New models of care: Focusing on substitution of hospital care with primary care. Trend setting or trend breaking

This dissertation describes the research into two substitution initiatives implemented in two pioneer sites located in the province of Limburg, in the south of the Netherlands. The first initiative are the Primary Care Plus (PC+) centres implemented in the pioneer site "Blue Care" located in the Maastricht-Heuvelland region, focusing on medical specialists providing consultations in a primary care setting. The second initiative is the care pathway ‘Better exercise in osteoarthritis’ implemented in pioneer site ‘Differently Better’ located in the Western Mining District. Part I of this dissertation presented several studies conducted to examine the influence of the implementation of PC+ and the care pathway ‘Better exercise in osteoarthritis’ on the referral behaviour from primary to secondary care and the request of diagnostic imaging. Part II of this dissertation consisted of several studies examining the effect of PC+ on the health-related quality of patients, the perceived quality of care, the cost-effectiveness and the care volume at regional level

Verkenning mogelijkheden doorontwikkeling Anderhalvelijnszorg Maastricht-Heuvelland

De Academische Werkplaats Duurzame Zorg van Maastricht University/Maastricht UMC+ heeft in opdracht van de Raad van Bestuur van het Maastricht UMC+ verkend wat de mogelijkheden zijn voor verdere doorontwikkeling en optimalisatie van de anderhalvelijnszorg. Dit naar aanleiding van het uitkomen van het in juli 2019 verschenen rapport ‘Monitoring en evaluatie van substitutie van zorg in drie Limburgse proeftuinen’.Anderhalvelijnszorg richt zich op de inzet van specialisten uit het ziekenhuis en gespecialiseerde huisartsen dan wel kaderhuisartsen in de eerstelijnssetting van een anderhalvelijnscentrum buiten de ‘muren’ van het ziekenhuis. Huisartsen verwijzen laagrisicopatiënten met laagcomplexe klachten naar het anderhalvelijnscentrum, waar op basis van één of twee consulten een behandeladvies wordt gegeven aan de huisarts. De patiënt blijft onder regie van de huisarts en de specialisten worden als inhoudelijk deskundigen ‘ingehuurd’.Verkenningsgesprekken (semi-gestructureerde interviews) zijn gehouden met betrokken specialisten op de Stadspoli’s en enkele specialisten van mogelijk toekomstige specialismen die daar actief kunnen worden, huisartsen en de initiatiefnemers van de anderhalvelijnszorg (ZIO, Maastricht UMC+, VGZ en Burgerkracht). In aanvulling hierop hebben observaties (bijeenkomsten van de Stadspoli Gebruikersraad in 2019), een documentenanalyse (eerdere notulen van de Stadspoli Gebruikersraad en documenten verkregen van vertegenwoordigers van verschillende betrokken medische specialismen) en een focusgroep plaatsgevonden. De focusgroep bestond uit medisch specialisten, huisartsen en vertegenwoordigers van de vier initiatiefnemers. Daarnaast zijn aanvullende analyses uitgevoerd met VGZ-data om inzichten te verkrijgen in de verschillen in verwijsgedrag tussen de huisartspraktijken in de regio Maastricht-Heuvelland.De uitnodiging voor het verkenningsgesprek werd positief ontvangen. Met name de verschillende medisch specialismen waren zeer bereid om mee te doen wat zichtbaar was in de hoge respons (94,1%). Bij de huisartsen lag de respons lager (35,3%). Het verschil in respons kan mogelijk verklaard worden door de mate waarin zorgprofessionals zijn betrokken bij de anderhalvelijnszorg, zoals eerder al bleek uit de rapportage van juli 2019. Veel specialisten die al ervaring hadden op de stadspoli gaven aan daar graag te willen werken.De verkenningsgesprekken en de focusgroep hebben plaatsgevonden aan de hand van de volgende thema’s: visie op en positionering van de Stadspoli, verwijsgedrag, communicatie, samenwerking en leereffect, wachttijden en vernieuwing en uitbreiding van professionals, patiëntengroepen en specialismen. Door de deelnemers aan het onderzoek zijn op deze thema’s suggesties en aanbevelingen gedaan voor doorontwikkeling van de Stadspoli. Deze aanbevelingen zijn in hoofdstuk 4 samengevat en geherformuleerd voor de verschillende belanghebbenden bij de Stadspoli (huisarts, specialist, patiënt en initiatiefnemers)

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

Referral decisions and its predictors related to orthopaedic care. A retrospective study in a novel primary care setting

Due to the ageing population, the prevalence of musculoskeletal disorders will continue to rise, as well as healthcare expenditure. To overcome these increasing expenditures, integration of orthopaedic care should be stimulated. The Primary Care Plus (PC+) intervention aimed to achieve this by facilitating collaboration between primary care and the hospital, in which specialised medical care is shifted to a primary care setting. The present study aims to evaluate the referral decision following orthopaedic care in PC+ and in particular to evaluate the influence of diagnostic tests on this decision. Therefore, retrospective monitoring data of patients visiting PC+ for orthopaedic care was used. Data was divided into two periods; P1 and P2. During P2, specialists in PC+ were able to request additional diagnostic tests (such as ultrasounds and MRIs). A total of 2,438 patients visiting PC+ for orthopaedic care were included in the analysis. The primary outcome was the referral decision following PC+ (back to the general practitioner (GP) or referral to outpatient hospital care). Independent variables were consultation- and patient-related predictors. To describe variations in the referral decision, logistic regression modelling was used. Results show that during P2, significantly more patients were referred back to their GP. Moreover, the multivariable analysis show a significant effect of patient age on the referral decision (OR 0.86, 95% CI = 0.81-0.91) and a significant interaction was found between the treating specialist and the period (p = 0.015) and between patient's diagnosis and the period (p ≤ 0.001). Despite the significant impact of the possibility of requesting additional diagnostic tests in PC+, it is important to discuss the extent to which the availability of diagnostic tests fits within the vision of PC+. In addition, selecting appropriate profiles for specialists and patients for PC+ are necessary to further optimise the effectiveness and cost of care

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 (

Reorganising dermatology care:predictors of the substitution of secondary care with primary care

Background: The substitution of healthcare is a way to control rising healthcare costs. The Primary Care Plus (PC+) intervention of the Dutch ‘Blue Care’ pioneer site aims to achieve this feat by facilitating consultations with medical specialists in the primary care setting. One of the specialties involved is dermatology. This study explores referral decisions following dermatology care in PC+ and the influence of predictive patient and consultation characteristics on this decision. Methods: This retrospective study used clinical data of patients who received dermatology care in PC+ between January 2015 and March 2017. The referral decision following PC+, (i.e., referral back to the general practitioner (GP) or referral to outpatient hospital care) was the primary outcome. Stepwise logistic regression modelling was used to describe variations in the referral decisions following PC+, with patient age and gender, number of PC+ consultations, patient diagnosis and treatment specialist as the predicting factors. Results: A total of 2952 patients visited PC+ for dermatology care. Of those patients with a registered referral, 80.2% (N = 2254) were referred back to the GP, and 19.8% (N = 558) were referred to outpatient hospital care. In the multivariable model, only the treating specialist and patient’s diagnosis independently influenced the referral decisions following PC+. Conclusion: The aim of PC+ is to reduce the number of referrals to outpatient hospital care. According to the results, the treating specialist and patient diagnosis influence referral decisions. Therefore, the results of this study can be used to discuss and improve specialist and patient profiles for PC+ to further optimise the effectiveness of the initiative

Does the implementation of a care pathway for patients with hip or knee osteoarthritis lead to fewer diagnostic imaging and referrals by general practitioners?:A pre-post-implementation study of claims data

BackgroundThe Dutch care for hip and knee osteoarthritis (OA) is of good quality, but there is room for improvement regarding the efficient use of diagnostic imaging and conservative treatment. Therefore a stepped-care approach, in the shape of the care pathway 'Better exercise in osteoarthritis', was implemented to reduce the number of diagnostic imaging requested by GPs and referrals of GPs to orthopaedic care.MethodsIn 2015, the pathway is implemented with the use of educational meetings, distributing guidelines and incorporating reminders in the GPs' referral application. To evaluate the effect of the pathway on the diagnostic and referral behaviour of GPs, hip and knee related health insurance claims are used together with claims of other joints and of a control region for comparison. The average number of claims and the percentage change in the post-implementation period are described. Binary logistic regression analysis is used to examine the interaction between region (intervention and control) and period (pre- and post-implementation). Using random sampling of patient records, information about the practical application of the pathway and the number of hip or knee arthroplasties is added.ResultsIn both regions, the number of diagnostic imaging decreased and the number of initial orthopaedic consultations increased during the post-implementation period. Significant interaction effects were found in knee-related diagnostics (

Patient versus proxy-reported problematic activities of daily life in patients with COPD

Background and objective: Loved ones (proxies) of patients with COPD are confronted with the patients' limitations in activities of daily living (ADLs). However, it remains unknown whether proxies are able to correctly estimate the problematic ADLs of the patient. Therefore, we aimed to investigate the level of agreement between patient-reported and proxy-reported problematic ADLs of the patient.Methods: Stable outpatients with moderate to very severe COPD (n = 194) and their resident proxies (n = 194) were included in this cross-sectional study. Patients' problematic ADLs were assessed in the domains 'self-care', 'mobility', 'productivity' and ;'leisure' using the Canadian Occupational Performance Measure (COPM) in both patients and resident proxies. Furthermore, the perceived performance and satisfaction for important problematic ADLs were rated on a 10-point scale.Results: In total, 830 problematic ADLs were reported by patients, and 735 by proxies. Agreement in reporting problematic ADLs within a domain was poor (productivity and leisure; kappa = 0.20 and 0.16, respectively) to fair (self-care and mobility; kappa = 0.32 and 0.22, respectively). Similar performance and satisfaction scores, for equally reported problematic ADLs, were given by 24.0% and 17.6% of the pairs, respectively.Conclusion: Proxies were often not able to identify the patients' most important problematic ADLs. Moreover, when patient and proxy agreed about the presence of a specific problematic ADL, the perception of the performance and the satisfaction with that performance differed within most pairs. This emphasizes the importance of involving proxies, besides patients alone, in identifying patients' problematic ADLs.</p