Publications by authors named "Johanna Aarts"

27 Publications

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Structurally collecting patient feedback on trainee skills: A pilot study in Obstetrics and Gynaecology.

Patient Educ Couns 2021 Aug 26. Epub 2021 Aug 26.

Radboud University Medical Center, Department of Obstetrics and Gynaecology, Nijmegen, The Netherlands; Amsterdam University Medical Centers, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands.

Objective: This pilot study tested a tool that collects patient feedback on trainees' skills in shared decision-making (SDM) and general consultation. It also examined trainees' views on SDM and patient feedback, exploring potential skills improvement through reflexive practice.

Methods: Patients were asked to rate trainees after consultation in a six-itemed questionnaire. The questionnaire included 'CollaboRATE' (a validated tool to test SDM), the 'Net Promoter Score' and two open-ended questions. Questionnaire results were described quantitatively and tested for differences. Results were presented to trainees at three intervals. Trainees were interviewed afterwards. Interview transcripts were thematically analysed.

Results: Eleven trainees in Obstetrics and Gynaecology participated. Out of 1651 sent questionnaires 399 were returned (response rate 24%). Questionnaire results showed no differences when comparing trainees or group scores over time. Interview results were thematically analysed using the reflexivity framework. Trainees were able to reflect on their SDM skills. They valued receiving patient feedback, yet were able to formulate few learning points from it.

Conclusion: Although skills improvement was not evident, patient feedback still has potential benefits.

Practice Implications: Patient feedback should be combined with facilitated reflections at timely intervals to reinforce behaviour change. Supervisors play an important role in facilitating reflections with trainees.
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http://dx.doi.org/10.1016/j.pec.2021.08.026DOI Listing
August 2021

Letter to the editors re-PEC-20-380.

Patient Educ Couns 2021 Nov 6;104(11):2845. Epub 2021 Aug 6.

Dartmouth Medical Center, Dartmouth College, Department of Obstetrics and Gynecology, Lebanon NH, USA.

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http://dx.doi.org/10.1016/j.pec.2021.08.007DOI Listing
November 2021

Implementation and sustainability factors of two early-stage breast cancer conversation aids in diverse practices.

Implement Sci 2021 05 10;16(1):51. Epub 2021 May 10.

The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA.

Background: Conversation aids can facilitate shared decision-making and improve patient-centered outcomes. However, few examples exist of sustained use of conversation aids in routine care due to numerous barriers at clinical and organizational levels. We explored factors that will promote the sustained use of two early-stage breast cancer conversation aids. We examined differences in opinions between the two conversation aids and across socioeconomic strata.

Methods: We nested this study within a randomized controlled trial that demonstrated the effectiveness of two early-stage breast cancer surgery conversation aids, one text-based and one picture-based. These conversation aids facilitated more shared decision-making and improved the decision process, among other outcomes, across four health systems with socioeconomically diverse patient populations. We conducted semi-structured interviews with a purposive sample of patient participants across conversation aid assignment and socioeconomic status (SES) and collected observations and field notes. We interviewed trial surgeons and other stakeholders. Two independent coders conducted framework analysis using the NOrmalization MeAsure Development through Normalization Process Theory. We also conducted an inductive analysis. We conducted additional sub-analyses based on conversation aid assignment and patient SES.

Results: We conducted 73 semi-structured interviews with 43 patients, 16 surgeons, and 14 stakeholders like nurses, cancer center directors, and electronic health record (EHR) experts. Patients and surgeons felt the conversation aids should be used in breast cancer care in the future and were open to various methods of giving and receiving the conversation aid (EHR, email, patient portal, before consultation). Patients of higher SES were more likely to note the conversation aids influenced their treatment discussion, while patients of lower SES noted more influence on their decision-making. Intervention surgeons reported using the conversation aids did not lengthen their typical consultation time. Most intervention surgeons felt using the conversation aids enhanced their usual care after using it a few times, and most patients felt it appeared part of their normal routine.

Conclusions: Key factors that will guide the future sustained implementation of the conversation aids include adapting to existing clinical workflows, flexibility of use, patient characteristics, and communication preferences.

Trial Registration: ClinicalTrials.gov Identifier: NCT03136367 , registered on May 2, 2017.
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http://dx.doi.org/10.1186/s13012-021-01115-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8108365PMC
May 2021

Encounter decision aids to facilitate shared decision-making with women experiencing heavy menstrual bleeding or symptomatic uterine fibroids: A before-after study.

Patient Educ Couns 2021 09 15;104(9):2259-2265. Epub 2021 Feb 15.

The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon NH, USA; Department Obstetrics & Gynaecology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.

Objective: Is the level of shared decision-making (SDM) higher after introduction of a SDM package (including encounter decision aids on treatment options for heavy menstrual bleeding and training for clinicians) than before?.

Methods: This before-after study, performed in OB-GYN practice, compared consultations before and after introduction of a SDM package. The target sample size was 25 patients per group. Women seeking treatment for heavy menstrual bleeding were eligible. After their appointments, patients filled out a three-item patient-reported SDM measure. Treatment discussions were audio-recorded and rated for SDM using Observer OPTION. Consultation transcripts in the 'after' group were checked for adherence to the steps required for intended use of decision aids.

Results: 16 gynaecologists participated. 25 patients participated before introduction of the decision aids and 28 after. The proportion of women reporting optimal SDM was higher after introduction (75 %) than before (50 %;p < 0.001). The mean observer-rated level of SDM was also significantly higher after than before (MD = 12.50,95 % CI 5.53-19.47).

Conclusion: The level of SDM was higher after the introduction of the package than before.

Practice Implications: This study was conducted in a real-life setting in three clinics, both large academic and small rural, offering opportunities for implementation in different type of organizations.
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http://dx.doi.org/10.1016/j.pec.2021.02.027DOI Listing
September 2021

Multidisciplinary management of patients with pubic osteomyelitis, a rare but serious complication after surgery and radiation therapy for advanced gynaecological cancer.

BMJ Case Rep 2021 Jan 11;14(1). Epub 2021 Jan 11.

Amsterdam UMC, Amsterdam, The Netherlands

Pubic osteomyelitis is a rare and often late-onset complication of radiation therapy and surgery for vulvar and vaginal carcinoma. It typically presents with vulvar pain, fever, vaginal discharge and/or gait disorders. Pubic osteomyelitis is often accompanied by fistulas or wound dehiscence in the pelvic area. Its accurate diagnosis and treatment are challenging and require a multidisciplinary team effort. In our patients, multiple combined surgical procedures, long-term antibiotic treatment and days to weeks of hospital admission were necessary to treat pubic osteomyelitis. We emphasise the importance of timely and adequate diagnosis and multidisciplinary approach resulting in a course of treatment that is as effective as possible, limiting the impact on quality of life, which is generally high in this group of patients.
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http://dx.doi.org/10.1136/bcr-2020-236289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802652PMC
January 2021

Patients' and gynecologists' views on sentinel lymph node mapping in low- and intermediate-risk endometrial cancer: a Dutch vignette study.

Int J Gynecol Cancer 2020 06 7;30(6):813-818. Epub 2020 May 7.

Obstetrics and Gynecology, Radboudumc, Nijmegen, The Netherlands.

Objective: Sentinel lymph node (SLN) mapping in endometrial cancer is gaining ground. However, patient views on this new technique are unknown. The aim of this study was to determine factors important to patients and gynecologists when considering SLN mapping in low- and intermediate-risk endometrial cancer.

Methods: We performed a vignette study. Patients who underwent a total hysterectomy for low- or intermediate-risk endometrial cancer between 2012 and 2015 were invited. Dutch gynecologists specializing in gynecologic oncology were also invited. We based the selection for attributes in the vignettes on literature and interviews: risk of complications of SLN mapping; chance of finding a metastasis; survival gain; risk of complications after radiotherapy; operation time; and hospital of surgery (travel time). We developed a questionnaire with 18 hypothetical scenarios. Each attribute level varied and for each scenario, participants were asked how strongly they would prefer SLN on a scale from 1 to 7. The strength of preference for each scenario was analyzed using linear mixed effects models.

Results: A total of 38% of patients (41/108) and 33% of gynecologists (42/126) participated in the study. Overall, they had a preference for SLN. The mean preference for patients was 4.29 (95% CI 3.72 to 4.85) and 4.39 (95% CI 3.99 to 4.78) for gynecologists. Patients' preferences increased from 3.4 in the case of no survival gain to 4.9 in the case of 3-year survival gain (P<0.05) and it decreased when travel time increased to >60 min (-0.4, P=0.024), or with an increased risk of complications after adjuvant radiotherapy (-0.6, P=0.002). For gynecologists all attributes except travel time were important.

Conclusions: Overall, patients and gynecologists were in favor of SLN mapping in low- and intermediate-risk endometrial cancer. Most important to patients were survival gain, travel time, and complication risk after adjuvant radiotherapy. These preferences should be taken into account when counseling about SLN mapping.
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http://dx.doi.org/10.1136/ijgc-2019-001138DOI Listing
June 2020

Neoadjuvant Chemotherapy Followed by Vaginal Radical Trachelectomy as Fertility-Preserving Treatment for Patients with FIGO 2018 Stage 1B2 Cervical Cancer.

Oncologist 2020 07 11;25(7):e1051-e1059. Epub 2020 May 11.

Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands.

Background: Standard treatment for International Federation of Gynecology and Obstetrics (FIGO) 2018 stage 1B2 cervical cancer (i.e., tumor size between 2 and 4 cm) is a radical hysterectomy (RH) with pelvic lymph node dissection (PLND). We evaluated the oncological and fertility outcomes treatment in patients receiving a fertility-sparing alternative consisting of neoadjuvant chemotherapy (NACT) followed by vaginal radical trachelectomy (VRT).

Methods: Patients with stage 1B2 cervical cancer who wished to preserve fertility were included from September 2009 to September 2018. NACT consisted of 6-week cycles of cisplatin or carboplatin with paclitaxel. If tumor size decreased to 2 cm or smaller, NACT was followed by a robot-assisted PLND and VRT.

Results: Eighteen patients were included. Median follow-up time was 49.7 months (range 11.4-110.8). Median tumor size was 32 mm (range 22-40 mm). Complete remission after NACT occurred in seven women. Four women had a poor response on NACT. Three underwent RH with PLND; one received chemoradiation after PLND instead of VRT because of positive lymph nodes. The remaining 14 patients received VRT 3-4 weeks after NACT. Four recurrences occurred: three after NACT and VRT and one after NACT and RH. Median time to recurrence was 20.8 months (range 17.0-105.7). Three recurrences occurred in women with adenocarcinoma with lymph vascular space invasion (LVSI). In four women fertility could not be preserved. To date, four women had six pregnancies, including three live births born at term, two first trimester miscarriages, and one currently ongoing pregnancy.

Conclusion: NACT and VRT in women with stage 1B2 cervical cancer showed promising results. In 78% fertility was preserved. However, patients with poor response on NACT and with adenocarcinoma and/or LVSI were possibly at risk for recurrence. Long-term results in relation to fertility and oncological outcome are needed to corroborate these findings.

Implications For Practice: Standard treatment for women with International Federation of Gynecology and Obstetrics (FIGO) 2018 stage 1B2 cervical cancer (tumor size 2-4 cm) is a radical hysterectomy and pelvic lymph node dissection (PLND). However, many of these women are young and wish to preserve fertility. Data on fertility-sparing treatment options are sparse, but neoadjuvant chemotherapy followed by a vaginal radical trachelectomy and PLND could be an alternative. Since 2009 we performed an observational cohort study in which 18 women opted for this treatment in our center. In 14 women fertility could be preserved. In four patients the tumor recurred. In four women six pregnancies occurred. After careful selection this treatment could be a good fertility-sparing treatment option.
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http://dx.doi.org/10.1634/theoncologist.2020-0063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7356752PMC
July 2020

Knowing what the patient wants: a hospital ethnography studying physician culture in shared decision making in the Netherlands.

BMJ Open 2020 03 18;10(3):e032921. Epub 2020 Mar 18.

Department of Research and Education, OLVG Hospital, Amsterdam, The Netherlands.

Objectives: To study physician culture in relation to shared decision making (SDM) practice.

Design: Execution of a hospital ethnography, combined with interviews and a study of clinical guidelines. Ten-week observations by an insider (physician) and an outsider (student medical anthropology) observer. The use of French sociologist Bourdieu's 'Theory of Practice' and its description of habitus, field and capital, as a lens for analysing physician culture.

Setting: The gynaecological oncology department of a university hospital in the Netherlands. Observations were executed at meetings, as well as individual patient contacts.

Participants: Six gynaecological oncologists, three registrars and two specialised nurses. Nine of these professionals were also interviewed.

Main Outcome Measures: Common elements in physician habitus that influence the way SDM is being implemented.

Results: Three main elements of physician habitus were identified. First of all, the 'emphasis on medical evidence' in group meetings as well as in patient encounters. Second 'acting as a team', which confronts the patient with the recommendations of a whole team of professionals. And lastly 'knowing what the patient wants', which describes how doctors act on what they think is best for patients instead of checking what patients actually want. Results were viewed in the light of how physicians deal with uncertainty by turning to medical evidence, as well as how the educational system stresses evidence-based medicine. Observations also highlighted the positive attitude doctors actually have towards SDM.

Conclusions: Certain features of physician culture hinder the correct implementation of SDM. Medical training and guidelines should put more emphasis on how to elicit patient perspective. Patient preferences should be addressed better in the patient workup, for example by giving them explicit attention first. This eventually could create a physician culture that is more helpful for SDM.
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http://dx.doi.org/10.1136/bmjopen-2019-032921DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7150589PMC
March 2020

Medical Students' Knowledge and Attitudes Toward Shared Decision Making: Results From a Multinational, Cross-Sectional Survey.

MDM Policy Pract 2019 Jul-Dec;4(2):2381468319885871. Epub 2019 Nov 8.

The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, New Hampshire.

We aimed to conduct a multinational cross-sectional online survey of medical students' attitudes toward, knowledge of, and experience with shared decision making (SDM). We conducted the survey from September 2016 until May 2017 using the following: 1) a convenience sample of students from four medical schools each in Canada, the United States, and the Netherlands ( = 12), and 2) all medical schools in the United Kingdom through the British Medical School Council ( = 32). We also distributed the survey through social media. A total of 765 students read the information sheet and 619 completed the survey. Average age was 24, 69% were female. Mean SDM knowledge score was 83.6% (range = 18.8% to 100%; 95% confidence interval [CI] = 82.8% to 84.5%). US students had the highest knowledge scores (86.2%, 95% CI = 84.8% to 87.6%). The mean risk communication score was 57.4% (range = 0% to 100%; 95% CI = 57.4% to 60.1%). Knowledge did not vary with age, race, gender, school, or school year. Attitudes were positive, except 46% believed SDM could only be done with higher educated patients, and 80.9% disagreed that physician payment should be linked to SDM performance (increased with years in training, < 0.05). Attitudes did not vary due to any tested variable. Students indicated they were more likely than experienced clinicians to practice SDM (72.1% v. 48.8%). A total of 74.7% reported prior SDM training and 82.8% were interested in learning more about SDM. SDM knowledge is high among medical students in all four countries. Risk communication is less well understood. Attitudes indicate that further research is needed to understand how medical schools deliver and integrate SDM training into existing curricula.
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http://dx.doi.org/10.1177/2381468319885871DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6843737PMC
November 2019

Implementation of the uterine fibroids Option Grid patient decision aids across five organizational settings: a randomized stepped-wedge study protocol.

Implement Sci 2019 09 2;14(1):88. Epub 2019 Sep 2.

The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, One Medical Center Drive, 5th floor, Lebanon, NH, 03756, USA.

Background: Uterine fibroids are non-cancerous overgrowths of the smooth muscle in the uterus. As they grow, some cause problems such as heavy menstrual bleeding, pelvic pain, discomfort during sexual intercourse, and rarely pregnancy complications or difficulty becoming pregnant. Multiple treatment options are available. The lack of comparative evidence demonstrating superiority of any one treatment means that choosing the best option is sensitive to individual preferences. Women with fibroids wish to consider treatment trade-offs. Tools known as patient decision aids (PDAs) are effective in increasing patient engagement in the decision-making process. However, the implementation of PDAs in routine care remains challenging. Our aim is to use a multi-component implementation strategy to implement the uterine fibroids Option Grid™ PDAs at five organizational settings in the USA.

Methods: We will conduct a randomized stepped-wedge implementation study where five sites will be randomized to implement the uterine fibroid Option Grid PDA in practice at different time points. Implementation will be guided by the Consolidated Framework for Implementation Research (CFIR) and Normalization Process Theory (NPT). There will be a 6-month pre-implementation phase, a 2-month initiation phase where participating clinicians will receive training and be introduced to the Option Grid PDAs (available in text, picture, or online formats), and a 6-month active implementation phase where clinicians will be expected to use the PDAs with patients who are assigned female sex at birth, are at least 18 years of age, speak fluent English or Spanish, and have new or recurrent symptoms of uterine fibroids. We will exclude postmenopausal patients. Our primary outcome measure is the number of eligible patients who receive the Option Grid PDAs. We will use logistic and linear regression analyses to compare binary and continuous quantitative outcome measures (including survey scores and Option Grid use) between the pre- and active implementation phases while adjusting for patient and clinician characteristics.

Discussion: This study may help identify the factors that impact the implementation and sustained use of a PDA in clinic workflow from various stakeholder perspectives while helping patients with uterine fibroids make treatment decisions that align with their preferences.

Trial Registration: Clinicaltrials.gov , NCT03985449. Registered 13 July 2019, https://clinicaltrials.gov/ct2/show/NCT03985449.
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http://dx.doi.org/10.1186/s13012-019-0933-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6721118PMC
September 2019

Productivity loss due to menstruation-related symptoms: a nationwide cross-sectional survey among 32 748 women.

BMJ Open 2019 06 27;9(6):e026186. Epub 2019 Jun 27.

Department of Obstetrics and Gynaecology, Radboudumc, Nijmegen, The Netherlands.

Objective: To evaluate age-dependent productivity loss caused by menstruation-related symptoms, measured in absenteeism (time away from work or school) and presenteeism (productivity loss while present at work or school).

Methods: Design/setting: internet-based, cross-sectional survey conducted in the Netherlands from July to October 2017.

Participants: 32 748 women aged 15-45 years, recruited through social media.

Outcome Measures: self-reported lost productivity in days, divided into absenteeism and presenteeism; impact of menstrual symptoms; reasons women give when calling in sick; and women's preferences regarding the implications of menstruation-related symptoms for schools and workplaces.

Results: A total of 13.8% (n=4514) of all women reported absenteeism during their menstrual periods with 3.4% (n=1108) reporting absenteeism every or almost every menstrual cycle. The mean absenteeism related to a woman's period was 1.3 days per year. A total of 80.7% (n=26 438) of the respondents reported presenteeism and decreased productivity a mean of 23.2 days per year. An average productivity loss of 33% resulted in a mean of 8.9 days of total lost productivity per year due to presenteeism. Women under 21 years were more likely to report absenteeism due to menstruation-related symptoms (OR 3.3, 95% CI 3.1 to 3.6). When women called in sick due to their periods, only 20.1% (n=908) told their employer or school that their absence was due to menstrual complaints. Notably, 67.7% (n=22 154) of the participants wished they had greater flexibility in their tasks and working hours at work or school during their periods.

Conclusions: Menstruation-related symptoms cause a great deal of lost productivity, and presenteeism is a bigger contributor to this than absenteeism. There is an urgent need for more focus on the impact of these symptoms, especially in women aged under 21 years, for discussions of treatment options with women of all ages and, ideally, more flexibility for women who work or go to school.
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http://dx.doi.org/10.1136/bmjopen-2018-026186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6597634PMC
June 2019

Factors influencing decision-making around opportunistic salpingectomy: a nationwide survey.

J Gynecol Oncol 2019 01 30;30(1):e2. Epub 2018 Apr 30.

Radboud Institute for Health Sciences, Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands.

Objective: To explore current practice and influencing factors on adoption of the opportunistic salpingectomy (OS), particularly regarding the decision making, to eventually enhance the development and implementation of clear guidelines.

Methods: This nationwide cross-sectional survey study was conducted in all hospitals in the Netherlands. An anonymous online survey was sent to gynecologists with special interest in gynecological oncology, gynecological endoscopy or urogynecology and all Dutch gynecology trainees. The survey mainly focused on current practice regarding OS and identification of influencing factors on the level of innovation, organization, healthcare professional and individual patient.

Results: The response rate was 348 out of 597 gynecologists (58.3%) and 142 out of 340 trainees (41.8%). Current practice of discussing and performing the OS varied widely, with ovarian cancer (OC) risk reduction as most important supportive factor on innovation level. Supportive factors on the level of organization and healthcare provider were; working in a non-training hospital, knowledge of current literature and extensive work experience (in years and annual number of hysterectomies). On individual patient level, a vaginal approach of hysterectomy, negative family history for OC and the presence of firm adhesions were suppressive factors for the OS.

Conclusion: In this study we evaluated the current practice regarding the opportunistic salpingectomy in the Netherlands and identified influencing factors on different levels to raise awareness and attribute to development of a targeted implementation strategy, on both national and international level.
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http://dx.doi.org/10.3802/jgo.2019.30.e2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6304401PMC
January 2019

Information Priorities for Deciding on Treatment of Pelvic Organ Prolapse.

Female Pelvic Med Reconstr Surg 2019 Sep/Oct;25(5):372-377

The Dartmouth Institute for Health Policy and Clinical Practice, The Geisel School of Medicine at Dartmouth, Lebanon, NH.

Objective: The objective of this study was to elicit information priorities from women considering treatment for pelvic organ prolapse (POP).

Study Design: This is a cross-sectional study of women before and after treatment of stage II or higher POP. Women were recruited either at the conclusion of their initial evaluation (before treatment) or at postoperative or pessary maintenance visits (after treatment). Women completed a written survey that used a Likert scale to rank potentially frequently asked questions (FAQs) that could be important information to use in decision making for POP.

Results: Among the 100 women surveyed, 32 women wanted to pursue surgical options and 18 women wanted to pursue nonsurgical treatment options in the before treatment group. In the after treatment group, 35 women had undergone surgery and 15 women were using a pessary.Overall, women ranked FAQs about treatment success (overall Likert score, 1.11±0.35), quality of life after treatment (1.18±0.41), and complications and side effects (1.20±0.57) as the most important information when making a decision. Women were least concerned with FAQs regarding cost (2.39±1.48), impact on sexual function (2.21±1.4), and impact on hormones (2.20±1.27).

Conclusions: Women with POP identified the most important FAQs related to treatment success and complications, quality of life, and understanding how the treatment works. This information will be used to develop a comprehensive decision aid for women considering treatment options for POP.
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http://dx.doi.org/10.1097/SPV.0000000000000572DOI Listing
March 2020

The association between experiences with patient-centred care and health-related quality of life in women with endometriosis.

Reprod Biomed Online 2018 Feb 27;36(2):197-205. Epub 2017 Oct 27.

Radboud University Medical Center, Nijmegen 6525GA, The Netherlands.

In this cross-sectional study, we investigated whether patient-centred endometriosis care (PCEC) is associated with health-related quality of life (HRQOL). Dutch-speaking women with endometriosis, treated by laparoscopy in a university clinic between 2009 and 2010, were eligible (n = 194). Endometriosis Health Profile-30 and ENDOCARE questionnaire were used to assess HRQOL and PCEC, respectively. Overall and subscale scores were converted to a scale from 0 (best score) to 100 (worst score). Linear regression analyses were conducted while controlling for confounders. Participants (n = 109) had a mean age of 35.4 years; 79.6% had moderate-severe endometriosis. Mean scores for overall HRQOL and PCEC were 29.3/100 and 38.0/100, respectively. The PCEC-subscale 'continuity' was significantly associated with overall HRQOL (P = 0.029). A significant association was found between overall PCEC and the HRQOL-subscale 'social support' (P = 0.026). The PCEC-subscales 'information' and 'continuity' were significantly associated with the HRQOL-subscales 'emotional wellbeing' and 'social support' (P < 0.05). The PCEC-subscale 'respect' was significantly associated with the HRQOL-subscale 'emotional wellbeing' (P = 0.023). Multivariable regression analyses produced no significant associations, including all subscales of PCEC. Providing PCEC could lead to better HRQOL, especially if paying attention to 'continuity', 'respect' and 'information'. Large-scale longitudinal research is needed.
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http://dx.doi.org/10.1016/j.rbmo.2017.10.106DOI Listing
February 2018

A three-talk model for shared decision making: multistage consultation process.

BMJ 2017 Nov 6;359:j4891. Epub 2017 Nov 6.

Department of Family Medicine, School CAPHRI, Maastricht University Medical Centre, Maastricht, Netherlands.

 To revise an existing three-talk model for learning how to achieve shared decision making, and to consult with relevant stakeholders to update and obtain wider engagement. Multistage consultation process. Key informant group, communities of interest, and survey of clinical specialties. 19 key informants, 153 member responses from multiple communities of interest, and 316 responses to an online survey from medically qualified clinicians from six specialties. After extended consultation over three iterations, we revised the three-talk model by making changes to one talk category, adding the need to elicit patient goals, providing a clear set of tasks for each talk category, and adding suggested scripts to illustrate each step. A new three-talk model of shared decision making is proposed, based on "team talk," "option talk," and "decision talk," to depict a process of collaboration and deliberation. Team talk places emphasis on the need to provide support to patients when they are made aware of choices, and to elicit their goals as a means of guiding decision making processes. Option talk refers to the task of comparing alternatives, using risk communication principles. Decision talk refers to the task of arriving at decisions that reflect the informed preferences of patients, guided by the experience and expertise of health professionals. The revised three-talk model of shared decision making depicts conversational steps, initiated by providing support when introducing options, followed by strategies to compare and discuss trade-offs, before deliberation based on informed preferences.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683042PMC
http://dx.doi.org/10.1136/bmj.j4891DOI Listing
November 2017

Assessing medical student knowledge and attitudes about shared decision making across the curriculum: protocol for an international online survey and stakeholder analysis.

BMJ Open 2017 06 23;7(6):e015945. Epub 2017 Jun 23.

The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA.

Introduction: Shared decision making (SDM) is a goal of modern medicine; however, it is not currently embedded in routine care. Barriers include clinicians’ attitudes, lack of knowledge and training and time constraints. Our goal is to support the development and delivery of a robust SDM curriculum in medical education. Our objective is to assess undergraduate medical students’ knowledge of and attitudes towards SDM in four countries.

Methods And Analysis: The first phase of the study involves a web-based cross-sectional survey of undergraduate medical students from all years in selected schools across the United States (US), Canada and undergraduate and graduate students in the Netherlands. In the United Kingdom (UK), the survey will be circulated to all medical schools through the UK Medical School Council. We will sample students equally in all years of training and assess attitudes towards SDM, knowledge of SDM and participation in related training. Medical students of ages 18 years and older in the four countries will be eligible. The second phase of the study will involve semistructured interviews with a subset of students from phase 1 and a convenience sample of medical school curriculum experts or stakeholders. Data will be analysed using multivariable analysis in phase 1 and thematic content analysis in phase 2. Method, data source and investigator triangulation will be performed. Online survey data will be reported according to the Checklist for Reporting the Results of Internet E-Surveys. We will use the COnsolidated criteria for REporting Qualitative research for all qualitative data.

Ethics And Dissemination: The study has been approved for dissemination in the US, the Netherlands, Canada and the UK. The study is voluntary with an informed consent process. The results will be published in a peer-reviewed journal and will help inform the inclusion of SDM-specific curriculum in medical education worldwide.
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http://dx.doi.org/10.1136/bmjopen-2017-015945DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5541622PMC
June 2017

Surgical approach to hysterectomy for benign gynaecological disease.

Cochrane Database Syst Rev 2015 Aug 12(8):CD003677. Epub 2015 Aug 12.

Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Center, Geert Grooteplein 10, Nijmegen, Netherlands, 6500HB.

Background: The four approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RH).

Objectives: To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions.

Search Methods: We searched the following databases (from inception to 14 August 2014) using the Ovid platform: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. We also searched relevant citation lists. We used both indexed and free-text terms.

Selection Criteria: We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another.

Data Collection And Analysis: At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction, quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvi-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction).

Main Results: We included 47 studies with 5102 women. The evidence for most comparisons was of low or moderate quality. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (nine RCTs, 762 women)Return to normal activities was shorter in the VH group (mean difference (MD) -9.5 days, 95% confidence interval (CI) -12.6 to -6.4, three RCTs, 176 women, I(2) = 75%, moderate quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (25 RCTs, 2983 women)Return to normal activities was shorter in the LH group (MD -13.6 days, 95% CI -15.4 to -11.8; six RCTs, 520 women, I(2) = 71%, low quality evidence), but there were more urinary tract injuries in the LH group (odds ratio (OR) 2.4, 95% CI 1.2 to 4.8, 13 RCTs, 2140 women, I(2) = 0%, low quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. LH versus VH (16 RCTs, 1440 women)There was no evidence of a difference between the groups for any primary outcomes. Robotic-assisted hysterectomy (RH) versus LH (two RCTs, 152 women)There was no evidence of a difference between the groups for any primary outcomes. Neither of the studies reported satisfaction rates or quality of life.Overall, the number of adverse events was low in the included studies.

Authors' Conclusions: Among women undergoing hysterectomy for benign disease, VH appears to be superior to LH and AH, as it is associated with faster return to normal activities. When technically feasible, VH should be performed in preference to AH because of more rapid recovery and fewer febrile episodes postoperatively. Where VH is not possible, LH has some advantages over AH (including more rapid recovery and fewer febrile episodes and wound or abdominal wall infections), but these are offset by a longer operating time. No advantages of LH over VH could be found; LH had a longer operation time, and total laparoscopic hysterectomy (TLH) had more urinary tract injuries. Of the three subcategories of LH, there are more RCT data for laparoscopic-assisted vaginal hysterectomy and LH than for TLH. Single-port laparoscopic hysterectomy and RH should either be abandoned or further evaluated since there is a lack of evidence of any benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed and decided in the light of the relative benefits and hazards. These benefits and hazards seem to be dependent on surgical expertise and this may influence the decision. In conclusion, when VH is not feasible, LH may avoid the need for AH, but LH is associated with more urinary tract injuries. There is no evidence that RH is of benefit in this population. Preferably, the surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon.
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http://dx.doi.org/10.1002/14651858.CD003677.pub5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6984437PMC
August 2015

Lessons learned from the implementation of an online infertility community into an IVF clinic's daily practice.

Hum Fertil (Camb) 2015 13;18(4):238-47. Epub 2015 Jul 13.

a Department of Obstetrics and Gynaecology , Radboudumc university medical centre Nijmegen , Nijmegen , The Netherlands.

The Internet is expected to innovate healthcare, in particular patient-centredness of care. Within fertility care, information provision, communication with healthcare providers and support from peers are important components of patient-centred care. An online infertility community added to an in vitro fertilisation or IVF clinic's practice provides tools to healthcare providers to meet these. This study's online infertility community facilitates peer-to-peer support, information provision to patients and patient provider communication within one clinic. Unfortunately, these interventions often fail to become part of clinical routines. The analysis of a first introduction into usual care can provide lessons for the implementation in everyday health practice. The aim was to explore experiences of professionals and patients with the implementation of an infertility community into a clinic's care practice. We performed semi-structured interviews with both professionals and patients to collect these experiences. These interviews were analyzed using the Normalisation Process Model. Assignment of a community manager, multidisciplinary division of tasks, clear instructions to staff in advance and periodical evaluations could contribute to the integration of this online community. Interviews with patients provided insights into the possible impact on daily care. This study provides lessons to healthcare providers on the implementation of an online infertility community into their practice.
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http://dx.doi.org/10.3109/14647273.2015.1057901DOI Listing
September 2016

Evaluation of patients' questions to identify gaps in information provision to infertile patients.

Hum Fertil (Camb) 2014 Jun 28;17(2):133-40. Epub 2014 May 28.

Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Radboud University Medical Centre , Nijmegen , the Netherlands.

The objective of this observational study was to identify gaps in written patient information at an infertility clinic, by systematically analysing the questions raised by infertile patients in a forum or during 'phone and group consultations. This was done (1) by identifying themes raised by patients undergoing Medically Assisted Reproduction and (2) by determining to what extent the questions asked by patients were absent from information leaflets provided by the clinic. A total of 193 questions were included and 24 different themes identified (e.g. blood loss during treatment, use of and side-effects of medication). Half of the patients' questions could not or could only partially be answered using the conventional patient information leaflets (51%). Healthcare providers should be aware that the information they provide does not necessarily cover all information needs. The involvement of patients in the creation of information, for instance through an approach such as that described in the paper, can provide insight into the informational needs of patients, and help healthcare providers keep their information up-to-date and patient-centred.
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http://dx.doi.org/10.3109/14647273.2014.912762DOI Listing
June 2014

Robotic compared with laparoscopic sacrocolpopexy: a randomized controlled trial.

Obstet Gynecol 2014 Jun;123(6):1357-1358

Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands Department of Obstetrics and Gynecology, Gelderse Vallei Hospital, Ede, The Netherlands.

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http://dx.doi.org/10.1097/AOG.0000000000000311DOI Listing
June 2014

Personal health communities: a phenomenological study of a new health-care concept.

Health Expect 2015 Dec 19;18(6):2091-106. Epub 2014 Mar 19.

Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.

Context: Fragmentation of care, complexity of diseases and the need to involve patients actively in their individual health care led to the development of the personal health community (PHC). In a PHC, patients can -regardless of the nature of their condition- invite all professionals that are involved in their health care process. Once gathered, the patient and health care team can exchange information about the patient's health and communicate through several functionalities, in a secured environment.

Objectives: Exploring the use, first experiences and potential consequences of using PHCs in health care.

Design: Qualitative phenomenological study.

Participants: Eighteen respondents, consisting of women experiencing infertility (n = 5), persons with Parkinson's disease (n = 6), a gynaecologist, a fertility doctor, a fertility nurse, three Parkinson's specialist nurses and a neurologist.

Results: First experiences with PHCs showed that patients use their PHC differently, dependending on their condition and people involved. Various (potential) advantages for future health care were mentioned relating to both organizational aspects of care (e.g. continuity of care) and the human side of care (e.g. personal care). Patient involvement in care was facilitated. Disadvantages were the amount of work that it took and technological issues.

Conclusions: Using PHCs leads to promising improvements in both the organization of care and care experience, according to the participants in this study. They indicate that patients with different diseases and in different circumstances can benefit from these improvements. The PHC seem to be an online tool that can be applied in a personalized way. When (technically) well facilitated, it could stimulate active involvement of patients in their own health and health care. It warrants further research to study its effect on concrete health outcomes.
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http://dx.doi.org/10.1111/hex.12177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5810707PMC
December 2015

Barriers and facilitators for the implementation of an online clinical health community in addition to usual fertility care: a cross-sectional study.

J Med Internet Res 2013 Aug 30;15(8):e163. Epub 2013 Aug 30.

Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Center, Radboud University, Nijmegen, Netherlands.

Background: Online health communities are becoming more popular in health care. Patients and professionals can communicate with one another online, patients can find peer support, and professionals can use it as an additional information channel to their patients. However, the implementation of online health communities into daily practice is challenging. These challenges relate to the fact that patients need to be activated to (1) become a member (ie, subscription) and (2) participate actively within the community before any effect can be expected. Therefore, we aimed at answering 2 research questions: (1) what factors are associated with subscription to an online health community, and (2) which are associated with becoming an active participant within an online health community.

Objective: To identify barriers and facilitators as perceived by patients for the implementation of an online health community.

Methods: We performed a cross-sectional study. Three Dutch fertility clinics (2 IVF-licensed) offered their patients a secure online clinical health community through which clinicians can provide online information and patients can ask questions to the medical team or share experiences and find support from peers. We randomly selected and invited 278 men and women suffering from infertility and attending 1 of the participating clinics. Participants filled out a questionnaire about their background characteristics and current use of the online community. Possible barriers and facilitators were divided into 2 parts: (1) those for subscription to the community, and (2) those for active participation in the community. We performed 2 multivariate logistic regression analyses to calculate determinants for both subscription and active participation.

Results: Subscription appeared to be associated with patients' background characteristics (eg, gender, treatment phase), intervention-related facilitators (odds ratio [OR] 2.45, 95% CI 1.14-5.27), and patient-related barriers (OR 0.20, 95% CI 0.08-0.54), such as not feeling the need for such an online health community. After subscription, determinants for participation consisted of aspects related to participant's age (OR 0.86, 95% CI 0.76-0.97), length of infertility (OR 1.48, 05% CI 1.09-2.02), and to intervention-related facilitators (OR 5.79, 95% CI 2.40-13.98), such as its reliable character and possibility to interact with the medical team and peers.

Conclusions: Implementing an online health community in addition to usual fertility care should be performed stepwise. At least 2 strategies are needed to increase the proportion of patient subscribers and consequently make them active participants. First, the marketing strategy should contain information tailored to different subgroups of the patient population. Second, for a living online health community, incorporation of interactive elements, as well as frequent news and updates are needed. These results imply that involving patients and their needs into the promotion strategy, community's design, and implementation are crucial.
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http://dx.doi.org/10.2196/jmir.2098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3815434PMC
August 2013

Using online health communities to deliver patient-centered care to people with chronic conditions.

J Med Internet Res 2013 Jun 25;15(6):e115. Epub 2013 Jun 25.

Radboud University Nijmegen Medical Centre, Nijmegen Centre for Evidence Based Practice, Department of Neurology (935), Nijmegen, Netherlands.

Background: Our health care system faces major threats as the number of people with multiple chronic conditions rises dramatically.

Objective: To study the use of Online Health Communities (OHCs) as a tool to facilitate high-quality and affordable health care for future generations.

Methods: OHCs are Internet-based platforms that unite either a group of patients, a group of professionals, or a mixture of both. Members interact using modern communication technologies such as blogs, chats, forums, and wikis. We illustrate the use of OHCs for ParkinsonNet, a professional network for Parkinson disease whose participants-both patients and professionals-use various types of OHCs to deliver patient-centered care.

Results: We discuss several potential applications in clinical practice. First, due to rapid advances in medical knowledge, many health professionals lack sufficient expertise to address the complex health care needs of chronic patients. OHCs can be used to share experiences, exchange knowledge, and increase disease-specific expertise. Second, current health care delivery is fragmented, as many patients acquire relationships with multiple professionals and institutions. OHCs can bridge geographical distances and enable interdisciplinary collaboration across institutions and traditional echelons. Third, chronic patients lack adequate tools to self-manage their disease. OHCs can be used to actively engage and empower patients in their health care process and to tailor care to their individual needs. Personal health communities of individual patients offer unique opportunities to store all medical information in one central place, while allowing transparent communication across all members of each patient's health care team.

Conclusions: OHCs are a powerful tool to address some of the challenges chronic care faces today. OHCs help to facilitate communication among professionals and patients and support coordination of care across traditional echelons, which does not happen spontaneously in busy practice.
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http://dx.doi.org/10.2196/jmir.2476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3713879PMC
June 2013

Feedback to professionals on patient-centered fertility care is insufficient for improvement: a mixed-method study.

Fertil Steril 2013 Apr 26;99(5):1419-27. Epub 2013 Jan 26.

Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands.

Objective: To determine the effect of audits and feedback on the level of patient-centeredness in fertility care, and to obtain a more in-depth understanding of professionals' views on patient-centered care and achieving improvements.

Design: Mixed-method design, using semistructured in-depth interviews and patient questionnaires.

Setting: Fifteen Dutch fertility clinics.

Patient(s): Women in infertility treatment (quantitative section) and fertility care professionals (qualitative section).

Intervention(s): Audit of the level of patient-centeredness of care, and feedback provided to clinics by a personalized paper-based feedback report.

Main Outcome Measure(s): Quantitative section: the patient-reported differences in the level of patient-centered fertility care between 2009 and 2011 measured by the Patient-Centeredness Questionnaire-Infertility. Qualitative section: professionals views on improving patient-centered fertility care arranged into a Hibbard framework for behavioral change.

Result(s): Multilevel regression analysis showed no statistically significant differences between the overall levels of patient-centeredness in 2009 and 2011. Qualitative research showed that professionals' urge to change and their ability to translate feedback were suboptimal to achieve behavioral change.

Conclusion(s): Audits and feedback alone are not enough to improve the level of patient-centeredness in fertility care. Increasing professionals' desire to change and their ability to translate feedback about their performance into an optimal quality improvement strategy appear to be the key issues.
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http://dx.doi.org/10.1016/j.fertnstert.2012.12.024DOI Listing
April 2013

Patient-centeredness in PD care: development and validation of a patient experience questionnaire.

Parkinsonism Relat Disord 2012 Nov 15;18(9):1011-6. Epub 2012 Jun 15.

Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen Medical Centre, The Netherlands.

Introduction: Patient-centeredness is increasingly recognized as a crucial element of quality of care. A suitable instrument to assess the level of patient-centeredness for Parkinson's disease (PD) care is lacking. Here we describe the development and validation of the Patient-Centered Questionnaire for PD (PCQ-PD), and its initial application in a large patient sample.

Methods: Based on the outcomes of eight focus groups we composed a questionnaire that measures patient-centeredness by assessing patients' care experiences. The questionnaire was sent to 1112 Dutch PD patients, and face-, content- and construct-validity and reliability were assessed. The level of patient-centeredness was determined by calculating scores for overall patient-centeredness [0-3], subscale experiences [0-3], item experience, item priority and quality improvement.

Results: 895 PD patients (net response 82.0%) completed the questionnaire. After the validation procedure, the PCQ-PD addressed 46 care aspects in six different subscales of patient-centeredness. The internal consistency of the instrument, expressed in Cronbach's α per subscale, ranged from 0.62 to 0.84. The overall patient-centeredness score was 1.69 (SD 0.45). 'Emotional support' (1.05, SD 0.90) and 'provision of tailored information' (1.18, SD 0.57) subscales received the lowest experience ratings. 'Access to medical records' obtained the highest item quality improvement score (5.44).

Conclusions: This study produced a valid instrument to measure patient-centeredness in PD care. Psychometric properties of the instrument were good. Application of the PCQ-PD revealed the level of patient-centeredness in the care for PD patients in The Netherlands. The main outcome was a compelling call for the provision of tailored information and emotional support.
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http://dx.doi.org/10.1016/j.parkreldis.2012.05.017DOI Listing
November 2012

Measuring patient-centredness, the neglected outcome in fertility care: a random multicentre validation study.

Hum Reprod 2010 Oct 18;25(10):2516-26. Epub 2010 Aug 18.

Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands.

Background: High-quality fertility care should be effective and safe, but also patient-centred. However, a suitable instrument for measuring patient-centredness is lacking. This study aims to develop and validate an instrument that can reliably measure patient-centredness in fertility care: patient-centredness questionnaire-infertility (PCQ-infertility).

Methods: The PCQ's content, addressing 53 care aspects, was generated by seven focus groups with 54 infertile patients. Besides background questions, the questionnaire included one 'experience item' and one 'importance item' for each care aspect. Thirty Dutch fertility clinics were invited to participate in the validation study. The questionnaire was sent at random to 1200 infertile couples. Psychometric tests included inter-item and reliability analyses. Importance scores were calculated. The discriminative power was determined using multilevel analysis.

Results: The questionnaire was completed by 888 infertile couples (net response 75%) from 29 clinics. The ultimate PCQ-infertility, comprising 46 items and seven subscales, appeared reliable and valid for measuring patient-centredness in fertility care. Of the seven subscales, 'communication' received the best ratings and 'continuity' the worst. 'Honesty and clearness on what to expect from fertility care' appeared most important to patients. Significant differences between clinics were found, even after case-mix adjustment.

Conclusion: This study resulted in a valid, reliable and strongly discriminating instrument for measuring patient-centredness in fertility care. The PCQ-infertility can identify shortcomings on patient-centredness and can be adopted for quality improvement. Therefore, fertility care can now be monitored and benchmarked on patient-centredness, as well as on live birth and complication rates.
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http://dx.doi.org/10.1093/humrep/deq219DOI Listing
October 2010

Alterations in the nasopharyngeal bacterial flora after adenoidectomy in children: a systematic review.

Otolaryngol Head Neck Surg 2010 Jan 25;142(1):15-20.e1. Epub 2009 Nov 25.

Department of Otorhinolaryngology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.

Objective: To review the current literature on alterations in the nasopharyngeal bacterial flora in relation to adenoidectomy in children with recurrent upper respiratory tract infections (rURTIs).

Data Sources: A systematic literature search of PubMed (from 1966 on) and EMBASE (from 1974 on) to May 3 2008.

Review Methods: A study was selected if it included children aged less than 18 years who had undergone adenoidectomy or adenotonsillectomy, and in whom nasopharyngeal bacterial flora was studied before and after or only after surgery. Data from eight studies were included in this review. We extracted from each study which potentially pathogenic and nonpathogenic nasopharyngeal flora were cultured before and after surgery.

Results: Streptococcus pneumoniae and Haemophilus influenzae were most often detected in the nasopharynx of children with rURTI. Carriage of these bacteria decreased after adenoidectomy in the majority of studies. In contrast, carriage of bacteria belonging to the nonpathogenic nasopharyngeal flora increased after surgery.

Conclusion: Adenoidectomy seems to have a beneficial effect on the nasopharyngeal bacterial flora. Because the overall quality of the available evidence is low, it is important that controlled studies are initiated into the short- and long-term effect of adenoidectomy on the nasopharyngeal bacterial flora and its relationship with the recurrence of URTIs in children.
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http://dx.doi.org/10.1016/j.otohns.2009.09.017DOI Listing
January 2010
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