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Background In older patients with end-stage kidney disease (ESKD), the choice between kidney transplantation (KT) and dialysis may be more complex than in younger patients because of a higher prevalence of comorbidities and frailty. This study aims to provide greater insight into the current decision-making process by exploring the expectations, experiences and health outcome priorities of all stakeholders. Methods We performed semi-structured interviews with patients ≥65 years with ESKD (eGFR <15 ml/min/1.73m2, KT recipient or treated with dialysis), patients' relatives and healthcare professionals (nephrologists, nurses and medical social workers). Interviews were conducted until data saturation and thematically analysed. Results We performed 36 interviews (patients n  = 18, relatives n  = 5, healthcare professionals n  = 13). Thematic analysis revealed five themes. Older patients' health outcome priorities were mostly related to quality of life (QOL). Individual older patients showed marked differences in the preferred level of engagement during the decision-making process (varying from 'wants to be in the lead' to 'follows the nephrologist') and in informational needs (varying from evidence-based to experience-based). On the contrary, healthcare professionals were quite unanimous on all aspects. They focused on determining eligibility for KT as start of the decision-making process, on clear and extensive information provision and on classical, medical outcomes. Conclusions The decision-making process could benefit from early identification of older patients' values, needs and health outcome priorities, in parallel with assessment of KT eligibility and before discussing the treatment options, and the explicit use of this information in further steps of the decision-making process. [ABSTRACT FROM AUTHOR]

Background: As the number of patients with complex healthcare needs grows, inter-professional collaboration between primary care professionals must be constantly optimized. General practitioners (GPs) and community nurses (CNs) are key professions in primary care; however, poor GP-CN communication is common, and research into the factors influencing its quality is limited.Objective: To explore patient-related GP-CN communication and facilitating and hindering factors, and to identify strategies to enhance this communication.Method: A qualitative focus group design was used to identify the facilitating and hindering factors and strategies for improvement. In a Dutch primary care setting, 6 mono-professional focus group interviews (3 meetings of 13 GPs; 3 meetings of 18 CNs) were organized between June 2015 and April 2016, recorded and transcribed verbatim. Two independent researchers performed the coding of these interviews, identifying their categories and themes.Results: Results show that, despite the regular contact between GPs and CNs, communication was generally perceived as poor in effectiveness and efficiency by both professions. Mutual trust was considered the most important facilitating factor for effective communication. Profession-specific factors (e.g. differences in responsibility and profession-specific language) and organizational factors (e.g. lack of shared care plans, no in-person communication, lack of time) may be of influence on communication. Participants' suggestions for improvement included organizing well-structured and reimbursed team meetings and facilitating face-to-face contact.Conclusion: GP-CN patient-related communication benefits most from trusting inter-personal relationships. Inter-professional training programmes should address both professional and organizational factors and should be evaluated for their effect on quality of care. [ABSTRACT FROM AUTHOR]

Introduction: Care for the frail elderly is often provided by several professionals. Collaboration between them is essential, but remains difficult to achieve. Interprofessional education (IPE) can improve this collaboration. We developed a 9-hour IPE program for primary care professionals from 7 disciplines caring for the frail elderly, and aimed to establish whether the program improved professionals' interprofessional attitudes and attitudes toward collaboration, collaboration skills, and collaborative behavior. We also evaluated learners' reactions to the program. Methods: Before-after study, using the Interprofessional Attitudes Questionnaire (IAQ, score:1 to 7); Attitudes Toward Health Care Teams Scale (ATHCTS, score: 0 to 105); and Team Skills Scale (TSS, score:17 to 85). Additionally, semistructured interviews were conducted with 10 selected participants. Results: Participants' ( N = 80) overall interprofessional attitudes improved (IAQ baseline: 5.49; follow-up: 5.67, p = 0.001); attitudes toward geriatric teams did not change (ATHCTS baseline: 69.9; follow-up: 69.1, p = 0.32). Participants' self-reported team skills improved (TSS baseline: 45.7; follow-up: 48.1, p = 0.001). In the interviews, many interviewees reported increased collaboration with professionals of other disciplines due to the program. Interviewees considered the program's interprofessional nature and attending the program with local professionals important contributing factors to the experienced improvements in collaboration. However, they also noted that not all parts of the program had met the needs of all participating disciplines, due to differences in professional background and knowledge. Discussion: A brief IPE program can improve interprofessional attitudes, collaboration skills, and collaborative behavior. That such a program allows professionals to get acquainted with each other and each other's viewpoints appears to be as important as the educational content. [ABSTRACT FROM AUTHOR]

Background This study aims to provide greater insight into the current decision-making process on diagnostic testing for dementia by exploring the expectations, needs and experiences of patients with memory complaints, significant others and general practitioners (GPs). Methods We performed semi-structured interviews with patients (>60 years) who consulted their GP on memory complaints, significant others and GPs. Participants were recruited until data saturation was reached in thematic analysis of interview transcripts. Results We performed 51 interviews (patients n  = 20, significant others n  = 15, GPs n  = 16). Thematic analysis revealed four themes: (i) 'drivers to (not) testing', i.e. need to act on symptoms, beliefs on the necessity and expected outcomes of diagnostic testing; (ii) 'patient preferences and context are critical in the actual decision', i.e. in the actual decision-making process interpretation of symptoms, GPs' desire to meet patient preferences, social context and healthcare system dynamics guided the decision; (iii) 'need for individualised communication in the decision-making process', i.e. for patients feeling heard was a prerequisite for decision-making and GPs tailored communication strategies to individual patients and (iv) 'GP practice and barriers to shared decision-making (SDM)', i.e. although GPs value SDM in the decision on diagnostic testing for dementia, patients express limited awareness of the decision and options at stake. Conclusions Decision-making on diagnostic testing for dementia is a multifactorial and preference-guided process for all involved stakeholders, but decisions are often not explicitly jointly made. Development of patient decision aids could facilitate better involvement and more informed choices by patients. [ABSTRACT FROM AUTHOR]

Background: Advance care planning (ACP) is a crucial element of palliative care. It improves the quality of end-of-life care and reduces aggressive and needless life-prolonging medical interventions. However, little is known about its application in daily practice. This study aims to examine the application of ACP for patients with cancer in general practice.Methods: We performed a retrospective cohort study in 11 general practices in the Netherlands. Electronic patient records (EPRs) of deceased patients with colorectal or lung cancer were analysed. Data on ACP documentation, correspondence between medical specialist and GP, and health care use in the last year of life were extracted.Results: Records of 163 deceased patients were analysed. In 74% of the records, one or more ACP items were registered. GPs especially documented patients' preferences for euthanasia (58%), palliative sedation (46%) and preferred place of death (26%). Per patient, GPs received on average six letters from medical specialists. These letters mainly contained information regarding medical treatment and rarely ACP items. In the last year of life, patients contacted the GP over 30 times, and 51% visited the emergency department at least once, of whom 54% in the last month.Conclusions: Registration of ACP items in GPs' EPRs appeared to be limited. ACP elements were rarely subject of communication between primary and secondary care, which may impact the continuity of patient care during the last year of life. More emphasis on registration of ACP items and better exchange of information regarding patients' preferences are needed. [ABSTRACT FROM AUTHOR]

Communication and coordination between primary healthcare professionals and informal caregivers involved in the care for frail older adults is suboptimal and could benefit from interprofessional digital communication tools. Implementation in daily practice however frequently fails. We aim to identify generic barriers and facilitators experienced by healthcare professionals and informal caregivers during implementation of interprofessional communication tools to improve their long-term use. Qualitative content analysis using individual semi-structured interviews was used for evaluating three different digital communication tools used by interprofessional primary care networks for frail older adults by 28 professionals and 10 caregivers. After transcription and open coding, categories and themes were identified. Barriers and facilitators were related to: tool characteristics, context of use, involvement of professionals and caregivers. The tool improved availability, approachability and users' involvement. The large number of digital systems professionals simultaneously use, and different work agreements hampered tool use. The tools facilitated care coordination, and professionals declared to be better informed about patients' current situations. Overall, interprofessional digital communication tools can facilitate communication in networks for primary elderly care. However, integration between digital systems is needed to reduce the number of tools. Organizations and policy makers have an important role in realizing the tools' long-term use. [ABSTRACT FROM AUTHOR]

Introduction: Care integration in primary elderly care is suboptimal. Validated instruments are needed to enable the implementation of integrated primary care. We aimed to assess construct validity of the Rainbow Model of Integrated Care measurement tool (RMIC-MT) for healthcare professionals working in an integrated primary elderly care setting in the Netherlands. Methods: In a cross-sectional study, the RMIC-MT, a 36-item questionnaire covering all domains of the Rainbow Model of Integrated Care (RMIC), was sent out to local networks of primary elderly care professionals. Confirmatory factor analysis with maximum likelihood estimation was used for the validation of the factor structure the RMIC-MT. Model fit was assessed by the chi-square test and fit indices. Results: The RMIC-MT was completed by 323 professionals, primarily general practitioners, community nurses, practice nurses, and case managers. Confirmatory factor analysis and corresponding fit indices showed moderate to good fit, thereby confirming a nine factor model with a total of 36 items. Conclusions: The RMIC-MT is promising for the primary elderly care setting in the Netherlands. It can be used for evaluating integrated care initiatives in a primary care setting, thereby contributing to implementation of integrated primary elderly care. [ABSTRACT FROM AUTHOR]

Background: Although frail older people can be more reluctant to become involved in clinical decision making, they do want professionals to take their concerns and wishes into account. Discussing goals can help professionals to achieve this. Objective: To describe the development of a two‐step method for discussing goals with frail older people in primary care and professionals' first experiences with it. Methods: The method consisted of (i) an open‐ended question: If there is one thing we can do for you to improve your situation, what would you like? if necessary, followed by (ii) a bubble diagram with goal subject categories. We reviewed the goals elaborated with the method and surveyed professionals' (primary care nurses and social workers) experiences, using questions concerning time investment, reasons for not formulating goals, and perceived value of the method. Results: One hundred and thirty‐seven community‐dwelling frail older people described 173 goals. These most frequently concerned mobility (n = 43; 24.9%), well‐being (n = 52; 30.1%) and social context (n = 57; 32.9%). Professionals (n = 18) were generally positive about the method, as it improved their knowledge about what the frail older person valued. Not all frail older people formulated goals; reasons for this included being perfectly comfortable, not being used to discussing goals or cognitive problems limiting their ability to formulate goals. Conclusions: This two‐step method for discussing goals can assist professionals in gaining insight into what a frail older person values. This can guide professionals and frail older people in choosing the most appropriate treatment option, thus increasing frail older people's involvement in decision making. [ABSTRACT FROM AUTHOR]

Background: Sporadic cerebral amyloid angiopathy (sCAA) research of the past decade has increasingly focused on developing biomarkers that allow for an earlier and more accurate sCAA-diagnosis. Considering that sCAA does not have treatment options available (yet), more fundamental questions concerning the desirability of using such early-sCAA biomarkers in clinical practice need to be addressed.Objective: In this qualitative interview study, we aim to explore the views of vascular neurologists on the purpose and possible consequences of an earlier and more accurate sCAA-diagnosis, using new biomarkers.Methods: Vascular neurologists from around the world were approached via email and interviewed via video call. Topics included views on current sCAA diagnostic practice, considerations on the use of new biomarkers, and expectations and hopes for the future. All interviews were transcribed ad verbatim using a transcription program (Otter.ai). Transcripts were analyzed using inductive content analysis.Results: We interviewed 14 vascular neurologists. Views regarding the desirability of new sCAA-biomarkers differed substantially between interviewees as to when and in whom these biomarkers could be of benefit in clinical practice. These differences were mainly reported with regards to prognosis, risk stratification, and biological precision, between general stroke neurologists and neurologists with specific sCAA-expertise.Conclusion: Views on the use of sCAA-biomarkers in clinical practice differ substantially between vascular neurologists. There is particularly no consensus regarding when, and in whom sCAA biomarkers could be useful in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Hope for future treatments to prevent or slow down dementia motivates researchers to strive for ever-earlier diagnoses of Alzheimer's disease (AD) based on biomarkers, even before symptoms occur. But is a biomarker-based early diagnosis desirable in clinical practice?Objective: This study explores the ethical considerations that shape current clinical practice regarding early AD diagnostics and the use of biomarkers.Methods: In this qualitative study, Dutch physicians were interviewed. Topics included physicians' views concerning early AD diagnosis in persons with no or mild cognitive impairment, physicians' considerations regarding current and expected future practices of early AD diagnosis, the use of biomarkers, and the use of the concepts preclinical and prodromal AD. We analyzed the transcripts using directed content analysis.Results: 15 general practitioners, neurologists, and geriatricians in the Netherlands were interviewed. Most of them interpreted an early AD diagnosis with an early diagnosis of dementia. We identified six clusters of considerations sometimes in favor but most often against pursuing an early AD diagnosis in people with no or mild cognitive impairment that influence physicians' diagnostic decision-making: preferences and characteristics of persons, test characteristics, impact on care, type of setting, disease concepts, and issues on a societal level.Conclusion: The discussion concerning an early AD diagnosis based on biomarkers which is widely held in the scientific field, has not entered clinical practice structurally. A biomarker-based early diagnosis does not fit within Dutch physicians' views on what good care for people with no, subjective, or mild cognitive impairment should entail. [ABSTRACT FROM AUTHOR]

The complex care needs of frail older persons living at home is a major challenge for health care systems worldwide. One possible solution is to employ a primary care physician (PCP) with additional geriatric expertise. In the Netherlands, elderly care physicians (ECPs), who traditionally work in nursing homes, are increasingly encouraged to utilize their expertise within primary care. However, little is known about how PCPs and ECPs collaborate. Therefore, we aimed to unravel the nature of the current PCP-ECP collaboration in primary care for frail older persons, and to identify key concepts for success. A qualitative multiple case study with semistructured interviews. A selection of 22 participants from 7 "established collaboration practices" within the primary care setting in the Netherlands, including at least 1 ECP, 1 PCP, and 1 other health care professional for every included established collaboration practice. Transcripts of individual interviews were analyzed using largely double and independent open and axial coding, and formulation of themes and subthemes. Data analysis revealed 4 key concepts for success: (1) clarification of roles and expectations (ie, patient-centered care and embedding in existing care networks), (2) trust, respect, and familiarity as drivers for collaboration (ie, mutual trust through knowing each other and having shared goals); (3) framework for regular communication (ie, structural meetings and a shared vision); and (4) government, payer, and organization support (ie, financial support and emphasis on the collaboration's urgency by organizations and national policy makers). For a successful generalist-specialist collaboration, health care professionals need to invest in building relationships and mutual trust, and incorporating their efforts in the existing care networks to guarantee patient-centeredness. When provided with reimbursement and appreciation, this collaboration is a promising change in general practice to improve the care and outcomes of frail older persons. [ABSTRACT FROM AUTHOR]

Background: General practitioners (GPs) are advised to offer advance care planning (ACP) to people with dementia (PWD). In a randomized controlled trial, an educational intervention for GPs aimed at initiating and optimizing ACP proved to be effective. During the intervention most GPs were accompanied by their practice nurse (PN). To provide insights into the intervention's successful components and what could be improved, we conducted a process evaluation and explored implementation, mechanisms of impact and contextual factors. Methods: We used the Medical Research Council guidance for process evaluations. Implementation was explored identifying reach and acceptability. We performed descriptive analyses of participants' characteristics; selection, inclusion and intervention attendance; a GP post-intervention survey on initiating ACP; a post intervention focus group with trainers of the intervention. Mechanisms of impact were explored identifying adoption and appropriateness. We used: participants' intervention ratings; a GP post-intervention survey on conducting ACP; ACP documentation in PWD's medical files; post-intervention interviews with PWD/FC dyads. All data was used to identify contextual factors. Results: The intervention was implemented by a small percentage of the total Dutch GP population invited, who mostly included motivated PWD/FC dyads with relatively little burden, and PWD with limited cognitive decline. The mechanisms of impact for GPs were: interactively learning to initiate ACP with training actors with a heterogeneous group of GPs and PNs. For PWD/FCs dyads, discussing non-medical preferences was most essential regarding their SDM experience and QoL. Some dyads however found ACP stressful and not feasible. Younger female GPs more often initiated ACP. Male PWD and those with mild dementia more often had had ACP. These characteristics and the safe and intimate training setting, were important contextual facilitators. Conclusion: We recommend Interventions aimed at improving ACP initiation with PWD by GPs to include interactive components and discussion of non-medical preferences. A safe environment and a heterogeneous group of participants facilitates such interventions. However, in practice not all FC/PWD dyads will be ready to start. Therefore, it is necessary to check their willingness when ACP is offered. [ABSTRACT FROM AUTHOR]