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Burns M, Robben P, Venkataraman R. Lyme Carditis With Complete Heart Block Successfully Treated With Oral Doxycycline. Mil Med 2021; 188:usab420. [PMID: 34612503 DOI: 10.1093/milmed/usab420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/15/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
Lyme disease is a vector-borne infection that can affect multiple different organ systems. Lyme carditis represents one of these sequelae and is defined by acute onset of high-grade atrioventricular block in the presence of laboratory-confirmed infection. Current guidelines recommend patients with Lyme carditis be admitted for close cardiac monitoring and intravenous antibiotics therapy. Our case illustrates an active duty male who was initially diagnosed with Lyme disease after initially reporting symptoms including headache, fever, eye pain, and rash, with subsequent development of exercise intolerance 6 weeks later. An electrocardiogram (ECG) obtained at that time was misinterpreted as first-degree heart block, and he was initiated on oral doxycycline therapy and referred to cardiology. On follow-up to cardiology clinic, the prior ECG was reviewed and interpreted as complete heart block. A repeat ECG showed resolution of the heart block, and exercise stress testing showed chronotropic competence. This case illustrates the resolution of complete heart block in Lyme carditis with oral doxycycline, suggesting this antibiotic as a possible alternative treatment agent.
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Affiliation(s)
- Michael Burns
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889-5611, USA
| | - Paul Robben
- Department of Infectious Diseases, Walter Reed National Military Medical Center, Bethesda, MD 20889-5611, USA
- Center for Infectious Disease Research, Walter Reed Army Institute of Research, Bethesda, MD 20817, USA
| | - Ramesh Venkataraman
- Department of Cardiology, Walter Reed National Military Medical Center, Bethesda, MD 20889-5611, USA
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Bouwman R, Bomhoff M, Robben P, Friele R. Is There a Mismatch Between the Perspectives of Patients and Regulators on Healthcare Quality? A Survey Study. J Patient Saf 2021; 17:473-482. [PMID: 28857951 DOI: 10.1097/pts.0000000000000413] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Internationally, healthcare quality regulators are criticized for failing to respond to patients' complaints. Patient involvement is, therefore, an important item on the policy agenda. However, it can be argued that there is a discrepancy between the patients' perspective and current regulatory approaches.This study examines whether a discrepancy exists between the perspectives of patients and regulators on healthcare quality. METHODS A questionnaire was sent to 996 people who had registered a complaint with the Dutch Healthcare Inspectorate to measure expectations of and experiences with the Inspectorate. A taxonomy was used to classify their complaints into the clinical, relationship, or management domains. RESULTS The response was 54%. More complaints about clinical issues (56%, P = 0.000) were investigated by the regulator than complaints about organizational (37%) and relational issues (51%). Patients with complaints about management issues less often indicated (13%, P = 0.002) that healthcare is improved by making their complaint than patients with complaints about clinical or relationship issues did (22%-23%). Patients who reported about relational issues with care providers attached more importance to issuing sanctions against the care provider than other patients (mean score 2.89 versus 2.62-2.68, P = 0.006). CONCLUSIONS The predominant clinical approach taken by regulators does not match the patients' perspective of what is relevant for healthcare quality. In addition, patients seem to be more tolerant of what they perceive to be clinical or management errors than of perceived relational deficiencies in care providers. If regulators want to give patients a voice, they should expand their horizon beyond the medical framework.
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Affiliation(s)
- Renée Bouwman
- From the NIVEL, Netherlands Institute for Health Services Research
| | - Manja Bomhoff
- From the NIVEL, Netherlands Institute for Health Services Research
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Abstract
OBJECTIVES It is assumed that classifying and aggregated reporting of patients' complaints by regulators helps to identify problem areas, to respond better to patients and increase public accountability. This pilot study addresses what a classification of complaints in a regulatory setting contributes to the various goals. METHODS A taxonomy with a clinical, management, and relationship domain was used to systematically analyze 364 patients' complaints received by the Dutch regulator. RESULTS Most complaints were about hospital care, mental health care, and elder care. About certain sectors such as emergency care, little numbers of complaints were received. The largest proportion of complaints concerned the clinical domain (51%), followed by the management domain (47%) and the relationship domain (42%).Clinical domain complaints were more prevalent in elder care (65%) than in hospital care (56%) and mental health care (41%). In complaints about mental health care, the relationship domain was the most important (65%). The management domain was most prevalent in elder care (49%) compared with the other sectors. CONCLUSIONS Problem areas within different health-care sectors could be identified by classifying the complaints. It provided insight in the regulator's own practices, which are aimed at public accountability. However, there are several limitations. Aggregated analyses were not possible in sectors with low numbers of complaints. Furthermore, the information remains rather superficial, and a standardized detailed system of reporting among agencies is needed. To assess which complaints need regulatory action, an in-depth analysis, using standardized methodology and criteria, of specific complaints is needed. Improving responses to patients requires more than merely aggregated reporting of complaints.
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Affiliation(s)
- Renée Bouwman
- From the NIVEL, Netherlands Institute for Health Services Research
| | - Manja Bomhoff
- From the NIVEL, Netherlands Institute for Health Services Research
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Robben P, Neff LA. The True Exercise of Leadership: a Blend of Balance, Endurance and Resistance Training? Mil Med 2020; 184:115-116. [PMID: 30793184 DOI: 10.1093/milmed/usz011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 01/11/2019] [Indexed: 11/14/2022] Open
Abstract
The exercise of leadership demands leaders draw upon multiple capabilities in order to simultaneously enforce standards and achieve mission success while successfully nurturing candor and engagement within the organization. The following case highlights one officer's challenge related to balancing mission requirements with the aspirations of personnel.
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Affiliation(s)
- Paul Robben
- Division of Infectious Diseases, Walter Reed National Military Medical Center, Bldg 7, 1st Floor, 8960 Brown Dr, Bethesda, MD
| | - Laurel A Neff
- Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA
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Haas K, Robben P, Kiesslich A, Volkert M, Jaeger H. Stabilization of Crystalline Carotenoids in Carrot Concentrate Powders: Effects of Drying Technology, Carrier Material, and Antioxidants. Foods 2019; 8:foods8080285. [PMID: 31349652 PMCID: PMC6724047 DOI: 10.3390/foods8080285] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 07/19/2019] [Accepted: 07/23/2019] [Indexed: 11/16/2022] Open
Abstract
Coloring concentrates of carotenoid-rich plant materials are currently used in the food industry to meet the consumer's demand for natural substitutes for food colorants. The production of shelf-stable powders of such concentrates comes with particular challenges linked to the sensitivity of the active component towards oxidation and the complexity of the composition and microstructure of such concentrates. In this study, different strategies for the stabilization of crystalline carotenoids as part of a natural carrot concentrate matrix during drying and storage were investigated. The evaluated approaches included spray- and freeze drying, the addition of functional additives, and oxygen free storage. Functional additives comprised carrier material (maltodextrin, gum Arabic, and octenyl succinic anhydride (OSA)-modified starch) and antioxidants (mixed tocopherols, sodium ascorbate). Degradation and changes in the physical state of the carotenoid crystals were monitored during processing and storage. Carotenoid losses during processing were low (>5%) irrespective of the used technology and additives. During storage, samples stored in nitrogen showed the highest carotenoid retention (97-100%). The carotenoid retention in powders stored with air access varied between 12.3% ± 2.1% and 66.0% ± 5.4%, having been affected by the particle structure as well as the formulation components used. The comparative evaluation of the tested strategies allows a more targeted design of processing and formulation of functional carrot concentrate powders.
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Affiliation(s)
- Klara Haas
- Department of Food Science and Technology, University of Natural Resources and Life Sciences (BOKU), 1190 Vienna, Austria.
| | | | | | | | - Henry Jaeger
- Department of Food Science and Technology, University of Natural Resources and Life Sciences (BOKU), 1190 Vienna, Austria
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Verver D, Stoopendaal A, Merten H, Robben P, Wagner C. What are the perceived added values and barriers of regulating long-term care in the home environment using a care network perspective: a qualitative study. BMC Health Serv Res 2018; 18:946. [PMID: 30522469 PMCID: PMC6282343 DOI: 10.1186/s12913-018-3770-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Changes in Dutch policy towards long-term care led to the Dutch Health and Youth Care Inspectorate testing a regulatory framework focusing on care networks around older adults living independently. This regulatory activity involved all care providers and the older adults themselves. METHODS Semi-structured interviews with the older adults, and focus groups with care providers and inspectors were used to assess the perceived added value of, and barriers to the framework. RESULTS The positive elements of this framework were the involvement of the older adults in the regulatory activity, the focus of the framework on care networks and the open character of the conversations with the inspectors. However, applying the framework requires a substantial investment of time. Care providers often did not perceive themselves as being part of a care network around one person and they expressed concerns about financial and privacy issues when thinking in terms of care networks. CONCLUSIONS The experiences of the client were seen as important in regulating long-term care. Regulating care networks as a whole puts cooperation between care providers involved around one person on the agenda. However, barriers for this form of regulation were also perceived and, therefore, careful consideration when and how to regulate care networks is recommended.
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Affiliation(s)
- Didi Verver
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, Van der Boechorststraat 7, NL, 1081 Amsterdam, BT Netherlands
| | - Annemiek Stoopendaal
- Erasmus School of Health Policy and Management (ESHPM), Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 Rotterdam, PA Netherlands
| | - Hanneke Merten
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, Van der Boechorststraat 7, NL, 1081 Amsterdam, BT Netherlands
| | - Paul Robben
- Erasmus School of Health Policy and Management (ESHPM), Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 Rotterdam, PA Netherlands
| | - Cordula Wagner
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, Van der Boechorststraat 7, NL, 1081 Amsterdam, BT Netherlands
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118-124, 3513 CR Utrecht, the Netherlands
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Verver D, Merten H, Robben P, Wagner C. Care and support for older adults in The Netherlands living independently. Health Soc Care Community 2018; 26:e404-e414. [PMID: 29377470 DOI: 10.1111/hsc.12539] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/06/2017] [Indexed: 05/14/2023]
Abstract
The growth in the numbers of older adults needing long-term care has resulted in rising costs which have forced the Dutch government to change its long-term care system. Now, the local authorities have greater responsibility for supporting older adults and in prolonging independent living with increased support provided by the social network. However, it is unclear whether these older adults have such a network to rely upon. The objective of this study was to gain insight into the providers of formal and informal care to older adults, and to assess possible differences between older adults who are frail and those who are not. In addition, we investigated their care and support needs. We used data from a quantitative survey using a cross-sectional design in different regions of the Netherlands from July until September 2014 (n = 181). Frailty was measured using the Tilburg Frailty indicator. To analyse the data chi-square tests, crosstabs and odds ratios were used for dichotomous data and the Mann-Whitney U-Test for nominal data. The number of formal care providers involved was significantly higher (median = 2) for those deemed frail than for those not deemed frail (median = 1), U = 2,130, p < .005. However, more than one-third of the respondents deemed frail did not get the care or support they needed (33.7%). There was a significant positive association between being frail and having an informal care provider (χ2 = 18.78, df = 1, p < .005). However, more than one-third of those deemed frail did not have an informal care provider (36.8%). One-third of older adults deemed to be frail did not have their needs sufficiently addressed by their care network. For a substantial part of this group of older adults, the informal network seems to be unable to support them sufficiently. Additional attention for their needs and wishes is required to implement the policy reforms successfully.
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Affiliation(s)
- Didi Verver
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Hanneke Merten
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Paul Robben
- Dutch Healthcare Inspectorate (IGZ), Utrecht, The Netherlands
- Institute of Health Policy and Management (iBMG), Erasmus Universiteit Rotterdam, Rotterdam, The Netherlands
| | - Cordula Wagner
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
- The Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
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Rutz S, van de Bovenkamp H, Buitendijk S, Robben P, de Bont A. Inspectors' responses to adolescents' assessment of quality of care: a case study on involving adolescents in inspections. BMC Health Serv Res 2018; 18:226. [PMID: 29606117 PMCID: PMC5880074 DOI: 10.1186/s12913-018-2998-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 03/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Users of care services are increasingly participating in inspections of the quality of care. In practice, incorporating service users' views is difficult, as users may have other views on good care than inspectors and thus give information that does not fit the inspectors' assessment criteria. This study compared the views on good care of young care users (adolescents) and inspectors, seeking to understand what the differences and similarities mean to incorporating the users' views in inspections. METHODS We conducted a single-case study combining document analysis with a meeting with inspectors. The selected case came from a Dutch inspectorate and involved a thematic inspection of care for children growing up poor. RESULTS Inspectors and adolescents agree on the importance of timely care, creating opportunities for personal development, and a respectful relationship. The views on quality of care differ with regard to sharing information, creating solutions, and the right moment to offer help. We identified three ways inspectors deal with the differences: 1) prioritize their own views, 2) pass the problem onto others to solve, and 3) separate the differing perspectives. With similar viewpoints, inspectors use the adolescents' views to support their assessments. When viewpoints conflict, information from adolescents does not affect the inspectors' judgments. Explanations are related to the vulnerability of the adolescents involved, the inspectorate's organizational rules and routines and the external regulatory context. CONCLUSIONS Service user involvement in inspections potentially impacts the quality of care. Yet, conflicts between the views of service users and inspectors are not easily overcome in the regulatory context.
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Affiliation(s)
- Suzanne Rutz
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands
- Joint Inspectorate Social Domain, Utrecht, The Netherlands
- Health and Youth Care Inspectorate, Utrecht, The Netherlands
| | - Hester van de Bovenkamp
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands
| | | | - Paul Robben
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Antoinette de Bont
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands
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Koornneef E, Robben P, Blair I. Progress and outcomes of health systems reform in the United Arab Emirates: a systematic review. BMC Health Serv Res 2017; 17:672. [PMID: 28931388 PMCID: PMC5607589 DOI: 10.1186/s12913-017-2597-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 09/06/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The United Arab Emirates (UAE) government aspires to build a world class health system to improve the quality of healthcare and the health outcomes for its population. To achieve this it has implemented extensive health system reforms in the past 10 years. The nature, extent and success of these reforms has not recently been comprehensively reviewed. In this paper we review the progress and outcomes of health systems reform in the UAE. METHODS We searched relevant databases and other sources to identify published and unpublished studies and other data available between 01 January 2002 and 31 March 2016. Eligible studies were appraised and data were descriptively and narratively synthesized. RESULTS Seventeen studies were included covering the following themes: the UAE health system, population health, the burden of disease, healthcare financing, healthcare workforce and the impact of reforms. Few, if any, studies prospectively set out to define and measure outcomes. A central part of the reforms has been the introduction of mandatory private health insurance, the development of the private sector and the separation of planning and regulatory responsibilities from provider functions. The review confirmed the commitment of the UAE to build a world class health system but amongst researchers and commentators opinion is divided on whether the reforms have been successful although patient satisfaction with services appears high and there are some positive indications including increasing coverage of hospital accreditation. The UAE has a rapidly growing population with a unique age and sex distribution, there have been notable successes in improving child and maternal mortality and extending life expectancy but there are high levels of chronic diseases. The relevance of the reforms for public health and their impact on the determinants of chronic diseases have been questioned. CONCLUSIONS From the existing research literature it is not possible to conclude whether UAE health system reforms are working. We recommend that research should continue in this area but that research questions should be more clearly defined, focusing whenever possible on outcomes rather than processes.
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Affiliation(s)
- Erik Koornneef
- Institute for Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
- Truven Health Analytics, An IBM Company, Michigan, USA
| | - Paul Robben
- Institute for Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
- Dutch Healthcare Inspectorate, Utrecht, The Netherlands
| | - Iain Blair
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates
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Abstract
Insight into risks concerning older adults living independently from their own perspective and their care provider's perspective is essential to address issues that may threaten their independent living. The most often mentioned perceived risks by older adults and their care providers in different regions in the Netherlands were: loneliness, falls, budget cuts in Dutch long-term care and not being able to call for help. The different perspectives of the respondents show a wide variety in risks, but also some similarities. The perspective of the frail older adults is required to gain insight into the priority of their perceived risks. An additional finding was the reluctance shown by the older adults to ask others in their social network for help. Results imply that possible preventive measures should not only focus on the medical or physical domain because older adults are likely to have other priorities to maintain self-reliance and live independently.
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Affiliation(s)
- Didi Verver
- Amsterdam Public Health research institute, Department of Epidemiology and Biostatistics, VU University Medical Centre
| | - Hanneke Merten
- Amsterdam Public Health research institute, Department of Epidemiology and Biostatistics, VU University Medical Centre
| | - Paul Robben
- Dutch Healthcare Inspectorate (IGZ) & Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam
| | - Cordula Wagner
- Amsterdam Public Health research institute, Department of Epidemiology and Biostatistics, VU University Medical Centre & The Netherlands Institute for Health Services Research (NIVEL)
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Seekles W, Widdershoven G, Robben P, van Dalfsen G, Molewijk B. Inspectors' ethical challenges in health care regulation: a pilot study. Med Health Care Philos 2017; 20:311-320. [PMID: 28130719 PMCID: PMC5569140 DOI: 10.1007/s11019-016-9736-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
There is an increasing body of research on what kind of ethical challenges health care professionals experience regarding the quality of care. In the Netherlands the Dutch Health Care Inspectorate is responsible for monitoring and regulating the quality of health care. No research exists on what kind of ethical challenges inspectors experience during the regulation process itself. In a pilot study we used moral case deliberation as method in order to reflect upon inspectors' ethical challenges. The objective of this paper is to give an overview of the ethical challenges which health care inspectors encounter in their daily work. A thematic qualitative analysis was performed on cases (n = 69) that were collected from health care inspectors in a moral case deliberation pilot study. Eight themes were identified in health care regulation. These can be divided in two categories: work content and internal collaboration. The work of the health care inspectorate is morally loaded and our recommendation is that some form of ethics support is provided for health care inspectors.
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Affiliation(s)
- W Seekles
- Medical Humanities, VU University Medical Centre (EMGO+), Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
- University of Humanistic Studies, Kromme Nieuwegracht 29, 3512 HD, Utrecht, The Netherlands.
| | - G Widdershoven
- Medical Humanities, VU University Medical Centre (EMGO+), Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - P Robben
- The Health Care Inspectorate (IGZ), Stadsplateau 1, 3521 AZ, Utrecht, The Netherlands
| | - G van Dalfsen
- The Health Care Inspectorate (IGZ), Stadsplateau 1, 3521 AZ, Utrecht, The Netherlands
| | - B Molewijk
- Medical Humanities, VU University Medical Centre (EMGO+), Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
- Centre for Medical Ethics, HELSAM, University of Oslo, Forskningsveien 3A, 0373, Oslo, Norway
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Seekles W, Widdershoven G, Robben P, van Dalfsen G, Molewijk B. Evaluation of moral case deliberation at the Dutch Health Care Inspectorate: a pilot study. BMC Med Ethics 2016; 17:31. [PMID: 27209161 PMCID: PMC4875757 DOI: 10.1186/s12910-016-0114-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 05/11/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Moral case deliberation (MCD) as a form of clinical ethics support is usually implemented in health care institutions and educational programs. While there is no previous research on the use of clinical ethics support on the level of health care regulation, employees of regulatory bodies are regularly confronted with moral challenges. This pilot study describes and evaluates the use of MCD at the Dutch Health Care Inspectorate (IGZ). The objective of this pilot study is to investigate: 1) the current way of dealing with moral issues at the IGZ; 2) experience with and evaluation of MCD as clinical ethics support, and 3) future preferences and (perceived) needs regarding clinical ethics support for dealing with moral questions at the IGZ. METHODS We performed an explorative pilot study. The research questions were assessed by means of: 1) interviews with MCD participants during four focus groups; and 2) interviews with six key stakeholders at the IGZ. De qualitative data is illustrated by data from questionnaires on MCD outcomes, perspective taking and MCD evaluation. RESULTS Professionals do not always recognize moral issues. Employees report a need for regular and structured moral support in health care regulation. The MCD meetings are evaluated positively. The most important outcomes of MCD are feeling secure and learning from others. Additional support is needed to successfully implement MCD at the Inspectorate. CONCLUSION We conclude that the respondents perceive moral case deliberation as a useful form of clinical ethics support for dealing with moral questions and issues in health care regulation.
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Affiliation(s)
- Wike Seekles
- Medical Humanities, VU University Medical Centre, Amsterdam, The Netherlands. .,University of Humanistic Studies, Utrecht, The Netherlands.
| | - Guy Widdershoven
- Medical Humanities, VU University Medical Centre, Amsterdam, The Netherlands
| | - Paul Robben
- The Health Care Inspectorate (IGZ), Utrecht, The Netherlands.,Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Bert Molewijk
- Medical Humanities, VU University Medical Centre, Amsterdam, The Netherlands.,Centre of Medical Ethics, HELSAM, University of Oslo, Oslo, Norway
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Leistikow I, Mulder S, Vesseur J, Robben P. Learning from incidents in healthcare: the journey, not the arrival, matters. BMJ Qual Saf 2016; 26:252-256. [PMID: 27037302 PMCID: PMC5339566 DOI: 10.1136/bmjqs-2015-004853] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 02/27/2016] [Accepted: 03/12/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Ian Leistikow
- Medical Specialist Care, Dutch Healthcare Inspectorate, Utrecht, The Netherlands.,Department of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Sandra Mulder
- Medical Specialist Care, Dutch Healthcare Inspectorate, Utrecht, The Netherlands
| | - Jan Vesseur
- Medical Specialist Care, Dutch Healthcare Inspectorate, Utrecht, The Netherlands
| | - Paul Robben
- Department of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands.,Dutch Health Care Inspectorate, Utrecht, The Netherlands
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Koornneef E, Robben P, Hajat C, Ali A. The development, implementation and evaluation of clinical practice guidelines in Gulf Cooperation Council (GCC) countries: a systematic review of literature. J Eval Clin Pract 2015; 21:1006-13. [PMID: 25756849 DOI: 10.1111/jep.12337] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2015] [Indexed: 12/26/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Our aim was to examine and describe the current situation in Gulf Cooperation Council (GCC) member countries regarding the development, implementation and evaluation of clinical practice guidelines (CPG). The objectives were to describe from where the studies originated, what the clinical focus was of each study and examine the methodology and the status of each study (i.e. development, dissemination, implementation and evaluation). METHODS Review of literature - two stages: stage 1: screening through an abstract review, followed by independent adjudicator; stage 2: detailed assessment and classification. RESULTS Considering the widespread acceptance that CPG's are useful and effective tools for quality improvement in health care, it is worth noting that relatively few studies have been conducted in the GCC region that examine CPG. Furthermore, the reviewers found that the quality of the research methods used could be improved. The majority of the studies that were conducted evaluated the effects of guidelines and focused on the 'lifestyle diseases', in particular diabetes and cardiovascular diseases. It is also worth noting that there has been a steady increase in the number of publications over the 10 years period. CONCLUSIONS More attention needs to be given to developing, disseminating, implementing and evaluating CPG's in the GCC region in order to improve the quality and safety of health care.
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Affiliation(s)
- Erik Koornneef
- Healthcare Quality, Ministry of Presidential Affairs, Abu Dhabi, United Arab Emirates.,Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Paul Robben
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Dutch Health Care Inspectorate, Utrecht, The Netherlands
| | - Cother Hajat
- Institute of Public Health, UAE University, Al Ain, United Arab Emirates
| | - Azhar Ali
- Institute of Public Health, UAE University, Al Ain, United Arab Emirates.,Abu Dhabi Health Services Co. (SEHA), Abu Dhabi, United Arab Emirates
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Verver D, Merten H, Robben P, Wagner C. Supervision of care networks for frail community dwelling adults aged 75 years and older: protocol of a mixed methods study. BMJ Open 2015; 5:e008632. [PMID: 26307619 PMCID: PMC4550721 DOI: 10.1136/bmjopen-2015-008632] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/06/2015] [Accepted: 06/13/2015] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The Dutch healthcare inspectorate (IGZ) supervises the quality and safety of healthcare in the Netherlands. Owing to the growing population of (community dwelling) older adults and changes in the Dutch healthcare system, the IGZ is exploring new methods to effectively supervise care networks that exist around frail older adults. The composition of these networks, where formal and informal care takes place, and the lack of guidelines and quality and risk indicators make supervision complicated in the current situation. METHODS AND ANALYSIS This study consists of four phases. The first phase identifies risks for community dwelling frail older adults in the existing literature. In the second phase, a qualitative pilot study will be conducted to assess the needs and wishes of the frail older adults concerning care and well-being, perception of risks, and the composition of their networks, collaboration and coordination between care providers involved in the network. In the third phase, questionnaires based on the results of phase II will be sent to a larger group of frail older adults (n=200) and their care providers. The results will describe the composition of their care networks and prioritise risks concerning community dwelling older adults. Also, it will provide input for the development of a new supervision framework by the IGZ. During phase IV, a second questionnaire will be sent to the participants of phase III to establish changes of perception in risks and possible changes in the care networks. The framework will be tested by the IGZ in pilots, and the researchers will evaluate these pilots and provide feedback to the IGZ. ETHICS AND DISSEMINATION The study protocol was approved by the Scientific Committee of the EMGO+institute and the Medical Ethical review committee of the VU University Medical Centre. Results will be presented in scientific articles and reports and at meetings.
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Affiliation(s)
- Didi Verver
- Department of Public and Occupational health, EMGO+Institute/VU University Medical Centre, Amsterdam, The Netherlands
| | - Hanneke Merten
- Department of Public and Occupational health, EMGO+Institute/VU University Medical Centre, Amsterdam, The Netherlands
| | - Paul Robben
- Dutch Healthcare Inspectorate (IGZ), Utrecht, The Netherlands
- Institute of Health Policy and Management (iBMG), Erasmus Universiteit Rotterdam, Rotterdam, The Netherlands
| | - Cordula Wagner
- Department of Public and Occupational health, EMGO+Institute/VU University Medical Centre, Amsterdam, The Netherlands
- The Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
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Bouwman R, Bomhoff M, de Jong JD, Robben P, Friele R. The public's voice about healthcare quality regulation policies. A population-based survey. BMC Health Serv Res 2015; 15:325. [PMID: 26272506 PMCID: PMC4536787 DOI: 10.1186/s12913-015-0992-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 08/05/2015] [Indexed: 11/10/2022] Open
Abstract
Background In the wake of various high-profile incidents in a number of countries, regulators of healthcare quality have been criticised for their ‘soft’ approach. In politics, concerns were expressed about public confidence. It was claimed that there are discrepancies between public opinions related to values and the values guiding regulation policies. Although the general public are final clients of regulators’ work, their opinion has only been discussed in research to a limited extent. The aim of this study is to explore possible discrepancies between public values and opinions and current healthcare quality regulation policies. Methods A questionnaire was submitted to 1500 members of the Dutch Healthcare Consumer Panel. Questions were developed around central ideas underlying healthcare quality regulation policies. Results The response rate was 58.3 %. The regulator was seen as being more responsible for quality of care than care providers. Patients were rated as having the least responsibility. Similar patterns were observed for the food service industry and the education sector. Complaints by patients’ associations were seen as an important source of information for quality regulation, while fewer respondents trusted information delivered by care providers. However, respondents supported the regulator’s imposition of lighter measures firstly. Conclusions There are discrepancies and similarities between public opinion and regulation policies. The discrepancies correspond to fundamental concepts; decentralisation of responsibilities is not what the public wants. There is little confidence in the regulator’s use of information obtained by care providers’ internal monitoring, while a larger role is seen for complaints of patient organisations. This discrepancy seems not to exist regarding the regulator’s approach of imposing measures. A gradual, and often soft approach, is favoured by the majority of the public in spite of the criticism that is voiced in the media regarding this approach. Our study contributes to the limited knowledge of public opinion on government regulation policies. This knowledge is needed in order to effectively assess different approaches to involve the public in regulation policies.
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Affiliation(s)
- Renée Bouwman
- NIVEL, Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN, Utrecht, Netherlands.
| | - Manja Bomhoff
- NIVEL, Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN, Utrecht, Netherlands.
| | - Judith D de Jong
- NIVEL, Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN, Utrecht, Netherlands.
| | - Paul Robben
- Dutch Healthcare Inspectorate, PO box 2680, 3500 GR, Utrecht, Netherlands. .,Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, PO box 1738, 3000 DR, Rotterdam, Netherlands.
| | - Roland Friele
- NIVEL, Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN, Utrecht, Netherlands. .,TRANZO (Scientific Centre for Care and Welfare), Faculty of Social and Behavioural Sciences, Tilburg University, PO Box 90153, 5000 LE, Tilburg, Netherlands.
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Adams SA, Paul KT, Ketelaars C, Robben P. The use of mystery guests by the Dutch Health Inspectorate: Results of a pilot study in long-term intramural elderly care. Health Policy 2015; 119:821-30. [PMID: 25796315 DOI: 10.1016/j.healthpol.2015.02.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 01/15/2015] [Accepted: 02/12/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Samantha A Adams
- Erasmus University Rotterdam, Institute of Health Policy and Management, Postbox 1738, 3000 DR Rotterdam, The Netherlands.
| | - Katharina T Paul
- Erasmus University Rotterdam, Institute of Health Policy and Management, Postbox 1738, 3000 DR Rotterdam, The Netherlands.
| | - Corry Ketelaars
- Dutch Health Inspectorate, Postbox 2680, 3500 GR Utrecht, The Netherlands.
| | - Paul Robben
- Erasmus University Rotterdam, Institute of Health Policy and Management, Postbox 1738, 3000 DR Rotterdam, The Netherlands; Dutch Health Inspectorate, Postbox 2680, 3500 GR Utrecht, The Netherlands.
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Bouwman R, Bomhoff M, Robben P, Friele R. Patients' perspectives on the role of their complaints in the regulatory process. Health Expect 2015; 19:483-96. [PMID: 25950924 DOI: 10.1111/hex.12373] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Governments in several countries are facing problems concerning the accountability of regulators in health care. Questions have been raised about how patients' complaints should be valued in the regulatory process. However, it is not known what patients who made complaints expect to achieve in the process of health-care quality regulation. OBJECTIVE To assess expectations and experiences of patients who complained to the regulator. DESIGN Interviews were conducted with 11 people, and a questionnaire was submitted to 343 people who complained to the Dutch Health-care Inspectorate. The Inspectorate handled 92 of those complaints. This decision was based on the idea that the Inspectorate should only deal with complaints that relate to 'structural and severe' problems. RESULTS The response rate was 54%. Self-reported severity of physical injury of complaints that were not handled was significantly lower than of complaints that were. Most respondents felt that their complaint indicated a structural and severe problem that the Inspectorate should act upon. The desire for penalties or personal satisfaction played a lesser role. Only a minority felt that their complaint had led to improvements in health-care quality. CONCLUSIONS Patients and the regulator share a common goal: improving health-care quality. However, patients' perceptions of the complaints' relevance differ from the regulator's perceptions. Regulators should favour more responsive approaches, going beyond assessing against exclusively clinical standards to identify the range of social problems associated with complaints about health care. Long-term learning commitment through public participation mechanisms can enhance accountability and improve the detection of problems in health care.
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Affiliation(s)
- Renée Bouwman
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Manja Bomhoff
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Paul Robben
- Dutch Health-care Inspectorate, Utrecht, The Netherlands.,Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Roland Friele
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands.,TRANZO (Scientific Centre for Care and Welfare), Faculty of Social and Behavioural Sciences, Tilburg University, Tilburg, The Netherlands
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Sherwood J, Park M, Robben P, Whitman T, Ellis MW. USA300 Methicillin-Resistant Staphylococcus aureus Emerging as a Cause of Bloodstream Infections at Military Medical Centers. Infect Control Hosp Epidemiol 2015; 34:393-9. [DOI: 10.1086/669866] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background.USA300 methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of skin and soft-tissue infection (SSTI) in military personnel. USA300 MRSA has emerged as an important cause of healthcare-associated bloodstream infection (BSI) in metropolitan centers.Objective.To determine the prevalence, risk factors, and patient outcomes associated with USA300 MRSA BSI in military tertiary medical centers.Design.Retrospective case-control study.Patients.Patients admitted during the period 2001–2009 with MRSA BSI.Setting.Walter Reed Army Medical Center (Washington, DC) and National Naval Medical Center (Bethesda, MD) tertiary medical centers with 500 inpatient beds combined, which provide care to active duty service members and military beneficiaries.Methods.After identifying patients with MRSA BSI, we collected epidemiological data from electronic medical records and characterized bacterial isolates using pulsed-field gel electrophoresis (PFGE).Results.A total of 245 MRSA BSI cases were identified, and 151 isolates were available for analysis. Epidemiological characteristics for the 151 patients with available isolates included the following: mean age, 61 years; male sex, 70%; white race, 62%; and combat-wounded service members, 11%. The crude in-hospital mortality rate was 17%. PFGE demonstrated that 30 (20%) of 151 MRSA BSI cases with isolates available for analysis were due to USA300, and 27 (87%) of these 30 cases were healthcare-associated infection. USA300 was associated with a significantly increasing proportion of MRSA BSI when examined over sequential time periods: 2 (4%) of 51 isolates during 2001–2003, 9 (19%) of 47 isolates during 2004–2006, and 19 (36%) of 53 isolates during 2007–2009 (P<.001).Conclusion.USA300 MRSA is emerging as a cause of healthcare-associated BSI in tertiary military medical centers.
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Tuijn SM, van den Bergh H, Robben P, Janssens F. Experimental studies to improve the reliability and validity of regulatory judgments on health care in the Netherlands: a randomized controlled trial and before and after case study. J Eval Clin Pract 2014; 20:352-61. [PMID: 24819044 PMCID: PMC4282468 DOI: 10.1111/jep.12136] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2014] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES We examined the effect of two interventions on both the reliability and validity of regulatory judgments: adjusting the regulatory instrument and attending a consensus meeting. METHOD We adjusted the regulatory instrument. With a randomized controlled trial (RCT) we examined the effect of the adjustments we made to the instrument. In the consensus meeting inspectors discussed cases and had to reach consensus about the order of the cases. We used a before and after case study to assess the effect of the consensus meeting. We compared the judgments assigned in the RCT with the unadjusted instrument with the judgments assigned with the unadjusted instrument after the consensus meeting. Moreover we explored the effect of increasing the number of inspectors per regulatory visit based on the estimates of the two interventions. RESULTS The consensus meeting improved the agreement between inspectors; the variance between inspectors was smallest (0.03) and the reliability coefficient was highest (0.59). Validity is assessed by examining the relation between the assigned judgments and the corporate standard and expressed by a correlation coefficient. This coefficient was highest after the consensus meeting (0.48). Adjustment of the instrument did not increase reliability and validity coefficients. CONCLUSIONS Participating in a consensus meeting improved reliability and validity. Increasing the number of inspectors resulted in both higher reliability and validity values. Organizing consensus meetings and increasing the number of inspectors per regulatory visit seem to be valuable interventions for improving regulatory judgments.
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Adams SA, van de Bovenkamp H, Robben P. Including citizens in institutional reviews: expectations and experiences from the Dutch Healthcare Inspectorate. Health Expect 2013; 18:1463-73. [PMID: 24112128 DOI: 10.1111/hex.12126] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Recent changes in the structure and policy context of Dutch health care have placed the issue of citizen participation high on the agenda of the Dutch Healthcare Inspectorate (IGZ), which conducts quality and safety reviews in medical practices and health-care institutions. With a few exceptions, the potential role that citizens can play in the regulation of health-care institutions is overlooked in research on patient/citizen participation in health care. OBJECTIVE This research addressed the following question: What are the (political) expectations for increasing citizen participation in health-care regulation and how do these compare to regulators' expectations and experiences in practice? DESIGN Because of the largely explorative nature of this study, we used qualitative methods (document and web analysis, focus groups and interviews) to answer this question. RESULTS Our study shows that inspectors already have experience with participatory formats that lead to important information. There are three areas where the IGZ is currently increasing citizen participation: (i) providing individuals with information about inspectorate processes and activities, (ii) including patients as sources of information, and (iii) formally reviewing how citizen participation is ensured by health-care institutions. In situations where the patient has the clearest overview of the whole care trajectory, intensive methods of participation deliver valuable information. CONCLUSIONS It is important to target participation activities and to capitalize on existing opportunities and activities, rather than creating participation activities for the sake of participation. In this regard, further research on the effectiveness and efficacy of different participatory strategies is necessary.
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Affiliation(s)
- Samantha A Adams
- Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Hester van de Bovenkamp
- Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Paul Robben
- Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
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Abstract
OBJECTIVES In the scientific literature about reliability, the main approach to increasing reliability seems to involve increasing the number of observers and improving the instrument used. Other aspects for improving reliability - like the training of raters - seem to receive less notice. It is worth asking whether this technical approach could be complemented by training the user of the instrument. A systematic meta-analytical review of the research literature was performed to answer this question and examine the effectiveness of planned interventions for improving interrater reliability of health care professionals. METHOD The databases of PubMed (MEDLINE), Embase, Omega and PsycINFO were searched. The inclusion criteria were met by 57 studies. Details extracted from the studies included the study design, the number of observers and the number of observed cases, the intervention, the type of instrument (whether or not it was highly technical), and statistical information about the agreement before and after the intervention. Interventions were categorized into three groups: training of professionals, improving the diagnostic instrument and a combination of training and improving the instrument. A meta-analysis was performed by means of linear regression. RESULTS The interventions were arranged according to their effectiveness in improving the diagnostic instrument (mean change: β = 0.13), training combined with improving the instrument (mean change: β = 0.10) and training (mean change: β = 0.09). CONCLUSION On average, although all types of interventions are effective, improving the diagnostic instrument seems to be the most effective. Especially when highly technical instruments were concerned, improvement proved to be very effective (β = 0.52). Because instrumental variables constitute a major source of error, improving the instrument is an important approach. However, this review offers solid arguments that can complement the literature and practice, with a focus on training the user of the instrument.
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Affiliation(s)
- Saskia Tuijn
- Knowledge Centre, Dutch Health Care Inspectorate, Utrecht, the Netherlands.
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