approach, including continuous peer review and careful documentation of our decisions. The qualitative analysis was supported by ATLAS.ti. RESULTS: Based on a qualitative analysis of 25 empirical papers, we identified four clusters of themes: 1) facilitators and barriers in the preparation and context of MCD, i.e., a safe and open atmosphere created by a facilitator, a concrete case, commitment of participants, a focus on the moral dimension, and a supportive organization; 2) changes that are brought about on a personal and inter-professional level, with regard to professional's feelings of relief, relatedness and confidence; understanding of the perspectives of colleagues, one's own perspective and the moral issue at stake; and awareness of the moral dimension of one's work and awareness of the importance of reflection; 3) changes that are brought about in caring for patients and families; and 4) changes that are brought about on an organizational level. CONCLUSIONS: This review shows that MCD brings about changes in practice, mostly for the professional in inter-professional interactions. Most reported changes are considered positive, although challenges, frustrations and absence of change were also reported. Empirical evidence of a concrete impact on the quality of patient care is limited and is mostly based on self-reports. With patient-focused and methodologically sound qualitative research, the practice and the value of MCD in healthcare settings can be better understood, thus making a stronger case for this kind of ethics support

Advance care planning in primary care: a retrospective medical record study among patients with different illness trajectories

BACKGROUND: Advance Care Planning (ACP) enables physicians to align healthcare with patients' wishes, reduces burdensome life-prolonging medical interventions, and potentially improves the quality of life of patients in the last phase of life. However, little objective information is available about the extent to which structured ACP conversations are held in general practice. Our aim was to examine the documentation of ACP for patients with cancer, organ failure and multimorbidity in medical records (as a proxy for ACP application) in Dutch general practice. METHODS: We chose a retrospective medical record study design in seven primary care facilities. Medical records of 119 patients who died non-suddenly (55 cancer, 28 organ failure and 36 multimorbidity) were analysed. Other variables were: general characteristics, data on ACP documentation, correspondence between medical specialist and general practitioner (GP), and healthcare utilization in the last 2 years of life. RESULTS: In 65% of the records, one or more ACP items were registered by the GP. Most often documented were aspects regarding euthanasia (35%), the preferred place of care and death (29%) and concerns and hopes towards the future (29%). Median timing of the first ACP conversation was 126 days before death (inter-quartile range (IQR) 30-316). ACP was more often documented in patients with cancer (84%) than in those with organ failure (57%) or multimorbidity (42%) (p = 0.000). Patients with cancer had the most frequent (median 3 times, IQR 2-5) and extensive (median 5 items, IQR 2-7) ACP consultations. CONCLUSION: Documentation of ACP items in medical records by GPs is present, however limited, especially in patients with multimorbidity or organ failure. We recommend more attention for - and documentation of - ACP in daily practice, in order to start anticipatory conversations in time and address the needs of all people living with advanced conditions in primary care