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AbstractIntroduction: A national healthcare system can be managed by the government, independent market‐driven providers, networks of managed care organizations, or a combination of the public—private partnership. While the benefits and limitations of government‐managed care and market competition are well documented, little is known about the functioning of privately operated networks. In 2008, we investigated how the quality of care provided by these private networks is affected by unique characteristics and external influences. Methods: Over 1,000 managers and municipal administrators in eight regional healthcare networks in South Holland (a Dutch province; population 3.5 million) were surveyed. Results: The overall survey response rate was 49%. We found that the fitness of a network depends on the tightness of the couplings between its elements and the interactions with its environment. Loose couplings in a simple environment and tight couplings in a complex environment result in positive outcomes. The opposite is true if internal constraints (tightness) do not match external complexity. Fitness and regional outcome variability were measured by the quality of care provided by the networks. Correlations were found between quality and two independent variables: environmental complexity (r=0.75, p=0.017) and strength of couplings (r=0.76, p=0.015). Together complexity and coupling tightness explain almost three‐quarters of the quality of care variability (adjusted R square=0.74). Conclusions: The authors propose that the knowledge of network mechanisms can guide interventions to improve care, as compared to government planning or free market competition. SamenvattingInleiding: een nationaal zorgsysteem kan georganiseerd worden door de overheid, onafhankelijke marktgedreven aanbieders, netwerken van zorgorganisaties, of een combinatie van publiek/private samenwerking. Terwijl de voordelen en beperkingen van door de overheid geplande zorg en marktwerking goed gedocumenteerd zijn, is er weinig bekend over het functioneren van privaat opererende netwerken. In 2008 hebben we onderzocht hoe de zorgkwaliteit, die deze netwerken leveren, door unieke eigenschappen en externe krachten beïnvloed wordt. Methoden: Ruim 1.000 managers en locale beleidsambtenaren in acht regionale zorgnetwerken in Zuid‐Holland (een Nederlandse provincie; 3,5 miljoen inwoners) werden bevraagd. Resultaten: De respons was 49%. We vonden dat de geschiktheid van een netwerk afhankelijk was van de sterkte van de koppelingen tussen de netwerkelementen en de interactie met zijn omgeving. Losse koppelingen in een simpele omgeving en strakke koppelingen in een complexe omgeving hebben positieve uitkomsten tot resultaat. Het omgekeerde geldt als de (sterkte) van de interne verknooptheid niet in overeenstemming is met de omgevingscomplexiteit. Geschiktheid en variatie in de regionale outcome werden afgemeten aan de zorgkwaliteit die de netwerken leveren. Verbanden werden gevonden tussen de kwaliteit en twee onafhankelijke variabelen: omgevingscomplexiteit (r=0.75, p=0.017) en sterkte van de koppelingen (r=0.76, p=0.015). Samen verklaren complexiteit en sterkte van de koppelingen bijna driekwart van de variatie in zorgkwaliteit (adjusted R square=0.74). Conclusies: De auteurs stellen dat kennis van netwerkmechanismen beter de interventies om de zorg te verbeteren kunnen leiden dan overheidsplanning of marktconcurrentie.

Evaluation of the implementation of integrated care can differ from trial-based research due to complexity. Therefore, we examined whether a theory-based method for process description of implementation can contribute to improvement of evidence-based care. MOVIT, a Dutch project aimed at implementing integrated care for older vulnerable persons in residential care homes, was used as a case study. The project activities were defined according to implementation taxonomy and mapped in a matrix of theoretical levels and domains. Project activities mainly targeted professionals (both individual and group). A few activities targeted the organizational level, whereas none targeted the policy level, or the patient, or the "social, political, and legal" domains. However, the resulting changes in care delivery arrangement had consequences for professionals, patients, organizations, and the social, political, and legal domains. A structured process description of a pragmatic implementation project can help assess the fidelity and quality of the implementation, and identify relevant contextual factors for immediate adaptation and future research. The description showed that, in the MOVIT project, there was a discrepancy between the levels and domains targeted by the implementation activities and those influenced by the resulting changes in delivery arrangement. This could have influenced, in particular, the adoption and sustainability of the project.

Background The use of levothyroxine to treat subclinical hypothyroidism is controversial. We aimed to determine whether levothyroxine provided clinical benefits in older persons with this condition. Methods We conducted a double-blind, randomized, placebo-controlled, parallel-group trial involving 737 adults who were at least 65 years of age and who had persisting subclinical hypothyroidism (thyrotropin level, 4.60 to 19.99 mIU per liter; free thyroxine level within the reference range). A total of 368 patients were assigned to receive levothyroxine (at a starting dose of 50 μg daily, or 25 μg if the body weight was <50 kg or the patient had coronary heart disease), with dose adjustment according to the thyrotropin level; 369 patients were assigned to receive placebo with mock dose adjustment. The two primary outcomes were the change in the Hypothyroid Symptoms score and Tiredness score on a thyroid-related quality-of-life questionnaire at 1 year (range of each scale is 0 to 100, with higher scores indicating more symptoms or tiredness, respectively; minimum clinically important difference, 9 points). Results The mean age of the patients was 74.4 years, and 396 patients (53.7%) were women. The mean (±SD) thyrotropin level was 6.40±2.01 mIU per liter at baseline; at 1 year, this level had decreased to 5.48 mIU per liter in the placebo group, as compared with 3.63 mIU per liter in the levothyroxine group (P<0.001), at a median dose of 50 μg. We found no differences in the mean change at 1 year in the Hypothyroid Symptoms score (0.2±15.3 in the placebo group and 0.2±14.4 in the levothyroxine group; between-group difference, 0.0; 95% confidence interval [CI], -2.0 to 2.1) or the Tiredness score (3.2±17.7 and 3.8±18.4, respectively; between-group difference, 0.4; 95% CI, -2.1 to 2.9). No beneficial effects of levothyroxine were seen on secondary-outcome measures. There was no significant excess of serious adverse events prespecified as being of special interest. Conclusions Levothyroxine provided no apparent benefits in older persons with subclinical hypothyroidism. (Funded by European Union FP7 and others; TRUST ClinicalTrials.gov number, NCT01660126 .).

BACKGROUND: The use of levothyroxine to treat subclinical hypothyroidism is controversial. We aimed to determine whether levothyroxine provided clinical benefits in older personswith this condition. METHODS: We conducted a double-blind, randomized, placebo-controlled, parallel-group trial involving 737 adults who were at least 65 years of age and who had persisting subclinical hypothyroidism (thyrotropin level, 4.60 to 19.99 mIU per liter; free thyroxine level within the reference range). A total of 368 patients were assigned to receive levothyroxine (at a starting dose of 50 μg daily, or 25 μg if the body weight was <50 kg or the patient had coronary heart disease), with dose adjustment according to thethyrotropin level; 369 patients were assigned to receive placebo with mock dose adjustment. The two primary outcomes were the change in the Hypothyroid Symptomsscore and Tiredness score on a thyroid-related quality-of-life questionnaire at 1 year (range of each scale is 0 to 100, with higher scores indicating more symptoms or tiredness, respectively; minimum clinically important difference, 9 points). RESULTS: The mean age of the patients was 74.4 years, and 396 patients (53.7%) were women.The mean (±SD) thyrotropin level was 6.40±2.01 mIU per liter at baseline; at 1 year,this level had decreased to 5.48 mIU per liter in the placebo group, as compared with3.63 mIU per liter in the levothyroxine group (P<0.001), at a median dose of 50 μg. We found no differences in the mean change at 1 year in the Hypothyroid Symptomsscore (0.2±15.3 in the placebo group and 0.2±14.4 in the levothyroxine group; between-group difference, 0.0; 95% confidence interval [CI], −2.0 to 2.1) or the Tirednessscore (3.2±17.7 and 3.8±18.4, respectively; between-group difference, 0.4; 95% CI,−2.1 to 2.9). No beneficial effects of levothyroxine were seen on secondary-outcome measures. There was no significant excess of serious adverse events prespecified as being of special interest. CONCLUSIONS: Levothyroxine provided no apparent benefits in older persons with subclinical hypothyroidism. (Funded by European Union FP7 and others; TRUST ClinicalTrials.govnumber, NCT01660126.)