Conclusions:Findings from this study indicate that language proficiency and education level have the most significant impact on health literacy among immigrants.Furthermore, engagement in the health sector can contribute positively to the increase of health literacy, given the evidence surrounding outlier cases.The findings indicate that social policies, such as welcoming immigrants into the host society, would improve their health literacy and health status.

OBJECTIVES:Asylum seekers have been recognized as having unique and complex health needs which require attention upon arrival in the host country. Not much is known about what issues to address in first contacts with asylum seekers. The purpose of this study is to give insight in the specific issues that healthcare providers need to address in the first contacts with newly arrived asylum seekers. STUDY DESIGN:A qualitative study using different types of data in 2007 and 2008. METHODS:Questionnaires (n = 89) were used as input for seven group interviews with Dutch care providers (n = 46) working with asylum seekers in the Netherlands, were qualitatively analysed, using a framework method. RESULTS:Healthcare providers identified four issues they aimed to address in first contacts with asylum seekers: (1) assessing the current health condition; (2) health risk assessment; (3) providing information about the healthcare system of the host country; and (4) health education. CONCLUSION:The first contacts between healthcare providers and asylum seekers serve different goals, especially assessing health problems and risks, and providing health information. These issues may, however, be addressed differently by different healthcare providers, across different host countries, dependent on the way healthcare and medical insurance for asylum seekers are organized.

ObjectiveTo describe long-term physical functioning and its association with somatic comorbidity and comorbid depression in patients with established rheumatoid arthritis (RA).MethodsLongitudinal data over a period of 11 years were collected from 882 patients with RA at study inclusion. Patient-reported outcomes were collected in 1997, 1998, 1999, 2002, and 2008. Physical functioning was measured with the Health Assessment Questionnaire and the physical component summary score of the Short Form 36 health survey. Somatic comorbidity was measured by a questionnaire including 12 chronic diseases. Comorbid depression was measured with the Center for Epidemiologic Studies Depression Scale. We distinguished 4 groups of patients based on comorbidity at baseline.ResultsSeventy-two percent of the patients at baseline were women. The mean +/- SD age was 59.3 +/- 14.8 years and the median disease duration was 5.0 years (interquartile range 2.0-14.0 years). For the total group of patients with RA, physical functioning improved over time. Patients with somatic comorbidity, comorbid depression, or both demonstrated worse physical functioning than patients without comorbidity at all data collection points. Both groups with comorbid depression had the lowest scores. Only patients with both somatic comorbidity and comorbid depression showed significantly less improvement in physical functioning over time.ConclusionBoth somatic comorbidity and comorbid depression were negatively associated with physical functioning during an 11-year followup period. Furthermore, their combination seems to be especially detrimental to physical functioning over time. These results emphasize the need to take somatic comorbidity and comorbid depression into account in the screening and treatment of patients with RA.

Background Mental functioning is reported as an important outcome measure in patients with Rheumatoid Arthritis (RA). Patients show lower mental functioning scores than the general population (1). A factor that has great impact on the overall health outcomes is comorbidity (2). Both somatic and depression comorbidity are common in patients with RA. Investigating the influence of comorbidity on mental functioning provides clinicians long term information for a particular patient. Objectives To asses the long term association of somatic and depression comorbidity and mental functioning in patients with RA. Methods Longitudinal data over a period of eleven years were collected among 882 patients with RA of varying disease duration. Patient reported outcomes were collected in 1997, 1998, 1999, 2002 and 2008. Mental functioning was measured with the Mental Component Scale of the Short Form-36 Health Survey. Somatic comorbidity was measured by a self administered questionnaire including 13 chronic diseases. Depression comorbidity was measured with the Center for Epidemiologic Depression Scale. We distinguished four groups of patients based on comorbidity at baseline: patients 1) without comorbidity 2) with only somatic comorbidity 3) with only depression comorbidity and 4) with both somatic and depression comorbidity. The influence of comorbidity at baseline on mental functioning over time was investigated in a longitudinal analysis. Results 882 patients responded to the questionnaire, of whom 78% were women. The mean age of the patients at baseline was 59.3 (SD 14.8) years and the mean disease duration was 8.9 (SD 9.9) years. For the total group of patients with RA mental functioning stayed stable over time. There was no difference in mental functioning between patients without comorbidity and patients with somatic comorbidity. Patients without comorbidity at baseline had better mental functioning at all time points than patients with depression comorbidity and patients with both somatic and depression comorbidity (p<0.01). However, the difference in mental functioning between patients without comorbidity and patients with both somatic and depression comorbidity decreased between baseline and eleven years follow up (p<0.01). Conclusions Depression comorbidity and the combination of both somatic and depression comorbidity was negatively associated with mental functioning and this association was present during eleven years follow up. Because of its long term consequences, early screening for depression comorbidity in RA would be recommended, so additional intervention can start early in the disease process to reduce the negative effects of this comorbidity. References Uhlig T, Loge JH, Kristiansen IS, Kvien TK. Quantification of reduced health-related quality of life in patients with rheumatoid arthritis compared to the general population. J Rheumatol 2007; 34(6):1241-1247. Gabriel SE, Michaud K. Epidemiological studies in incidence, prevalence, mortality, and comorbidity of the rheumatic diseases. Arthritis Res Ther 2009; 11(3):229. Disclosure of Interest None Declared

Background The prevalence of comorbidity in patients with rheumatoid arthritis (RA) is higher than in the general population (1). There is increasing evidence that comorbidity plays an important role in determining RA-related outcomes, like physical functioning (2). Little is known about the impact of comorbidity on the long term. Further, the studies that investigated the effects of comorbidity on physical functioning, did not compare the influence of both somatic and depression comorbidity. With this information clinicians can early adjust their treatment to the comorbidity. Objectives To asses the long term association of comorbidity and physical functioning in patients with established RA. Methods Longitudinal data were collected among 882 patients with RA of varying disease duration at inclusion in the study. Patient reported outcomes were collected in 1997, 1998, 1999, 2002 and 2008. Physical functioning was measured with the Health Assessment Questionnaire and the Physical Component Scale of the SF-36 Health Survey. Somatic comorbidity was measured by a self administered questionnaire including 13 chronic diseases. Depression comorbidity was measured with the Center for Epidemiologic Depression Scale. We distinguished four groups of patients based on comorbidity at baseline: patients 1) without comorbidity 2) with only somatic comorbidity 3) with only depression comorbidity and 4) with both somatic and depression comorbidity. The influence of comorbidity on physical functioning over time was investigated in a longitudinal analysis. Results 882 patients respond to the questionnaire, of whom 78% were woman. The mean (SD) age of the patients at baseline was 59.3 (SD 14.8) years and the mean (SD) disease duration was 8.9(SD 9.9) years. For the total group of patients with RA, physical functioning improved over an eleven year period. Patients with comorbidity had a worse physical functioning than patients without comorbidity at all time points, by which both groups with depression comorbidity had the lowest score (p<0.01). Only, patients with both somatic and depression comorbidity at baseline had significant less improvement in physical functioning over time (p<0.05). Conclusions Both somatic comorbidity and depression comorbidity had a negative impact on physical functioning during eleven years follow up in patients with RA, and their combination seems to be especially detrimental over time. Clinicians need to take somatic comorbidity and depression into account in screening and treatment of patients with rheumatoid arthritis to improve physical functioning in the long term. References Kroot EJ, van Gestel AM, Swinkels HL, Albers MM, van de Putte LB, van Riel PL. Chronic comorbidity in patients with early rheumatoid arthritis: a descriptive study. J Rheumatol 2001; 28(7):1511-1517. Gabriel SE, Michaud K. Epidemiological studies in incidence, prevalence, mortality, and comorbidity of the rheumatic diseases. Arthritis Res Ther 2009; 11(3):229. Disclosure of Interest None Declared

Asylum seekers often have complex medical needs. Little is known about the cultural competences health care providers should have in their contact with asylum seekers in order to meet their needs. Cultural competence is generally defined as a combination of knowledge about certain cultural groups, as well as attitudes towards and skills for dealing with cultural diversity. Given asylum seekers' specific care needs, it may be asked whether this set of general competences is adequate for the medical contact with asylum seekers. We explored the cultural competences that nurse practitioners working with asylum seekers thought were important. A purposive sample of 89 nurse practitioners in the Netherlands completed a questionnaire. In addition, six group interviews with nurse practitioners were also conducted. A framework analysis was used to analyse the data of the questionnaires and the interviews. From the analysis, several specific competences emerged, which were required for the medical contact with asylum seekers: knowledge of the political situation in the country of origin; knowledge with regard to diseases common in the country of origin; knowledge of the effects of refugeehood on health; awareness of the juridical context in the host country; ability to deal with asylum seekers' traumatic experiences; and skills to explain the host country's health care system. Apart from these cultural competences specific for the situation of asylum seekers, general cultural competences were also seen as important, such as the ability to use interpretation services. We conclude that insight into these cultural competences may help to develop related education and training for health care providers working with asylum seekers.

CONTEXT:This study was part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project investigating the impact of quality improvement strategies on hospital care in various countries of the European Union (EU), in relation to specific needs of cross-border patients.AIM:This paper describes how EU hospitals have applied seven quality improvement strategies previously defined by the MARQuIS study: organisational quality management programmes; systems for obtaining patients' views; patient safety systems; audit and internal assessment of clinical standards; clinical and practice guidelines; performance indicators; and external assessment.METHODS:A web-based questionnaire was used to survey acute care hospitals in eight EU countries. The reported findings were later validated via on-site survey and site visits in a sample of the participating hospitals. Data collection took place from April to August 2006.RESULTS:389 hospitals participated in the survey; response rates varied per country. All seven quality improvement strategies were widely used in European countries. Activities related to external assessment were the most broadly applied across Europe, and activities related to patient involvement were the least widely implemented. No one country implemented all quality strategies at all hospitals. There were no differences between participating hospitals in western and eastern European countries regarding the application of quality improvement strategies.CONCLUSIONS:Implementation varied per country and per quality improvement strategy, leaving considerable scope for progress in quality improvements. The results may contribute to benchmarking activities in European countries, and point to further areas of research to explore the relationship between the application of quality improvement strategies and actual hospital performance.

Aim: This study, part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project focusing on cross-border patients in Europe, investigated quality policies and improvement in healthcare systems across the European Union (EU). The aim was to develop a classification scheme for the level of quality improvement (maturity) in EU hospitals, in order to evaluate hospitals according to the maturity of their quality improvement activities. Methods: A web-based questionnaire survey designed to measure quality improvement in EU hospitals was used as the basis for the classification scheme. Items included for the development of an evaluation tool—the maturity index—were considered important contributors to quality improvement. The four-stage quality cycle (plan, do, check and act) was used to determine the level of maturity of the various items. Psychometric properties of the classification scheme were assessed, and validation analyses were performed. Results: A total of 389 hospitals participated in a questionnaire survey; response rates varied by country. For a final sample of 349 hospitals, it was possible to construct a quality improvement maturity index which consisted of seven domains and 113 items. The results of independent analyses sustained the validity of the index, which was useful in differentiating between hospitals in the research sample according to the maturity of their quality improvement system (defined as the total of all quality improvement activities). Discussion: Further research is recommended to develop an instrument which for use in the future as a practical tool to evaluate the maturity of hospital quality improvement systems.

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OBJECTIVE:The development and testing of a questionnaire to enable anesthesiology residents to assess the training qualities oftheir clinician-educators.DESIGN:Questionnaire.METHODS:The taskforce drafted a questionnaire based on the 26 item Stanford Faculty Development Program questionnaire (SFDP26) and adapted to the Dutch situation. Following its discussion in separate meetings ofanesthesiology residents and clinical staff, the questionnaire was further edited. The resulting instrument contained 6 teaching domains and 26 items. The questionnaire was made available electronically to anesthesiology residents only. Participation was voluntary, confidential and anonymous. Group results were presented at a plenary session. Anesthesiology staff received their individual scores by e-mail; results were confidential.RESULTS:21 residents assessed 39 anesthesiologists. A total of 423 questionnaires were completed. Factor analysis resulted in the reduction and re-grouping of the teaching domains. The internal consistency ofthe teaching domains was high (Cronbach-alpha > or = 0.86). The assessment results of the teaching qualities of the anesthesiology faculty were positive. 'Communication of goals' was the lowest scoring (mean = 3.41) and 'Professional attitude towards residents' the highest scoring teaching domain (mean = 4.07). Gender did not correlate with the assessment scores of faculty. 'Year of training' was negatively correlated with most of the teaching domains.CONCLUSION:A feasible and reliable instrument for the evaluation of Dutch clinician-educators is now available.

OBJECTIVE:To describe health outcomes reported by patients with rheumatoid arthritis (RA), i.e., pain, disability and health-related quality of life, as a function of disease duration in a longitudinal approach, and to compare the course of patient-reported health outcomes by a longitudinal versus a cross-sectional approach.METHODS:Data were collected with 4 series of questionnaires between 1997 and 2002 among patients with RA (maximum number = 882) of varying disease duration. The course of patient-reported health outcomes as a function of disease duration was evaluated using both longitudinal data and cross-sectional data of the first series.RESULTS:The course of RA shows a different pattern for various health outcomes. We observed similar trends in health outcomes in this large patient sample using the longitudinal and the cross-sectional approach.CONCLUSION:Although longterm consequences of RA are preferably assessed in longer duration followup studies, cross-sectional studies, including patients with a broad range of disease durations, seem to provide fairly reliable estimates of the course of health outcomes.

Objective. To assess the predictive value of selected sociodemographic characteristics, rheumatoid arthritis (RA)-specific clinical factors, and comorbidity with respect to patient-reported health outcomes, i.e., pain, disability, and health-related quality of life, among patients with RA. Methods. Data were collected between 1997 and 2002 among 882 patients with RA of varying disease duration using questionnaires and clinical examinations. Health outcomes were evaluated over 5 years as a function of disease duration by means of random intercept linear regression. Then we selected the 10% of patients with the poorest and best health outcomes during the 5 years of followup compared to others with equal disease duration. Separate multivariate logistic regression analyses were conducted to identify factors associated with poor and good outcomes. Results. Sociodemographic characteristics seemed to be less important in the prediction of health outcomes. After RA-specific clinical factors, comorbidity appeared to be a major predictive factor for health outcomes. In particular, psychological comorbidity, i.e., depressive symptomatology, was a consistent predictive factor with respect to all health outcomes. Conclusion. Assessment of comorbidity needs to be incorporated into the management of RA in order to prevent poor outcomes and to adapt therapies to the specific situation of individual patients. Periodic routine screening for and monitoring of somatic and psychological comorbidity should be included in clinical practice.

Objective: To study the associations between disability and health‐related quality of life (HRQoL), respectively, and radiographic joint damage, disease activity, pain, and depressive symptoms among patients with rheumatoid arthritis (RA). Methods: Data were collected through questionnaires and clinical examinations at baseline (1997) and at 2 years' follow‐up among patients with RA (n = 307). Disability was measured with a validated Dutch questionnaire, derived from the Health Assessment Questionnaire (HAQ), and HRQoL with a validated Dutch version of the RAND‐36, using physical (PCS) and mental (MCS) component summary scales. Multivariate linear regression analyses were performed to assess the relationship between disability or HRQoL and radiographic damage, disease activity, pain, and depressive symptoms. Results: Pain, with respect to disability and PCS, and depressive symptoms, with respect to MCS, were more important predictors than radiographic damage and disease activity. Conclusions: Daily RA practice needs to be broadened by regular assessment of disease burden from the patients' perspectives. Patient‐reported measures, such as disability or HRQoL, should be incorporated for monitoring health outcomes of individual patients and for initiating and evaluating therapy.

Background: The introduction of market mechanisms in Dutch healthcare engages insurance companies in competition. Patient experience surveys are increasingly applied to generate performance information guiding consumers and insurers to choose and contract high performers, as well as holding them accountable. Thus, there is an increased need for standardized patient experience measurement tools for specific types of care. Here, we report on the reliability and validity of a new instrument we developed to measure patient experiences with diabetes care. Methods: We combined and adapted existing CAHPS and QUOTE-Diabetes instruments into one self-administered questionnaire (118 items) to assess (i) patients’ experiences with diabetes care provided by their general practitioner (GP), internist, nurse, or dietician and (ii) their diabetes-specific health outcomes. Survey population diabetes patients of one insurer (Agis), enrolled in the sickness fund and aged 50 or above. Sample 983 patients who claimed reimbursement for diabetes medication in the 12 months prior to November 2003 were sent a questionnaire. Results: A total of 563 patients returned the questionnaire and confirmed being diabetic (response rate 63.5%). 510 diabetes patients completed the questionnaire. Non-response bias was unlikely. Filling out the questionnaire did not seem a problem for the majority of respondents. Psychometric properties of the questionnaire compared well with the two underlying pre-existing questionnaires. ‘Diabetes specific communication’ was a consistent 4-item factor in the new instrument, independent of the type of care provider. Internal consistency reliability was good (Cronbach’s alpha ranged 0.84–0.89). ‘Provider-patient interaction’ was a consistent 5-item factor for care by GP’s, internists and nurses (Cronbach’s alpha 0.89–0.92), but not dieticians. Respondents reported case management and outcome measures similar to those in other studies. Conclusions: The newly constructed—CAHPS and QUOTE-Diabetes based—questionnaire is reliable and valid and is well received by respondents. It offers a strong basis for further development of patient experiences survey for Diabetes Care in the Dutch healthcare context. (aut.ref.)

OBJECTIVE:To identify health care aspects of inadequate quality in rheumatoid arthritis (RA) care from the perspective of patients, and to study to what extent patients' perspectives on quality of care are associated with patient characteristics.DESIGN:Cross-sectional questionnaire survey performed in 1999.SETTING:Secondary and tertiary rheumatology outpatient clinics.STUDY PARTICIPANTS:A random sample (n = 683) of patients diagnosed with rheumatoid arthritis according to the 1987 revised American College of Rheumatology criteria. Patients varied widely with respect to age (mean 61.5 years) and disease duration (mean 10.7 years).MAIN OUTCOME MEASURES:Using the method of the QUOTE-questionnaire, patients' were asked to rate the importance to them of 29 aspects of care, and to rate the performance of five different health care providers [i.e. rheumatologist, general practitioner (GP), physiotherapist, home nurse, and formal home help] relating to these aspects. To identify aspects of inadequate quality, patients' performance ratings were weighted by importance ratings within each health care service. Inadequate performance on an extremely important aspect was found to be a more serious quality problem than an inadequate performance on an aspect that was less important to patients. Using regression analyses, the association between patients' quality ratings and patient characteristics was assessed.RESULTS:Several aspects of inadequate quality were identified, namely in the field of knowledge of rheumatism and particularly for GPs, physiotherapists, home nurses, and formal home help, and in the field of information on medication and treatment for rheumatologists and GPs. Furthermore, for the majority of the importance and performance ratings, we found no association with patient-related characteristics.CONCLUSIONS:Our study demonstrated that the quality of care could be improved further from the perspective of patients. These findings may be used for making health care more responsive to patients' needs.

OBJECTIVE:To describe the extent of somatic comorbid conditions in patients with rheumatoid arthritis (RA) and to assess the influence of comorbidity on health-related quality of life (HRQOL).METHODS:A 2-year followup study on health and HRQOL was conducted among 679 patients with RA with varying disease duration. Data were collected by means of questionnaires and clinical examinations at baseline and at 2-year followup. Comorbidity was measured by a self-administered questionnaire including 17 chronic diseases. HRQOL was assessed with the RAND-36. The effect of incident comorbid conditions on HRQOL was investigated with linear regression analyses.RESULTS:At least one comorbid condition was reported at baseline by 56% of patients. Significant differences in prevalence rates with the Dutch population were found. The effect of comorbidity on HRQOL depended on both the type of comorbid condition and the dimension of HRQOL. Gastrointestinal (GI) diseases, cancer, dizziness with falling (and less severe chronic pulmonary disease and heart complaints) resulted in significant adverse changes in HRQOL. For the other conditions under study no influence could be detected.CONCLUSION:Our results indicate that measuring comorbidity by a summary count, assuming an overall equally large effect of each comorbid condition, may not reveal the real effect. With respect to clinical practice, our results emphasize the relevance for health care providers to be aware of specific comorbid conditions exposing patients with RA at risk for additional impairment of HRQOL, and to be aware of interactions with RA that may be unique.

Objective. To multidimensionally assess fatigue in rheumatoid arthritis (RA) and to evaluate the impact of fatigue on health-related quality of life (HRQOL).Methods. The study was conducted in 1999 among 490 RA patients with varying disease duration. Fatigue was measured with the Multidimensional Fatigue Inventory (MFI-20) and HRQOL with a validated Dutch version of the RAND 36-Item Health Survey. We evaluated the impact of fatigue on HRQOL by multiple linear regression analyses taking into account RA-related pain and depressive symptoms.Results. Different aspects of fatigue selectively explained different dimensions of HRQOL. The MFI-20 was entered last to the linear regression models, resulting in an additional increase of explained variance of 1% (mental health) to 14% (vitality).Conclusion. The multidimensional portrayal of RA-related fatigue can be used to develop intervention strategies targeted to specific aspects of fatigue. Fatigue, supplementary to RA-related pain and depressive symptoms, appears to be a feasible and treatable target in the clinical management of RA to increase HRQOL.

OBJECTIVETo assess the prevalence of unmet health care demands among rheumatoid arthritis (RA) patients, and to determine if these unmet demands indicate underuse.METHODSA total of 679 patients with RA participated in a questionnaire survey and clinical examination. Unmet health care demands and health care use were assessed for orthopedic care, allied health care, home care, and psychosocial care. Indications for underuse were determined by comparing health outcomes of patients with unmet health care demands and of health care users.RESULTSOf the 679 patients, 28.7% had an unmet demand for 1 of the 4 services: 13.4% for allied health care, 9.7% for orthopedic care, 9.4% for home care, and 6.2% for psychosocial care. Underuse of allied health care, home care and psychosocial care was observed.CONCLUSIONUnmet demands for health care are frequent among RA patients. Most unmet demands indicate underuse. Health care professionals should therefore be more responsive to the demands of patients.