What's up doc? Physicians' reflections on their sustainable employability throughout careers: a narrative inquiry

BACKGROUND

Physicians have complex and demanding jobs that may negatively affect their sustainable employability (SE) and quality of care. Despite its societal and occupational relevance, empirical research on physicians' SE is scarce. To further advance our understanding of physicians' SE, this study explores how physicians perceive their employment context to affect their SE, how physicians self-regulate with the intent to sustain their employability, and how self-regulations affect physicians' SE and their employment context.

METHODS

Twenty Dutch physicians from different specialisms were narratively interviewed between March and September 2021 by a researcher with a similar background (surgeon) to allow participants to speak in their own jargon. The interviews were analyzed collaboratively by the research team in accordance with theory-led thematic analysis.

RESULTS

According to the interviewees, group dynamics, whether positive or negative, and (mis)matches between personal professional standards and group norms on professionalism, affect their SE in the long run. Interviewees self-regulate with the intent to sustain their employability by (I) influencing work; (II) influencing themselves; and (III) influencing others. Interviewees also reflect on long-term, unintended, and dysfunctional consequences of their self-regulations.

CONCLUSIONS

We conclude that physicians' SE develops from the interplay between the employment context in which they function and their self-regulations intended to sustain employability. As self-regulations may unintentionally contribute to dysfunctional work practices in the employment context, there is a potential for a vicious cycle. Insights from this study can be used to understand and appraise how physicians self-regulate to face complex challenges at work and to prevent both dysfunctional work practices that incite self-regulation and dysfunctional consequences resulting from self-regulations.

Room for resilience: a qualitative study about accountability mechanisms in the relation between work-as-done (WAD) and work-as-imagined (WAI) in hospitals

BACKGROUND

Central to Safety-II is promoting resilience of healthcare practices. In the "Room for Resilience" research project we focus on the role of horizontal and vertical accountability in healthcare teams and aim to discover how the relation between the two impacts team reflections and discussions. In this article, we report on an explorative study at the start of the project which aimed to assess the structures and dynamics of horizontal and vertical accountability.

METHODS

A qualitative study in six teams in three hospitals in the Netherlands. For the project, each team selected a specific clinical process to work on (e.g. pain assessment). We interviewed healthcare professionals, managers, and quality advisors about these processes, how they are discussed in practice and how teams need to account for them. Additionally, we observed the processes and how teams discuss them in practice. In total, we conducted 35 interviews and 67.5 h of observation. Transcripts and field notes were analyzed using thematic analysis.

RESULTS

Professionals at times varied in what they considered the right approach in the clinical process, with differing views on the importance of certain actions. When processes were discussed, this mostly was done during clinical work, and it often concerned reflections about the care for a specific patient instead of reflecting on the team's general approach of the clinical process. Organized reflections on the processes were sparse. How processes were conducted in practice deviated from guidelines, mainly due to staff shortages, a perceived lack of value of a guideline, equipment issues, and collaboration issues. For most processes, accountability to hierarchical layers consisted of quality indicator scores. Professionals were tasked with registering indicator data but did not find this meaningful for their work.

CONCLUSIONS

The observed different perspectives within teams on what good quality care is show the importance of having team reflections about these processes. How vertical accountability was organized at times impacted the conditions for teams to discuss resilient performance. Following these findings, we recommend that reflection on resilient practice and the role of accountability processes is organized on all levels in (and outside) the organization.

What are Effective Strategies to Reduce Low-Value Care? An Analysis of 121 Randomized Deimplementation Studies

BACKGROUND

Low-value care is healthcare leading to no or little clinical benefit for the patient. The best (combinations of) interventions to reduce low-value care are unclear.

PURPOSE

To provide an overview of randomized controlled trials (RCTs) evaluating deimplementation strategies, to quantify the effectiveness and describe different combinations of strategies.

METHODS

Analysis of 121 RCTs (1990-2019) evaluating a strategy to reduce low-value care, identified by a systematic review. Deimplementation strategies were described and associations between strategy characteristics and effectiveness explored.

RESULTS

Of 109 trials comparing deimplementation to usual care, 75 (69%) reported a significant reduction of low-value healthcare practices. Seventy-three trials included in a quantitative analysis showed a median relative reduction of 17% (IQR 7%-42%). The effectiveness of deimplementation strategies was not associated with the number and types of interventions applied.

CONCLUSIONS AND IMPLICATIONS

Most deimplementation strategies achieved a considerable reduction of low-value care. We found no signs that a particular type or number of interventions works best for deimplementation. Future deimplementation studies should map relevant contextual factors, such as the workplace culture or economic factors. Interventions should be tailored to these factors and provide details regarding sustainability of the effect.

[Structurally supporting health care professionals' well-being: the relevance of a national program Caring for Healthcare Professionals.]

Stressful working conditions in health care put the well-being of healthcare professionals at risk. This well-being is increasingly being supported by diverse initiatives in the Netherlands. However, these initiatives are dispersed across micro-, meso- and macro-levels and not equally accessible to all health care professionals. A national, integral approach is lacking in which initiatives across levels are more effectively combined. Therefore, we suggest the initiation of a national program "Caring for Healthcare Professionals", which structurally supports the well-being of healthcare professionals. We reflect on science- and practice-based insights from interventions in three domains: (a) workplace management, (b) self-care, and (c) treatment and recovery. We propose to translate the lessons learned in these domains into a national program combining best practices, aiming to structurally support healthcare professionals' well-being.

Fostering a just culture in healthcare organizations: experiences in practice

Background

A just culture is regarded as vital for learning from errors and fostering patient safety. Key to a just culture after incidents is a focus on learning rather than blaming. Existing research on just culture is mostly theoretical in nature.

Aim

This study aims to explore requirements and challenges for fostering a just culture within healthcare organizations.

Methods

We examined initiatives to foster the development of a just culture in five healthcare organizations in the Netherlands. Data were collected through interviews with stakeholders and observations of project group meetings in the organizations.

Results

According to healthcare professionals, open communication is particularly important, paying attention to different perspectives on an incident. A challenge related to open communication is how to address individual responsibility and accountability. Next, room for emotions is regarded as crucial. Emotions are related to the direct consequences of incidents, but also to the response of the outside world, including the media and the health inspectorate.

Conclusions

A challenge in relation to emotions is how to combine attention for emotions with focusing on facts, both within and outside the organization. Finally, healthcare professionals attach importance to commitment and exemplary behavior of management. A challenge as a manager here is how to keep distance while also showing commitment. Another challenge is how to combine openness with privacy of the parties involved, and how to deal with less nuanced views in other layers of the organization and in the outside world. Organizing reflection on the experienced tensions may help to find the right balance.

Role of the regulator in enabling a just culture: a qualitative study in mental health and hospital care

OBJECTIVES

A just culture is considered a promising way to improve patient safety and working conditions in the healthcare sector, and as such is also of relevance to healthcare regulators who are tasked with monitoring and overseeing quality and safety of care. The objective of the current study is to explore the experiences in healthcare organisations regarding the role of the healthcare inspectorate in enabling a just culture.

DESIGN

Qualitative study using interviews and focus groups that were transcribed verbatim, and observations of which written reports were made. Transcripts and observation reports were thematically analysed.

SETTING

Three mental healthcare providers, two hospitals and the healthcare inspectorate in the Netherlands.

PARTICIPANTS

We conducted 61 interviews and 7 focus groups with healthcare professionals, managers and other staff in healthcare organisations and with inspectors. Additionally, 27 observations were conducted in healthcare organisations.

RESULTS

We identified three themes in our data. First, professionals and managers in healthcare organisations perceive the inspectorate as a potential catalyst for learning processes, for example, as an instigator of investigating incidents thoroughly, yet also as a potential barrier as its presence and procedures limit how open employees feel they can be. Second, a just culture is considered relational and layered, meaning that relationships between different layers within or outside the organisation might hinder or promote a just culture. Finally, for inspectors to enable a just culture requires finding a balance between allowing organisations the time to take responsibility for quality and safety issues, and timely regulatory intervention when healthcare providers are unwilling or unable to act.

CONCLUSIONS

If regulators intend to enable the development of a just culture within healthcare organisations, they must adopt regulatory procedures that support reflection and learning within the organisations they regulate and consider mutual trust as a vital regulatory tool.

Combining rules and dialogue: exploring stakeholder perspectives on preventing sexual boundary violations in mental health and disability care organizations

Background

Sexual boundary violations (SBV) in healthcare are harmful and exploitative sexual transgressions in the professional–client relationship. Persons with mental health issues or intellectual disabilities, especially those living in residential settings, are especially vulnerable to SBV because they often receive long-term intimate care. Promoting good sexual health and preventing SBV in these care contexts is a moral and practical challenge for healthcare organizations.

Methods

We carried out a qualitative interview study with 16 Dutch policy advisors, regulators, healthcare professionals and other relevant experts to explore their perspectives on preventing SBV in mental health and disability care organizations. We used inductive thematic analysis to interpret our data.

Results

We found three main themes on how healthcare organizations can prevent SBV in mental health and disability care: (1) setting rules and regulations, (2) engaging in dialogue about sexuality, and (3) addressing systemic and organizational dimensions.

Conclusion

Our findings suggest that preventing SBV in mental health and disability care organizations necessitates setting suitable rules and regulations and facilitating dialogue about positive aspects of sexuality and intimacy, as well as about boundaries, and inappropriate behaviors or feelings. Combining both further requires organizational policies and practices that promote transparency and reflection, and focus on creating a safe environment. Our findings will help prevent SBV and promote sexual health in mental health and disability care organizations.

Sexual abuse of people with intellectual disabilities in residential settings: a 3-year analysis of incidents reported to the Dutch Health and Youth Care Inspectorate

OBJECTIVES

To explore characteristics of sexual abuse within residential settings for people with an intellectual disability and to map out measures undertaken and improvement plans made by healthcare organisations after sexual abuse.

DESIGN

Descriptive analysis of reports about sexual violence against persons with an intellectual disability submitted to the Dutch Health and Youth Care Inspectorate by healthcare organisations.

SETTING

Residential settings for people with an intellectual disability in The Netherlands.

SELECTION

186 incident reports submitted to the Inspectorate between January 2017 and December 2019 were included.

RESULTS

125 incident reports concerned sexual abuse by fellow clients and 61 reports concerned sexual abuse by professionals. Client perpetrators were predominantly male whereas almost 30% of the abusing professionals were female. The majority of the perpetrating professionals were unlicensed professionals. Clients who committed sexual abuse were mostly relocated to another residential setting. Most healthcare organisations invested in education and training for employees instead of improving the sexual education programme for clients after an incident of sexual abuse. If there was a strong suspicion of sexual abuse by a professional, resignation followed in most cases. In just two cases, the perpetrating professional was reported to a warning registry.

CONCLUSIONS

A small amount of the perpetrating professionals held a licensed profession, which makes it challenging to address this form of sexual abuse through healthcare regulation. It raises the question why warning registries are not engaged more often after alleged sexual abuse. Constantly relocating abusing clients might endanger the (sexual) safety of clients in these new environments. Previous literature suggests that adequate sexual education regarding social skills and sexual behaviour is very effective for the majority of clients who commit sexual abuse. Healthcare organisations could take up a more prominent role in this to ensure safety for their own clients and for clients residing elsewhere.

Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings

Background

The Dutch healthcare inspectorate publishes its inspection frameworks to inform both the public and healthcare providers about regulatory procedures and in the hope that publication will motivate healthcare providers to improve quality and comply with standards. This study explores the consequences of publishing these frameworks for the regulation of quality and safety in healthcare.

Methods

We selected recently published inspection frameworks used in three healthcare settings: nursing home care, dental care and hospital care. We conducted 37 interviews with 39 respondents (healthcare professionals, managers, quality officers, policy advisers and inspectors) and explored their awareness of and experiences with these frameworks. We held a group interview with three inspectors to reflect on our findings. All data underwent thematic content analysis.

Results

We found that the institutional infrastructure of a sector plays an important role in how an inspection framework is used after publication; particularly the presence and maturity of quality improvement work in the sector and the inspectorate’s grip on a sector matter. Respondents mentioned differences in framework use in organisational contexts, particularly relating to scale. In some organisations, the framework served as an accountability mechanism to check if quality meets basic standards, while in other organisations professionals adopted it to stimulate discussion and learning across teams.

Conclusion

Publication of inspection frameworks might result in quality improvement work, and in particular contexts could be used as a regulatory strategy to target quality improvement in a healthcare sector. For this, it is important that regulators consider the capabilities and possibilities for learning and improving within a sector.

Moving regional health services planning and management to a population-based approach: implementation of the Regional Operating Model (ROM) in Victoria, Australia

Various jurisdictions are moving towards population-based approaches to plan and manage healthcare services. The evidence on the implementation of these models remains limited. The aim of this study is to evaluate the effect of a regional operating model (ROM) on internal functioning and stakeholder engagement of a regional office. Semi-structured interviews and focus groups with staff members and stakeholders of the North West Metropolitan Regional office in Victoria, Australia, were conducted. Overall, the ROM was perceived as relevant to staff and stakeholders. However, creating shared objectives and priorities across a range of organisations remained a challenge. Area-based planning and management is seen as simplifying management of contracts; however, reservations were expressed about moving from specialist to more generalist approaches. A clearer articulation of the knowledge, skills and competencies required by staff would further support the implementation of the model. The ROM provides a platform for public services and stakeholders to discuss, negotiate and deliver on shared outcomes at the regional level. It provides an integrated managerial platform to improve service delivery and avoid narrow programmatic approaches.

Prevention of and dealing with poor performance: an interview study about how professional associations aim to support healthcare professionals

Objective

To explore how professional associations of nine healthcare professions aim to support professionals to prevent and deal with poor performance.

Design

Qualitative interview study.

Setting

The Netherlands.

Participants

Representatives of professional associations for dentists, general practitioners, medical specialists, midwives, nurses, pharmacists, physiotherapists, psychologists and psychotherapists.

Interventions

During nine face-to-face semi-structured interviews we asked how associations aim to support professionals in prevention of and dealing with poor performance. Following the first interview, we monitored new initiatives in support over a 2.5-year period, after which we conducted a second interview. Interviews were analysed using thematic analysis.

Main outcome measures

Available policy and support regarding poor performance.

Results

Three themes emerged from our data (i.e. elaborating on professional performance, performance insight and dealing with poor performance) for which we identified a total of 10 categories of support. Support concerned professional codes, guidelines and codes of conduct, quality registers, individual performance assessment, peer consultation, practice evaluation, helpdesk and expert counselling, a protocol for dealing with poor performance, a place for support and to report poor performance, and internal disciplinary procedures.

Conclusions

This study provides an overview of support given to nine healthcare professions by their associations regarding poor performance, and identifies gaps that associations could follow up on, such as clarifying what to do when confronted with a poorly performing colleague, supporting professionals that poorly perform, and developing methods for individual performance assessment to gain performance insight. A next step would be to evaluate the use and effect of different types of support.

Dimensions and intensity of inter-professional teamwork in primary care: evidence from five international jurisdictions

BACKGROUND

Inter-professional teamwork in primary care settings offers potential benefits for responding to the increasing complexity of patients' needs. While it is a central element in many reforms to primary care delivery, implementing inter-professional teamwork has proven to be more challenging than anticipated.

OBJECTIVE

The objective of this study was to better understand the dimensions and intensity of teamwork and the developmental process involved in creating fully integrated teams.

METHODS

Secondary analyses of qualitative and quantitative data from completed studies conducted in Australia, Canada and USA. Case studies and matrices were used, along with face-to-face group retreats, using a Collaborative Reflexive Deliberative Approach.

RESULTS

Four dimensions of teamwork were identified. The structural dimension relates to human resources and mechanisms implemented to create the foundations for teamwork. The operational dimension relates to the activities and programs conducted as part of the team's production of services. The relational dimension relates to the relationships and interactions occurring in the team. Finally, the functional dimension relates to definitions of roles and responsibilities aimed at coordinating the team's activities as well as to the shared vision, objectives and developmental activities aimed at ensuring the long-term cohesion of the team. There was a high degree of variation in the way the dimensions were addressed by reforms across the national contexts.

CONCLUSION

The framework enables a clearer understanding of the incremental and iterative aspects that relate to higher achievement of teamwork. Future reforms of primary care need to address higher-level dimensions of teamwork to achieve its expected outcomes.

Barriers to accessing primary health care: comparing Australian experiences internationally

Most highly developed economies have embarked on a process of primary health care (PHC) transformation. To provide evidence on how nations vary in terms of accessing PHC, the aim of this study is to describe the extent to which barriers to access were experienced by adults in Australia compared with other countries. Communities participating in an international research project on PHC access interventions were engaged to prioritise questions from the 2013 Commonwealth Fund International Health Policy Survey within a framework that conceptualises access across dimensions of approachability, acceptability, availability, affordability and appropriateness. Logistic regression models, with barriers to access as outcomes, found measures of availability to be a problematic dimension in Australia; 27% of adults experienced difficulties with out-of-hours access, which was higher than 5 of 10 comparator countries. Although less prevalent, affordability was also perceived as a substantial barrier; 16% of Australians said they had forgone health care due to cost in the previous year. After adjusting for age and health status, this barrier was more common in Australia than 7 of 10 countries. Findings of this integrated assessment of barriers to access offer insights for policymakers and researchers on Australia's international performance in this crucial PHC domain.

Scoping of models to support population-based regional health planning and management: comparison with the regional operating model in Victoria, Australia

Objective The aim of the present study was to try to understand the breadth and comprehensiveness of a regional operating model (ROM) developed within the Victorian Department of Health's North West Metropolitan Region office in Melbourne, Australia. Methods A published literature search was conducted, with additional website scanning, snowballing technique and expert consultation, to identify existing operating models. An analytical grid was developed covering 16 components to evaluate the models and assess the exhaustiveness of the ROM. Results From the 34 documents scoped, 10 models were identified to act as a direct comparator to the ROM. These concerned models from Australia (n=5) and other comparable countries (Canada, UK). The ROM was among the most exhaustive models, covering 13 of 16 components. It was one of the few models that included intersectoral actions and levers of influence. However, some models identified more precisely the planning tools, prioritisation criteria and steps, and the allocation mechanisms. Conclusions The review finds that the ROM appears to provide a wide coverage of aspects of planning and integrates into a single model some of the distinctive elements of the other models scoped. What is known about the topic? Various jurisdictions are moving towards a population-based approach to manage public services with regard to the provision of individual medical and social care. Various models have been proposed to guide the planning of services from a population health perspective. What does this paper add? This paper assesses the coverage of attributes of operating models supporting a population health planning approach to the management of services at the regional or local level. It provides a scoping of current models proposed to organise activities to ensure an integrated approach to the provision of services and compares the scoped models to a model recently implemented in Victoria, Australia. What are the implications for practitioners? This paper highlights the relative paucity of operating models describing in concrete terms how to manage medical and social services from a population perspective and encourages organisations that are accountable for securing population health to clearly articulate their own operating model. It outlines strengths and potential gaps in current models.

The disciplined healthcare professional: a qualitative interview study on the impact of the disciplinary process and imposed measures in the Netherlands

OBJECTIVE

It is known that doctors who receive complaints may have feelings of anger, guilt, shame and depression, both in the short and in the long term. This might lead to functional impairment. Less is known about the impact of the disciplinary process and imposed measures. Previous studies of disciplinary proceedings have mainly focused on identifying characteristics of disciplined doctors and on sentencing policies. Therefore, the aim of this study is to explore what impact the disciplinary process and imposed measures have on healthcare professionals.

DESIGN

Semistructured interview study, with purposive sampling and inductive qualitative content analysis.

PARTICIPANTS

16 healthcare professionals (9 medical specialists, 3 general practitioners, 2 physiotherapists and 2 psychologists) that were sanctioned by the disciplinary tribunal.

SETTING

The Netherlands.

RESULTS

Professionals described feelings of misery and insecurity both during the process as in its aftermath. Furthermore, they reported to fear receiving new complaints and provide care more cautiously after the imposed measure. Factors that may enhance psychological and professional impact are the publication of measures online and in newspapers, media coverage, the feeling of treated as guilty before any verdict has been reached, and the long duration of the process.

CONCLUSIONS

This study shows that the disciplinary process and imposed measures can have a profound psychological and professional impact on healthcare professionals. Although a disciplinary measure is meant to have a corrective effect, our results suggest that the impact that is experienced by professionals might hamper optimal rehabilitation afterwards. Therefore, organising emotional support should be considered during the disciplinary process and in the period after the verdict.

Barriers and Facilitators for Primary Care Reform in Canada: Results from a Deliberative Synthesis across Five Provinces

INTRODUCTION

Since 2000, primary care (PC) reforms have been implemented in various Canadian provinces. Emerging organizational models and policies are at various levels of implementation across jurisdictions. Few cross-provincial analyses of these reforms have been realized. The aim of this study is to identify the factors that have facilitated or hindered implementation of reforms in Canadian provinces between 2000 and 2010.

METHODS

A literature and policy scan identified evaluation studies across Canadian jurisdictions. Experts from British Columbia, Manitoba, Nova Scotia, Ontario and Quebec were asked to review the scope of published evaluations and draft provincial case descriptions. A one-day deliberative forum was held, bringing together researchers (n = 40) and decision-makers (n = 20) from all the participating provinces.

RESULTS

Despite a relative lack of published evaluations, our results suggest that PC reform has varied with regard to the scope and the policy levers used to implement change. Some provinces implemented specific PC models, while other provinces designed overarching policies aiming at changing professional behaviour and practice. The main perceived barriers to reform were the lack of financial investment, resistance from professional associations, too overtly prescriptive approaches lacking adaptability and an overly centralized governance model. The main perceived facilitators were a strong financial commitment using various allocation and payment approaches, the cooperation of professional associations and an incremental emergent change philosophy based on a strong decentralization of decisions allowing adaptation to local circumstances. So far the most beneficial results of the reforms seem to be an increase in patients' affiliation with a usual source of care, improved experience of care by patients and a higher workforce satisfaction.

CONCLUSION

PC reforms currently under consideration in other jurisdictions could learn from the factors identified as promoting or hindering change in the provinces that have been most proactive.

Implementation of multiple-domain covering computerized decision support systems in primary care: a focus group study on perceived barriers

BACKGROUND

Despite the widespread availability of computerized decision support systems (CDSSs) in various healthcare settings, evidence on their uptake and effectiveness is still limited. Most barrier studies focus on CDSSs that are aimed at a limited number of decision points within selected small-scale academic settings. The aim of this study was to identify the perceived barriers to using large-scale implemented CDSSs covering multiple disease areas in primary care.

METHODS

Three focus group sessions were conducted in which 24 primary care practitioners (PCPs) participated (general practitioners, general practitioners in training and practice nurses), varying from 7 to 9 per session. In each focus group, barriers to using CDSSs were discussed using a semi-structured literature-based topic list. Focus group discussions were audio-taped and transcribed verbatim. Two researchers independently performed thematic content analysis using the software program Atlas.ti 7.0.

RESULTS

Three groups of barriers emerged, related to 1) the users' knowledge of the system, 2) the users' evaluation of features of the system (source and content, format/lay out, and functionality), and 3) the interaction of the system with external factors (patient-related and environmental factors). Commonly perceived barriers were insufficient knowledge of the CDSS, irrelevant alerts, too high intensity of alerts, a lack of flexibility and learning capacity of the CDSS, a negative effect on patient communication, and the additional time and work it requires to use the CDSS.

CONCLUSIONS

Multiple types of barriers may hinder the use of large-scale implemented CDSSs covering multiple disease areas in primary care. Lack of knowledge of the system is an important barrier, emphasizing the importance of a proper introduction of the system to the target group. Furthermore, barriers related to a lack of integration into daily practice seem to be of primary concern, suggesting that increasing the system's flexibility and learning capacity in order to be able to adapt the decision support to meet the varying needs of different users should be the main target of CDSS interventions.

Patient reported outcome measures (PROMs) in primary care: an observational pilot study of seven generic instruments

Background

Patient reported outcome measures (PROMs) have been introduced in studies to assess healthcare performance. The development of PROMs for primary care poses specific challenges, including a preference for generic measures that can be used across diseases, including early phases or mild conditions. This pilot study aimed to explore the potential usefulness of seven generic measures for assessing health outcomes in primary care patients.

Methods

A total of 300 patients in three general practices were invited to participate in the study, shortly after their visit to the general practitioner. Patients received a written questionnaire, containing seven validated instruments, focused on patient empowerment (PAM-13 or EC-17), quality of life (EQ-5D or SF-12), mental health (GHQ-12), enablement (PEI) and perceived treatment effect (GPE). Furthermore, questions on non-specific symptoms and number of GP contacts were included. After 4 weeks patients received a second, identical, questionnaire. Response and missing items, total scores and dispersion, responsiveness, and associations between instruments and other measures were examined.

Results

A total of 124 patients completed the questionnaire at baseline, of whom 98 completed it both at baseline and 4 weeks later (response rate: 32.7%). The instruments had a full completion rate of 80% or higher. Differences between baseline and follow up were significant for the EQ-5D (p = 0.026), SF-12 PCS (p = 0.026) and the GPE (p = 0.006). A strong correlation (r ≥ 0.6) was found between the SF-12 MCS and GHQ-12, at both baseline measurement and after four weeks. Other observed associations between instruments were moderately strong. No strong correlations were found between instruments and non-specific symptoms or number of GP contacts.

Conclusions

The present study is among the first to explore the use of generic patient-reported outcome measures in primary care. It provides several leads for developing a generic PROM questionnaire in primary care as well as for potential limitations of such instruments.

Patient Care Teams in treatment of diabetes and chronic heart failure in primary care: an observational networks study

Background

Patient care teams have an important role in providing medical care to patients with chronic disease, but insight into how to improve their performance is limited. Two potentially relevant determinants are the presence of a central care provider with a coordinating role and an active role of the patient in the network of care providers. In this study, we aimed to develop and test measures of these factors related to the network of care providers of an individual patient.

Methods

We performed an observational study in patients with type 2 diabetes or chronic heart failure, who were recruited from three primary care practices in The Netherlands. The study focused on medical treatment, advice on physical activity, and disease monitoring. We used patient questionnaires and chart review to measure connections between the patient and care providers, and a written survey among care providers to measure their connections. Data on clinical performance were extracted from the medical records. We used network analysis to compute degree centrality coefficients for the patient and to identify the most central health professional in each network. A range of other network characteristics were computed including network centralization, density, size, diversity of disciplines, and overlap among activity-specific networks. Differences across the two chronic conditions and associations with disease monitoring were explored.

Results

Approximately 50% of the invited patients participated. Participation rates of health professionals were close to 100%. We identified 63 networks of 25 patients: 22 for medical treatment, 16 for physical exercise advice, and 25 for disease monitoring. General practitioners (GPs) were the most central care providers for the three clinical activities in both chronic conditions. The GP's degree centrality coefficient varied substantially, and higher scores seemed to be associated with receiving more comprehensive disease monitoring. The degree centrality coefficient of patients also varied substantially but did not seem to be associated with disease monitoring.

Conclusions

Our method can be used to measure connections between care providers of an individual patient, and to examine the association between specific network parameters and healthcare received. Further research is needed to refine the measurement method and to test the association of specific network parameters with quality and outcomes of healthcare.