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Background As the number and complexity of patients living with serious illness continue to rise, delivering care that is both effective and responsive to individual life contexts has become increasingly important. Despite its potential benefits, the implementation of contextualized care in the management of serious illness remains limited and poorly understood. To address this gap, this study aimed to identify barriers and facilitators influencing the delivery of contextualized care for patients with serious illness, as perceived by healthcare professionals (HCPs), and to generate recommendations for improving its implementation. Methods Three focus groups were conducted with 20 HCPs from multiple disciplines and hospital settings in the Netherlands, all involved in the care of patients with serious illness. Discussions were guided and analysed using a directed content analysis informed by the COM-B model (Capability, Opportunity, Motivation–Behaviour) combined with the Theoretical Domains Framework. Factors were mapped to intervention functions from the Behaviour Change Wheel (BCW) to provide recommendations. Results Nine factors influencing contextualized care were identified across COM-B components. Capability-related factors included skills and knowledge to engage with the relevant patient context and the ability to distinguish between general and clinically relevant context. Opportunity-related factors included environmental conditions, fragmented information systems, systemic incentives misaligned with contextual care, a lack of shared team norms, collaboration challenges, and the perceived emotional complexity of contextual conversations in the palliative phase. Motivation-related factors included strong intrinsic commitment to person-centred care and awareness of the consequences of overlooking context for patients, HCPs, and the overall system. Most barriers were concentrated in the Opportunity component, with environmental and team-level constraints often outweighing individual motivation and basic skills. Conclusions Delivering contextualized care for patients with serious illness is not primarily limited by individual willingness or basic capability but by environmental and systemic feasibility. Sustainable implementation requires multilevel strategies targeting team culture, interprofessional collaboration, and a supportive infrastructure. Moving from individual intent to shared norms may improve both patient outcomes and resource efficiency. Key steps include continuous education, embedding contextual care in team culture, adapting workflows and documentation, and integrating contextualization into quality measures and incentives.

Approaches such as shared decision-making emphasize effective patient-provider communication to ensure that patient preferences are integrated into clinical practice. However, they often overlook crucial aspects of patient context, which can affect the appropriateness and feasibility of care planning. Applying a contextual care model addresses this gap, yet the extent to which relevant patient context is considered in routine clinical practice remains largely unknown. Previous studies have primarily focused on the United States, leaving a gap in understanding how care is contextualized in Europe. This study explored how medical specialists in the Netherlands interpret, perceive and incorporate patient context into care planning. A qualitative interview study was performed with 18 medical specialists from 11 specialties working in academic and peripheral hospitals. Open coding was applied to explore how specialists defined and perceived patient context. Directed content analysis, based on the 4C coding process, was applied to analyze narrated case examples of contextualized and non-contextualized care. All participants acknowledged the importance of patient context for providing appropriate care, though they differed in how broadly they defined it - from physical and cognitive abilities, to social, emotional and environmental circumstances. Context was considered most relevant for making treatment decisions and, by half of the participants, for ongoing monitoring of treatment. Participants also described cases where contextualization developed over time or was shared among team members. Key challenges included distinguishing context from patient preferences and sufficiently probing red flags to inform care planning. Medical specialists emphasized the essential role of patient context in enabling personalized and efficient decision-making, enhancing care monitoring, and ultimately improving clinical outcomes. However, systematic and continuous integration of contextual information into decision-making remains challenging. Addressing this requires proactive exploration, improved communication training, and organizational support to embed contextualized care in routine practice.

Background Emergency department (ED) visits due to non-coronavirus disease 2019 (COVID-19) conditions have drastically decreased since the outbreak of the COVID-19 pandemic. This study aimed to identify the magnitude, characteristics and underlying motivations of ED visitors with delayed healthcare seeking behaviour during the first wave of the pandemic. Methods Between March 9 and July 92,020, adults visiting the ED of an academic hospital in the East of the Netherlands received an online questionnaire to collect self-reported data on delay in seeking emergency care and subsequent motivations for this delay. Telephone interviews were held with a subsample of respondents to better understand the motivations for delay as described in the questionnaire. Quantitative data were analysed using descriptive statistics. Qualitative data were thematically analysed. Results One thousand three hundred thirty-eight questionnaires were returned (34.0% response). One in five respondents reported a delay in seeking emergency care. Almost half of these respondents ( n  = 126; 45.4%) reported that the pandemic influenced the delay. Respondents reporting delay were mainly older adults (mean 61.6; ±13.1 years), referred to the ED by the general practitioner (GP; 35.1%) or a medical specialist (34.7%), visiting the ED with cardiac problems (39.7%). The estimated median time of delay in receiving ED care was 3 days (inter quartile range  8 days). Respectively 46 (16.5%) and 26 (9.4%) respondents reported that their complaints would be either less severe or preventable if they had sought for emergency care earlier. Delayed care seeking behaviour was frequently motivated by: fear of contamination, not wanting to burden professionals, perceiving own complaints less urgent relative to COVID-19 patients, limited access to services, and by stay home instructions from referring professionals. Conclusions A relatively large proportion of ED visitors reported delay in seeking emergency care during the first wave. Delay was often driven by misperceptions of the accessibility of services and the legitimacy for seeking emergency care. Public messaging and close collaboration between the ED and referring professionals could help reduce delayed care for acute needs during future COVID-19 infection waves.

Background The growing demand for elderly care often exceeds the ability of emergency department (ED) services to provide quality of care within reasonable time. The purpose of this systematic review is to assess the effectiveness of interventions on reducing ED crowding by older patients, and to identify core characteristics shared by successful interventions. Methods Six major biomedical databases were searched for (quasi)experimental studies published between January 1990 and March 2017 and assessing the effect of interventions for older patients on ED crowding related outcomes. Two independent reviewers screened and selected studies, assessed risk of bias and extracted data into a standardized form. Data were synthesized around the study setting, design, quality, intervention content, type of outcome and observed effects. Results Of the 16 included studies, eight (50%) were randomized controlled trials (RCTs), two (13%) were non-RCTs and six (34%) were controlled before-after (CBA) studies. Thirteen studies (81%) evaluated effects on ED revisits and four studies (25%) evaluated effects on ED throughput time. Thirteen studies (81%) described multicomponent interventions. The rapid assessment and streaming of care for older adults based on time-efficiency goals by dedicated staff in a specific ED unit lead to a statistically significant decrease of ED length of stay (LOS). An ED-based consultant geriatrician showed significant time reduction between patient admission and geriatric review compared to an in-reaching geriatrician. Conclusion Inter-study heterogeneity and poor methodological quality hinder drawing firm conclusions on the intervention’s effectiveness in reducing ED crowding by older adults. More evidence-based research is needed using uniform and valid effect measures. Trial registration The protocol is registered with the PROSPERO International register of systematic reviews: ID =  CRD42017075575 ).

Background The coronavirus disease 2019 (COVID-19) outbreak has been associated with stress and challenges for healthcare professionals, especially for those working in the front-line of treating COVID-19 patients. This study aimed to: 1) assess changes in well-being and perceived stress symptoms of Dutch emergency department (ED) staff in the course of the first COVID-19 wave, and 2) assess and explore stressors experienced by ED staff since the COVID-19 outbreak. Methods We conducted a cross-sectional study. An online questionnaire was administered during June–July 2020 to physicians, nurses and non-clinical staff of four EDs in the Netherlands. Well-being and stress symptoms (i.e., cognitive, emotional and physical) were scored for the periods pre, during and after the first COVID-19 wave using the World Health Organization Well-Being Index (WHO-5) and a 10-point Likert scale. Stressors were assessed and explored by rating experiences with specific situations (i.e., frequency and intensity of distress) and in free-text narratives. Quantitative data were analyzed with descriptive statistics and generalized estimating equations (GEE). Narratives were analyzed thematically. Results In total, 192 questionnaires were returned (39% response). Compared to pre-COVID-19, the mean WHO-5 index score (range: 0–100) decreased significantly with 14.1 points ( p  < 0.001) during the peak of the first wave and 3.7 points (< 0.001) after the first wave. Mean self-perceived stress symptom levels almost doubled during the peak of the first wave (≤0.005). Half of the respondents reported experiencing more moral distress in the ED since the COVID-19 outbreak. High levels of distress were primarily found in situations where the staff was unable to provide or facilitate necessary emotional support to a patient or family. Analysis of 51 free-texts revealed witnessing suffering, high work pressure, fear of contamination, inability to provide comfort and support, rapidly changing protocols regarding COVID-19 care and personal protection, and shortage of protection equipment as important stressors. Conclusions The first COVID-19 wave took its toll on ED staff. Actions to limit drop-out and illness among staff resulting from psychological distress are vital to secure acute care for (non-)COVID-19 patients during future infection waves.

The number of older cancer patients is rising. Especially in older people, treatment considerations should balance the impact of disease and treatment on quality of life (QOL) and survival. How a cancer diagnosis in older people interacts with concomitant frailty to impact on QOL is largely unknown. We aimed to determine the association between frailty and QOL among community-dwelling older people aged 65 years or above with and without a cancer diagnosis cross-sectionally and at 12 months follow-up. Data were derived from the TOPICS-MDS database. Frailty was quantified by a frailty index (FI). QOL was measured with the subjective Cantril's Self Anchoring Ladder (CSAL, range: 0-10) and the health-related EuroQol-5D (EQ-5D, range:-0.33-1.00) at baseline and after 12 months. To determine associations, linear mixed models were used. 7493 older people (78.6±6.4 years, 58.4% female) were included. Dealing with a cancer diagnosis (n = 751) was associated with worse QOL both at baseline (CSAL:-0.25 (95%-CI:-0.36;-0.14), EQ-5D:-0.03 (95%-CI:-0.05;-0.02)) and at follow-up (CSAL:-0.13 (95%-CI:-0.24;-0.02), EQ-5D:-0.02 (95%-CI:-0.03;-0.00)). A ten percent increase in frailty was also associated with a decrease in QOL at baseline (CSAL:-0.35 (95%-CI:-0.38;-0.32), EQ-5D:-0.12 (95%-CI:-0.12;-0.11)) and follow-up (CSAL:-0.27 (95%-CI:-0.30;-0.24), EQ-5D:-0.07 (95%-CI:-0.07;-0.06)). When mutually adjusting for frailty and a cancer diagnosis, associations between a cancer diagnosis and QOL only remained significant for CSAL at baseline (-0.14 (95%-CI:-0.25;-0.03)), whereas associations between frailty and QOL remained significant for all QOL outcomes at baseline and follow-up. No statistical interactions between cancer and frailty in their combined impact on QOL were found. Cancer diagnosis and frailty were associated with worse health-related and self-perceived QOL both at baseline and at follow-up. Differences in QOL between older people with and without a cancer diagnosis were explained to a large extent by differences in frailty levels. This stresses the importance to take into account frailty in routine oncologic care.

ObjectiveSuboptimal transitional care (ie, needs assessment and coordination of follow-up care) in the emergency department (ED) is an important cause of ED revisits and hospital admissions and may potentially harm patients, especially frail older adults. We aimed to systematically review the effect of ED-based interventions by health professionals who are dedicated to providing transitional care to older adults.DesignSystematic review.MeasurementsWe searched five biomedical databases for published (quasi)experimental studies evaluating the effects of health professionals in the ED dedicated to providing transitional care to older ED patients on clinical, process and/or service use outcomes. Reviewers screened studies for relevance and assessed methodological quality with published criteria (Robins-1 and the Cochrane risk of bias tool). Data were synthesised around study and intervention characteristics and outcomes of interest.ResultsFrom the 6561 references initially extracted from the databases, 12 studies were eligible for inclusion. Two types of interventions were identified, namely, individual needs assessment of ED patients (8 studies; 75%) and discharge planning and coordination of services (4 studies; 25%). Structured individual needs assessment was associated with a significant decrease in hospital admissions, hospital readmissions and ED revisits. Individualised discharge plans from the ED were associated with a significant decrease in ED revisits and hospital readmission. The overall methodological quality of the included studies was relatively low.ConclusionsComprehensive assessment of patient needs and ED discharge planning and coordination of services by health professionals interested in transitional care can help optimise the transition of care for older ED patients and reduce the risk of costly and potentially harmful (re)admissions for this population. However, more robust research is needed on the effectiveness of these interventions aiming to improve clinical, process and service use outcomes.PROSPERO registration numberCRD42021237345.

In addition to the evidence on benefits and harms, treatment considerations should depend on the patients’ preferences regarding quality or quantity of life. [...]patients should be involved in the decision-making process to improve the quality of care delivered. [...]they mentioned that patients’ characteristics for SDM, such as a low level of education, presence of cognitive impairment or difficulties in communication, complicate SDM. [...]research is needed to study communication patterns in current (surgical) decision-making processes in relation to theoretical SDM competencies, such as the conceptual model proposed by Elwyn. [...]observations of clinical practice consultations will provide insight into patients’ and professionals’ competences and needs for SDM, for example, revealing the need for patient empowerment. [...]specifically among older patients due to multimorbidity and heterogeneity, the SDM process is complex but

Background Older adults are too often hospitalized from the emergency department (ED) without needing hospital care. Knowledge about rates and causes of these preventable emergency admissions (PEAs) is limited. This study aimed to assess the proportion of PEAs, the level of agreement on perceived preventability between physicians and patients, and to explore their underlying causes as perceived by patients, their relatives, and the admitting physician. Methods A multi-center multi-method study at the ED of one academic and two regional hospitals in the Netherlands was performed. All patients aged > 70 years and hospitalized from the ED were consecutively sampled during a six-week period. Quantitative data regarding patient and clinical characteristics and perceived preventability of the admission were prospectively collected from the electronical medical record and analyzed using descriptive statistics. Agreement on preventability between patient, caregivers and physicians was assessed by using the Cohen’s kappa. Underlying causes of a PEA were subsequently collected by semi-structured interviews with patients and caregivers. Physician’s perceived causes of a PEA were collected by telephone interviews and by open-ended questions sent by email. Thematic content analysis was used to analyze the interview transcripts and email narratives. Results Out of 773 admissions, 56 (7.2%) were deemed preventable by patients or their caregivers. Admitting physicians regarded 75 (9.7%) admissions as preventable. The level of agreement between these two groups was low with a Cohen’s kappa score of 0.10 ( p  = 0.003). Perceived causes for PEAs related to six themes: (1) insufficient support at home, (2) suboptimal care in the community setting, (3) errors in hospital care, (4) time of presentation to ED and availability of resources, (5) delayed help seeking behavior, and (6) errors made by patients. Conclusions Our findings contribute to the existing evidence that a substantial part (almost one out of ten) of the older adults visiting the ED is perceived as unnecessary hospital care by patients, caregivers and health care providers. Findings also provide valuable insight into the causes for PEAs from a patient perspective. Further research is needed to understand why the perspectives of those responsible for hospital admission and those being admitted vary considerably. Strengths and limitations of this study •To our knowledge, this is the first study that structurally explored perceived causes from a patient, caregiver and physician’s perspective. All patients who were eligible were included during a six-week period. •The study was performed in three different hospitals. •Including the patient and caregiver perspective provided a better understanding of PEAs. •Including general practitioner perspectives would have contributed to a more comprehensive and reliable understanding of causes for PEAs.

ObjectiveOlder adults are prone to unplanned emergency department (ED) return visits (URVs). Knowledge about patient perspectives on the preventability and reasons for these URVs is limited and lacks a representable ED study population. This study aims to determine the proportion of URVs and to explore the preventability and underlying causes as perceived by a wide range of older adults and their caregivers.DesignA multicentre mixed-methods study.SettingThe ED of one academic and one regional hospital in the Netherlands.ParticipantsPatients aged ≥70 years with a URV within 30 days after the index ED visit, consecutively sampled during a 6-week period.Outcome measurementsQuantitative data regarding patient and clinical characteristics and perceived preventability of a URV were prospectively collected and analysed using descriptive statistics. Underlying causes of a URV were collected by semistructured interviews with patients and caregivers. Thematic content analysis was used to analyse the interview transcripts.ResultsOut of 1291 patients of 70 years and older, 151 patients had a URV (11.7%). In total, 64 patients were included after informed consent (42.4%). A total of 33 patients (51.5%) found their URV preventable. Perceived causes for a URV were categorised in six themes: (1) suboptimal treatment of health complaints, (2) premature hospital discharge, (3) poor assessment and arrangement of postdischarge needs, (4) patient and caregiver behaviour, (5) lack of advance care planning and insight in treatment options and (6) deficits in general practitioner care.ConclusionsOur high rate of preventable URVs (51.5%) perceived by patients and caregivers underscores the importance to reduce URVs among older adults. Perceived causes in this study add other unexplored themes to the existing knowledge and create support for further research and interventional opportunities.