Over verklaren en beslissen in de gezondheidszorg

Rede, uitgesproken bij de aanvaarding van het ambt van gewoon hoogleraar in de maatschappelijke gezondheidszorg, aan de Erasmus Universiteit Rotterdam op 10 oktober 198

CARA bij kinderen : in verband met luchtverontreiniging en andere faktoren

Op 2 maart 1971 en 25 april 1971 werd in de gemeenteraad van Amsterdam een aantal vragen gesteld over schadelijke gevolgen van de in Amsterdam Noord heersende luchtverontreiniging voor de gezondheid van de bewoners (cf. appendix I). Ter beantwoording van de vragen stelden de afdeling Volksgezondheid van de Gemeentelijke Geneeskundige en Gezondheidsdienst te Amsterdam (hoofd destijds dr. A.L. Noordam) en de afdeling wetenschappelijk onderzoek van de Gemeentelijke Geneeskundige en Gezondheidsdienst te Rotterdam (hoofd destijds dr. K. Biersteker) samen een onderzoek in, waarbij 1446 10- en 11-jarige kinderen uit negen Amsterdamse wijken en daarnaast 318 kinderen uit Den Helder, werden onderzocht. Projektleider bij dit onderzoek was P.J. van der Maas (Instituut Maatschappelijke Gezondheidszorg van de Erasmus Universiteit Rotterdam). De resultaten van dit onderzoek werden in 1973 gepubliceerd (van der Maas e.a. 1973). Konklusie van dat onderzoek was dat er in Amsterdam Noord over het geheel meer aandoeningen van longen en luchtwegen bij 10- en 11 jarigen werden gerapporteerd dan in de overige onderzochte wijken en dat deze aandoeningen een kleine maar signifikante nadelige invloed hadden op de longfunktie van deze kinderen. Voor verdere gegevens over dit onderzoek wordt verwezen naar appendix XIII, waar ook een nieuwe analyse van de destijds gevonden resultaten wordt gegeven. Dit onderzoek was zodanig opgezet dat het herhaalbaar zou zijn. Daarvoor waren twee redenen: ten eerste was de opzet zeer beperkt gehouden om het onderzoek zo snel mogelijk te kunnen voltooien in verband met de beantwoording van de gestelde vragen, ten tweede was het duidelijk dat de niveaus van verontreiniging, althans voorzover het 802 betreft, in Amsterdam Noord dalende waren. Wanneer er in 1971 nog mogelijke nadelige gevolgen zouden worden aangetroffen, was het wenselijk om na verdere daling van de 802-niveaus te zien of deze nadelige gevolgen dan ook inderdaad zouden verdwijnen. In 1975 werd besloten de vraagstelling uit 1971 opnieuw te onderzoeken. Aanleiding vormde het feit dat de 802-niveaus in Amsterdam, en vooral in Noord, inmiddels sterk gedaald waren (figuur I,2 en I,3; zie verder Heida 1975), terwijl de indruk bestond dat er onder de bevolking nog steeds veel klachten over luchtverontreinigingshinder bestonden. Daarnaast had het vorige onderzoek door zijn beperkte opzet een groot aantal vragen open moeten laten, waarover uitsluitsel bij nader inzien wel wenselijk was. Dankzij een ruim krediet van de gemeente Amsterdam en voor dit onderzoek gekreëerde ruimte in het budget van het Instituut Maatschappelijke Gezondheidszorg was het mogelijk om het onderzoek van 1971 in aanzienlijk uitgebreide en verbeterde vorm te herhalen. Daarnaast en onafhankelijk daarvan werd nog een tweede, geheel anderssoortig onderzoek opgezet om dit probleem te benaderen. Alvorens daarop in te gaan, zullen we eerst de vraagstelling, zoals die door ons werd opgevat, formuleren: 1. Zijn er binnen de bevolking van Amsterdam en met name die van Amsterdam Noord in vergelijking met die van overige delen in Amsterdam, verschillen in gezondheidstoestand aan te wijzen, welke het gevolg kunnen zijn van verschillen in blootstelling aan luchtverontreiniging? 2. Zo ja, zijn die verschillen vrijwel zeker een gevolg van verschillen in (bekende of onbekende) kortdurende of langdurige luchtverontreiniging, of zijn er andere redelijke verklaringen voor de verschillen aan te voeren

All the world's a screen.

Charlotte Gould and Paul Sermon developed and presented this collaborative new artwork entitled 'All the World's a Screen', a live interactive telecommunications performance, to link public audiences in Manchester and Barcelona. On the evening of Saturday 28th May 2011 participants at MadLab in Manchester's Northern Quarter and Hangar Artist Studios in Poblenou, Barcelona were joined together on screen for the first time to create their very own interactive generative cinema experience, complete with sets, costumes and props. Employing the scenography techniques of Alfred Hitchcock the artists created a miniature film set in which the remote audiences acted and directed their own movie, transporting participants into animated environments and sets where they created unique personalised narratives

Medical decision making in scarcity situations

The issue of the allocation of resources in health care is here to stay. The goal of this study was to explore the views of physicians on several topics that have arisen in the debate on the allocation of scarce resources and to compare these with the views of policy makers. We asked physicians (oncologists, cardiologists, and nursing home physicians) and policy makers to participate in an interview about their practices and opinions concerning factors playing a role in decision making for patients in different age groups. Both physicians and policy makers recognised allocation decisions as part of their reality. One of the strong general opinions of both physicians and policy makers was the rejection of age discrimination. Making allocation decisions as such seemed to be regarded as a foreign entity to the practice of medicine. In spite of the reluctance to make allocation decisions, physicians sometimes do. This would seem to be only acceptable if it is justified in terms of the best interests of the patient from whom treatment is withheld

Indirect costs of disease; an international comparison

Results of economic evaluations are often strongly influenced by estimates of indirect costs. International comparability of these estimates may contribute to rational decision-making in health care policy. Hence, estimates should be international comparable. Comparability of these results between countries may be hampered due to variation in methodology, data sources, valuation of production losses, and social security arrangements. Furthermore differences in epidemiology, demography and economic environment may cause variation in the level and the distribution by diagnosis of indirect costs. In this study indirect costs of disease for the Netherlands are compared with estimates for Sweden and the United States. We found large differences: both in the share of indirect costs in GDP as in the constituting elements, absence from work, disability and mortality. The level of indirect costs due to absence from work and the distribution according to diagnosis are quite similar for the two European countries. The costs of disability are particularly high for the Netherlands. Comparison of disability costs between the three countries is hampered due to lack of quantitative information on the influence of social insurance arrangements on the level of indirect costs and the distribution by diagnosis. The large number of deaths at young age in the U.S. is responsible for the higher mortality costs compared to the two European countries

Factors that determine the effectiveness of screening for congenital heart malformations at child health centres

BACKGROUND: The actual yield from current screening for clinically significant congenital heart malformations in Dutch child health care is far from optimal. In this study factors that determine the effectiveness of this screening are identified and recommendations for the optimization of the screening programme are formulated. METHODS: Eighty-two patients with a clinically significant congenital heart malformation were consecutively included in this study. Parents and child health centre physicians were interviewed in order to establish the screening, detection and referral history. Paediatric cardiologists established whether these patients were diagnosed 'in time' or 'too late'. RESULTS: Incomplete performance of the screening examination has more influence on the occurrence of delayed diagnoses than failure by parents to adhere to the complete visit schedule. Adequate screening advances detection of congenital heart malformations. Severity, however, is the most predominant determinant of the age at referral and diagnosis, as well as of the risk of complications. In only 7 out of 39 patients diagnosed 'too late', could no avoidable cause for an adverse outcome be found. In 10 cases (25%) there was a prolonged interval between first referral and diagnosis. CONCLUSION: To optimize the yield of the screening programme, improvement in the performance of the child health centre physicians and the co-operation of other physicians involved in reducing the interval between referral and diagnosis are required. Thus a considerable improvement in the prevention of complications of congenital heart malformations can be obtained

Improving the quality of palliative and terminal care in the hospital by a network of palliative care nurse champions: The study protocol of the PalTeC-H project

Background: The quality of care of patients dying in the hospital is often judged as insufficient. This article describes the protocol of a study to assess the quality of care of the dying patient and the contribution of an intervention targeted on staff nurses of inpatient wards of a large university hospital in the Netherlands. Methods/Design. We designed a controlled before and after study. The intervention is the establishment of a network for palliative care nurse champions, aiming to improve the quality of hospital end-of-life care. Assessments are performed among bereaved relatives, nurses and physicians on seven wards before and after introduction of the intervention and on 11 control wards where the intervention is not applied. We focus on care provided during the last three days of life, covered in global ratings of the quality of life in the last three days of life and the quality of dying, and various secondary endpoints of treatment and care affecting quality of life and dying. Discussion. With this study we aim to improve the understanding of and attention for patients' needs, and the quality of care in the dying phase in the hospital and measure the impact of a quality improvement intervention targeted at nurses

Dying at home or in an institution: perspectives of Dutch physicians and bereaved relatives

Introduction Previous studies have shown that most people prefer to die at their own home. We investigated whether physicians or bereaved relatives in retrospect differently appreciate the dying of patients in an institution or at home. Materials and methods Of 128 patients with incurable cancer who were followed in the last phase of their lives, 103 passed away during follow-up. After death, physicians filled out a written questionnaire for 102 of these patients, and 63 bereaved relatives were personally interviewed. Results Of 103 patients, 49 died in an institution (mostly a hospital), and 54 died at home (or in two cases in a home-like situation). Patients who had been living with a partner relatively often died at home. Bereaved relatives knew of the patient’s wish to die at home in 25 out of 63 cases; 20 of these patients actually died at home. Thirty-one patients had no known preference concerning their place of dying. Most symptoms and the care provided to address them were equally prevalent in patients dying in an institution and patients dying at home. Bereaved relatives were in general quite satisfied about the provision of medical and nursing care in both settings. Conclusion We conclude that most patients’ preferences concerning the place of dying can be met. In about half of all cases, patients do not seem to have a clear preference concerning their place of dying, which is apparently not a major concern for many people. We found no indication that dying in an institution or at home involves major differences in the process and quality of dying