Background: Research into termination of long-term psychosocial treatment of mental disorders is scarce. Yearly 25% of people in Dutch mental health services receive long-term treatment. They account for many people, contacts, and costs. Although relevant in different health care systems, (dis)continuation is particularly problematic under universal health care coverage when secondary services lack a fixed (financially determined) endpoint. Substantial, unaccounted, differences in treatment duration exist between services. Understanding of underlying decisional processes may result in improved decision making, efficient allocation of scarce resources, and more personalized treatment.
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BACKGROUND: Many older patients with cancer have their family members, often their adult children, involved in a process of treatment decision-making. Despite the growing awareness that family members can facilitate a process of shared decision-making, strategies for involving family members are scarce. Furthermore, literature about shared decision-making pays little attention to family involvement or to the impact that family relations have on the decision process. The purpose of this study was to explore how surgeons and nurses perceive the involvement of adult children of older patients with cancer in treatment decision-making. Subsequently, it identified strategies to ensure family involvement in the decision-making process, used in clinical practice.METHODS: Qualitative open in-depth interviews were conducted with 13 surgeons and 13 nurses working in a university or general hospital. Qualitative content analysis was conducted according to the steps of thematic analysis.RESULTS: Both nurses and surgeons indicated that adult children's involvement in decision-making about treatment increases when patients become frail. They mentioned several characteristics of adult children's behaviour during the decision-making process. Most of these characteristics are beneficial, but they also can be challenging. The distinct nature of adult children's involvement can help older patients with cancer reach better-informed treatment decisions. Health professionals reported six strategies to support positive family involvement in decision-making about treatment.CONCLUSION: Adult children may facilitate a process of shared decision-making and help patients reach well-informed treatment decisions. Health professionals' strategies deliberately support positive family involvement.
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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: In geriatric oncology, family members frequently accompany patients during medical consultations, providing emotional and practical support while participating in shared decision-making (SDM). Family involvement in SDM can facilitate the decision-making process but also pose challenges for healthcare professionals. Additionally, much of the SDM deliberation occurs outside the clinical setting, making it important to understand family dynamics to ensure treatment decisions align with the patient's values and preferences. Therefore this study aims to explore the experiences and perspectives of family members regarding their involvement in decision-making processes for older patients with cancer, and the subsequent impact on roles and family dynamics.METHODS: Qualitative open in-depth interviews were conducted with 16 family members of 11 patients with cancer of 70 years and older in the Netherlands. Qualitative data analysis was conducted using a thematic analysis approach.RESULTS: Four interconnected themes emerged. The first theme, "Roles" revealed that family members often provide both practical and informational support, and sometimes act as advocates for the patient. The second theme, "Family Values and Beliefs," highlighted a strong sense of unconditional and reciprocal support within families, emphasizing the core value of caring for one another. Third, "Family Dynamics," encompasses: keeping everyone informed, dividing caregiver tasks, dealing with disappointment and sadness, managing different opinions, and coping with uncertainty. Finally, "Dilemma's" describes: family members balancing their own opinions with the patient's preferences, reconciling hope and fear, weighing trust in medical professionals against their own judgment, and balancing caregiving responsibilities with their personal lives. These dilemmas were shaped by roles the family members assumed, the underlying values and beliefs, and family dynamics.CONCLUSION: The findings of this interview study provide valuable insights into the complex roles that family members of older patients with cancer play in medical consultations and treatment decision-making and their dilemma's. These roles are deeply influenced by family values and dynamics, which can significantly shape decision-making processes and outcomes. Understanding these factors can help healthcare professionals as it highlights the evolving responsibilities of family caregivers and the importance of supporting them in navigating the intricacies of treatment decisions while maintaining respect for patient autonomy.
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Aim To provide insight into the basic characteristics of decision making in the treatment of symptomatic severe aortic stenosis (SSAS) in Dutch heart centres with specific emphasis on the evaluation of frailty, cognition, nutritional status and physical functioning/functionality in (instrumental) activities of daily living [(I)ADL]. Methods A questionnaire was used that is based on the European and American guidelines for SSAS treatment. The survey was administered to physicians and non-physicians in Dutch heart centres involved in the decision-making pathway for SSAS treatment. Results All 16 Dutch heart centres participated. Before a patient case is discussed by the heart team, heart centres rarely request data from the referring hospital regarding patients’ functionality (n = 5), frailty scores (n = 0) and geriatric consultation (n = 1) as a standard procedure. Most heart centres ‘often to always’ do their own screening for frailty (n = 10), cognition/mood (n = 9), nutritional status (n = 10) and physical functioning/functionality in (I)ADL (n = 10). During heart team meetings data are ‘sometimes to regularly’ available regarding frailty (n = 5), cognition/mood (n = 11), nutritional status (n = 8) and physical functioning/functionality in (I)ADL (n = 10). After assessment in the outpatient clinic patient cases are re-discussed ‘sometimes to regularly’ in heart team meetings (n = 10). Conclusions Dutch heart centres make an effort to evaluate frailty, cognition, nutritional status and physical functioning/functionality in (I)ADL for decision making regarding SSAS treatment. However, these patient data are not routinely requested from the referring hospital and are not always available for heart team meetings. Incorporation of these important data in a structured manner early in the decision-making process may provide additional useful information for decision making in the heart team meeting.
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Analyzing historical decision-related data can help support actual operational decision-making processes. Decision mining can be employed for such analysis. This paper proposes the Decision Discovery Framework (DDF) designed to develop, adapt, or select a decision discovery algorithm by outlining specific guidelines for input data usage, classifier handling, and decision model representation. This framework incorporates the use of Decision Model and Notation (DMN) for enhanced comprehensibility and normalization to simplify decision tables. The framework’s efficacy was tested by adapting the C4.5 algorithm to the DM45 algorithm. The proposed adaptations include (1) the utilization of a decision log, (2) ensure an unpruned decision tree, (3) the generation DMN, and (4) normalize decision table. Future research can focus on supporting on practitioners in modeling decisions, ensuring their decision-making is compliant, and suggesting improvements to the modeled decisions. Another future research direction is to explore the ability to process unstructured data as input for the discovery of decisions.
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Blood draws for laboratory investigations are essential for patient management in neonatal intensive care units (NICU). When blood samples clot before analysis, they are rejected, which delays treatment decisions and necessitates repeated sampling.
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Abstract Background: Approximately one-third of all patients with schizophrenia are treatment resistant. Worldwide, undertreatment with clozapine and other effective treatment options exist for people with treatment-resistant schizophrenia (TRS). In this respect, it appears that regular health care models do not optimally fit this patient group. The Collaborative Care (CC) model has proven to be effective for patients with severe mental illness, both in primary care and in specialized mental health care facilities. The key principles of the CC model are that both patients and informal caregivers are part of the treatment team, that a structured treatment plan is put in place with planned evaluations by the team, and that the treatment approach is multidisciplinary in nature and uses evidence-based interventions. We developed a tailored CC program for patients with TRS. Objective: In this paper, we provide an overview of the research design for a potential study that seeks to gain insight into both the process of implementation and the preliminary effects of the CC program for patients with TRS. Moreover, we aim to gain insight into the experiences of professionals, patients, and informal caregivers with the program. Methods: This study will be underpinned by a multiple case study design (N=20) that uses a mixed methods approach. These case studies will focus on an Early Psychosis Intervention Team and 2 Flexible Assertive Community treatment teams in the Netherlands. Data will be collected from patient records as well as through questionnaires, individual interviews, and focus groups. Patient recruitment commenced from October 2020. Results: Recruitment of participants commenced from October 2020, with the aim of enrolling 20 patients over 2 years. Data collection will be completed by the end of 2023, and the results will be published once all data are available for reporting. Conclusions: The research design, framed within the process of developing and testing innovative interventions, is discussed in line with the aims of the study. The limitations in clinical practice and specific consequences of this study are explained.
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The aim of this study is to obtain insight, from a patient's perspective, into the results and essential components of treatment in specialist settings for so-called ‘difficult’ patients in mental health care. In cases where usual hospital treatment is not successful, a temporary transfer to another, specialist hospital may provide a solution. We investigated which aspects of specialist treatment available to ‘difficult’ patients are perceived as essential by the patients and what are the results of this treatment in their perception. A qualitative research design based on the Grounded Theory method was used. To generate data, 14 semi-structured interviews were held with 12 patients who were admitted to a specialist hospital in the Netherlands. Almost all respondents rated the results of the specialist treatment as positive. The therapeutic climate was perceived as extremely strict, with a strong focus on structure, cooperation and safety. This approach had a stabilizing effect on the patients, even at times when they were not motivated. Most patients developed a motivation for change, marked by a growing and more explicit determination of their future goals. We concluded that a highly structured treatment environment aimed at patient stabilization is helpful to most ‘difficult’ patients.
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Background: More knowledge about characteristics of children and adolescents who need intensive levels of psychiatric treatment is important to improve treatment approaches. These characteristics were investigated in those who need youth Assertive Community Treatment (youth-ACT). Method: A cross-sectional study among children/adolescents and their parents treated in either a regular outpatient clinic or a youth-ACT setting in a specialized mental health treatment center in the Netherlands. Results: Child, parent and family/social context factors were associated with treatment intensification from regular outpatient care to youth-ACT. The combination of the child, parent, and family/social context factors adds substantially to the predictive power of the model (Nagelkerke R2 increasing from 36 to 45% for the three domains separately, to 61% when all domains are combined). The strongest predictors are the severity of psychiatric disorders of the child, parental stress, and domestic violence. Conclusions: Using a wide variety of variables that are potentially associated with treatment intensification from regular outpatient clinic to youth-ACT, we constructed a regression model illustrating a relatively strong relation between the predictor variables and the outcome (Nagelkerke R2 = 0.61), with three strong predictors, i.e. severity of psychiatric disorders of the child, parental stress, and domestic violence. This emphasizes the importance of a system-oriented approach with primary attention for problem solving and stress reduction within the system, in addition to the psychiatric treatment of the child, and possibly also the parents. Auteurs: Vijverberg, R., Ferdinand, R., Beekman, A., & van Meijel B.
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