Due to the ageing population, the prevalence of musculoskeletal disorders will continue to rise, as well as healthcare expenditure. To overcome these increasing expenditures, integration of orthopaedic care should be stimulated. The Primary Care Plus (PC+) intervention aimed to achieve this by facilitating collaboration between primary care and the hospital, in which specialised medical care is shifted to a primary care setting. The present study aims to evaluate the referral decision following orthopaedic care in PC+ and in particular to evaluate the influence of diagnostic tests on this decision. Therefore, retrospective monitoring data of patients visiting PC+ for orthopaedic care was used. Data was divided into two periods; P1 and P2. During P2, specialists in PC+ were able to request additional diagnostic tests (such as ultrasounds and MRIs). A total of 2,438 patients visiting PC+ for orthopaedic care were included in the analysis. The primary outcome was the referral decision following PC+ (back to the general practitioner (GP) or referral to outpatient hospital care). Independent variables were consultation- and patient-related predictors. To describe variations in the referral decision, logistic regression modelling was used. Results show that during P2, significantly more patients were referred back to their GP. Moreover, the multivariable analysis show a significant effect of patient age on the referral decision (OR 0.86, 95% CI = 0.81– 0.91) and a significant interaction was found between the treating specialist and the period (p = 0.015) and between patient’s diagnosis and the period (p < 0.001). Despite the significant impact of the possibility of requesting additional diagnostic tests in PC+, it is important to discuss the extent to which the availability of diagnostic tests fits within the vision of PC+. In addition, selecting appropriate profiles for specialists and patients for PC+ are necessary to further optimise the effectiveness and cost of care.
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Background: The substitution of healthcare is a way to control rising healthcare costs. The Primary Care Plus (PC+) intervention of the Dutch ‘Blue Care’ pioneer site aims to achieve this feat by facilitating consultations with medical specialists in the primary care setting. One of the specialties involved is dermatology. This study explores referral decisions following dermatology care in PC+ and the influence of predictive patient and consultation characteristics on this decision. Methods: This retrospective study used clinical data of patients who received dermatology care in PC+ between January 2015 and March 2017. The referral decision following PC+, (i.e., referral back to the general practitioner (GP) or referral to outpatient hospital care) was the primary outcome. Stepwise logistic regression modelling was used to describe variations in the referral decisions following PC+, with patient age and gender, number of PC+ consultations, patient diagnosis and treatment specialist as the predicting factors. Results: A total of 2952 patients visited PC+ for dermatology care. Of those patients with a registered referral, 80.2% (N = 2254) were referred back to the GP, and 19.8% (N = 558) were referred to outpatient hospital care. In the multivariable model, only the treating specialist and patient’s diagnosis independently influenced the referral decisions following PC+. Conclusion: The aim of PC+ is to reduce the number of referrals to outpatient hospital care. According to the results, the treating specialist and patient diagnosis influence referral decisions. Therefore, the results of this study can be used to discuss and improve specialist and patient profiles for PC+ to further optimise the effectiveness of the initiative.
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Abstract Background: Many countries in Europe have implemented managed competition and patient choice during the last decade. With the introduction of managed competition, health insurers also became an important stakeholder. They purchase services on behalf of their customers and are allowed to contract healthcare providers selectively. It has, therefore, become increasingly important to take one's insurance into account when choosing a provider. There is little evidence that patients make active choices in the way that policymakers assume they do. This research aims to investigate, firstly, the role of patients in choosing a healthcare provider at the point of referral, then the role of the GP and, finally, the influence of the health insurer/insurance policies within this process. Methods: We videotaped a series of everyday consultations between Dutch GPs and their patients during 2015 and 2016. In 117 of these consultations, with 28 GPs, the patient was referred to another healthcare provider. These consultations were coded by three observers using an observation protocol which assessed the role of the patient, GP, and the influence of the health insurer during the referral. Results: Patients were divided into three groups: patients with little or no input, patients with some input, and those with a lot of input. Just over half of the patients (56%) seemed to have some, or a lot of, input into the choice of a healthcare provider at the point of referral by their GP. In addition, in almost half of the consultations (47%), GPs inquired about their patients' preferences regarding a healthcare provider. Topics regarding the health insurance or insurance policy of a patient were rarely (14%) discussed at the point of referral. Conclusions: Just over half of the patients appear to have some, or a lot of, input into their choice of a healthcare provider at the point of referral by their GP. However, the remainder of the patients had little or no input. If more patient choice continues to be an important aim for policy makers, patients should be encouraged to actively choose the healthcare provider who best fits their needs and preferences.
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Background: Dermoscopy is known to increase the diagnostic accuracy of pigmented skin lesions (PSLs) when used by trained professionals. The effect of dermoscopy training on the diagnostic ability of dermal therapists (DTs) has not been studied so far. Objectives: This study aimed to investigate whether DTs, in comparison with general practitioners (GPs), benefited from a training programme including dermoscopy, in both their ability to differentiate between different forms of PSL and to assign the correct therapeutic strategy. Methods: In total, 24 DTs and 96 GPs attended a training programme on PSLs. Diagnostic skills as well as therapeutic strategy were assessed, prior to the training (pretest) and after the training (post-test) using clinical images alone, as well as after the addition of dermatoscopic images (integrated post-test). Bayesian hypothesis testing was used to determine statistical significance of differences between pretest, post-test and integrated post-test scores. Results: Both the DTs and the GPs demonstrated benefit from the training: at the integrated post-test, the median proportion of correctly diagnosed PSLs was 73% (range 30–90) for GPs and 63% (range 27–80) for DTs. A statistically significant difference between pretest results and integrated test results was seen, with a Bayes factor>100. At 12 percentage points higher, the GPs outperformed DTs in the accuracy of detecting PSLs. Conclusions: The study shows that a training programme focusing on PSLs while including dermoscopy positively impacts detection of PSLs by DTs and GPs. This training programme could form an integral part of the training of DTs in screening procedures, although additional research is needed.
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Studenten ervaren maar beperkt dat ze regie kunnen nemen op hun eigen leerproces. Regie nemen op je leerproces vraagt van studenten dat zij zelfregulerende vaardigheden bezitten. Ontwikkelingsgerichte feedback biedt enorme kansen om de zelfregulatie van studenten te ontwikkelen. De processen die ten grondslag liggen aan feedback en zelfregulatie kennen grote overeenkomsten. Wil feedback bijdragen aan zelfregulatie, dan moet de student een actievere rol krijgen in het feedbackproces. Om het gesignaleerde probleem van te weinig zelfregulatie door studenten en een te weinig actieve rol van studenten in het feedbackproces aan te pakken, zijn in dit project een aantal interventies ingezet gericht op het ontwikkelen van feedbackgeletterdheid bij studenten. De innovatie in dit project bestaat uit een feedbacktraining die wordt uitgevoerd in het propedeusejaar van een hbo opleiding. Met de training leert de student in het feedbackproces vier activiteiten: de student leert (1) de feedback te begrijpen, (2) de feedback te gebruiken, (3) op de feedback te reageren en (4) gericht te vragen naar feedback. Om de invloed van de training te bepalen is de feedbackgeletterdheid en zelfregulatie van studenten gemeten.
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Een groeiend aantal hbo-opleidingen in Nederland heeft programmatisch toetsen geïmplementeerd als een nieuwe benadering van toetsen. De theoretische principes die als basis kunnen dienen voor het ontwerp van programmatisch beoordelen zijn beschreven in de literatuur. Opleidingen maken op basis van de principes verschillende specifieke ontwerpkeuzes, passend bij hun eigen context. In deze inspiratiesessie werd op basis van een NRO-overzichtsstudie inzicht gegeven in welke ontwerpkeuzes hbo-opleidingen maken bij het implementeren van programmatisch toetsen en welke overwegingen en ervaringen ze daarbij hebben gehad.
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Background Variations in childbirth interventions may indicate inappropriate use. Most variation studies are limited by the lack of adjustments for maternal characteristics and do not investigate variations in adverse outcomes. This study aims to explore regional variations in the Netherlands and their correlations with referral rates, birthplace, interventions, and adverse outcomes, adjusted for maternal characteristics. Methods In this nationwide retrospective cohort study, using a national data register, intervention rates were analysed between twelve regions among single childbirths after 37 weeks’ gestation in 2010–2013 (n = 614,730). These were adjusted for maternal characteristics using multivariable logistic regression. Primary outcomes were intrapartum referral, birthplace, and interventions used in midwife- and obstetrician-led care. Correlations both between primary outcomes and between adverse outcomes were calculated with Spearman’s rank correlations. Findings Intrapartum referral rates varied between 55–68% (nulliparous) and 20–32% (multiparous women), with a negative correlation with receiving midwife-led care at the onset of labour in two-thirds of the regions. Regions with higher referral rates had higher rates of severe postpartum haemorrhages. Rates of home birth varied between 6–16% (nulliparous) and 16–31% (multiparous), and was negatively correlated with episiotomy and postpartum oxytocin rates. Among midwife-led births, episiotomy rates varied between 14–42% (nulliparous) and 3–13% (multiparous) and in obstetrician-led births from 46–67% and 14–28% respectively. Rates of postpartum oxytocin varied between 59–88% (nulliparous) and 50–85% (multiparous) and artificial rupture of membranes between 43–52% and 54–61% respectively. A north-south gradient was visible with regard to birthplace, episiotomy, and oxytocin. Conclusions Our study suggests that attitudes towards interventions vary, independent of maternal characteristics. Care providers and policy makers need to be aware of reducing unwarranted variation in birthplace, episiotomy and the postpartum use of oxytocin. Further research is needed to identify explanations and explore ways to reduce unwarranted intervention rates.
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Bij de pabo van de Hogeschool Utrecht zijn twee cursussen ontworpen op basis van de principes van programmatisch toetsen. In de voltijd jaar 1 van de propedeuse is dit experiment in het studiejaar 2022-2023 gestart. Met het experiment wil de opleiding onderzoeken of de principes van dit onderwijsconcept passend zijn bij de pabo. Studenten nemen bewijsmateriaal op in een portfolio systeem en verschillende feedbackgevers geven daar feedback op. Na het geven van feedback wordt zo’n bewijsstuk een datapunt. Een datapunt is niet meer dan 1 brokje informatie die iets zegt over het functioneren van de student. De examinator beoordeelt in het portfolio niet het bewijsmateriaal zelf, maar integreert de feedback die is gegeven door experts (vakdocenten en praktijkopleider) en combineert dit met de feedback van de student zelf en zijn medestudenten. Tijdens deze workshop hebben deelnemers ervaring opgedaan met dit experiment. Hoe beoordelen onze examinatoren het programmatische portfolio. De deelnemers hebben zelf een beoordeling uitgevoerd enkel op basis van feedback van anderen. Lukt het zonder inhoudelijk expert te zijn tot een holistisch oordeel te komen van de leeruitkomsten die centraal staan.
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Geen samenvatting beschikbaar / No summary available
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Een groeiend aantal HBO-opleidingen in Nederland heeft programmatisch toetsen (PT) geïmplementeerd als een nieuwe benadering van toetsen. Torre et al. (2020) en Baartman et al. (2022) nemen ontwerpgerichte perspectieven in wanneer ze beschrijven hoe de implementatie van programmatisch toetsen zich in de praktijk manifesteert. Onderzoek naar het ontwerpen van leeromgevingen laat zien welke verschillende ontwerpkeuzes gemaakt kunnen worden (Bouw et al., 2021). De theoretische principes die als basis kunnen dienen voor het ontwerp van programmatisch beoordelen zijn beschreven (Heeneman et al., 2021). Opleidingen maken op basis van deze principes verschillende specifieke ontwerpkeuzes maken, passend bij hun eigen context. Dit ontwerpperspectief op programmatisch toetsen wordt echter vaak niet geëxpliciteerd. Hierdoor is er beperkt inzicht in welke ontwerpkeuzes zijn gemaakt bij het implementeren van programmatisch toetsen (Torre et al., 2020).
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