The discriminative power of the ReproQ

Background. The aim of the ReproQuestionnaire (ReproQ) is to measure the client's experience with maternity care, following WHO's responsiveness model. To support quality improvement, ReproQ should be able to discriminate best from worst organisational units. Methods. We sent questionnaires to 27,487 third-trimester pregnant women (response 31%) and to 37,230 women 6 weeks after childbirth (response 39%). For analysis we first summarized the ReproQ domain scores into three summary scores: total score (all eight domains), personal score (four personal domains), and setting score (four setting domains). Second, we estimated the proportion of variance across perinatal units attributable to the `actual' difference across perinatal units using intraclass correlation coefficients (ICCs). Third, we assessed the ability of ReproQ to discriminate between perinatal units based on both a statistical approach using multilevel regression analyses, and a relevance approach based on the minimally important difference (MID). Finally, we compared the domain scores of the best and underperforming units. Results. ICCs ranged between 0.004 and 0.025 for the summary scores, and between 0.002 and 0.125 for the individual domains. ReproQ was able to identify the best and worst performing units with both the statistical and relevance approach. The statistical approach was able to identify four underperforming units during childbirth (total score), while the relevance approach identified 10 underperforming units. Conclusions. ReproQ, a valid and efficient measure of client experiences in maternity care, has the ability to discriminate well across perinatal units, and is suitable for benchmarking under routine conditions

Measuring client experiences in maternity care under change

Background Maternity care is an integrated care process, which consists of different services, involves different professionals and covers different time windows. To measure performance of maternity care based on clients' experiences, we developed and validated a questionnaire. Methods and Findings We used the 8-domain WHO Responsiveness model, and previous materials to develop a self-report questionnaire. A dual study design was used for development and validation. Content validity of the ReproQ-version-0 was determined through structured interviews with 11 pregnant women (≤28 weeks), 10 women who recently had given birth (≤12 weeks), and 19 maternity care professionals. Structured interviews established the domain relevance to the women; all items were separately commented on. All Responsiveness domains were judged relevant, with Dignity and Communication ranking highest. Main missing topic was the assigned expertise of the health professional. After first adaptation, construct validity of the ReproQ-version-1 was determined through a web-based survey. Respondents were approached by maternity care organizations with different levels of integration of services of midwives and obstetricians. We sent questionnaires to 605 third trimester pregnant women (response 65%), and 810 women 6 weeks after delivery (response 55%). Construct validity was based on: response patterns; exploratory factor analysis; association of the overall score with a Visual Analogue Scale (VAS), known group comparisons. Median overall ReproQ score was 3.70 (range 1-4) showing good responsiveness. The exploratory factor analysis supported the assumed domain structure and suggested several adaptations. Correlation of the VAS rating and overall ReproQ score (antepartum, postpartum) supported validity (r = 0.56; 0.59, p< 0.001 Spearman's correlation coefficient). Pre-stated group comparisons confirmed the expected difference following a good vs. adverse birth outcome. Fully integrated organizations performed slightly better (median = 3.78) than less integrated organizations (median = 3.63; p< 0.001). Participation rate of women with a low educational level and/or a non-western origin was low. Conclusions The ReproQ appears suitable for assessing quality of maternity care from the clients' perspective. Recruitment of disadvantaged groups requires additional non-digital approaches

Parental perspectives on the awareness and delivery of preconception care

Background: The attention for Preconception Care (PCC) has grown substantially in recent years, yet the implementation of PCC appears challenging as uptake rates remain low. The objective of this study was to assess parental perspectives on how PCC should be provided. Methods: Recruitment of participants took place among couples who received antenatal care at a Dutch community midwifery practice. Between June and September 2014, five focus group sessions were held with 29 women and one focus group session with 5 men. Thematic analysis was conducted using NVivo 10 software. Results: Participants were generally unfamiliar with the concept of PCC. It was proposed to raise awareness by means of a promotional campaign, stipulating that PCC is suited for every couple with a (future) child wish. Suggestions were made to display marketing materials in both formal and informal (local community) settings. Addressing existing social networks and raising social dialogue was expected to be most efficient. It was recommended to make PCC more accessible by offering multiple forms and to involve male partners. Opportunistic offering PCC by healthcare providers was considered more acceptable when the subject was deliberately raised, for example while discussing contraceptives, lifestyle risks or drug prescriptions. GP's or midwifes were regarded the most suitable PCC providers, however provider characteristics such as experience, empathy and communication skills were considered more important. Conclusions: This study showed that from the parental perspective it is recommended to address every couple with a (future) child wish by means of enlarging the awareness and accessibility of PCC. In order to enlarge the awareness, it is recommended to address social networks, to raise the social dialogue and to conduct promotional campaigns regarding PCC. In order to improve the accessibility of PCC, it was suggested to simultaneously offer multiple forms: group sessions, individual consultations, walk-in-hours and online sessions, and to involve male partners

The effect of a local promotional campaign on preconceptional lifestyle changes and the use of preconception care

Purpose: The objective of this study was to investigate the effect of a local promotional campaign on preconceptional lifestyle changes and the use of preconception care (PCC). Material and methods: This quasi-comparative study was carried out between February 2015 and February 2016 at a community midwifery practice in the Netherlands. The intervention consisted of a dual track approach (i) a promotional campaign for couples who wish to conceive and (ii) a PCC pathway for health care providers. Questionnaires were collected from a sample of women who received antenatal care during the pre-intervention (n = 283) and post-intervention (n = 257) period. Main outcome measures were preconceptional lifestyle changes and PCC use (defined as searching for information and/or consulting a health care provider). Results: Women who were exposed to the intervention were significantly more likely to make at least one lifestyle change during the preconception period [adjusted OR 1.56 (95% CI 1.02–2.39)]. Women were especially more likely to preconceptionally reduce or quit [adjusted OR 1.72 (95% CI 1.05–2.83)] their alcohol consumption after exposure to the intervention. Although non-significant, it appeared that women who were exposed to the intervention more often prepared themselves for pregnancy by means of independently searching for preconception health information [adjusted OR 1.13 (95% CI 0.77–1.65)] or consulting a health care provider regarding their wish to conceive [adjusted OR 1.24 (95% CI 0.81–1.92)]. Conclusions: Exposure to a local promotional campaign targeted at preconceptional health was associated with improved preconceptional lifestyle behaviours, especially with regard to alcohol consumption, and has the potential to improve the use of PCC

Improving transitional patient safety: research protocol of the Transitional Incident Prevention Programme

__Introduction:__ Patient transitions between primary and hospital care include referral, discharge, and simultaneous care by the outpatient clinic and the general practitioner (GP). Research on referrals and discharge shows that safety incidents in these transitions are common. We developed the multifaceted Transitional Incident Prevention Programme (TIPP), which aims to improve transitional patient safety preventing future incidents. With this study, we aim to evaluate the effectiveness of the TIPP programme on transitional patient safety, and to evaluate its implementation and the acceptance in GP-practices and hospitals. __Methods:__ The TIPP intervention study is a controlled before and after study combined with qualitative methods. The study will be conducted in both rural and urban settings including three hospitals, together with referring primary care practices. The TIPP intervention is aimed at three aspects of transitional safety: 1) Healthcare process, 2) Transitional patient safety culture, and 3) Patient participation. Together with the participating hospital departments, GPs and patients, we will develop a tailored improvement programme, taking into account the different context of each setting. __Discussion:__ The purpose of this protocol paper is to present and discuss the research design and methodology of the TIPP intervention

De psychometrische eigenschappen van de ReproQuestionnaire

__Abstract__ De organisatie van de geboortezorg is in beweging. Er zijn nieuwe samenwerkingsvormen, er zijn nieuwe risicobenaderingen, nieuwe verdelingen van taken en andere settings van bevallingszorg. Sommige disciplines zoals de huisarts hebben een steeds kleinere rol, andere zoals de klinisch-verloskundigen een steeds grotere. Er is geen masterplan van verandering, en er heerst op onderdelen verscheidenheid van opvatting over de wenselijke richting. Al deze veranderingen zijn - naar men stelt - gericht op het verbeteren van de kwaliteit van zorg. Hiermee wordt niet alleen het terugdringen van de perinatale sterfte (‘baby-sterfte’) beoogd, maar ook het verbeteren van de onderlinge samenwerking, met name, tussen eerstelijns verloskundigen en gynaecologen, en het realiseren van zorg die de zwangere als cliënt centraal stelt. Er is weinig informatie bekend over de huidige proceskwaliteit van de Nederlandse geboortezorg, mede door het ontbreken van daartoe geëigende lijnoverstijgende instrumenten. Kwaliteitsindicatoren zijn momenteel primair harde uitkomstindicatoren ontleend aan informatie uit zorgregistraties zoals de PRN. Deze geven wel een beeld van de medische uitkomsten, van sommige procedures, en van de belangrijkste bevallingsinterventies, maar niet van de cliëntervaringen met de zorgverlening, en ook niet van de subjectief ervaren uitkomst van c.q. bij moeder en kind. Proceskwaliteit kan men benaderen vanuit de professional bijvoorbeeld aan de hand van richtlijnen of het realiseren van procesdoelen zoals bij risicoselectie, maar dat is een ander perspectief dan de proceskwaliteit vanuit het cliëntperspectief. Ongeacht de vraag wie de zorg verleende, en los van de vraag of alle richtlijnen in acht werden genomen, is namelijk van belang of de cliënte in haar eigen ogen respect en bejegening ontving, of de communicatie in orde was, en of faciliteiten voldeden. Een en ander vraagt zorgvuldig ontwerp van vragenlijsten omdat alle betrokken professionals zeggen vanuit het cliëntperspectief te werken. Vaak, zo is ons gebleken, doelen professionals dan op het volgen van gedragsregels en richtlijnen zoals de beroepsorganisaties die aan hun leden voorschrijven. Het cliëntperspectief doet niets af aan dit professioneel perspectief, en een eindoordeel over de zorg kan ook niet zonder harde uitkomsten en procedure kwaliteit worden geveld, maar het cliëntperspectief vraagt niettemin een ander type vragen

Measuring clients’ experiences with antenatal care before or after childbirth: It matters

Background. When clients’ experiences with maternity care are measured for quality improvement, surveys are administered once, usually six weeks or more after childbirth. Most surveys conveniently cover pregnancy, childbirth and postnatal care all in one. However, the validity of measuring the experiences during pregnancy (antenatal experiences) after childbirth is unknown. We explored the relation between the measurement of antenatal experiences late in pregnancy but prior to childbirth (‘test’or gold standard) and its retrospective measurement after childbirth (retrospective test). Additionally, we explored the role of modifying determinants that explained the gap between these two measurements. Methods and Findings. Client’s experiences were measured by the ReproQuestionnaire that consists of an antenatal and postnatal version, and covers the eight WHO Responsiveness domains. 462 clients responded to the antenatal and postnatal questionnaire, and additionally filled out the repeated survey on antenatal experiences after childbirth. First, we determined the association between the test and retrospective test using three scoring models: mean score, equal or above the median score and having a negative experience. The association was moderate for having any negative experience (absolute agreement = 68%), for the median (absolute agreement = 69%) and for the mean score (ICC = 0.59). Multiple linear and logistic regression analysis for all three scoring models revealed systematic modifiers. The gap between antenatal and postnatal measurement was (partly) associated with clients’ experiences during childbirth and postnatal care and by professional discontinuity during childbirth but unrelated to the perceived health outcome. Conclusions. The antenatal experiences should be measured before and not after childbirth, as the association between the antenatal experiences measured before and after childbirth is moderate

Laparoscopic versus open gastrectomy for gastric cancer, a multicenter prospectively randomized controlled trial (LOGICA-trial)

Background: For gastric cancer patients, surgical resection with en-bloc lymphadenectomy is the cornerstone of curative treatment. Open gastrectomy has long been the preferred surgical approach worldwide. However, this procedure is associated with considerable morbidity. Several meta-analyses have shown an advantage in short-term outcomes of laparoscopic gastrectomy compared to open procedures, with similar oncologic outcomes. However, it remains unclear whether the results of these Asian studies can be extrapolated to the Western population. In this trial from the Netherlands, patients with resectable gastric cancer will be randomized to laparoscopic or open gastrectomy. Methods: The study is a non-blinded, multicenter, prospectively randomized controlled superiority trial. Patients (≥18 years) with histologically proven, surgically resectable (cT1-4a, N0-3b, M0) gastric adenocarcinoma and European Clinical Oncology Group performance status 0, 1 or 2 are eligible to participate in the study after obtaining informed consent. Patients (n = 210) will be included in one of the ten participating Dutch centers and are randomized to either laparoscopic or open gastrectomy. The primary outcome is postoperative hospital stay (days). Secondary outcome parameters include postoperative morbidity and mortality, oncologic outcomes, readmissions, quality of life and cost-effectiveness. Discussion: In this randomized controlled trial laparoscopic and open gastrectomy are compared in patients with resectable gastric cancer. It is expected that laparoscopic gastrectomy will result in a faster recovery of the patient and a shorter hospital stay. Secondly, it is expected that laparoscopic gastrectomy will be associated with a lower postoperative morbidity, less readmissions, higher cost-effectiveness, better postoperative quality of life, but with similar mortality and oncologic outcomes, compared to open gastrectomy. The study started on 1 December 2014. Inclusion and follow-up will take 3 and 5 years respectively. Short-term results will be analyzed and published after discharge of the last randomized patient

Evaluation of PET and laparoscopy in STagIng advanced gastric cancer: A multicenter prospective study (PLASTIC-study)

Background: Initial staging of gastric cancer consists of computed tomography (CT) and gastroscopy. In locally advanced (cT3-4) gastric cancer, fluorodeoxyglucose positron emission tomography with CT (FDG-PET/CT or PET) and staging laparoscopy (SL) may have a role in staging, but evidence is scarce. The aim of this study is to evaluate the impact and cost-effectiveness of PET and SL in addition to initial staging in patients with locally advanced gastric cancer. Methods: This prospective observational cohort study will include all patients with a surgically resectable, advanced gastric adenocarcinoma (cT3-4b, N0-3, M0), that are scheduled for treatment with curative intent after initial staging with gastroscopy and CT. The modalities to be investigated in this study is the addition of PET and SL. The primary outcome of this study is the proportion of patients in whom the PET or SL lead to a change in treatment strategy. Secondary outcome parameters are: diagnostic performance, morbidity and mortality, quality of life, and cost-effectiveness of these additional diagnostic modalities. The study recently started in August 2017 with a duration of 36 months. At least 239 patients need to be included in this study to demonstrate that the diagnostic modalities are break-even. Based on the annual number of gastrectomies in the participating centers, it is estimated that approximately 543 patients are included in this study. Discussion: In this study, it is hypothesized that performing PET and SL for locally advanced gastric adenocarcinomas results in a change of treatment strategy in 27% of patients and an annual cost-reduction in the Netherlands of €916.438 in this patient group by reducing futile treatment. The results of this study may be applicable to all countries with comparable treatment algorithms and health care systems

The impact of critical illness on perceived health-related quality of life during ICU treatment, hospital stay, and after hospital discharge: A long-term follow-up study

Background: The time course of changes in health-related quality of life (HRQOL) following discharge from the ICU and during a general ward stay has not been studied. We therefore studied the immediate impact of critical illness on HRQOL and its recovery over time. Methods: In a prospective study, all patients admitted to the ICU for > 48 h who ultimately survived to follow-up at 6 months were included. The Medical Outcomes Study 36-item short form was used to measure HRQOL before ICU admission, at discharge from the ICU and hospital, and at 3 and 6 months following discharge from the ICU and hospital. An age-matched healthy Dutch population was used as a reference. Results: Of the 451 included patients, 252 could be evaluated at 6 months (40 were lost to follow-up, and 159 died). Pre-ICU admission HRQOL in survivors was significantly worse compared to the healthy population. Patients who died between ICU admission and long-term follow-up had significantly worse HRQOL in all dimensions already at ICU admission when compared to the long-term survivors. HRQOL decreased in all dimensions (p < 0.001) during ICU stay followed by a rapid improvement during hospital stay, gradually improving to near pre-ICU admission HRQOL at 6 months following ICU discharge. Physical functioning (PF), general health (GH), and social functioning (SF) remained significantly lower than pre-ICU admission values. Compared to the healthy Dutch population, ICU survivors had significantly lower HRQOL 6 months following ICU discharge (except for the bodily pain score). Conclusions: A sharp multidimensional decline in HRQOL occurs during ICU admission where recovery already starts following ICU discharge to the general ward. Recovery is incomplete for PF, GH, and SF when compared to baseline values and the healthy population