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Contains fulltext : 215841.pdf (Publisher’s version ) (Closed access) De vorming van zorgnetwerken wordt alom gezien als de oplossing voor de fragmentatie van de moderne zorg. In dit artikel onderzoeken we dat ‘medicijn’ op werkzaamheid en bijwerkingen. Eén ding is duidelijk: er bestaat geen ‘one size fits all-oplossing’. 20 januari 2020

OBJECTIVE: To determine characteristics and healthcare utilization of high-cost patients in the Netherlands. DESIGN: Cross-sectional study, using claim data for 2013 from one Dutch health insurer. Analyses were limited to the curative health system (care that falls under the Health Insurance Act), including voluntary supplementary insurance. METHOD: We established total healthcare costs per beneficiary by summing all claims with a starting date in 2013. We categorized hospital-related diagnosis related groups (DRGs) and mental health care DRGs according to the ICD-10 International Classification of Diseases main chapters and sub-chapters. Per patient we determined which ICD-10-(sub-)chapter carried the highest costs. In addition, we developed several indicators for healthcare utilization and analysed healthcare utilization using descriptive statistics. Finally, we broke down high-cost patients by age group and compared characteristics and health care utilization between age groups. RESULTS: High-cost patients, those in the top 1% in 2013, incurred an average total cost of over € 56,000 per patient. They were treated by multiple providers for numerous health problems. Approximately one third of high-cost patients had one or more expensive treatments, including transplant surgery, dialysis, expensive drugs, intensive care unit use, or DRGs exceeding € 30,000. The majority of high-cost patients were treated for cardiovascular disorders, neoplasms or mental and behavioural disorders. Though the high-cost patients were relatively old, more than half were younger than 65 years and average costs per patient decreased sharply with age. CONCLUSIONS: There is a need for an integral approach in the treatment of high-cost patients. Tailored policy and interventions are needed to improve care quality and to avoid unnecessarily high costs of care.

Ankle injuries are a huge medical and socioeconomic problem. Many people have a traumatic injury of the ankle, most of which are a result of sports. Total costs of treatment and work absenteeism due to ankle injuries are high. The prevention of recurrences can result in large savings on medical costs. A multidisciplinary clinical practice guideline was developed with the aim to prevent further health impairment of patients with acute lateral ankle ligament injuries by giving recommendations with respect to improved diagnostic and therapeutic opportunities. The recommendations are based on evidence from published scientific research, which was extensively discussed by the guideline committee. This clinical guideline is helpful for healthcare providers who are involved in the management of patients with ankle injuries.

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Objective: To determine the evidence for physical therapy interventions aimed at improving functional outcome after stroke. Methods: MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, DARE, PEDro, EMBASE and DocOnline were searched for controlled studies. Physical therapy was divided into 10 intervention categories, which were analysed separately. If statistical pooling (weighted summary effect sizes) was not possible due to lack of comparability between interventions, patient characteristics and measures of outcome, a bestresearch synthesis was performed. This best-research synthesis was based on methodological quality (PEDro score). Results: In total, 151 studies were included in this systematic review; 123 were randomized controlled trials (RCTs) and 28 controlled clinical trials (CCTs). Methodological quality of all RCTs had a median of 5 points on the 10-point PEDro scale (range 2–8 points). Based on high-quality RCTs strong evidence was found in favour of task-oriented exercise training to restore balance and gait, and for strengthening the lower paretic limb. Summary effect sizes (SES) for functional outcomes ranged from 0.13 (95% CI 0.03–0.23) for effects of high intensity of exercise training to 0.92 (95% CI 0.54–1.29) for improving symmetry when moving from sitting to standing. Strong evidence was also found for therapies that were focused on functional training of the upper limb such as constraint-induced movement therapy (SES 0.46; 95% CI 0.07–0.91), treadmill training with or without body weight support, respectively 0.70 (95% CI 0.29–1.10) and 1.09 (95% CI 0.56–1.61), aerobics (SES 0.39; 95% CI 0.05–0.74), external auditory rhythms during gait (SES 0.91; 95% CI 0.40–1.42) and neuromuscular stimulation for glenohumeral subluxation (SES 1.41; 95% CI 0.76–2.06). No or insufficient evidence in terms of functional outcome was found for: traditional neurological treatment approaches; exercises for the upper limb; biofeedback; functional and neuromuscular electrical stimulation aimed at improving dexterity or gait performance; orthotics and assistive devices; and physical therapy interventions for reducing hemiplegic shoulder pain and hand oedema. Conclusions: This review showed small to large effect sizes for task-oriented exercise training, in particular when applied intensively and early after stroke onset. In almost all high-quality RCTs, effects were mainly restricted to tasks directly trained in the exercise programme.

Contains fulltext : 217376.pdf (Publisher’s version ) (Open Access) Radboud University, 08 april 2020 Promotor : Nijhuis-van der Sanden, M.W.G. Co-promotores : Janssen, A.J.W.M., Swart, B.J.M. de

Chapter 2 discusses the feasibility and preliminary effectiveness of tailoring general scientific recommendations on exercise for patients with diabetes into a program for patients with multiple diabetic complications. Chapter 3 is a case report providing a detailed description of the individual adjustments and prerequisites required to ensure safety and effectiveness when tailoring general scientific recommendations to a patient with multiple diabetic complications. In Chapters 2 & 3 we provide in-depth information at the patient level and discuss the organizational and professional conditions needed to effectively carry out an exercise program for patients with diabetes and multiple complications. Chapter 4 examines early in-patient stroke rehabilitation based on a survey among physical therapists in the stroke units of Dutch hospitals. It discusses the organization of care and the current practice with respect to early mobilization and augmented exercise therapy time. The study presented in this chapter also aimed to identify the perceived barriers and facilitators for the use of the clinical practice guideline. The chapter addresses both the patient and the organizational level. Chapter 5 reports on the process of establishing recommendations for relevant and feasible measurement instruments in the clinical practice guideline for patients with stroke, which was revised by a team of physical therapists and researchers. This chapter thus addresses the innovation level. Chapter 6 focusses on the use of the stroke guideline in the clinical reasoning of physical therapists. This chapter describes the development of an instrument to measure guideline-consistent clinical reasoning. In addition, the study assessed the validity of the instrument and factors related to guideline-consistent clinical reasoning. This chapter mainly addresses the level of the professional. The general discussion, Chapter 7, summarizes the main findings reported in this thesis, as well presenting implications and suggestions for future research and offering further considerations on implementation.