Publications by authors named "Philip J van der Wees"

79 Publications

Routine provision of feedback from patient-reported outcome measurements to healthcare providers and patients in clinical practice.

Cochrane Database Syst Rev 2021 Oct 12;10:CD011589. Epub 2021 Oct 12.

Health Services & Policy Research, Exeter Collaboration for Academic Primary Care (APEx), NIHR School for Primary Care Research, NIHR ARC South West Peninsula (PenARC), University of Exeter, Exeter, UK.

Background: Patient-reported outcomes measures (PROMs) assess a patient's subjective appraisal of health outcomes from their own perspective. Despite hypothesised benefits that feedback  on PROMs can support decision-making in clinical practice and improve outcomes, there is uncertainty surrounding the effectiveness of PROMs feedback.

Objectives: To assess the effects of PROMs feedback to patients, or healthcare workers, or both on patient-reported health outcomes and processes of care.

Search Methods: We searched MEDLINE, Embase, CENTRAL, two other databases and two clinical trial registries on 5 October 2020. We searched grey literature and consulted experts in the field.

Selection Criteria: Two review authors independently screened and selected studies for inclusion. We included randomised trials directly comparing the effects on outcomes and processes of care of PROMs feedback to healthcare professionals and patients, or both with the impact of not providing such information.

Data Collection And Analysis: Two groups of two authors independently extracted data from the included studies and evaluated study quality. We followed standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the evidence. We conducted meta-analyses of the results where possible.

Main Results: We identified 116 randomised trials which assessed the effectiveness of PROMs feedback in improving processes or outcomes of care, or both in a broad range of disciplines including psychiatry, primary care, and oncology. Studies were conducted across diverse ambulatory primary and secondary care settings in North America, Europe and Australasia. A total of 49,785 patients were included across all the studies. The certainty of the evidence varied between very low and moderate. Many of the studies included in the review were at risk of performance and detection bias. The evidence suggests moderate certainty that PROMs feedback probably improves quality of life (standardised mean difference (SMD) 0.15, 95% confidence interval (CI) 0.05 to 0.26; 11 studies; 2687 participants), and leads to an increase in patient-physician communication (SMD 0.36, 95% CI 0.21 to 0.52; 5 studies; 658 participants), diagnosis and notation (risk ratio (RR) 1.73, 95% CI 1.44 to 2.08; 21 studies; 7223 participants), and disease control (RR 1.25, 95% CI 1.10 to 1.41; 14 studies; 2806 participants). The intervention probably makes little or no difference for general health perceptions (SMD 0.04, 95% CI -0.17 to 0.24; 2 studies, 552 participants; low-certainty evidence), social functioning (SMD 0.02, 95% CI -0.06 to 0.09; 15 studies; 2632 participants; moderate-certainty evidence), and pain (SMD 0.00, 95% CI -0.09 to 0.08; 9 studies; 2386 participants; moderate-certainty evidence). We are uncertain about the effect of PROMs feedback on physical functioning (14 studies; 2788 participants) and mental functioning (34 studies; 7782 participants), as well as fatigue (4 studies; 741 participants), as the certainty of the evidence was very low. We did not find studies reporting on adverse effects defined as distress following or related to PROM completion.

Authors' Conclusions: PROM feedback probably produces moderate improvements in communication between healthcare professionals and patients as well as in diagnosis and notation, and disease control, and small improvements to quality of life. Our confidence in the effects is limited by the risk of bias, heterogeneity and small number of trials conducted to assess outcomes of interest. It is unclear whether   many of these improvements are clinically meaningful or sustainable in the long term. There is a need for more high-quality studies in this area, particularly studies which employ cluster designs and utilise techniques to maintain allocation concealment.
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http://dx.doi.org/10.1002/14651858.CD011589.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8509115PMC
October 2021

Healthcare needs, expectations, utilization, and experienced treatment effects in patients with hereditary spastic paraplegia: a web-based survey in the Netherlands.

Orphanet J Rare Dis 2021 06 24;16(1):283. Epub 2021 Jun 24.

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

Background: We aimed to identify healthcare needs, expectations, utilization, and the experienced treatment effects in a population of Dutch patients with hereditary spastic paraplegia (HSP).

Methods: We distributed an online questionnaire among 194 adult persons with HSP in the Netherlands, of which 166 returned a fully completed version. After applying predefined exclusion criteria, 109 questionnaires from persons with pure HSP were analysed.

Results: Healthcare needs and expectations were primarily focused on the relief of muscle stiffness and reduction of balance and gait impairments (65-80%), but many participants also expressed needs regarding relief of non-motor symptoms (e.g. pain, fatigue), emotional problems, impaired sleep and self-care capacity, and participation problems (> 60%). Remarkably, despite these frequent needs, relatively few participants (< 33%) expected to be able to improve in these additional domains. Rehabilitation physicians and physiotherapists were more frequently consulted than neurologists and occupational therapists, respectively. Physiotherapy was the most often proposed non-pharmacological intervention (85%), followed by orthopedic footwear (55%) and splints (28%). Approximately one third of the participants was never offered any pharmacological (spasmolytic) treatment. Spasmolytic oral drugs, injections, and intrathecal baclofen were given to 41%, 26%, and 5% of the participants, respectively. Independent of the type of pharmacological intervention, 35-46% of these participants experienced decreased spastiticy and improved general fitness. Other experienced effects differed per type of intervention.

Conclusions: Based on this web-based survey in the Netherlands, there seems to be ample room for improvement to meet and attune the healthcare needs and expectations of people with HSP concerning both their motor and non-motor symptoms and functional limitations. In addition, the provision of adequate information about non-pharmacological and pharmacological interventions seems to be insufficient for many patients to allow shared decision making. These conclusions warrant a more pro-active attitude of healthcare providers as well as an interdisciplinary approach for a substantial proportion of the HSP population, also involving professionals with a primary occupational and/or psychosocial orientation.
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http://dx.doi.org/10.1186/s13023-021-01915-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8223283PMC
June 2021

Reliability, validity and discriminability of patient reported outcomes for non-specific low back pain in a nationwide physical therapy registry: A retrospective observational cohort study.

PLoS One 2021 3;16(6):e0251892. Epub 2021 Jun 3.

Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands.

Background: A national clinical registry was established in the Netherlands containing data directly sampled from electronic health record systems of physical therapists (PTs). This registry aims to evaluate the potential of patient reported outcome measures (PROMs) to develop quality indicators (QIs) in physical therapy care.

Purpose: To test to what extent the collected PROM data are reliable, valid and discriminatory between practices in measuring outcomes of patients with non-specific low back pain (NSLBP).

Methods: In this retrospective cohort study 865 PT practices with 6,560 PTs voluntarily collected PROM data of patients with NSLBP, using the Quebec Back Pain Disability Scale (QBPDS), the Numeric Pain Rating Scale (NPRS) and the Patient Specific Functioning Scale (PSFS). Reliability was determined by analysing the completeness of the dataset, the comparability by using national reference data, and through checking selection bias in the included patients. Validity was tested using the known-groups contrast between patients with (sub)acute vs. chronic NSLBP. To determine discriminative ability of outcomes between PT practices, case-mix corrected hierarchical multilevel analyses were performed.

Results: Reliability was sufficient by confirming fifteen of the sixteen hypotheses: 59% of all patients opted in for data analysis, 42% of these included patients showed repeated measurement, comparing with reference data and potential selection bias showed < 5% between group differences, while differences between (sub)acute and chronic NSLB-groups were significantly larger than 5% (less treatment sessions, lager differences in outcomes in (sub)acute NSLB patients). In addition, all nine adjusted hierarchical multilevel models confirm that the collected dataset on outcomes in PT care is able to discriminate between practices using PROM results of patients with NSLBP (ICC-scores range 0.11-0.21).

Limitations: Although we have shown the reliability, validity and discriminative ability of the dataset in the quest to develop QIs, we are aware that reducing missing values in patient records and the selective participation of PTs that belong to the innovators needs attention in the next stages of implementation to avoid bias in the results.

Conclusion: PROMs of patients with NSLBP collected in the national clinical registry of KNGF are reliable, valid and able to discriminate between primary care PT practices.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0251892PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174721PMC
June 2021

Patient-Reported Outcome-Based Quality Indicators in Dutch Primary Care Physical Therapy for Patients With Nonspecific Low Back Pain: A Cohort Study.

Phys Ther 2021 Aug;101(8)

Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.

Objective: The purpose of this study was to define and select a core set of outcome-based quality indicators, accepted by stakeholders on usability and perceived added value as a quality improvement tool, and to formulate recommendations for the next implementation step.

Methods: In phase 1, 15 potential quality indicators were defined for patient-reported outcome measures and associated domains, namely the Numeric Pain Rating Scale (NPRS) for pain intensity, the Patient Specific Functioning Scale (PSFS) for physical activity, the Quebec Back Pain Disability Scale for physical functioning, and the Global Perceived Effect-Dutch Version for perceived effect. Their comparability and discriminatory characteristics were described using cohort data. In phase 2, a core set of quality indicators was selected based on consensus among stakeholders in focus group meetings.

Results: In total, 65,815 completed treatment episodes for patients with nonspecific low back pain were provided by 1009 physical therapists from 219 physical therapist practices. The discriminability between physical therapists of all potential 15 quality indicators was adequate, with intraclass correlation coefficients between 0.08 and 0.30. Stakeholders selected a final core set of 6 quality indicators: 2 process indicators (the routine measurement of NPRS and the PSFS) and 4 outcome indicators (pretreatment and posttreatment change scores for the NPRS, PSFS, Quebec Back Pain Disability Scale, and the minimal clinically important difference of the Global Perceived Effect-Dutch Version).

Conclusion: This study described and selected a core set of outcome-based quality indicators for physical therapy in patients with nonspecific low back pain. The set was accepted by stakeholders for having added value for daily practice in physical therapy primary care and was found useful for quality improvement initiatives. Further studies need to focus on improvement of using the core set of outcome-based quality indicators as a quality monitoring and evaluation instrument.

Impact: Patient-reported outcome-based quality indicators developed from routinely collected clinical data are promising for use in quality improvement in daily practice.
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http://dx.doi.org/10.1093/ptj/pzab118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8336590PMC
August 2021

Development of a patient-reported outcome measure for patients who have recovered from a subarachnoid hemorrhage: the "questionnaire for the screening of symptoms in aneurysmal subarachnoid hemorrhage" (SOS-SAH).

BMC Neurol 2021 Apr 16;21(1):162. Epub 2021 Apr 16.

Department of Neurosurgery, Radboud University Medical Center, HB, 6500, Nijmegen, the Netherlands.

Background: Patients who have been successfully treated for an aneurysmal subarachnoid hemorrhage (aSAH) often retain multiple health complaints, including mood disorders, cognitive complaints, fatigue, and problems with social participation. These problems are not always fully addressed during hospital visits or in current outcome measures, such as the modified Rankin score and the Glasgow Outcome Scale. Here, we present the development of the "Questionnaire for the Screening of Symptoms in aneurysmal Subarachnoid Hemorrhage" (SOS-SAH), which screens for the self-reported symptoms of patients with mild disabilities.

Methods: During the development of the SOS-SAH we adhered to the PROM-cycle framework for the selection and implementation of patient-reported outcome measures (PROMs). The SOS-SAH was developed in an iterative process informed by a literature study. Patients and healthcare professionals were involved in the development process through participating in a working group, interviews, and a cognitive validation study.

Results And Conclusions: Relevant patient-reported outcomes (PROs) were identified for patients with aSAH. The SOS-SAH was developed primarily using domains and items from existing PROMs and, if necessary, by developing new items. The SOS-SAH consists of 40 items and covers 14 domains: cognitive abilities, hypersensitivity to stimuli, anxiety, depression, fatigue, social roles, personality change, language, vision, taste, smell, hearing, headache, and sexual function. It also includes a proxy measurement for use by family members to assess cognitive functioning and personality change.
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http://dx.doi.org/10.1186/s12883-021-02184-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051103PMC
April 2021

Measurement properties of the Dutch-Flemish patient-reported outcomes measurement information system (PROMIS) physical function item bank and instruments: a systematic review.

Health Qual Life Outcomes 2021 Feb 24;19(1):62. Epub 2021 Feb 24.

Radboud University Medical Center, Radboud Institute of Health Sciences, IQ healthcare, Geert Grooteplein 21 (route 114), P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.

Background: Limitations in physical functioning are a big concern especially for patients with chronic or musculoskeletal diseases. Therefore, physical functioning is often used as a core outcome of treatments. The generic patient-reported outcomes information system (PROMIS) physical function (PF) item bank has shown potential to measure PF with better precision, interpretability and lower respondent burden compared with traditional patient-reported outcome measures. This study provides an overview of the current evidence on the quality of the measurement properties of the translated Dutch-Flemish PROMIS-PF item bank and its subdomains, and their derived short forms and computer adaptive tests (CATs).

Methods: PubMed was searched up to June 17th 2020 for validation studies of Dutch-Flemish PROMIS-PF in Dutch and Flemish adults. Quality assessment of the included studies was conducted using the COSMIN Risk of bias checklist. The COSMIN criteria for good measurement properties were used to judge the results of the studies, which were adjusted and added to where needed for this review, in the context of IRT instruments and item banks. The quality of evidence was summarized for each measurement property based on the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach.

Results: Eleven studies were included, evaluating the PROMIS-PF item bank, the Upper Extremity (UE) subdomain, and/or their derived short forms and CATs in different clinical populations. There is evidence for sufficient structural validity, measurement precision, construct validity, and cross-cultural validity of the Dutch-Flemish PROMIS-PF item bank. The upper extremity subdomain item bank shows high quality evidence for structural validity and measurement precision. Content validity of these item banks has not been thoroughly demonstrated in a Dutch-Flemish population. Furthermore, the derived instruments have far less robust evidence: there are fewer validation studies available and none examined their performance as stand-alone administered instruments.

Conclusions: The first studies into the Dutch-Flemish PROMIS-PF item bank and the UE subdomain show promising results, with especially high quality evidence for sufficient structural validity and measurement precision. However, more studies, and with higher methodological quality, are needed to study the instruments derived from these item banks. These studies should also evaluate content validity, reliability and responsiveness.
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http://dx.doi.org/10.1186/s12955-020-01647-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7905571PMC
February 2021

Guideline-based quality assurance: a conceptual framework for the definition of key elements.

BMC Health Serv Res 2021 Feb 24;21(1):173. Epub 2021 Feb 24.

Department of Health Research Methods, Evidence, and Impact McMaster University Health Sciences Centre, Room 2C16, 1280 Main Street, West Hamilton, ON, L8N 4K1, Canada.

Background: In 2017, the European Commission's Joint Research Centre (JRC) started developing a methodological framework for a guideline-based quality assurance (QA) scheme to improve cancer quality of care. During the first phase of the work, inconsistency emerged about the use of terminology for the definition, the conceptual underpinnings and the way QA relates to health questions that are answered in guidelines. The objective of this final of three articles is to propose a conceptual framework for an integrated approach to guideline and QA development and clarify terms and definitions for key elements. This work will inform the upcoming European Commission Initiative on Colorectal Cancer (ECICC).

Methods: A multidisciplinary group of 23 experts from key organizations in the fields of guideline development, performance measurement and quality assurance participated in a mixed method approach including face-to-face dialogue and several rounds of virtual meetings. Informed by results of a systematic literature review that indicated absence of an existing framework and practical examples, we first identified the relations of key elements in guideline-based QA and then developed appropriate concepts and terminology to provide guidance.

Results: Our framework connects the three key concepts of quality indicators, performance measures and performance indicators integrated with guideline development. Quality indicators are constructs used as a guide to monitor, evaluate, and improve the quality of the structure, process and outcomes of healthcare services; performance measures are tools that quantify or describe measurable elements of practice performance; and performance indicators are quantifiable and measurable units or scores of practice, which should be guided by guideline recommendations.

Conclusions: The inconsistency in the way key terms of QA are used and defined has confused the field. Our conceptual framework defines the role, meaning and interactions of the key elements for improving quality in healthcare. It directly builds on the questions asked in guidelines and answered through recommendations. These findings will be applied in the forthcoming ECICC and for the future updates of ECIBC. These are large-scale integrated projects aimed at improving healthcare quality across Europe through the development of guideline-based QA schemes; this will help in implementing and improving our approach.
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http://dx.doi.org/10.1186/s12913-021-06148-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903784PMC
February 2021

Patterns of healthcare resource utilization in patients with sarcoidosis: a cross-sectional study.

Sarcoidosis Vasc Diffuse Lung Dis 2020 30;37(3):e2020002. Epub 2020 Sep 30.

Radboud university medical center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Department of Rehabilitation.

Background: Limited data are available on healthcare resource use and costs in patients with sarcoidosis.

Objectives: The primary aim of this study was to describe cost-drivers of the top 1% and top ≥1-5% high-cost patients with sarcoidosis. The secondary aim was to compare costs of patients with and without fatigue complaints and to compare comorbidities.

Methods: We conducted a retrospective observational cross-sectional study in 200 patients diagnosed with sarcoidosis. Hospital administrative databases were used to extract healthcare utilization on the individual patient level. Healthcare costs were categorized into nine groups.

Results: Average total health care costs for the top 1% (n=22), top ≥1%-5% (n=88) and bottom 95% beneficiaries (n=90) were € 108.296, €53.237 and €4.817, respectively. Mean treatment time in days for the top 1%, top ≥1-5% and the random sample of the bottom 95% was 1688 days (±225), 1412 days (±367) and 775 days (±659), respectively. Mean annual costs for the top 1%, top ≥1-5% and the random sample of the bottom 95% are €51.082, €27.840 and €8.692, respectively. We identified three cost-drivers in the top 5% high-cost patients: 1) expensive medication, 2) intensive care and 3) costs made at the respiratory unit. Patients with and without fatigue showed to have comparable mean costs. High-cost patients were more likely to have multiple organs involved due to sarcoidosis.

Conclusions: We identified expensive medication as the main cost-driver in the top 5% high-cost patients with sarcoidosis. The study findings can help to tailor interventions for improving the quality of care and reducing overall costs. .
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http://dx.doi.org/10.36141/svdld.v37i3.9261DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7690057PMC
January 2021

The Effects of Respiratory Training in Parkinson's Disease: A Systematic Review.

J Parkinsons Dis 2020 ;10(4):1315-1333

Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Department of Rehabilitation, Nijmegen, the Netherlands.

Background: Signs of respiratory dysfunction can be present already early in the course of Parkinson's disease (PD). Respiratory training could alleviate this, but its effectiveness is not well understood.

Objective: The purpose of this systematic review is to review the efficacy of different respiratory training interventions in PD.

Methods: A search strategy was performed in four databases: PubMed, Physiotherapy Evidence Database (PEDro), Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Methodological quality of original full-text articles was assessed using the Cochrane Risk of Bias tool for randomized controlled trials (RCTs) and the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool for the controlled trials (CTs). Levels of evidence were rated by the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach.

Results: Six papers reporting on four randomized controlled trials and another four controlled trials were included. Positive effects were reported for inspiratory muscle strength training (IMST), expiratory muscle strength training (EMST), air stacking, breath-stacking, incentive spirometry and postural training on respiratory muscle strength, swallowing safety, phonatory aspects and chest wall volumes. Best methodological quality was found for breath-stacking and incentive spirometry. Best levels of evidence were found for EMST, IMST and EMST plus air stacking.

Conclusion: Respiratory training shows positive effects and should be considered when people with PD experience respiratory dysfunction. Future studies should focus on standardizing both training devices, instruments to measure outcomes and intervention protocols to further increase the level of evidence.
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http://dx.doi.org/10.3233/JPD-202223DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7683068PMC
September 2021

Approaches of integrating the development of guidelines and quality indicators: a systematic review.

BMC Health Serv Res 2020 Sep 16;20(1):875. Epub 2020 Sep 16.

Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.

Background: Guidelines and quality indicators (for example as part of a quality assurance scheme) aim to improve health care delivery and health outcomes. Ideally, the development of quality indicators should be grounded in evidence-based, trustworthy guideline recommendations. However, anecdotally, guidelines and quality assurance schemes are developed independently, by different groups of experts who employ different methodologies. We conducted an extension and update of a previous systematic review to identify, describe and evaluate approaches to the integrated development of guidelines and related quality indicators.

Methods: On May 24th, 2019 we searched in Medline, Embase and CINAHL and included studies if they reported a methodological approach to guideline-based quality indicator development and were published in English, French, or German.

Results: Out of 16,034 identified records, we included 17 articles that described a method to integrate guideline recommendations development and quality indicator development. Added to the 13 method articles from original systematic review we included a total 30 method articles. We did not find any evaluation studies. In most approaches, guidelines were a source of evidence to inform the quality indicator development. The criteria to select recommendations (e.g. level of evidence or strength of the recommendation) and to generate, select and assess quality indicators varied widely. We found methodological approaches that linked guidelines and quality indicator development explicitly, however none of the articles reported a conceptual framework that fully integrated quality indicator development into the guideline process or where quality indicator development was part of the question formulation for developing the guideline recommendations.

Conclusions: In our systematic review we found approaches which explicitly linked guidelines with quality indicator development, nevertheless none of the articles reported a comprehensive and well-defined conceptual framework which integrated quality indicator development fully into the guideline development process.
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http://dx.doi.org/10.1186/s12913-020-05665-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7493171PMC
September 2020

Recommendations for Hospital-Based Physical Therapists Managing Patients With COVID-19.

Phys Ther 2020 08;100(9):1444-1457

Department of Rehabilitation, Radboud Institute for Health Sciences, Radboud University Medical Center and IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center.

Objective: The COVID-19 pandemic is rapidly evolving and has led to increased numbers of hospitalizations worldwide. Hospitalized patients with COVID-19 experience a variety of symptoms, including fever, muscle pain, tiredness, cough, and difficulty breathing. Elderly people and those with underlying health conditions are considered to be more at risk of developing severe symptoms and have a higher risk of physical deconditioning during their hospital stay. Physical therapists have an important role in supporting hospitalized patients with COVID-19 but also need to be aware of challenges when treating these patients. In line with international initiatives, this article aims to provide guidance and detailed recommendations for hospital-based physical therapists managing patients hospitalized with COVID-19 through a national approach in the Netherlands.

Methods: A pragmatic approach was used. A working group conducted a purposive scan of the literature and drafted initial recommendations based on the knowledge of symptoms in patients with COVID-19 and current practice for physical therapist management for patients hospitalized with lung disease and patients admitted to the intensive care unit. An expert group of hospital-based physical therapists in the Netherlands provided feedback on the recommendations, which were finalized when consensus was reached among the members of the working group.

Results: The recommendations include safety recommendations, treatment recommendations, discharge recommendations, and staffing recommendations. Treatment recommendations address 2 phases of hospitalization: when patients are critically ill and admitted to the intensive care unit, and when patients are severely ill and admitted to the COVID ward. Physical therapist management for patients hospitalized with COVID-19 comprises elements of respiratory support and active mobilization. Respiratory support includes breathing control, thoracic expansion exercises, airway clearance techniques, and respiratory muscle strength training. Recommendations toward active mobilization include bed mobility activities, active range-of-motion exercises, active (assisted) limb exercises, activities-of-daily-living training, transfer training, cycle ergometer, pre-gait exercises, and ambulation.
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http://dx.doi.org/10.1093/ptj/pzaa114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7337861PMC
August 2020

Clinical adhesion score (CLAS): development of a novel clinical score for adhesion-related complications in abdominal and pelvic surgery.

Surg Endosc 2021 05 14;35(5):2159-2168. Epub 2020 May 14.

Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.

Background: Adhesions are a major cause of long-term postsurgical complications in abdominal and pelvic surgery. Existing adhesion scores primarily measure morphological characteristics of adhesions that do not necessarily correlate with morbidity. The aim of this study was to develop a clinical adhesion score (CLAS) measuring overall clinical morbidity of adhesion-related complications in abdominal and pelvic surgery.

Methods: An international Delphi study was performed to identify relevant score items for adhesion-related complications, including small bowel obstruction, female infertility, chronic abdominal or pelvic pain, and difficulties at reoperation. The CLAS includes clinical outcomes, related to morbidity of adhesions, and weight factors, to correct the outcome scores for the likelihood that symptoms are truly caused by adhesions. In a pilot study, two independent researchers retrospectively scored the CLAS in 51 patients to evaluate inter-observer reliability, by calculating the Intraclass correlation coefficient. During a feasibility assessment, we evaluated whether the CLAS completely covered different clinical scenarios of adhesion-related morbidity.

Results: Three Delphi rounds were performed. 43 experts agreed to participate, 38(88%) completed the first round, and 32 (74%) the third round. Consensus was reached on 83.4% of items. Inter-observer reliability for the CLAS was 0.95 (95% CI 0.91-0.97). During feasibility assessment, six items were included. As a result, the CLAS includes 22 outcomes and 23 weight factors.

Conclusion: The CLAS represents a promising scoring system to measure and monitor the clinical morbidity of adhesion-related complications. Further studies are needed to confirm its utility in clinical practice.
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http://dx.doi.org/10.1007/s00464-020-07621-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8057995PMC
May 2021

Dutch oral health care quality measures: a modified Delphi study.

Int Dent J 2020 Aug 14;70(4):277-286. Epub 2020 Apr 14.

Department of Dentistry - Quality and Safety of Oral Healthcare, Radboud University - Radboudumc (RIHS), Nijmegen, The Netherlands.

Objectives: Quality measures offer opportunities for evaluation and improvement of the quality of oral health care. This study describes the development of a core set of oral health care quality measures for adults in the Netherlands, which can be used in dental practice.

Materials And Methods: A comprehensive two-stage approach was used, consisting of: (1) identification of an initial set of measures based on appraised literature; and (2) a four-round modified RAND/UCLA Appropriateness Method to establish measures that are relevant, appropriate and important to oral health care. Measures were rated anonymously on a nine-point Likert scale, ranging from 1 (lowest rating) to 9 (highest rating), followed by a group discussion to reach consensus. Multiple key stakeholder groups in the Dutch oral health care field were involved in the Delphi rounds, including dental professionals, scientists and representatives from Dutch oral health care organisations.

Results: The study resulted in a core set of 13 oral health care quality measures. The measures cover domains related to oral disease outcomes, oral treatment and preventive services, patient experiences, patient safety, and organisational aspects of oral health care. In addition, the study led to the identification of 49 structural aspects of oral health care that are important to measure.

Discussion: To our knowledge, this is the first study combining appraised literature from a systematic review and a rigorous multi-stage procedure with extensive stakeholder involvement to develop a core set of oral health care quality measures. In the next phase, the measures will be tested on feasibility, reliability, and will be piloted and implemented in practice.
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http://dx.doi.org/10.1111/idj.12566DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7497121PMC
August 2020

Experienced consequences of spasticity and effects of botulinum toxin injections: a qualitative study amongst patients with disabling spasticity after stroke.

Disabil Rehabil 2020 Apr 7:1-8. Epub 2020 Apr 7.

Department of Rehabilitation, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands.

Chronic spasticity poses a major burden on patients after stroke. Intramuscular botulinum toxin injections constitute an important part of the treatment for patients suffering from troublesome focal spasticity. This study explores the experienced consequences of chronic spasticity amongst patients after stroke regarding physical impairments and activities, the experienced effects of botulinum toxin treatment on these domains, and whether current spasticity management addresses patients' needs. Fourteen participants with chronic spasticity after stroke who were treated with cyclical botulinum toxin injections in the upper and/or lower extremity muscles were interviewed. Inductive thematic analysis generated representative themes. Analyses of the interviews revealed three themes: (1) spasticity-related impairments and activity limitations; (2) fluctuations in spasticity related to botulinum toxin; (3) need for professional support and feedback. Besides motor impairments, participants experienced activity limitations in many domains of everyday life, with considerable day-to-day fluctuations. Moreover, treatment with botulinum toxin led to cyclical fluctuations in spasticity-related symptoms, which differed across participants. The participants called for shared responsibility for treatment, particularly regarding optimising the timing of injections. Incorporating patient-relevant outcomes into the current assessment of spasticity and monitoring these outcomes may improve spasticity management, particularly regarding the timing of botulinum toxin injections.Implications for rehabilitationBecause chronic spasticity after stroke impacts on almost all domains of everyday life, professionals should identify and target the most relevant problems in each individual patient.Monitoring patient-reported outcomes may help patients and professionals to get insight in the fluctuations of spasticity-related symptoms and may help to evaluate the effects of botulinum toxin injections from the patient's perspective.Patient education and providing insight in the fluctuations of spasticity-related symptoms may support self-management and shared decision-making in spasticity management.
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http://dx.doi.org/10.1080/09638288.2020.1746843DOI Listing
April 2020

Selecting interventions to improve patient-relevant outcomes in health care for aortic valve disease - the Intervention Selection Toolbox.

BMC Health Serv Res 2020 Mar 19;20(1):232. Epub 2020 Mar 19.

Department of Value-based Healthcare, St. Antonius Hospital, P.O. Box 2500, 3430, EM, Nieuwegein, the Netherlands.

Background: Measuring and improving outcomes is a central element of value-based health care. However, selecting improvement interventions based on outcome measures is complex and tools to support the selection process are lacking. The goal was to present strategies for the systematic identification and selection of improvement interventions applied to the case of aortic valve disease and to combine various methods of process and outcome assessment into one integrated approach for quality improvement.

Methods: For this case study a concept-driven mixed-method approach was applied for the identification of improvement intervention clusters including: (1) benchmarking outcomes, (2) data exploration, (3) care delivery process analysis, and (4) monitoring of ongoing improvements. The main outcome measures were long-term survival and 30-day mortality. For the selection of an improvement intervention, the causal relations between the potential improvement interventions and outcome measures were quantified followed by a team selection based on consensus from a multidisciplinary team of professionals.

Results: The study resulted in a toolbox: the Intervention Selection Toolbox (IST). The toolbox comprises two phases: (a) identifying potential for improvement, and (b) selecting an effective intervention from the four clusters expected to lead to the desired improvement in outcomes. The improvements identified for the case of aortic valve disease with impact on long-term survival in the context of the studied hospital in 2015 include: anticoagulation policy, increased attention to nutritional status of patients and determining frailty of patients before the treatment decision.

Conclusions: Identifying potential for improvement and carefully selecting improvement interventions based on (clinical) outcome data demands a multifaceted approach. Our toolbox integrates both care delivery process analyses and outcome analyses. The toolbox is recommended for use in hospital care for the selection of high-impact improvement interventions.
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http://dx.doi.org/10.1186/s12913-020-05090-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082899PMC
March 2020

Dysphagia and Dysarthria in Children with Neuromuscular Diseases, a Prevalence Study.

J Neuromuscul Dis 2020 ;7(3):287-295

Radboud University Medical Center, Department of Rehabilitation, Nijmegen, The Netherlands.

Background: Dysphagia and dysarthria are frequently described in pediatric neuromuscular diseases (pNMD). The consequences can be substantial: failure to thrive, malnutrition, aspiration pneumonia, or communication problems. Early detection and identification of risk factors and etiology support preventing complications and morbidity, including impact on quality of life. Information about the prevalence of dysphagia and dysarthria in pNMD is scarce.

Objective: To describe the pooled prevalence of dysphagia and dysarthria in pNMD in the Netherlands. In addition, we describe the prevalence of dysphagia and dysarthria each, and the prevalence of chewing (oral) and swallowing problems per diagnostic group, based on their anatomic origin.

Methods: Data were collected from 295 children (mean age 11;0 years, range 2;6-18;0) with pNMD in 12 hospitals and rehabilitation centers in the Netherlands. A speech language therapist established whether dysphagia and dysarthria were present or not.

Results: In almost all the 14 diagnostic groups of pNMD, dysphagia and dysarthria were present. Pooled overall prevalence of dysphagia and dysarthria was 47.2% and 31.5%, respectively. Of 114 children with dysphagia, 90.0% had chewing problems, 43.0% showed swallowing problems and 33.3% showed both chewing and swallowing problems.

Conclusions: The overall pooled prevalence of dysphagia and dysarthria was high in the population of pNMD. It can be argued that periodic monitoring of dysphagia and dysarthria and early referral to a speech language therapist should be a necessity from the start of the diagnosis in the whole pNMD population.
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http://dx.doi.org/10.3233/JND-190436DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7369072PMC
March 2021

Reliability and Responsiveness of the Observable Movement Quality Scale for Children with Mild to Moderate Motor Impairments.

Phys Occup Ther Pediatr 2020 27;40(6):681-696. Epub 2020 Feb 27.

Department of Rehabilitation, Pediatric Physical Therapy, Radboud University Medical Center, Amalia Children's Hospital, Radboud Institute for Health Sciences, The Netherlands.

Aim: The Observable Movement Quality (OMQ) scale measures generic movement quality and is used alongside standardized age-adequate motor performance tests. The scale consists of 15 items, each focusing on a different aspect; together, the entire construct of movement quality is assessed. This study aimed to determine interrater and intrarater reliability, and responsiveness of the OMQ scale.

Methods: A prospective intervention study with pre-post design in pediatric physical therapy practices. For interrater reliability, 3 physical therapists observed video-recorded motor assessments of 30 children with mild to moderate motor impairments -aged 4 to 12 years-using the OMQ scale. One therapist scored baseline assessment a second time for intrarater reliability, and to calculate smallest detectable change (SDC). Responsiveness ( = 28) was tested by comparing outcomes before and after intervention.

Results: Interrater reliability was moderate to good (ICC: 0.79); intrarater reliability was high (ICC: 0.97). Responsiveness results revealed an SDC of 2.4 and a minimal important change of 2.5; indicating sufficient validity in differentiating groups of children showing improved versus unchanged movement quality.

Conclusion: The OMQ scale is reliable and responsive to change when used to assess movement quality in clinical practice for children with mild to moderate motor impairments, aged 4-12 year.
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http://dx.doi.org/10.1080/01942638.2020.1729924DOI Listing
February 2021

Development of a framework with tools to support the selection and implementation of patient-reported outcome measures.

J Patient Rep Outcomes 2019 Dec 30;3(1):75. Epub 2019 Dec 30.

Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, the Netherlands.

Background: Patient reported outcomes (PROs) provide information on a patient's health status coming directly from the patient. Measuring PROs with patient reported outcome measures (PROMs) has gained wide interest in clinical practice for individual patient care, as well as in quality improvement, and for providing transparency of outcomes to stakeholders through public reporting. However, current knowledge of selecting and implementing PROMs for these purposes is scattered, and not readily available for clinicians and quality managers in healthcare organizations. The objective of this study is to develop a framework with tools to support the systematic selection, implementation and evaluation of PROs and PROMs in individual patient care, for quality improvement and public reporting.

Methods: We developed the framework in a national project in the Netherlands following a user-centered design. The development process of the framework contained five iterative components: (a) identification of existing tools, (b) identification of user requirements and designing steps for selection and implementation of PROs and PROMs, (c) discussing a prototype of the framework during a national workshop, (d) developing a web version, (e) pre-testing of the framework. A total of 40 users with different perspectives (clinicians, patient representatives, quality managers, purchasers, researchers) have been consulted.

Results: The final framework is presented as the PROM-cycle that consists of eight steps in four phases: (1) goal setting, (2) selecting PROs and PROMs, (3) developing and testing of quality indicator(s), (4) implementing and evaluating the PROM(s) and indicator(s). Users emphasized that the first step is the key element in which the why, for whom and setting of the PROM has to be defined. This information is decisive for the following steps. For each step the PROM-cycle provides guidance and tools, with instruments, checklists, methods, handbooks, and standards supporting the process.

Conclusion: We developed a framework to support the selection and implementation of PROs and PROMs. Each step provides guidance and tools to support the process. The PROM-cycle and its tools are publicly available and can be used by clinicians, quality managers, patient representatives and other experts involved in using PROMS. Through periodic evaluation and updates, tools will be added for national and international use of the PROM-cycle.
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http://dx.doi.org/10.1186/s41687-019-0171-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6937349PMC
December 2019

Which Factors Influence the Use of Patient-Reported Outcome Measures in Dutch Physiotherapy Practice? A Cross-Sectional Study.

Physiother Can 2020 ;72(1):63-70

Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen.

Patient-reported outcome measures (PROMs) have the potential to enhance the quality of health care but, as a result of suboptimal implementation, it is unclear whether they fulfil this role in physiotherapy practice. This cross-sectional study aimed to identify the factors influencing PROM use in Dutch private physiotherapy practices. A total of 444 physiotherapists completed a self-assessment questionnaire and uploaded the data from their electronic health record (EHR) systems to the national registry of outcome data. Univariate and multivariate ordinal logistic and linear regression analysis were used to identify the factors associated with self-reported PROM use and PROM use registered in the EHR systems, which were derived from the self-assessment questionnaire and from the data in the national registry, respectively. Five categories with nine independent variables were selected as potential factors for regression analysis. The similarity between self-reported and registered PROM use was verified. On the basis of self-report and EHR report, we found that 21.6% and 29.8% of participants, respectively, used PROMs with more than 80% of their patients, and we identified the factors associated with PROM use. The factors associated with PROM use are EHR systems that support PROM use and more knowledge about PROM use. These findings can guide future strategies to enhance the use of PROMs in physiotherapy practice.
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http://dx.doi.org/10.3138/ptc-2018-0028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8330984PMC
January 2020

Development of a Standard Set of Outcome Domains and Proposed Measures for Chronic Obstructive Pulmonary Disease in Primary Care Physical Therapy Practice in the Netherlands: a Modified RAND/UCLA Appropriateness Method.

Int J Chron Obstruct Pulmon Dis 2019 28;14:2649-2661. Epub 2019 Nov 28.

Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, Netherlands.

Background: Standardization of measures in a common set opens the opportunity to learn from differences in treatment outcomes which can be used for improving the quality of care. Furthermore, a standard set can provide the basis for development of quality indicators and is therefore useful for quality improvement and public reporting purposes. The aim of this study was to develop a standard set of outcome domains and proposed measures for patients with COPD in Dutch primary care physical therapy practice, including a proposal to stratify patients in subgroups.

Material And Methods: A consensus-driven modified RAND-UCLA appropriateness method was conducted with relevant stakeholders (patients, physical therapists, researchers, policy makers and health insurers) in Dutch primary physical therapy care in eight steps: (1) literature search, (2) first online survey, (3) patient interviews, (4) expert meeting, resulting in a concept standard set and methods to identify subgroups' (5) consensus meeting, (6) expert meeting (7) second online survey and (8) final approval of an advisory board resulting of the approved standard set.

Results: Five outcome domains were selected for COPD: physical capacity, muscle strength, physical activity, dyspnea and quality of life. A total of 21 measures were rated and discussed. Finally, eight measures were included, of which four mandatory measures: Characteristics of practices and physical therapists, Clinical COPD Questionnaire (CCQ) for quality of life, Global Perceived Effect (GPE) for experience, 6-mins Walk Test (6-MWT) for physical capacity; two conditional measures: Hand-Held Dynamometer (HHD) (with Microfet™) for Quadriceps strength, Medical Research Council Dyspnea (MRC) for monitoring dyspnea; and two exploratory measures: Accelerometry for physical activity, and the Assessment of Burden of COPD tool (ABC). To identify subgroups, a method described in the Dutch standard of care from the Lung Alliance was included.

Conclusion: This study described the development of a standard set of outcome domains and proposed measures for patients with COPD in primary care physical therapy. Each measure was accepted for relevance and feasibility by the involved stakeholders. The set is currently used in daily practice and tested on validity and reliability in a pilot for the development of quality indicators.
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http://dx.doi.org/10.2147/COPD.S219851DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6886541PMC
April 2020

Using research to guide practice: The Physiotherapy Evidence Database (PEDro).

Braz J Phys Ther 2020 Sep - Oct;24(5):384-391. Epub 2019 Nov 30.

Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Australia.

Background: The Physiotherapy Evidence Database (PEDro) is a free, preeminent, global resource to support evidence-based physical therapy. PEDro provides rapid access to randomized controlled trials, systematic reviews, and clinical practice guidelines evaluating physical therapy interventions.

Methods: This paper describes the PEDro scale, PEDro contents, who uses PEDro, searching, browsing the latest content, and developing skills in evidence-based physical therapy. Strategies specifically developed to break down barriers for Portuguese-speaking physical therapists are emphasized.

Results: All trials indexed in PEDro are assessed for methodological quality using the 10-point PEDro scale. These ratings are used to rank search results. In August 2019 PEDro indexed 44,309 articles: 34,619 trials, 9004 reviews, and 686 guidelines. The number of trials is predicted to double by 2025. PEDro users come from 214 countries. Physical therapists in Brazil are the largest users (23% of all searches). Physical therapists are encouraged to use the PEDro advanced search page to find answers for their clinical questions. PEDro's 'Evidence in your inbox' allows physical therapists to browse the latest content. To assist users develop skills in evidence-based physical therapy, PEDro includes tutorials and a series of 'how to' videos. PEDro web-site is fully available in Portuguese and English.

Conclusion: PEDro facilitates the use of high-quality clinical research by physical therapy clinicians, educators, students, and researchers. In 2019 PEDro celebrated its twentieth anniversary. Some enhancements to mark this milestone include launching a new database called DiTA (Diagnostic Test Accuracy) that focuses on the accuracy of diagnostic tests used by physical therapists.
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http://dx.doi.org/10.1016/j.bjpt.2019.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7563998PMC
April 2021

Development of a longlist of healthcare quality indicators for physical activity of patients during hospital stay: a modified RAND Delphi study.

BMJ Open 2019 11 10;9(11):e032208. Epub 2019 Nov 10.

IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands.

Objective: To develop a longlist of healthcare quality indicators for the care of hospitalised adults of all ages with (or at risk of) low physical activity during the hospital stay.

Design: A modified RAND/UCLA Appropriateness Method Delphi study.

Setting And Participants: Participants were physical therapists, nurses and managers working in Dutch university medical centres.

Methods: The current study consisted of three phases. Phase I was a systematic literature search for quality indicators and relevant domains. Phase II was a survey among healthcare professionals to collect additional data. Phase III consisted of three consensus rounds. In round 1, experts rated the relevance of the potential indicators online (Delphi). The second round was a face-to-face expert panel meeting managed by an experienced moderator. Acceptability, feasibility and validity of the quality indicators were discussed by the panel members. In round 3, the panel members rated the relevance of the potential indicators that were still under discussion.

Results: The search retrieved 1556 studies of which 53 studies were assessed full text. Data from 17 studies were included in a first draft longlist of indicators. Eighteen nurses and one physical therapist responded to the survey and added data for a second draft of the longlist. Experts constructed the final longlist of 23 indicators in three consensus rounds. Seven domains were identified: 'Policy', 'Attitude and education', 'Equipment and support', 'Evaluation', 'Information', 'Patient-tailored physical activity plan' and 'Outcome measure'.

Conclusion And Implications: The healthcare quality indicators developed in this study could help to grade, monitor and improve healthcare for hospitalised adults of all ages with (or at risk of) low physical activity during the hospital stay. Future research will focus on the psychometric quality of the indicators and selection of key performance indicators.
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http://dx.doi.org/10.1136/bmjopen-2019-032208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858236PMC
November 2019

Results of the standard set for pulmonary sarcoidosis: feasibility and multicentre outcomes.

ERJ Open Res 2019 Oct 30;5(4). Epub 2019 Oct 30.

Interstitial Lung Diseases Center of Excellence, Dept of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands.

Our study presents findings on a previously developed standard set of clinical outcome data for pulmonary sarcoidosis patients. We aimed to assess whether changes in outcome varied between the different centres and to evaluate the feasibility of collecting the standard set retrospectively. This retrospective observational comparative benchmark study included six interstitial lung disease expert centres based in the Netherlands, Belgium, the UK and the USA. The standard set of outcome measures included 1) mortality, 2) changes in pulmonary function (forced vital capacity (FVC), forced expiratory volume in 1 s, diffusing capacity of the lung for carbon monoxide), 3) soluble interleukin-2 receptor (sIL-2R) change, 4) weight changes, 5) quality-of-life (QoL) measures, 6) osteoporosis and 7) clinical outcome status (COS). Data collection was considered feasible if the data were collected in ≥80% of all patients. 509 patients were included in the retrospective cohort. In total six patients died, with a mean survival of 38±23.4 months after the diagnosis. Centres varied in mean baseline FVC, ranging from 110 (95% CI 92-124)% predicted to 99 (95% CI 97-123)% pred. Mean baseline body mass index (BMI) of patients in the different centres varied between 27 (95% CI 23.6-29.4) kg·m and 31.8 (95% CI 28.1-35.6) kg·m. 310 (60.9%) patients were still on systemic therapy 2 years after the diagnosis. It was feasible to measure mortality, changes in pulmonary function, weight changes and COS. It is not (yet) feasible to retrospectively collect sIL-2R, osteoporosis and QoL data internationally. This study shows that data collection for the standard set of outcome measures for pulmonary sarcoidosis was feasible for four out of seven outcome measures. Trends in pulmonary function and BMI were similar for different hospitals when comparing different practices.
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http://dx.doi.org/10.1183/23120541.00094-2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6819983PMC
October 2019

Exploring the perspective of patients with musculoskeletal health problems in primary care on the use of patient-reported outcome measures to stimulate quality improvement in physiotherapist practice; a qualitative study.

Physiother Theory Pract 2021 Sep 22;37(9):993-1004. Epub 2019 Oct 22.

Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, Netherlands.

: Patient-reported outcome measures (PROMs) in clinical practice might enhance patient- centeredness and effectiveness of physiotherapy practice. Although patients have a crucial role in using PROMs, little is known about their perspective on its usefulness.: Explore the perspective of patients with musculoskeletal health problems on using PROMs for quality improvement in primary care physiotherapy practice, and determine what barriers and facilitators patients perceive.: Semi-structured interviews were performed in 21 patients recruited from primary care physiotherapy practice and analyzed using theoretical thematic analysis. Barriers and facilitators on PROMs implementation were categorized into four predefined domains conform.: Across all domains, three major themes were identified: 1) Practicality; 2) Interaction with the physiotherapist for decision-making; and 3) Sharing information outside the clinical context. Generally, PROMs were perceived practically applicable instruments with added value to the interaction with the physiotherapist for shared decision-making and for stimulating quality improvement. The perceived barriers were: difficulties in administering PROMs for patients with poor computer skills, suboptimal efficiency when PROMs were administered at the expense of the consultation, the insufficient added value of PROMs for patients with recurrent health problems, and reluctance about sharing aggregated data for accountability purposes.: The dependence on the participating physiotherapists in patient recruitment might have resulted in selection bias.: Patients perceive that using PROMs has an added value in primary care physiotherapy practice. Optimizing implementation using tailored implementation strategies related to the identified barriers in all four domains might further improve the use of PROMs in clinical practice.
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http://dx.doi.org/10.1080/09593985.2019.1678205DOI Listing
September 2021

Characteristics and health care utilization among patients with chronic heart failure: a longitudinal claim database analysis.

ESC Heart Fail 2019 12 26;6(6):1243-1251. Epub 2019 Sep 26.

Scientific Center for Quality of Healthcare, Radboud University Medical Center, PO Box 9101, 6500, HB, Nijmegen, The Netherlands.

Aims: This study aimed to determine the characteristics of patients with heart failure and high costs (top 1% and top 2-5% highest costs in perspective of the general population) and to explore the longitudinal health care utilization and persistency of high costs.

Methods And Results: Longitudinal observational study using claims data from 2006 to 2014 in the Netherlands. We identified all patients that received a hospital treatment for chronic heart failure between 1 January 2008 and 31 December 2010. Of each selected patient, all claims from the Dutch curative health system and with a starting date between 1 January 2006 and 31 December 2014 were extracted. Pharmaceutical and hospital claims were used to establish characteristics and indicators for health care utilization. Descriptive analyses and generalized estimating equation models were used to analyse characteristics, longitudinal health care utilization and to identify factors associated with high costs. Our findings revealed that the difference in costs between top 1%, top 2-5%, and bottom 95% patients with heart failure was mainly driven by hospital costs; and the top 1% group experienced a remarkable increase of mental health costs. Top 1% and top 2-5% patients with heart failure differed from lower cost patients in their higher rate of chronic conditions, excessive polypharmacy, hospital admissions, and heart-related surgeries. Heart-related surgeries contributed to the incidental high costs in 54% of top 1% patients, and the costs of the remaining top 1% patients were driven by mental health and pharmaceuticals use and rates of chronic conditions and multimorbidity. Top 1% patients were relatively young. Anaemia, dementia, diseases of arteries, veins and lymphatic vessels, influenza, and kidney failure were significantly associated with high costs. The end-of-life period was predictive of top 1% and top 5% costs. More than 90% of the population incurred at least one top 5% year during follow-up, and 31.8% incurred at least one top 1% year. Fifty-seven per cent incurred multiple top 5% years whereas only 8.6% incurred multiple top 1% years. Top 5% years were more frequently consecutive than top 1% years.

Conclusions: Top 1% utilization occurs predominantly incidentally and among less than a third of patients with heart failure, whereas almost all patients with heart failure experience at least one top 5% year, and more than half experience two or more top 5% years. Both medical and psychiatric/psychosocial needs contribute to high costs in heart failure patients. Comprehensive and integrated efforts are needed to further improve quality of care and reduce unnecessary costs.
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http://dx.doi.org/10.1002/ehf2.12512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6989283PMC
December 2019

Does the Patient-Reported Apnea Questionnaire (PRAQ) increase patient-centredness in the daily practice of sleep centres? a mixed-methods study.

BMJ Open 2019 06 14;9(6):e025963. Epub 2019 Jun 14.

IQ Healthcare, Radboudumc, Nijmegen, The Netherlands.

Objectives: The objective of this exploratory study was to see how the Patient-Reported Apnea Questionnaire (PRAQ) may impact the daily clinical practice of sleep centres, and why it may or may not work as expected. The hypotheses were tested that this patient-reported outcome measure makes patients more aware of which of their health complaints may be related to obstructive sleep apnoea (OSA), and that it improves patient-centredness of care by shifting the focus of care away from (only) medical problems towards the individual burden of disease and quality of life.

Design: Mixed methods. The quantitative study (surveys, patient records) was a before-and-after study.

Setting: Three sleep centres in The Netherlands (secondary care).

Participants: 27 patients and 14 healthcare professionals were interviewed. 487 patients completed surveys pre-implementation, and 377 patients completed surveys post-implementation of the PRAQ. For the health records, 125 patients were included in the pre-implementation group, and 124 other patients in the post-implementation group.

Interventions: The PRAQ was used in clinical practice for six successive months.

Outcome Measures: Scores on individual survey items, number of patients receiving non-medical treatment, adjustment of treatment at first follow-up, compliance with treatment.

Results: Patients were generally positive about the usefulness of the PRAQ before and during the consultation, as they felt more informed. Healthcare providers did not consider the PRAQ very useful, and they reported minor impact on their consultations. The surveys and health record study did not show an impact of the PRAQ on clinical practice.

Conclusions: Implementing the PRAQ may be beneficial to patients, but this study does not show much impact with regard to patient-centredness of care. New Dutch guidelines for OSA care may lead to a greater emphasis on quality of life and value of care for patients, making its integration in clinical care potentially more useful.
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http://dx.doi.org/10.1136/bmjopen-2018-025963DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6585829PMC
June 2019

Organization of outcome-based quality improvement in Dutch heart centres.

Eur Heart J Qual Care Clin Outcomes 2020 01;6(1):49-54

Netherlands Heart Registry, Moreelsepark 1, 3511 EP Utrecht, The Netherlands.

Aims: Fourteen Dutch heart centres collected patient-relevant outcomes to support quality improvements in a value-based healthcare initiative that began in 2012. This study aimed to evaluate the current state of outcome-based quality improvement within six of these Dutch heart centres.

Methods And Results: Interviews and questionnaires among physicians and healthcare professionals in the heart centres were combined in a mixed-methods approach. The analysis indicates that the predominant focus of the heart centres is on the actual monitoring of outcomes. A systematic approach for the identification of improvement potential and the selection and implementation of improvement initiatives is lacking. The organizational context for outcome-based quality improvement is similar in the six heart centres.

Conclusion: Although these heart centres in the Netherlands measure health outcomes for the majority of cardiac diseases, the actual use of these outcomes to improve quality of care remains limited. The main barriers are limitations regarding (i) data infrastructure, (ii) a systematic approach for the identification of improvement potential and the selection and implementation of improvement initiatives, (iii) governance in which roles and responsibilities of physicians regarding outcome improvement are formalized, and (iv) implementation of outcomes within hospital strategy, policy documents, and the planning and control cycle.
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http://dx.doi.org/10.1093/ehjqcco/qcz021DOI Listing
January 2020

Patient-reported outcome measures in subarachnoid hemorrhage: A systematic review.

Neurology 2019 06 10;92(23):1096-1112. Epub 2019 May 10.

From the Department of Neurology (E.N.-J., W.I.M.V.), Canisius Wilhelmina Hospital; and Department of Neurosurgery (E.N.-J., R.H.M.A.B., J.D.B.) and Radboud Institute of Health Sciences, IQ Health care (P.J.v.d.W., G.P.W.), Radboud University Medical Center, Nijmegen, the Netherlands.

Objective: Patient-reported outcomes (PROs) are aspects of a patient's health status and are considered important for stimulating patient-centered care. Current outcome measures in clinical care for patients with aneurysmal subarachnoid hemorrhage (aSAH) are insufficient to capture PROs. In this systematic review, we aimed to summarize the evidence regarding the quality of patient-reported outcome measures (PROMs) in aSAH patients.

Methods: We performed a systematic review of the literature published from inception until October 29, 2018, in PubMed, the Cochrane Central Register of Controlled Trials, and EMBASE. Eligible studies had to evaluate measurement properties and capture PROs in aSAH patients. The quality of the studies and measurement properties were assessed using the consensus-based standards for the selection of health status measurement instruments (COSMIN) checklist. The review protocol was registered with PROSPERO (CRD42018058566).

Results: We identified 9 articles that reported the assessment of 7 different disease-specific and generic PROMs used for aSAH patients, including 5 that focused on the Stroke-Specific Quality of Life Scale (SS-QoL). The methodologic quality of the validation processes used was generally doubtful. None of the PROMs complied with current standards for content validity.

Conclusions: Due to the low quality of evidence for the measurement properties, the evidence base for selecting a suitable PROM for use with aSAH patients is insufficient. Given the specific long-term consequences of aSAH, we consider a disease-specific PROM the most appropriate, with SS-QoL the most suitable PROM currently available.
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http://dx.doi.org/10.1212/WNL.0000000000007618DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6556093PMC
June 2019

First patient-centred set of outcomes for pulmonary sarcoidosis: a multicentre initiative.

BMJ Open Respir Res 2019 18;6(1):e000394. Epub 2019 Feb 18.

Department of Value-Based Healthcare, St. Antonius Hospital, Nieuwegein, The Netherlands.

Introduction: Routine and international comparison of clinical outcomes enabling identification of best practices for patients with pulmonary sarcoidosis is lacking. The aim of this study was to develop a standard set of outcome measures for pulmonary sarcoidosis, using the value-based healthcare principles.

Methods: Six expert clinics for interstitial lung diseases in four countries participated in a consensus-driven RAND-modified Delphi study. A mixed-method approach was applied for the identification of an outcome measures set and initial conditions for patients with pulmonary sarcoidosis. The expert team consisted of multidisciplinary professionals (n=14) from Cleveland Clinic, Cincinnati MC, Erasmus MC, Leuven UZ, Royal Brompton and St. Antonius Hospital. During a ranking process, participants were instructed to rank variables on a scale from 1 to 10 based on whether it has (1) impact of the outcome on quality of life, (2) impact of quality of care on the outcome and (3) the number of patients negatively affected by the outcome.

Results: An outcome measures set was defined consisting of seven outcome measures: mortality, pulmonary function, soluble interleukin-2 receptor change as an activity biomarker, weight gain, quality of life, osteoporosis and clinical outcome status.

Discussion: Collecting outcomes in pulmonary sarcoidosis internationally and the use of a broadly accepted set can enable international comparison. Differences in outcomes can potentially be used as a starting point for quality improvement initiatives.
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http://dx.doi.org/10.1136/bmjresp-2018-000394DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6424298PMC
April 2020

Impact of Self- and Peer Assessment on the Clinical Performance of Physiotherapists in Primary Care: A Cohort Study.

Physiother Can 2018 ;70(4):393-401

Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen.

This study evaluated the impact of a quality improvement programme based on self- and peer assessment to justify nationwide implementation. Four professional networks of physiotherapists in The Netherlands ( = 379) participated in the programme, which consisted of two cycles of online self-assessment and peer assessment using video recordings of client communication and clinical records. Assessment was based on performance indicators that could be scored on a 5-point Likert scale, and online assessment was followed by face-to-face feedback discussions. After cycle 1, participants developed personal learning goals. These goals were analyzed thematically, and goal attainment was measured using a questionnaire. Improvement in performance was tested with multilevel regression analyses, comparing the self-assessment and peer-assessment scores in cycles 1 and 2. In total, 364 (96%) of the participants were active in online self-assessment and peer assessment. However, online activities varied between cycle 1 and cycle 2 and between client communication and recordkeeping. Personal goals addressed client-centred communication (54%), recordkeeping (24%), performance and outcome measurement (15%), and other (7%). Goals were completely attained (29%), partly attained (64%), or not attained at all (7%). Self-assessment and peer-assessment scores improved significantly for both client communication (self-assessment = 11%; peer assessment = 8%) and recordkeeping (self-assessment = 7%; peer assessment = 4%). Self-assessment and peer assessment are effective in enhancing commitment to change and improving clinical performance. Nationwide implementation of the programme is justified. Future studies should address the impact on client outcomes.
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http://dx.doi.org/10.3138/ptc.2017-40.pcDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6361404PMC
January 2018
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