Verticale samenwerking: een duurzaam perspectief?:Onderzoek naar de strategische samenwerking in duurzame coalities tussen zorgaanbieders en zorgverzekeraars

Achtergrond: Verticale samenwerking in de vorm van een duurzame coalitie tussen zorgaanbieders en zorgverzekeraars vraagt om fundamentele wijzigingen. Inzicht in impactvolle factoren is van belang voor het welslagen van duurzame coalities. Methode: Het betreft een beschrijvend en exploratief onderzoek. De vragenlijst ‘Succesfactoren in samenwerking’ werd geconstrueerd, gevalideerd en afgenomen bij 44 respondenten uit diverse duurzame coalities, werkzaam bij elf ggz-instellingen, drie ziekenhuizen en drie zorgverzekeraars. Resultaten: Verticale samenwerking wordt ingezet ten behoeve van een verbetering van de waardecreatie en kostenbesparing. Bij de onderzochte duurzame coalities was het belang dat gehecht werd aan twintig indicatoren, die bepalend zijn voor het succes van samenwerking, hoger dan hoe deze in de praktijk verliepen. Bij tien succesindicatoren was dit significant. Bovenal lijken zorgverzekeraars in vergelijking met zorgaanbieders meer waarde te hechten aan indicatoren van de invalshoeken belangen en relatie. Zorgaanbieders vonden dat de balans tussen inhoudelijke en procesmatige aandacht voor samenwerking in de praktijk minder goed verliep dan zorgverzekeraars aangaven. Conclusie: Verticale samenwerking tussen zorgaanbieder en zorgverzekeraar kan tot een duurzaam perspectief leiden indien draagvlak en procesvertrouwen permanent actief op de agenda staan. Vervolgonderzoek gericht op discrepanties kan een verdiepingsslag realiseren. Optimalisatie van het procesontwerp en continu monitoren dragen bij aan verbetering van onderlinge r

Effectiveness of a multi-facetted blended eHealth intervention during intake supporting patients and clinicians in Shared Decision Making : A cluster randomised controlled trial in a specialist mental health outpatient setting

OBJECTIVE: To investigate the effectiveness of a multi-facetted blended eHealth intervention, called SDM-Digital Intake (SDM-DI), in which patients and clinicians are supported in Shared Decision Making during the intake process. METHODS: The study is a two-arm matched-paired cluster Randomised Controlled Trial in a specialist mental health outpatient setting with two conditions: SDM-DI and Intake As Usual (IAU). Four intake teams were allocated to each arm. All patients who followed an intake, were asked to participate if they were capable to complete questionnaires. Decisional Conflict (DC), referring to patients' engagement and satisfaction with clinical decisions, was the primary outcome. Secondary outcomes were patient participation, applying Shared Decision Making (SDM), working alliance, treatment adherence and symptom severity. Effects were measured at two weeks (T1) and two months (T2) after intake. Multilevel regression and intention-to-treat analyses were used. Additionally, the influence of subgroups and intervention adherence on DC were explored. RESULTS: At T1, 200 patients participated (47% intervention, 53% control), and at T2 175 patients (47% intervention, 53% control). At T1 and T2, no differences were found between conditions on DC. Subgroup analyses showed that effects of SDM-DI on DC were not modified by primary diagnoses mood, anxiety and personality disorders. Compared to IAU, at T2, patients reported positive effects of SDM-DI on SDM (β 7.553, p = 0.038, 95%CI:0.403-14.703, d = 0.32) and reduction of symptoms (β -7.276, p = 0.0497, 95%CI:-14.544--0.008, d = -0.43). No effects were found on patient participation, working alliance and treatment adherence. Exploratory analyses demonstrated that if SDM was applied well, patients reported less DC (β = -0.457, p = 0.000, 95%CI:-0.518--0.396, d = -1.31), which was associated with better treatment outcomes. CONCLUSION: Although, this trial fails to demonstrate that SDM-DI by itself is sufficient to reduce DC, the results are encouraging for further efforts in improving and implementing the SDM intervention

Samen beslissen met ROM als informatiebron:Kwalitatief onderzoek onder cliënten

Achtergrond Acht ggz-organisaties hebben in de periode 2019-2022 gewerkt aan de doorontwikkeling en implementatie van ‘Samen beslissen met routine outcome monitoring (ROM) als informatiebron’.Doel Inzicht krijgen in behoeften en ervaringen van cliënten met samen beslissen en ROM, en onderzoeken welke implementatieaanpak dit vraagt.Methode Exploratief, kwalitatief onderzoek bestaande uit semigestructureerde interviews en focusgroepen met cliënten (n = 101) in behandeling bij ggz-organisaties verspreid over Nederland.Resultaten Cliënten vonden samen beslissen belangrijk. Voor een goede toepassing vonden zij generieke aspecten (luisteren, vertrouwen, volledige informatie en gelijkwaardige inbreng) én maatwerk (aansluiten bij hulpvraag en bij elk besluit metacommunicatie over de rolverdeling tussen cliënten, naaste(n) en behandelaren, en wijze van informatievoorziening) van belang. Cliënten waardeerden ROM als informatiebron bij samen beslissen, mits vragenlijsten niet te lang waren, aansloten bij de problematiek en uitkomsten besproken werden.Conclusie Samen beslissen met ROM is in de ggz nog niet breed geïmplementeerd. Dit vraagt een blijvende stimulans en evaluatie ervan. De toepassing kan verbeteren door (na)scholing van behandelaren en ondersteuning van cliënten met betrokkenheid van naaste(n), ervaringsdeskundigen en psycho-educatie. Cliënten waarderen ROM als hulpmiddel bij samen beslissen; inzage in de eigen ROM is hierbij nuttig

Efficacy of a digitally supported regional systems intervention for suicide prevention (SUPREMOCOL) in Noord-Brabant, the Netherlands

ObjectiveWe evaluated the effect of a digitally supported systems intervention for suicide prevention (SUPREMOCOL) in Noord-Brabant, the Netherlands. MethodNon-randomized stepped wedge trial design (SWTD). Stepwise implementation in the five subregions of the systems intervention. Pre-post analysis for the whole province (Exact Rate Ratio Test, Poisson count). SWTD Hazard Ratios of suicides per person-years for subregional analysis of control versus intervention conditions over five times three months. Sensitivity analysis. ResultsSuicide rates dropped 17.8% (p = .013) from 14.4 suicides per 100,000 before the start of implementation of the systems intervention (2017), to 11.9 (2018) and 11.8 (2019) per 100, during implementation; a significant reduction (p = .043) compared to no changes in the rest of the Netherlands. Suicide rates dropped further by 21.5% (p = .002) to 11.3 suicides per 100,000 during sustained implementation in 2021. Sensitivity analysis confirmed the reduction (p = .02). The SWTD analysis over 15 months in 2018–2019 did not show a significant association of this reduction with implementation per subregional level, probably due to insufficient power given the short SWTD timeframe for implementation and low suicide rates per subregion. ConclusionsDuring the SUPREMOCOL systems intervention, over four years, there was a sustained and significant reduction of suicides in Noord-Brabant

Shared decision-making in mental health care using routine outcome monitoring : results of a cluster randomised-controlled trial

PURPOSE: To investigate the effects of Shared Decision-Making (SDM) using Routine Outcome Monitoring (ROM) primary on patients' perception of Decisional Conflict (DC), which measures patients' engagement in and satisfaction with clinical decisions, and secondary on working alliance and treatment outcomes. METHOD: Multi-centre two-arm matched-paired cluster randomised-controlled trial in Dutch specialist mental health care. SDM using ROM (SDMR) was compared with Decision-Making As Usual (DMAU). Outcomes were measured at baseline (T0) and 6 months (T1). Multilevel regression and intention-to-treat analyses were used. Post hoc analyses were performed on influence of subgroups and application of SDMR on DC. RESULTS: Seven teams were randomised to each arm. T0 was completed by 186 patients (51% intervention; 49% control) and T1 by 158 patients (51% intervention, 49% control). DC, working alliance, and treatment outcomes reported by patients did not differ significantly between two arms. Post hoc analyses revealed that SDMR led to less DC among depressed patients (p = 0.047, d =- 0.69). If SDMR was applied well, patients reported less DC (SDM: p = 0.000, d = - 0.45; ROM: p = 0.021, d = - 0.32), which was associated with better treatment outcomes. CONCLUSION: Except for patients with mood disorders, we found no difference between the arms for patient-reported DC. This might be explained by the less than optimal uptake of this generic intervention, which did not support patients directly. Regarding the positive influence of a higher level of applying SDM and ROM on less DC and better treatment outcomes, the results are encouraging for further investments in patient-oriented development and implementation of SDMR

Rhetorical Transformations in Multimodal Advertising Texts: From General to Local Degree Zero

The use of rhetoric in advertising research has been steadily gaining momentum since the 1980’s. Coupled with an increased interest in multimodality and the multiple interactions among verbal, pictorial and auditory registers, as structural components of an ad filmic text, the hermeneutic tools furnished by traditional rhetoric have been expanded and elaborated. This paper addresses the fundamental question of how ad filmic texts assume signification from a multimodal rhetorical point of view, by engaging in a fruitful dialogue with various research streams within the wider semiotic discipline and consumer research. By critically addressing the context of analysis of a multimodal ad text in the course of the argumentation deployed by different approaches, such as Social Semiotics (Kress/Leeuwen 2001), Film Semiotics (i.e. Metz 1982, Carroll 1980, Branigan 1982), Visual Semiotics (i.e. Sonesson 2008; 2010, Eco 1972;1976;1986, Groupe " 1992), Consumer Research (i.e. Mick/McQuarrie 1999; 2004, Philips 2003, Scott 1994), the relative merits of a structuralist approach that prioritizes the distinction between local and general degree zero, as put forward by Groupe " (1992), are highlighted. Furthermore, the modes whereby rhetorical transformations are enacted are outlined, with view to deepening the conceptual tackling of degree zero of signification, while addressing its applicability to branding discourse and multimodal ad texts

A digital intake approach in specialized mental health care : study protocol of a cluster randomised controlled trial

Background: Enhancing patient participation is becoming increasingly important in mental health care as patients use to have a dependent, inactive role and nonadherence to treatment is a regular problem. Research shows promising results of initiatives stimulating patient participation in partnership with their clinicians. However, few initiatives targeting both patients’ and clinicians’ behaviour have been evaluated in randomised trials (RCT). Therefore, in GGz Breburg, a specialized mental health institution, a digital intake approach was developed aimed at exploring treatment needs, expectations and preferences of patients intended to prepare patients for the intake consultations. Subsequently, patients and clinicians discuss this information during intake consultations and make shared decisions about options in treatment. The aim of this trial is to test the efficacy of this new digital intake approach facilitated by Routine Outcome Monitoring (ROM), peer support and training of clinicians as compared to the intake as usual. The primary outcome is decisional conflict about choices in treatment. Secondary outcomes focus on patient participation, shared decision making, working alliance, adherence to treatment and clinical outcomes. Methods: This article presents the study protocol of a cluster-randomised controlled trial in four outpatient departments for adults with depression, anxiety and personality disorders, working in two different regions. Randomisation is done between two similar intake-teams within each department. In the four intervention teams the new intake approach is implemented. The four control teams apply the intake as usual and will implement the new approach after the completion of the study. In total 176 patients are projected to participate in the study. Data collection will be at baseline, and at two weeks and two months after the intake. Discussion: This study will potentially demonstrate the efficacy of the new digital intake approach in mental health care in terms of the primary outcome the degree of decisional conflict about choices in treatment. The findings of this study may contribute to the roll out of such eHealth initiatives fostering patient involvement in decision making about their treatment