Dinny de Bakker

Exercise adherence improving long-term patient outcome in patients with osteoarthritis of the hip and/or knee.

To determine the effect of patient exercise adherence within the prescribed physical therapy treatment period and after physical therapy discharge on patient outcomes of pain, physical function, and patient self‐perceived effect in individuals with osteoarthritis (OA) of the hip and/or knee.

Early Results From Adoption Of Bundled Payment For Diabetes Care In The Netherlands Show Improvement In Care Coordination

In 2010 a bundled payment system for diabetes care, chronic obstructive pulmonary disease care, and vascular risk management was introduced in the Netherlands. Health insurers now pay a single fee to a contracting entity, the care group, to cover all of the primary care needed by patients with these chronic conditions. The initial evaluation of the program indicated that it improved the organization and coordination of care and led to better collaboration among health care providers and better adherence to care protocols. Negative consequences included dominance of the care group by general practitioners, large price variations among care groups that were only partially explained by differences in the amount of care provided, and an administrative burden caused by outdated information and communication technology systems. It is too early to draw conclusions about the effects of the new payment system on the quality or the overall costs of care. However, the introduction of bundled payments might turn out to be a useful step in the direction of risk-adjusted integrated capitation payments for multidisciplinary provider groups offering primary and specialty care to a defined group of patients.

Self-referral in a gatekeeping system: patients’ reasons for skipping the general-practitioner

In the Netherlands general practitioners act as the gatekeepers at the primary level to the more specialized and more expensive secondary health-care. As a rule, patients are required to have a referral from their general practitioners to be able to utilize these services. Not all private insurance companies, however, require a referral letter from their customers before reimbursing them for their costs or do not always exert a control whether such referral indeed had taken place. A mail-questionnaire was targeted to a specific group of 2000 privately insured patients to find out the reasons of self-referral. The findings suggest that patients self-refer to a specialist for medical complaints for which they expect to end up at the specialist anyway as they consider these problems as specific for the specialist. Complaints of patients who first visit their general practitioners, however, might be considered as less typical to the specialist. Patients who are living in relatively highly urbanized areas, who are better educated, and who expect to achieve a better quality of communication at the consultation with the specialist, more commonly skip their GPs before visiting a specialist.

Behavioural graded activity results in better exercise adherence and more physical activity than usual care in people with osteoarthritis: a cluster-randomised trial

QUESTION Does behavioural graded activity result in better exercise adherence and more physical activity than usual care in people with osteoarthritis of the hip or knee? DESIGN Analysis of secondary outcomes of a cluster-randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis. PARTICIPANTS Two hundred patients with hip and/or knee osteoarthritis. INTERVENTION Experimental group received 18 sessions of behavioural graded activity over 12 weeks and up to 7 booster sessions over the next year. The control group received 18 sessions of usual care over 12 weeks according to the Dutch physiotherapy guideline. OUTCOME MEASURES Exercise adherence was measured using a questionnaire and physical activity was measured using the SQUASH questionnaire at baseline, 13, and 65 weeks. RESULTS Adherence to recommended exercises was significantly higher in the experimental group than in the control group at 13 weeks (OR 4.3, 95% CI 2.1 to 9.0) and at 65 weeks (OR 3.0, 95% CI 1.5 to 6.0). Significantly more of the experimental than the control group met the recommendations for physical activity at 13 weeks (OR 5.3, 95% CI 1.9 to 14.8) and at 65 weeks (OR 2.9, 95% CI 1.2 to 6.7). CONCLUSION Behavioural graded activity results in better exercise adherence and more physical activity than usual care in people with osteoarthritis of the hip or knee, both in the short- and long-term. TRIAL REGISTRATION NCT00522106.

Effectiveness of a Web-Based Physical Activity Intervention in Patients With Knee and/or Hip Osteoarthritis: Randomized Controlled Trial

Background Patients with knee and/or hip osteoarthritis (OA) are less physically active than the general population, while the benefits of physical activity (PA) have been well documented. Based on the behavioral graded activity treatment, we developed a Web-based intervention to improve PA levels in patients with knee and/or hip OA, entitled “Join2move”. The Join2move intervention is a self-paced 9-week PA program in which the patient’s favorite recreational activity is gradually increased in a time-contingent way. Objective The aim of the study was to investigate whether a fully automated Web-based PA intervention in patients with knee and/or hip OA would result in improved levels of PA, physical function, and self-perceived effect compared with a waiting list control group. Methods The study design was a two-armed randomized controlled trial which was not blinded. Volunteers were recruited via articles in newspapers and health-related websites. Eligibility criteria for participants were: (1) aged 50-75 years, (2) self-reported knee and/or hip OA, (3) self-reported inactivity (30 minutes of moderate PA, 5 times or less per week), (4) no face-to-face consultation with a health care provider other than general practitioners, for OA in the last 6 months, (5) ability to access the Internet weekly, and (6) no contra-indications to exercise without supervision. Baseline, 3-month, and 12-month follow-up data were collected through online questionnaires. Primary outcomes were PA, physical function, and self-perceived effect. In a subgroup of participants, PA was measured objectively using accelerometers. Secondary outcomes were pain, fatigue, anxiety, depression, symptoms, quality of life, self-efficacy, pain coping, and locus of control. Results Of the 581 interested respondents, 199 eligible participants were randomly assigned to the intervention (n=100) or waiting list control group (n=99). Response rates of questionnaires were 84.4% (168/199) after 3 months and 75.4% (150/199) after 12 months. In this study, 94.0% (94/100) of participants actually started the program, and 46.0% (46/100) reached the adherence threshold of 6 out of 9 modules completed. At 3 months, participants in the intervention group reported a significantly improved physical function status (difference=6.5 points, 95% CI 1.8-11.2) and a positive self-perceived effect (OR 10.7, 95% CI 4.3-26.4) compared with the control group. No effect was found for self-reported PA. After 12 months, the intervention group showed higher levels of subjective (difference=21.2 points, 95% CI 3.6-38.9) and objective PA (difference=24 minutes, 95% CI 0.5-46.8) compared with the control group. After 12 months, no effect was found for physical function (difference=5 points, 95% CI −1.0 to 11.0) and self-perceived effect (OR 1.2, 95% CI 0.6-2.4). For several secondary endpoints, the intervention group demonstrated improvements in favor of the intervention group. Conclusions Join2move resulted in changes in the desired direction for several primary and secondary outcomes. Given the benefits and its self-help format, Join2move could be a component in the effort to enhance PA in sedentary patients with knee and/or hip OA. Trial Registration The Netherlands National Trial Register: NTR2483; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2483 (Archived by WebCite at http://www.webcitation.org/67NqS6Beq).

Comparing patient characteristics and treatment processes in patients receiving physical therapy in the United States, Israel and the Netherlands: cross sectional analyses of data from three clinical databases.

BackgroundMany assume that outcomes from physical therapy research in one country can be generalized to other countries. However, no well designed studies comparing outcomes among countries have been conducted. In this exploratory study, our goal was to compare patient demographics and treatment processes in outpatient physical therapy practice in the United States, Israel and the Netherlands.MethodsCross-sectional data from three different clinical databases were examined. Data were selected for patients aged 18 years and older and started an episode of outpatient therapy between January 1st 2005 and December 31st 2005. Results are based on data from approximately 63,000 patients from the United States, 100,000 from Israel and 12,000 from the Netherlands.ResultsAge, gender and the body part treated were similar in the three countries. Differences existed in episode duration of the health problem, with more patients with chronic complaints treated in the United States and Israel compared to the Netherlands. In the United States and Israel, physical agents and mechanical modalities were applied more often than in the Netherlands. The mean number of visits per treatment episode, adjusted for age, gender, and episode duration, varied from 8 in Israel to 11 in the United States and the Netherlands.ConclusionThe current study showed that clinical databases can be used for comparing patient demographic characteristics and for identifying similarities and differences among countries in physical therapy practice. However, terminology used to describe treatment processes and classify patients was different among databases. More standardisation is required to enable more detailed comparisons. Nevertheless the differences found in number of treatment visits per episode imply that one has to be careful to generalize outcomes from physical therapy research from one country to another.

MORAL HAZARD AND SUPPLIER-INDUCED DEMAND: EMPIRICAL EVIDENCE IN GENERAL PRACTICE†

Changes in cost sharing and remuneration system in the Netherlands in 2006 led to clear changes in financial incentives faced by both consumers and general practitioner (GPs). For privately insured consumers, cost sharing was abolished, whereas those socially insured never faced cost sharing. The separate remuneration systems for socially insured consumers (capitation) and privately insured consumers (fee-for-service) changed to a combined system of capitation and fee-for-service for both groups. Our first hypothesis was that privately insured consumers had a higher increase in patient-initiated GP contact rates compared with socially insured consumers. Our second hypothesis was that socially insured consumers had a higher increase in physician-initiated contact rates. Data were used from electronic medical records from 32 GP-practices and 35336 consumers in 2005-2007. A difference-in-differences approach was applied to study the effect of changes in cost sharing and remuneration system on contact rates. Abolition of cost sharing led to a higher increase in patient-initiated utilisation for privately insured consumers in persons aged 65 and older. Introduction of fee-for-service for socially insured consumers led to a higher increase in physician-initiated utilisation. This was most apparent in persons aged 25 to 54. Differences in the trend in physician-initiated utilisation point to an effect of supplier-induced demand. Differences in patient-initiated utilisation indicate limited evidence for moral hazard.

Adherence to a Web-Based Physical Activity Intervention for Patients With Knee and/or Hip Osteoarthritis: A Mixed Method Study

Background Web-based interventions show promise in promoting a healthy lifestyle, but their effectiveness is hampered by high rates of nonusage. Predictors and reasons for (non)usage are not well known. Identifying which factors are related to usage contributes to the recognition of subgroups who benefit most from Web-based interventions and to the development of new strategies to increase usage. Objective The aim of this mixed methods study was to explore patient, intervention, and study characteristics that facilitate or impede usage of a Web-based physical activity intervention for patients with knee and/or hip osteoarthritis. Methods This study is part of a randomized controlled trial that investigated the effects of Web-based physical activity intervention. A total of 199 participants between 50-75 years of age with knee and/or hip osteoarthritis were randomly assigned to a Web-based intervention (n=100) or a waiting list (n=99). This mixed methods study used only data from the individuals allocated to the intervention group. Patients were defined as users if they completed at least 6 out of 9 modules. Logistic regression analyses with a stepwise backward selection procedure were executed to build a multivariate prediction usage model. For the qualitative part, semistructured interviews were conducted. Both inductive and deductive analyses were used to identify patterns in reported reasons for nonusage. Results Of the 100 participants who received a password and username, 46 completed 6 modules or more. Multivariate regression analyses revealed that higher age (OR 0.94, P=.08) and the presence of a comorbidity (OR 0.33, P=.02) predicted nonusage. The sensitivity analysis indicated that the model was robust to changes in the usage parameter. Results from the interviews showed that a lack of personal guidance, insufficient motivation, presence of physical problems, and low mood were reasons for nonusage. In addition, the absence of human involvement was viewed as a disadvantage and it negatively impacted program usage. Factors that influenced usage positively were trust in the program, its reliability, functionality of the intervention, social support from family or friends, and commitment to the research team. Conclusions In this mixed methods study, we found patient, intervention, and study factors that were important in the usage and nonusage of a Web-based PA intervention for patients with knee and/or hip osteoarthritis. Although the self-guided components offer several advantages, particularly in relation to costs, reach, and access, we found that older patients and participants with a comorbid condition need a more personal approach. For these groups the integration of Web-based interventions in a health care environment seems to be promising. Trial Registration The Netherlands National Trial Register (NTR): NTR2483; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2483 (Archived by Webcite at http://www.webcitation.org/67NqS6Beq).

Is there a geography of alternative medical treatment in The Netherlands

An increasing number of people are using alternative medical care. The literature suggests that there are important between place variations, however. This paper tries to assess the extent of these variations and mechanisms behind them for the utilization of homeopathy, paranormal healing and manual therapy. Are these variations a matter of level of supply, degree of urbanization, GP characteristics or simply a matter of composition of populations? Data are derived from the Dutch National Surgery of General Practice and analyzed using multilevel logistic regression models. Between place variation in utilization of homeopathy is mainly a matter of composition of populations with respect to health locus of control and religion. With respect to paranormal healing, it is exclusively a matter of religion. With respect to manual therapy, place variations are a matter of individual, GP, as well as area characteristics, but a relatively large amount remains unexplained.

The effectiveness of self-guided web-based physical activity interventions among patients with a chronic disease: a systematic review.

BACKGROUND Despite well-documented health benefits, adults with a physical chronic condition do not meet the recommended physical activity (PA) guidelines. Therefore, secondary prevention programs focusing on PA are needed. Web-based interventions have shown promise in the promotion of PA behavior change. We conducted a systematic review to summarize the evidence about the effectiveness of web-based PA interventions in adults with chronic disease. METHODS Articles were included if they evaluated a web-based PA intervention and used a randomized design. Moreover, studies were eligible for inclusion if they used a non- or minimal-treatment control group and if PA outcomes measures were applied. Seven articles were included. RESULTS Three high-quality studies were statistically significant to the control group, whereas 2 high- and 2 low-quality studies reported nonsignificant findings. CONCLUSION Our best evidence synthesis revealed that there is conflicting evidence on the effectiveness of web-based PA interventions in patients with a chronic disease.