Een studie naar het gebruik van jeugd-GGZ in Zuid-Limburg

Sinds de invoering van de Jeugdwet in 2015 zijn Nederlandse gemeenten bestuurlijk en financieel verantwoordelijk voor de gezondheidszorg voor de jeugd. De Jeugdwet vervangt niet alleen de wet op de jeugdzorg, maar ook de verschillende andere onderdelen van de jeugdzorg die onder de Zorgverzekeringswet (geestelijke gezondheidszorg voor jongeren) en de Algemene Wet Bijzondere Ziektekosten (zorg voor licht verstandelijk beperkte jeugd) vielen. Ook de jeugdbescherming en jeugdreclassering maken onderdeel uit van de wet. Het doel van Jeugdwet is het verbeteren van eigen kracht van jeugdigen en hun ouders, meer ambulante zorg inzetten in plaats van dure specialistische hulp, het versterken van het opvoedkundig klimaat en gezinnen ondersteunen via een geïntegreerde aanpak. De jeugdzorg bestaat voor een deel uit curatieve geestelijke gezondheidszorg voor kinderen en jongeren onder de 18 jaar; de zogenoemde jeugd-GGZ. Dit rapport beschrijft een onderzoek naar het gebruik van de jeugd-GGZ (in Zuid-Limburg). De jeugd-GGZ werd tot 2014 onderverdeeld in eerstelijns en tweedelijns GGZ en sinds 2014 in generalistische basis GGZ en gespecialiseerde GGZ. Sinds de introductie van de Jeugdwet zoeken gemeenten naar manieren om de jeugd-GGZ goed en efficiënt te organiseren. Veel gemeenten besteden daarbij aandacht aan het verbeteren van de samenhang tussen de jeugd-GGZ en het sociale domein om zo vroeg mogelijk de juiste hulp op maat te kunnen bieden. Hoewel uit verschillende studies blijkt dat het gebruik van jeugdzorg in Zuid-Limburg hoger is dan in andere delen van Nederland, zijn er weinig verklarende studies uitgevoerd, voornamelijk met betrekking tot de jeugd-GGZ. De 18 gemeenten in Zuid-Limburg hebben de Universiteit van Maastricht gevraagd om het gebruik van jeugd-GGZ in de regio Zuid-Limburg te onderzoeken

Patients' perspectives on a new delivery model in primary care: a propensity score matched analysis of patient-reported outcomes in a Dutch cohort study

Rationale, aims and objective: Primary Care Plus (PC+) focuses on the substitution of hospital-based medical care to the primary care setting without moving hospital facilities. The aim of this study was to examine whether population health and experience of care in PC+ could be maintained. Therefore, health-related quality of life (HRQoL) and experienced quality of care from a patient perspective were compared between patients referred to PC+ and to hospital-based outpatient care (HBOC). Methods: This cohort study included patients from a Dutch region, visiting PC+ or HBOC between December 2014 and April 2018. With patient questionnaires (T0, T1 and T2), the HRQoL and experience of care were measured. One-to-two nearest neighbour calliper propensity score matching (PSM) was used to control for potential selection bias. Outcomes were compared using marginal linear models and Pearson chi-square tests. Results: One thousand one hundred thirteen PC+ patients were matched to 606 HBOC patients with well-balanced baseline characteristics (SMDs .05), indicating no difference in HRQoL development between the groups over time. Regarding experienced quality of care, no differences were found between PC+ and HBOC patients. Only travel time was significantly shorter in the HBOC group (P ≤ .001). Conclusion: Results show equal effects on HRQoL outcomes over time between the groups. Regarding experienced quality of care, only differences in travel time were found. Taken as a whole, population health and quality of care were maintained with PC+ and future research should focus more on cost-related outcomes

Person-centred and efficient care delivery for high-need, high-cost patients:primary care professionals' experiences

Background High-need, high-cost (HNHC) patients, who typically have complex and long-term care demands, contribute considerably to the high work pressure of primary care professionals (PCPs). To improve patient as well as provider experiences, it is crucial to take into account the PCPs' perspective in designing health care strategies for HNHC patients. Therefore, this study aimed to create insight into PCPs' experienced barriers and possible solutions with regards to person-centred, efficient care delivery to HNHC patients. Methods We conducted a qualitative study using focus group interviews with PCPs at a Dutch primary care group. A semi-structured interview guide was developed for the interviews. Qualitative content analysis was employed deductively by means of a categorisation matrix. The matrix was based on the components retrieved from the SELFIE framework for integrated care for multi-morbidity. Results Forty-two PCPs participated in five focus group interviews. Discussed barriers and solutions were related to the core of the SELFIE framework (i.e. the individual and environment), and particularly four of the six health system components in the framework: service delivery, leadership &amp; governance, workforce, and technologies &amp; medical products. Many discussed barriers revolved around the complex biopsychosocial needs of HNHC patients: PCPs reported a lack of time (service delivery), insufficiently skilled PCPs (workforce), and inefficient patient information retrieval and sharing (technologies &amp; medical products) as barriers to adequately meet the biopsychosocial needs of HNHC patients. Conclusions This qualitative study suggests that primary care is currently insufficiently equipped to accommodate the complex biopsychosocial needs of HNHC patients. Therefore, it is firstly important to strengthen primary care internally, taking into account the experienced lack of time, the insufficient number of equipped PCPs and lack of inter-professional information retrieval and sharing. Secondly, PCPs should be supported in cooperating and communicating more efficiently with health services outside primary care to adequately deliver person-centred, efficient care. As a prerequisite, it is crucial to direct policy efforts at the design of a strong system of social and community services. In terms of future research, it is important to assess the feasibility and effects of re-designing primary care based on the provided recommendations.</p

Patients' perspectives on a new delivery model in primary care:A propensity score matched analysis of patient-reported outcomes in a Dutch cohort study

Rationale, aims and objective Primary Care Plus (PC+) focuses on the substitution of hospital-based medical care to the primary care setting without moving hospital facilities. The aim of this study was to examine whether population health and experience of care in PC+ could be maintained. Therefore, health-related quality of life (HRQoL) and experienced quality of care from a patient perspective were compared between patients referred to PC+ and to hospital-based outpatient care (HBOC). Methods This cohort study included patients from a Dutch region, visiting PC+ or HBOC between December 2014 and April 2018. With patient questionnaires (T0, T1 and T2), the HRQoL and experience of care were measured. One-to-two nearest neighbour calliper propensity score matching (PSM) was used to control for potential selection bias. Outcomes were compared using marginal linear models and Pearson chi-square tests. Results One thousand one hundred thirteen PC+ patients were matched to 606 HBOC patients with well-balanced baseline characteristics (SMDs .05), indicating no difference in HRQoL development between the groups over time. Regarding experienced quality of care, no differences were found between PC+ and HBOC patients. Only travel time was significantly shorter in the HBOC group (

Effect of Sustained-Release Morphine for Refractory Breathlessness in Chronic Obstructive Pulmonary Disease on Health Status A Randomized Clinical Trial

IMPORTANCE: Morphine is used as palliative treatment of chronic breathlessness in patients with advanced chronic obstructive pulmonary disease (COPD). Evidence on respiratory adverse effects and health status is scarce and conflicting. OBJECTIVE: To assess the effects of regular, low-dose, oral sustained-release morphine on disease-specific health status (COPD Assessment Test; CAT), respiratory outcomes, and breathlessness in patients with COPD. INTERVENTIONS: Participants were randomly assigned to 10 mg of regular, oral sustained-release morphine or placebo twice daily for 4 weeks, with the possibility to increase to 3 times daily after 1 or 2 weeks. DESIGN, SETTING, AND PARTICIPANTS: The Morphine for Treatment of Dyspnea in Patients With COPD (MORDYC) study was a randomized, double-blind, and placebo-controlled study of a 4-week intervention. Patients were enrolled between November 1, 2016, and January 24, 2019. Participants were recruited in a pulmonary rehabilitation center and 2 general hospitals after completion of a pulmonary rehabilitation program. Outpatients with COPD and moderate to very severe chronic breathlessness (modified Medical Research Council [mMRC] breathlessness grades 2-4) despite optimal pharmacological and nonpharmacological treatment were included. A total of 1380 patients were screened, 916 were ineligible, and 340 declined to participate. MAIN OUTCOMES AND MEASURES: Primary outcomes were CAT score (higher scores represent worse health status) and arterial partial pressure of carbon dioxide (Paco(2)). Secondary outcome was breathlessness in the previous 24 hours (numeric rating scale). Data were analyzed by intention to treat. Subgroup analyses in participants with mMRC grades 3 to 4 were performed. RESULTS: A total of 111 of 124 included participants were analyzed (mean [SD] age, 65.4 [8.0] years; 60 men [54%]). Difference in CAT score was 2.18 points lower in the morphine group (95% CI, –4.14 to –0.22 points; P = .03). Difference in Paco(2) was 1.19 mm Hg higher in the morphine group (95% CI, –2.70 to 5.07 mm Hg; P = .55). Breathlessness remained unchanged. Worst breathlessness improved in participants with mMRC grades 3 to 4 (1.33 points lower in the morphine group; 95% CI, –2.50 to –0.16 points; P = .03). Five participants of 54 in the morphine group (9%) and 1 participant of 57 in the placebo group (2%) withdrew because of adverse effects. No morphine-related hospital admissions or deaths occurred. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, regular, low-dose, oral sustained-release morphine for 4 weeks improved disease-specific health status in patients with COPD without affecting Paco(2) or causing serious adverse effects. The worst breathlessness improved in participants with mMRC grades 3 to 4. A larger randomized clinical trial with longer follow-up in patients with mMRC grades 3 to 4 is warranted. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT0242905