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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Previous research has shown clinical effectiveness of dermal substitution; however, in burn wounds, only limited effect has been shown. A problem in burn wounds is the reduced take of the autograft, when the substitute and graft are applied in one procedure. Recently, application of topical negative pressure (TNP) was shown to improve graft take. The aim of this study was to investigate if application of a dermal substitute in combination with TNP improves scar quality after burns. In a four-armed multicenter randomized controlled trial, a split-skin graft with or without a dermal substitute and with or without TNP was compared in patients with deep dermal or full-thickness burns requiring skin transplantation. Graft take and rate of wound epithelialization were evaluated. Three and 12 months postoperatively, scar parameters were measured. The results of 86 patients showed that graft take and epithelialization did not reveal significant differences. Significantly fewer wounds in the TNP group showed postoperative contamination, compared to other groups. Highest elasticity was measured in scars treated with the substitute and TNP, which was significantly better compared to scars treated with the substitute alone. Concluding, this randomized controlled trial shows the effectiveness of dermal substitution combined with TNP in burns, based on extensive wound and scar measurements.
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Purpose: The increasing number of cancer survivors has heightened demands on hospital-based follow-up care resources. To address this, involving general practitioners (GPs) in oncological follow-up is proposed. This study explores secondary care providers’ views on integrating GPs into follow-up care for curatively treated breast and colorectal cancer survivors. Methods: A qualitative exploratory study was conducted using semi-structured interviews with Dutch medical specialists and nurse practitioners. Interviews were recorded, transcribed verbatim, and analyzed using thematic analysis by two independent researchers. Results: Fifteen medical specialists and nine nurse practitioners participated. They identified barriers such as re-referral delays, inexperience to perform structured follow-up, and worries about the lack of oncological knowledge among GPs. Benefits included the GPs’ accessibility and their contextual knowledge. For future organization, they emphasized the need for hospital logistics changes, formal GP training, sufficient case-load, proper staffing, remuneration, and time allocation. They suggested that formal GP involvement should initially be implemented for frail older patients and for prevalent cancer types. Conclusions: The interviewed Dutch secondary care providers generally supported formal involvement of primary care in cancer follow-up. A well-organized shared-care model with defined roles and clear coordination, supported by individual patients, was considered essential. This approach requires logistics adaptation, resources, and training for GPs. Implications for cancer survivors: Integrating oncological follow-up into routine primary care through a shared-care model may lead to personalized, effective, and efficient care for survivors because of their long-term relationships with GPs.
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Whereas most continents see circulation of newspapers drop, Latin America is one of the few areas in the world with rising newspaper circulation. A substantial part of this rise is caused by the introduction of free newspapers in a dozen countries on the continent. We map this development, discuss possible reasons for the rapid growth and try to answer whether this introduction has substitution effects on paid newspapers. The growth of this new format is most probably caused by economic growth while we conclude that substitution is low, meaning that free dailies serve a new reading audience in Latin America
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In tourism and recreation management it is still common practice to apply traditional input-output (IO) economic impact models, despite their well-known limitations. In this study the authors analyse the usefulness of applying a non-linear input-output (NLIO) model, in which price-induced input substitution is accounted for. For large changes in final demand, a NLIO model is more useful than a traditional IO model, leading to higher or lower impacts. For small changes in final demand input substitution is less likely. In that case the application of the NLIO may lead to the same results as a traditional IO model. To analyse changes of subsidies, a traditional IO model is not an option. A more flexible model, such as the NLIO, is required. The NLIO model forces researchers to make choices about capacity constraints, factor mobility and the substitution elasticity, which can be difficult but create flexibility and allow for more realism.
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Substitution is an essential tool for a coach to influence the match. Factors like the injury of a player, required tactical changes, or underperformance of a player initiates substitutions. This study aims to predict the physical performance of individual players in an early phase of the match to provide additional information to the coach for his decision on substitutions. Tracking data of individual players, except for goalkeepers, from 302 elite soccer matches of the Dutch ‘Eredivisie’ 2018–2019 season were used to enable the prediction of the individual physical performance. The players’ physical performance is expressed in the variables distance covered, distance in speed category, and energy expenditure in power category. The individualized normalized variables were used to build machine learning models that predict whether players will achieve 100%, 95%, or 90% of their average physical performance in a match. The tree-based algorithms Random Forest and Decision Tree were applied to build the models. A simple Naïve Bayes algorithm was used as the baseline model to support the superiority of the tree-based algorithms. The machine learning technique Random Forest combined with the variable energy expenditure in the power category was the most precise. The combination of Random Forest and energy expenditure in the power category resulted in precision in predicting performance and underperformance after 15 min in a match, and the values were 0.91, 0.88, and 0.92 for the thresholds 100%, 95%, and 90%, respectively. To conclude, it is possible to predict the physical performance of individual players in an early phase of the match. These findings offer opportunities to support coaches in making more informed decisions on player substitutions in elite soccer.
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Background: A highly promoted opportunity for optimizing healthcare services is to expand the role of nonphysician care providers by care reallocation. Reallocating care from physicians to non-physicians can play an important role in solving systemic healthcare problems such as care delays, hospital overcrowding, long waiting lists, high work pressure and expanding healthcare costs. Dermatological healthcare services, such as the acne care provision, are well suited for exploring the opportunities for care reallocation as many different types of care professionals are involved in the care process. In the Netherlands, acne care is mainly delivered by general practitioners and dermatologists. The Dutch healthcare system also recognizes non-physician care providers, among which dermal therapists and beauticians are the most common professions. However, the role and added value of non-physicians is still unclear. The present study aimed to explore the possibilities for reallocating care to nonphysicians and identify drivers for and barriers to reallocation. Methods: A mixed-method design was used collecting quantitative and qualitative data from representatives of the main 4 Dutch professions providing acne care: dermatologists, GP’s, Dermal therapists and beauticians. Results: A total of 560 questionnaires were completed and 24 semi-structured interviews were conducted. A broad spectrum of non-physician tasks and responsibilities were delineated. Interviewed physicians considered acne as a low-complexity skin condition which made them willing to explore the possibilities for reallocating. A majority of all interviewees saw a key role for non-physicians in counselling and supporting patients during treatment, which they considered an important role for increasing patients’ adherence to proposed treatment regimes, contributing to successful clinical outcome. Also, the amount of time non-physicians spend on patients was experienced as driver for reallocation. Legislation and regulations, uncertainties about the extent of scientific evidence and proper protocols use within the non-physician clinical practice were experienced as barriers influencing the possibilities for reallocation. Conclusions: Delineated roles and drivers demonstrate there is room and potential for reallocation between physicians and non-physicians within acne healthcare, when barriers are adequately addressed.
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Rationale, aims and objective: Primary Care Plus (PC+) focuses on the substitution of hospital-based medical care to the primary care setting without moving hospital facilities. The aim of this study was to examine whether population health and experience of care in PC+ could be maintained. Therefore, health-related quality of life (HRQoL) and experienced quality of care from a patient perspective were compared between patients referred to PC+ and to hospital-based outpatient care (HBOC). Methods: This cohort study included patients from a Dutch region, visiting PC+ or HBOC between December 2014 and April 2018. With patient questionnaires (T0, T1 and T2), the HRQoL and experience of care were measured. One-to-two nearest neighbour calliper propensity score matching (PSM) was used to control for potential selection bias. Outcomes were compared using marginal linear models and Pearson chi-square tests. Results: One thousand one hundred thirteen PC+ patients were matched to 606 HBOC patients with well-balanced baseline characteristics (SMDs <0.1). Regarding HRQoL outcomes, no significant interaction terms between time and group were found (P > .05), indicating no difference in HRQoL development between the groups over time. Regarding experienced quality of care, no differences were found between PC+ and HBOC patients. Only travel time was significantly shorter in the HBOC group (P ≤ .001). Conclusion: Results show equal effects on HRQoL outcomes over time between the groups. Regarding experienced quality of care, only differences in travel time were found. Taken as a whole, population health and quality of care were maintained with PC+ and future research should focus more on cost-related outcomes.
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A tool to calculate the environmental and economic impact of different ways to collect and process organic waste. The tool contains calculations for waste generation, transport, waste processing and application/ substitution.
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New electronic tablet devices are often referred to as either saviours of newspapers or killers of traditional print media. These crude statements are based on a naive concept of media substitution and an overestimation of the actual use of new media for news consumption. It is much more likely that substitution will be marginal, and that the potential is much more in giving existing readers more options while attacking new users. Publishers should treat tablet devices as options, concentrating on issues like business models, free, freemium, sponsored and paid content, DRM, in-app payment models, partnerships, user-generated content, design and interface options. Academic research on the use of tablets is not yet available as these devices are not available on a massive scale, only appearing on the market since the spring of 2010, but experiences by many publishers of newspapers and magazines already provide us with enough material to map possibilities and no-go areas for publishers of news content
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