Background and ObjectivesFemale-specific factors and psychosocial factors may be important in the prediction of strokebut are not included in prediction models that are currently used. We... Show moreBackground and ObjectivesFemale-specific factors and psychosocial factors may be important in the prediction of strokebut are not included in prediction models that are currently used. We investigated whetheraddition of these factors would improve the performance of prediction models for the risk ofstroke in women younger than 50 years.MethodsWe used data from the Stichting Informatievoorziening voor Zorg en Onderzoek, population-based, primary care database of women aged 20–49 years without a history of cardiovasculardisease. Analyses were stratified by 10-year age intervals at cohort entry. Cox proportionalhazards models to predict stroke risk were developed, including traditional cardiovascularfactors, and compared with models that additionally included female-specific and psychosocialfactors. We compared the risk models using the c-statistic and slope of the calibration curve at afollow-up of 10 years. We developed an age-specific stroke risk prediction tool that may helpcommunicating the risk of stroke in clinical practice.ResultsWe included 409,026 women with a total of 3,990,185 person-years of follow-up. Strokeoccurred in 2,751 women (incidence rate 6.9 [95% CI 6.6–7.2] per 10,000 person-years).Models with only traditional cardiovascular factors performed poorly to moderately in all agegroups: 20–29 years: c-statistic: 0.617 (95% CI 0.592–0.639); 30–39 years: c-statistic: 0.615(95% CI 0.596–0.634); and 40–49 years: c-statistic: 0.585 (95% CI 0.573–0.597). After addingthe female-specific and psychosocial risk factors to the reference models, the model discrimi-nation increased moderately, especially in the age groups 30–39 (Dc-statistic: 0.019) and 40–49years (Dc-statistic: 0.029) compared with the reference models, respectively.DiscussionThe addition of female-specific factors and psychosocial risk factors improves the discrimina-tory performance of prediction models for stroke in women younger than 50 years. Show less
Smoorenburg, S. van; Kist, J.M.; Vos, R.C.; Vos, H.M.M. 2023
Improving population health and reducing inequalities through better integrated health and social care services is high up on the agenda of policymakers internationally. In recent years, regional... Show moreImproving population health and reducing inequalities through better integrated health and social care services is high up on the agenda of policymakers internationally. In recent years, regional cross-domain partnerships have emerged in several countries, which aim to achieve better population health, quality of care and a reduction in the per capita costs. These cross-domain partnerships aim to have a strong data foundation and are committed to continuous learning in which data plays an essential role. This paper describes our approach towards the development of the regional integrative population-based data infrastructure Extramural LUMC (Leiden University Medical Center) Academic Network (ELAN), in which we linked routinely collected medical, social and public health data at the patient level from the greater The Hague and Leiden area. Furthermore, we discuss the methodological issues of routine care data and the lessons learned about privacy, legislation and reciprocities. The initiative presented in this paper is relevant for international researchers and policy-makers because a unique data infrastructure has been set up that contains data across different domains, providing insights into societal issues and scientific questions that are important for data driven population health management approaches. Show less
Improving population health and reducing inequalities through better integrated health and social care services is high up on the agenda of policymakers internationally. In recent years, regional... Show moreImproving population health and reducing inequalities through better integrated health and social care services is high up on the agenda of policymakers internationally. In recent years, regional cross-domain partnerships have emerged in several countries, which aim to achieve better population health, quality of care and a reduction in the per capita costs. These cross-domain partnerships aim to have a strong data foundation and are committed to continuous learning in which data plays an essential role. This paper describes our approach towards the development of the regional integrative population-based data infrastructure Extramural LUMC (Leiden University Medical Center) Academic Network (ELAN), in which we linked routinely collected medical, social and public health data at the patient level from the greater The Hague and Leiden area. Furthermore, we discuss the methodological issues of routine care data and the lessons learned about privacy, legislation and reciprocities. The initiative presented in this paper is relevant for international researchers and policy-makers because a unique data infrastructure has been set up that contains data across different domains, providing insights into societal issues and scientific questions that are important for data driven population health management approaches. Show less
AimsImplicit gender biases (IGBs) are unconscious evaluations about a person based on gender. IGBs of healthcare providers may affect medical decision making. This study investigated whether IGBs... Show moreAimsImplicit gender biases (IGBs) are unconscious evaluations about a person based on gender. IGBs of healthcare providers may affect medical decision making. This study investigated whether IGBs and genders of patients and general practitioners (GPs) influence diagnostics and treatment decisions in the context of diabetes type 2.MethodsNinety-nine GPs participated in this randomized online study. Implicit Associations Tasks were used to measure two IGBs, related to lifestyle (women have a healthier lifestyle than men) and communication (men are less communicative than women). Clinical decisions regarding type 2 diabetes were measured with vignettes that included a fictional male or female patient case.ResultsFemale GPs exhibited a significant lifestyle IGB (p < 0.001). GPs of both genders exhibited a significant communication IGB (p < 0.001). Several associations between IGBs and clinical decisions were found. The gender of the vignette character affected several outcomes, for example GPs were less certain in the diabetes diagnosis when the character was a woman (p < 0.001).ConclusionWe demonstrated that GPs have IGBs and these biases as well as patient's gender affect decisions of GP's when they are solving a diabetes vignette case. Future research is needed to understand the most important consequences of IGBs in the context of type 2 diabetes. Show less
AimsCovid-19 caused changes on the delivery of diabetes care. This study aimed to explore perceptions of healthcare providers across Europe concerning 1) the impact of covid-19 on delivery of... Show moreAimsCovid-19 caused changes on the delivery of diabetes care. This study aimed to explore perceptions of healthcare providers across Europe concerning 1) the impact of covid-19 on delivery of diabetes care; 2) impact of changes in diabetes care on experienced workload; 3) experiences with video consultation in diabetes care.MethodsCross-sectional survey among healthcare providers in the Netherlands, United Kingdom, Turkey, Ukraine and Sweden, with a focus on primary care.ResultsThe survey was completed by 180 healthcare providers. During the COVID-19 pandemic 57.1% of respondents provided less diabetes care and 72.8% observed a negative impact on people with diabetes. More than half of respondents (61.9%) expressed worries to some extent about getting overloaded by work. Although the vast majority considered their work meaningful (85.6%). Almost half of healthcare providers (49.4%) thought that after the pandemic video-consultation could be blended with face-to-face contact.ConclusionsLess diabetes care was delivered and a negative impact on people with diabetes was observed by healthcare providers. Despite healthcare providers’ feeling overloaded, mental wellbeing seemed unaffected. Video consultations were seen as having potential. Given the remaining covid-19 risks and from the interest of proactive management of people with diabetes, these findings urge for further exploration of incorporating video consultation in diabetes care. Show less
Background Socioeconomic status and ethnicity are not explicitly incorporated as risk factors in the four SCORE2 cardiovascular disease (CVD) risk models developed for country-wide implementation... Show moreBackground Socioeconomic status and ethnicity are not explicitly incorporated as risk factors in the four SCORE2 cardiovascular disease (CVD) risk models developed for country-wide implementation across Europe (low, moderate, high and very-high model). The aim of this study was to evaluate the performance of the four SCORE2 CVD risk prediction models in an ethnic and socioeconomic diverse population in the Netherlands.Methods The SCORE2 CVD risk models were externally validated in socioeconomic and ethnic (by country of origin) subgroups, from a population-based cohort in the Netherlands, with GP, hospital and registry data. In total 155,000 individuals, between 40 and 70 years old in the study period from 2007 to 2020 and without previous CVD or diabetes were included. Variables (age, sex, smoking status, blood pressure, cholesterol) and outcome first CVD event (stroke, myocardial infarction, CVD death) were consistent with SCORE2. Findings 6966 CVD events were observed, versus 5495 events predicted by the CVD low-risk model (intended for use in the Netherlands). Relative underprediction was similar in men and women (observed/predicted (OE-ratio), 1.3 and 1.2 in men and women, respectively). Underprediction was larger in low socioeconomic subgroups of the overall study population (OE-ratio 1.5 and 1.6 in men and women, respectively), and comparable in Dutch and the combined "other ethnicities" low socioeconomic subgroups. Underprediction in the Surinamese subgroup was largest (OE-ratio 1.9, in men and women), particularly in the low socioeconomic Surinamese subgroups (OE-ratio 2.5 and 2.1 in men and women). In the subgroups with underprediction in the low-risk model, the intermediate or high-risk SCORE2 models showed improved OE-ratios. Discrimination showed moderate performance in all subgroups and the four SCORE2 models, with C-statistics between 0.65 and 0.72, similar to the SCORE2 model development study.Interpretation The SCORE 2 CVD risk model for low-risk countries (as the Netherlands are) was found to underpredict CVD risk, particularly in low socioeconomic and Surinamese ethnic subgroups. Including socioeconomic status and ethnicity as predictors in CVD risk models and implementing CVD risk adjustment within countries is desirable for adequate CVD risk prediction and counselling. Show less
Objective:As in many other countries, the Netherlands is facing challenges in the provision of healthcare to its population. To ensure the population remains in good health in coming decades, an... Show moreObjective:As in many other countries, the Netherlands is facing challenges in the provision of healthcare to its population. To ensure the population remains in good health in coming decades, an integrative approach to the many factors that influence health and health outcomes is needed. Population health management is gaining interest as a strategic framework for systems change in healthcare organisations. Based on population health management, the Dutch HealthKIC has developed the 'Plot model', which takes a regional perspective. The aim of this study was to detail the extent to which six prospective regions in the Netherlands were ready and willing to implement population health management using the Plot model, guided by the Five Lenses Model. Methods:Using an exploratory focus group reporting study, we involved stakeholders from six regions in the Netherlands. Thematic analysis followed the five predesigned dimensions of a validated cooperation model. Results:The study uncovered the potential for realisation of model aims, as assessed by an expert team, regarding shared ambition, mutual gains, relationship dynamics, organisational dynamics and process management. The exploratory questionnaire suggested that organisational dynamics is the least integrated topic in all areas, followed by process management, a finding confirmed in focus groups. Conclusion:The building themes of the Five Lenses Model all represent preconditions for the success of integration in the prospective regions. The present study showed that while some themes were reasonably represented in prospective regions, no region was satisfactory for all themes. Show less
Objective: The accessibility of acute care services is currently under pressure, and one way to improve services is better integration. Adequate methodology will be required to provide for a clear... Show moreObjective: The accessibility of acute care services is currently under pressure, and one way to improve services is better integration. Adequate methodology will be required to provide for a clear and accessible evaluation of the various intervention initiatives. The aim of this paper is to develop and propose a Population Health Management(PHM) methodology framework for evaluation of transitions in acute care services. Results: Our methodological framework is developed from several concepts found in literature, including Triple Aim, integrated care and PHM, and includes continuous monitoring of results at both project and population levels. It is based on a broad view of health rather than focusing on a specific illness and facilitates the evaluation of various intervention initiatives in acute care services in the Netherlands and distinctly explains every step of the evaluation process and can be applied to a heterogeneous group of patients. Show less
Grondelle, S.E. van; Bruggen, S. van; Meijer, J.; Duin, E. van; Bots, M.L.; Rutten, G.; ... ; Vos, R.C. 2022
Objectives: Hypertension is a common cause of cardiovascular morbidity and mortality. Although hypertension can be effectively controlled by blood pressure-lowering drugs, uncontrolled blood... Show moreObjectives: Hypertension is a common cause of cardiovascular morbidity and mortality. Although hypertension can be effectively controlled by blood pressure-lowering drugs, uncontrolled blood pressure is common despite use of these medications. One explanation is therapy non-adherence. Therapy non-adherence can be addressed at the individual level, the level of the healthcare provider and at the healthcare system level. Since the latter two levels are often overlooked, we wished to explore facilitators and barriers on each of these levels in relation to hypertension care for people with hypertension, with a specific focus on therapy adherence. Design: Qualitative study using focus groups of healthcare providers. Data were analysed using the theoretical domains framework (TDF) and the behaviour change wheel. Setting and participants: Participants were from a highly urbanised city environment (the Hague, Netherlands), and included nine primary care physicians, six practice nurses and five secondary care physicians involved in hypertension care. Results: Nine domains on the TDF were found to be relevant at the healthcare provider level ('knowledge', 'physical, cognitive and interpersonal skills', 'memory, attention and decision processes', 'professional, social role and identity', 'optimism', 'beliefs about consequences', 'intention', 'emotion' and 'social influences') and two domains ('resources' and 'goals') were found to be relevant at the system level. Facilitators for these domains were good interpersonal skills, paying attention to behavioural factors such as medication use, and the belief that treatment improves health outcomes. Barriers were related to time, interdisciplinary collaboration, technical and financial issues, availability of blood pressure devices and education of people with hypertension. Conclusions: This study highlighted a need for better collaboration between primary and secondary care, for more team-based care including pharmacists and social workers, tools to improve interpersonal skills and more time for patient-healthcare provider communication. Show less
Grondelle, S.E. van; Bruggen, S. van; Meijer, J.; Duin, E. van; Bots, M.L.; Rutten, G.; ... ; Vos, R.C. 2022
Objectives Hypertension is a common cause of cardiovascular morbidity and mortality. Although hypertension can be effectively controlled by blood pressure-lowering drugs, uncontrolled blood... Show moreObjectives Hypertension is a common cause of cardiovascular morbidity and mortality. Although hypertension can be effectively controlled by blood pressure-lowering drugs, uncontrolled blood pressure is common despite use of these medications. One explanation is therapy non-adherence. Therapy non-adherence can be addressed at the individual level, the level of the healthcare provider and at the healthcare system level. Since the latter two levels are often overlooked, we wished to explore facilitators and barriers on each of these levels in relation to hypertension care for people with hypertension, with a specific focus on therapy adherence.Design Qualitative study using focus groups of healthcare providers. Data were analysed using the theoretical domains framework (TDF) and the behaviour change wheel.Setting and participants Participants were from a highly urbanised city environment (the Hague, Netherlands), and included nine primary care physicians, six practice nurses and five secondary care physicians involved in hypertension care.Results Nine domains on the TDF were found to be relevant at the healthcare provider level (‘knowledge’, ‘physical, cognitive and interpersonal skills’, ‘memory, attention and decision processes’, ‘professional, social role and identity’, ‘optimism’, ‘beliefs about consequences’, ‘intention’, ‘emotion’ and ‘social influences’) and two domains (‘resources’ and ‘goals’) were found to be relevant at the system level. Facilitators for these domains were good interpersonal skills, paying attention to behavioural factors such as medication use, and the belief that treatment improves health outcomes. Barriers were related to time, interdisciplinary collaboration, technical and financial issues, availability of blood pressure devices and education of people with hypertension.Conclusions This study highlighted a need for better collaboration between primary and secondary care, for more team-based care including pharmacists and social workers, tools to improve interpersonal skills and more time for patient–healthcare provider communication. Show less
Kitselaar, W.M.; Vaart, R. van der; Tilborg-den Boeft, M. van; Vos, H.M.M.; Numans, M.E.; Evers, A.W.M. 2021
Background: Socioeconomic status and ethnicity are not incorporated as predictors in country-level cardiovascular risk charts on mainland Europe. The aim of this study was to quantify the sex... Show moreBackground: Socioeconomic status and ethnicity are not incorporated as predictors in country-level cardiovascular risk charts on mainland Europe. The aim of this study was to quantify the sex-specific cardiovascular death rates stratified by ethnicity and socioeconomic factors in an urban population in a universal healthcare system. Methods: Age-standardized death rates (ASDR) were estimated in a dynamic population, aged 45-75 in the city of The Hague, the Netherlands, over the period 2007-2018, using data of Statistics Netherlands. Results were stratified by sex, ethnicity (country of birth) and socioeconomic status (prosperity) and compared with a European cut-off for high-risk countries (ASDR men 225/100,000 and women 175/100,000). Findings: In total, 3073 CVD deaths occurred during 1 cent 76 million person years follow-up. Estimated ASDRs (selected countries of birth) ranged from 126 (95%CI 89-174) in Moroccan men to 379 (95%CI 272-518) in Antillean men, and from 86 (95%CI 50-138) in Moroccan women to 170 (95%CI 142-202) in Surinamese women. ASDRs in the highest and lowest prosperity quintiles were 94 (95%CI 90-98) and 343 (95%CI 334-351) for men, and 43 (95%CI 41-46) and 140 (95%CI 135-145), for women, respectively. Interpretation: In a diverse urban population, large health disparities in cardiovascular ASDRs exists across ethnic and socioeconomic subgroups. Identifying these high-risk subgroups followed by targeted preventive efforts, might provide a basis for improving cardiovascular health equity within communities. Instead of classifying countries as high-risk or low-risk, a shift towards focusing on these subgroups within countries might be needed. Funding: Leiden University Medical Center and Leiden University (c) 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/) Show less
Background: Acute care services are currently overstretched in many high income countries. Overcrowding also plays a major role in acute care in the Netherlands. In a region of the Netherlands, the... Show moreBackground: Acute care services are currently overstretched in many high income countries. Overcrowding also plays a major role in acute care in the Netherlands. In a region of the Netherlands, the general practice cooperative (GPC) and ambulance service have begun to integrate their care, and the rapid and complete transfer of information between these two care organisations is now the basis for delivering appropriate care. The primary aim of this mixed-methods study is to evaluate the Netherlands Triage System (NTS) merger project and answering the question: What is the added value of implementing a digital NTS merger in terms of healthcare use and healthcare costs? A secondary question is: What are the experiences of patients and care professionals in different acute healthcare organisations following implementation of the digital NTS merger?Methods: Patients who made an acute care request during the 12 months before the NTS merge intervention (control period) were compared with matched patients in the 12 months following the start of the NTS merge. Outcomes included difference in healthcare use 30 days after an acute event and patient' and care professional' experiences during the intervention period. To assess healthcare costs, we used reference prices updated to 2021.Results: Compared to patients in the control period, patients in the intervention period were hospitalized less often (52.9% vs 64.4%, p = 0.061) and had fewer emergency department (ED) visits (58.7% vs 69.3%, p = 0.074) in the 30 days following the acute care request. The ED costs were significantly lower during the intervention period compared to the control period (p = 0.042). Furthermore, patients in the intervention period were very satisfied overall with the acute care network (4.63 of 5) and care professionals were fairly satisfied with the cooperation to date (2.73 of 4).Conclusion: The Triple Aim for acute care can be met using relatively simple interventions, but medical data merging is a prerequisite for achieving more robust results covering on the various aspects of the Triple Aim. These successes should be communicated so that a common language can be developed that will support the successful further implementation of larger scale initiatives. Show less
Kitselaar, W.M.; Vaart, R. van der; Tilborg-den Boeft, M. van; Vos, H.M.M.; Numans, M.E.; Evers, A.W.M. 2021
BackgroundPersistent somatic symptoms (PSS) are common in primary care and often accompanied by an increasing disease burden for both the patient and healthcare. In medical practice, PSS is... Show moreBackgroundPersistent somatic symptoms (PSS) are common in primary care and often accompanied by an increasing disease burden for both the patient and healthcare. In medical practice, PSS is historically considered a diagnosis by exclusion or primarily seen as psychological. Besides, registration of PSS in electronic health records (EHR) is ambiguous and possibly does not reflect classification adequately. The present study explores how general practitioners (GPs) currently register PSS, and their view regarding the need for improvements in classification, registration, and consultations.MethodDutch GPs were invited by email to participate in a national cross-sectional online survey. The survey addressed ICPC-codes used by GPs to register PSS, PSS-related terminology added to free text areas, usage of PSS-related syndrome codes, and GPs’ need for improvement of PSS classification, registration and care.ResultsGPs (n = 259) were most likely to use codes specific to the symptom presented (89.3%). PSS-related terminology in free-text areas was used sparsely. PSS-related syndrome codes were reportedly used by 91.5% of GPs, but this was primarily the case for the code for irritable bowel syndrome. The ambiguous registration of PSS is reported as problematic by 47.9% of GPs. Over 56.7% of GPs reported needing additional training, tools or other support for PSS classification and consultation. GPs also reported needing other referral options and better guidelines.ConclusionsRegistration of PSS in primary care is currently ambiguous. Approximately half of GPs felt a need for more options for registration of PSS and reported a need for further support. In order to improve classification, registration and care for patients with PSS, there is a need for a more appropriate coding scheme and additional training. Show less
Objectives Overcrowding in acute care services gives rise to major problems, such as reduced accessibility and delay in treatment. In order to be able to continue providing high-quality health care... Show moreObjectives Overcrowding in acute care services gives rise to major problems, such as reduced accessibility and delay in treatment. In order to be able to continue providing high-quality health care, it is important that organizations are well integrated at all organizational levels. The objective of this study was to to gain an understanding in which extent cooperation within an urban acute care network in the Netherlands (The Hague) improved because of the COVID-19 crisis. Methods Exploratory mixed-methods questionnaire and qualitative interview study. Semistructured interviews with stakeholders in the acute care network at micro (n = 10), meso (n = 9), and macro (n = 3) levels of organization. Thematic analysis took place along the lines of the 6 dimensions of the Rainbow Model of Integrated Care. Results In this study we identified themes that may act as barriers or facilitators to cooperation: communication, interaction, trust, leadership, interests, distribution of care, and funding. During the crisis many facilitators were identified at clinical, professional, and system level such as clear agreements about work processes, trust in each other's work, and different stakeholders growing closer together. However, at an organizational and communicative level there were many barriers such as interference in each other's work and a lack of clear policies. Conclusion The driving force behind all changes in integration of acute care organizations in an urban context during the COVID-19 crisis seemed to be a great sense of urgency to cooperate in the shared interest of providing the best patient care. We recommend shifting the postcrisis focus from overcoming the crisis to overcoming cooperative challenges. Show less
Objectives This research aimed to provide a deeper insight into the gender-specific barriers to smoking cessation and gender-specific preferences for interventions in primary care, in order to... Show moreObjectives This research aimed to provide a deeper insight into the gender-specific barriers to smoking cessation and gender-specific preferences for interventions in primary care, in order to contribute to better aligned cessation care for women. Design Qualitative study using focus groups. Setting Regularly smoking female and male adults were recruited from four different general practices in The Hague (The Netherlands). Participants A total of 11 women and nine men participated. Participants included were regular smokers with a minimum age of 18 and sufficient command of the Dutch language, who were willing to talk about smoking cessation. Inclusion ended when saturation was reached for both women and men. Participants were selected by means of purposeful sampling, whereby looking at age, educational level and experience with quitting. Results The main barriers to smoking cessation in women were psychological factors, such as emotion and stress, compared with environmental factors in men. Women indicated they were in need of support and positivity, and both women and men expressed the desire for assistance without judgement. Contrary to men, women were not drawn to restrictions and (dis)incentives. Conclusion When counselling smokers, in women the focus should be on perceived internal problems, as opposed to more external obstacles in men. Contrary to men, female smokers seem to prefer non-coercive interventions, such as a group intervention offering support and positivity. Future research should focus on these gender differences, and how they could improve treatment in primary care. Show less
In the iZi study in The Hague, use and acceptance of commercially available technology by home-dwelling older citizens was studied, by comparing self-efficacy and perceived physical and mental... Show moreIn the iZi study in The Hague, use and acceptance of commercially available technology by home-dwelling older citizens was studied, by comparing self-efficacy and perceived physical and mental Quality of Life (QoL)-related parameters on an intervention location of 279 households and a control location of 301 households. Technology adoption was clinically significantly associated with increased perceived physical QoL, as compared with control group, depending on the number of technology interventions that were used. A higher number of adopted technologies was associated with a stronger effect on perceived QoL. We tried to establish a way to measure clinical significance by using mixed methods, combining quantitative and qualitative evaluation and feeding results and feedback of participants directly back into our intervention. In general, this research is promising, since it shows that successful and effective adoption of technology by older people is feasible with commercially available products amongst home-dwelling older citizens. We think this way of working provides a better integration of scientific methods and clinical usability but demands a lot of communication and patience of researchers, citizens, and policymakers. A change in policy on how to target people for this kind of intervention might be warranted. Show less
