Malignant lymphomas constitute a diverse group of cancers of lymphocytes. One well-known disease is Hodgkin’s lymphoma; the others are classified as non-Hodgkin’s lymphoma (NHL). NHLs are the most common hematologic neoplasms in adults worldwide, and in 2012 over 170,000 new cases were estimated in the United States and Europe.In previous studies, several practice gaps in hospital care for patients with NHL have been identified. To decrease this variation in care, the present study aims to perform a problem analysis in which barriers to and facilitators for optimal NHL care will be identified and, based on these findings, to develop (tailored) improvement strategies. Subsequently, we will assess the effectiveness, feasibility and costs of the improvement strategies.Barriers and facilitators will be explored using the literature, using interviews and questionnaires among physicians involved in NHL care, and patients diagnosed with NHL. The results will be used to develop a tailored improvement strategy. A cluster randomized controlled trial involving 19 Dutch hospitals will be conducted. Hospitals will be randomized to receive either an improvement strategy tailored to the barriers and facilitators found or, a standard strategy of audit and feedback.The effects of both strategies will be evaluated using previously developed quality indicators. Adherence to the indicators will be measured before and after the intervention period based on medical records from newly diagnosed NHL patients. To study the feasibility of both strategies, a process evaluation will be additionally performed. Data about exposure to the different elements of the strategies will be collected using questionnaires. Economic evaluation from a healthcare perspective will compare the two implementation strategies, where the costs of the implementation strategy and changes in healthcare consumption will be assessed.The presence of variation in the use of diagnostic tests, treatment, and follow-up between different physicians in different hospitals in the Netherlands is important for patients. To reduce the existing variation in care, implementation of tailored interventions to improve NHL care is necessary.NCT01562509.This trial is registered at ClinicalTrial.gov as the PEARL study, registration number  Malignant lymphomas represent a heterogeneous group of malignant lymphocyte proliferations, which can be classified as either Hodgkin’s lymphoma (HL) or non-Hodgkin’s lymphoma (NHL). NHLs are the sixth most common malignant neoplasm in the United States  and the Evidence-based guidelines on diagnosis, treatment, and follow-up of patients with NHL have been developed during the past years and provide recommendations for high quality NHL care -11. ThesTo improve quality of NHL care, it is important to know what the barriers to and facilitators for high-quality NHL care are. Based on this, tailored interventions can be developed to improve the quality of care. Most theories on implementation of evidence in healthcare emphasize assessment of influencing factors first, in order to acquire a tailor-made improvement strategy ,22. SeveThis study aims to perform a problem analysis in which barriers and facilitators for optimal NHL care will be identified. Based on these findings, we intend to develop (tailored) improvement strategies, and assess their effectiveness, feasibility and costs.Main objectives that will be investigated are:1. To explore barriers and facilitators according to patients and physicians, that influence optimal NHL care as described in evidence based NHL guidelines,2. To gain insight into the current NHL care based on previously developed quality indicators.3. To develop, test, and evaluate the improvement strategies, tailored to the barriers found and current practice.The objectives of this study will be examined in a cluster randomized controlled trial (cRCT), preceded by a problem analysis.Barriers and facilitators for delivering optimal care will be investigated at different levels. For the classification of the influencing factors a framework developed by Cabana  and GrolTo detect possible barriers and facilitators regarding optimal NHL care, a literature study will be performed. Second, a qualitative study will be conducted on the basis of  interviews among physicians involved in NHL care and on individual interviews with NHL patients. The interviewer will follow the framework as described above during the semi-structured interviews to explore influencing factors. This method will provide us with barriers and facilitators at different levels . Finally, a questionnaire survey will be performed to quantify the features mentioned in the  interviews. All participants will receive a web-based questionnaire by email and asked to fill in this questionnaire. The data will be gathered in an electronic database.Four small group interviews with seven to 10 physicians will be conducted. Physicians, including hematologists, pathologists, radiation oncologists, radiologists, and nuclear medicine physicians, from 22 hospitals involved in a previous NHL study  will be Barriers and facilitators regarding optimal NHL care based on evidence-based multidisciplinary NHL guidelines. They will be classified within the framework developed by Cabana and Grol ,25.The barriers and facilitators mentioned in the interviews with physicians and patients will be qualitatively analyzed using the software Atlas.ti®  and will be descriptive. Potential barriers and facilitators will be identified independently by two members of the project team, and any discrepancies will be discussed until consensus is reached.The influencing factors from these interviews are quantified on the basis of questionnaire surveys conducted among physicians and patients to assess the most frequently mentioned barriers and facilitators. Analysis of the questionnaires will be descriptive .Based on the results of the problem analysis and the care measurements of Wennekes et al. , tailoreThe interventions will be tested in a cRCT in 19 Dutch hospitals. The hospitals will be the level of randomization which includes two arms: centers receiving a standard strategy of audit and feedback, and centers receiving the standard strategy followed by an improvement strategy tailored to the barriers and facilitators found. Both strategies will be evaluated with an effect-, process-, and cost-evaluation. In the effect evaluation, the previously developed quality indicators will be used as effect measures: before and after implementing the strategies, quality indicator adherence will be assessed by retrospective searches in medical records by the Comprehensive Cancer Centre the Netherlands (CCC). After the intervention period, patients as well as physicians will be asked to fill out a questionnaire concerning the use and experiences with the interventions tested. Semi-structured interviews in each hospital will give insight into the processes concerning implementation of the interventions and local initiatives to improve NHL care during the intervention period. Costs of the interventions and the accompanied changes in consumption of care will be assessed as well.Nineteen hospitals, including university, teaching, and non-teaching hospitals, and their physicians involved in NHL care will participate in this study. Hospitals that participated in a previous NHL study  will be Randomization will take place after formal agreement of all hospitals to participate in the trial and will be based on randomly generated numbers (computer based) stratified by hospital size . The contact persons of all participating hospitals will be informed of the allocation after collection of the baseline measurement. In all participating hospitals, the trial will be conducted between November 2012 and June 2014.Per hospital, approximately 22 newly diagnosed NHL patients will be selected for data collection regarding adherence to the quality indicators. Selection of patients will take place using the cancer registry, with support of the CCC. The CCC will use the cancer registry to make a list of potentially eligible patients in the participating hospitals. From each list, the first 25 to 30 patients will be selected, and listed according to day of birth. This cancer registry is based on the pathology coding system of the World Health Organization (WHO) and patients with mature B-, T- and NK-cell neoplasms will be selected for inclusion. Patients diagnosed with cutaneous or leukemia-type neoplasms will be excluded, as well as patients younger than 18 years old.During the intervention period, physicians of the intervention hospitals will hand out patient information and an informed consent to all newly diagnosed NHL patients. Physicians are asked to use the different developed elements to improve quality of care. Patients will return their informed consent with permission (or prohibition) for sending them a questionnaire at the end of the intervention period. Patients as well as physicians will be stimulated to actively apply the interventions of our improvement strategy (when applicable).The effect evaluation aims to determine the effectiveness of the standard audit and feedback strategy versus the tailored improvement strategy using the previously developed quality indicators. Percentage of adherence to these indicators will be used as a primary measure for quality of NHL care. The effect measurement will be done by two assessments, one before and one after implementation of the improvement strategies. The data for these indicators will be collected on patient level from medical records. Additionally, morbidity in the patient groups, patient-related outcome measures, and potential confounders of the effects will be evaluated.To study the feasibility of both strategies, the process evaluation has to give insight into the mechanisms and processes responsible for the result . The actual exposure of the patients and physicians to the interventions, together with their experience with these elements may have influenced the final result (success or failure of indicator adherence).Data about exposure to the different interventions will be collected using a combination of data collection methods . This information will be related to effectiveness of the strategy to assess which interventions were particularly associated with successful implementation. At the end of the intervention period, experiences of patients and physicians with the implementation elements will be measured with questionnaires and/or interviews. This information will be used to, if necessary, adapt the interventions to make them more acceptable and effective for implementation on a national level.The economic evaluation will compare the two strategies in a healthcare perspective. Both the costs of the implementation strategy and changes in healthcare consumption will be assessed. Although the underlying technologies might be evaluated well on a national level, the aim of this analysis is to detect which strategy is the most cost-effective strategy on optimal care in common practice.The input of resources in the improvement strategies will be assessed by collecting volumes of consumed resources and multiplying these by the price of each resource unit  ,27. The We hope to detect a difference in adherence to the indicators between the two strategies of at least 20%. In a previous study, the mean adherence rate was 40%. To detect a difference of 20% (40% versus 60%), with alpha = 0.05, a two-sided testing and power = 0.80, at least 194 NHL patients are required.However, considering an intra-cluster correlation coefficient of 0.09 (mean ICC in previous study ) and a hMultilevel regression analyses will be performed to evaluate the effectiveness of both improvement strategies. Patient characteristics as gender, age, tumor type, and co-morbidity will be collected and included in the analysis as possible confounders for differences in actual care between the different hospitals and for differences in effectiveness between the two strategies.Exposure to and experiences with the improvement strategy elements will be analyzed descriptively. Possible local initiatives to improve NHL care during the intervention period will also be considered descriptively.The implementation process and consequently (full) costs of both strategies will be estimated by an Activity Based Costing (ABC) approach focusing on activities performed with costs accumulated at the activity level(s) of the healthcare implementation processes. The incremental costs will be determined by the difference in resource consumption between the two strategies. Next, the underlying activities  associated with these sub-processes are identified. Use of ABC concepts facilitates the identification of non-value-added activities.The output or consequences of the implementation strategies will be determined by the level of adherence to the quality indicators, measured before and after the intervention period. Adherence will be determined by using the repeated measures method over the two different time intervals. The decision criterion on which the efficient implementation strategy will be selected is the incremental cost per gained percentage adherence. The impact of variable(s) uncertainty on the decision criterion will be evaluated by sensitivity analyses.In the Netherlands, studies involving human subjects need to undergo a medical ethics review if they are subject to the Medical Research Involving Human Subjects Act (WMO). The Medical Ethics Committee (CMO) of district Arnhem/Nijmegen assessed the study protocol and declared that no further ethical approval was required (registration number 2011/560). Therefore, using the described study protocol, the study will be carried out in accordance with the applicable rules concerning the review of research ethics committees and informed consent.No data cleaning or analysis of the cRCT has been executed prior to submission of this manuscript.This paper describes the protocol of an improvement study, consisting of a problem analysis and a cRCT, to assess barriers and facilitators for optimal NHL care to develop, test, and evaluate (tailored) improvement strategies, based on these findings.The strength of this study is the use of multifaceted tailored interventions, which may be more effective than single ones ,28,29. TLocal initiatives to optimize NHL care during the intervention period might bias our study results. Therefore, information on local, non-study-related interventions will be additionally inquired during the process evaluation.The results of this study will contribute to a better knowledge of barriers and facilitators of optimal NHL care and thus improvement opportunities. Next to this, insight will be obtained in the effects of different strategies on the quality of NHL care, which enables us to define a preferred improvement strategy. We believe that the interventions tailored to the barriers found will optimize NHL care and might be applicable on a national level in the future.NHL: non-Hodgkin’s lymphoma; ZonMw: Netherlands organization for health research and development; LVN: Dutch lymphoma organization; cRCT: cluster randomized controlled trial; CCC: Comprehensive cancer centre the netherlands; WHO: World health organization; B- T- and NK-cell: B-lymphocyte, T-lymphocyte and natural killer cell; ICC: intra-cluster correlation coefficient; ABC: Activity based costing; WMO: Medical research involving human subjects act; CMO: Medical ethics committee.The authors declare that they have no competing interests.RH and PO had the basic idea for this study. RH, PO, and JvK were responsible for the research questions and designed the study. LW, RvdM, EA commented on the design of the problem analysis and all authors commented on the design of the cRCT. EA is the team’s expert in economic evaluations. JS wrote the first draft of this manuscript and was responsible for the revisions. All authors critically reviewed the drafts and approved the final manuscript before submission.


In the past 30 years, the average age of biomedical researchers has steadily increased. The average age of an investigator at the National Institutes of Health (NIH) rose from 39 to 51 between 1980 and 2008. The aging of the biomedical workforce was even more apparent when looking at first-time NIH grantees. The average age of a new investigator was 42 in 2008, compared to 36 in 1980. To determine if the rising barriers at NIH for entry in biomedical research might impact innovative ideas and research, we analyzed the research and publications of Nobel Prize winners from 1980 to 2010 to assess the age at which their pioneering research occurred. We established that in the 30-year period, 96 scientists won the Nobel Prize in medicine or chemistry for work related to biomedicine, and that their groundbreaking research was conducted at an average age of 41—one year younger than the average age of a new investigator at NIH. Furthermore, 78% of the Nobel Prize winners conducted their research before the age of 51, the average age of an NIH principal investigator. This suggested that limited access to NIH might inhibit research potential and novel projects, and could impact biomedicine and the next generation scientists in the United States. President Barack Obama pledged in 2009 to “devote more than 3% of our GDP [gross domestic product] to research and development,” and to specifically “promote breakthroughs in energy and medicine With a budget of approximately $31 billion a year, the National Institutes of Health (NIH)  and a first-time NIH grantee The average age of a PI at NIH has increased at a steady pace from 39 in 1980 to 51 in 2008 see  [3]. If With the increasing age of those obtaining funding from NIH, could the United States be losing out on innovative research and discouraging promising students from entering or continuing in science? Previous research suggested that the aging of the biomedical research sector will negatively impact productivity, as younger scientists are more likely to produce high-impact publications This study set out to assess when innovative biomedical research previously occurred by first establishing the age at which pioneering ideas of Nobel Prize winners arose. The Nobel Prize is awarded to scientists who have made the most significant discoveries in science—discoveries that withstand the “test of time.” These breakthroughs not only impact the scientists' respective fields, but also the advancement of other areas of science We began our study of NIH aging trends by surveying the publications of scientists who won the Nobel Prize in medicine or chemistry for work related to biomedicine, and deduced the age at which the research occurred. Our results indicated that the majority of winners were under the average age of first-time NIH grant recipients when the Nobel-recognized research was conducted. This suggested that the NIH might be setting high barriers for entry into biomedical research, as demonstrated by the rising age of PIs and first-time grantees.www.nobelprize.org, included all winners from 1980 to 2010 whose work was related to biomedical research. This consisted of all medicine and physiology winners and a subset of chemistry winners whose research involved DNA, RNA, or proteins. Using the description of the research and press releases from the Nobel website, we deduced the research topic and searched PubMed, the online database of biomedical research (www.pubmed.org), to find the seminal publication. We established either the specific publication for which the award was granted  or estimated when the researcher first published his or her pioneering work (as was the case for the 2003 award to Drs. Paul C. Lauterbur and Peter Mansfield for magnetic resonance imaging [MRI]). The publication year determined the age at which each winner conducted innovative research leading to his or her award. This methodology is similar to previous studies on Nobel laureates To ascertain the age at which Nobel laureates conducted their winning research, we first determined the project or idea that led to the prize and matched it to a corresponding publication. The list of recipients, obtained directly from the Nobel website, In the 30-year period studied (1980 to 2010), 96 people with biomedical research interests were awarded the Nobel Prize. This seemingly high total resulted from the naming of multiple winners in each category in most years . Of the http://projectreporter.nih.gov) was searched to verify the grant and topic. However, the database is limited to grants awarded after 1986, and many projects were conducted prior to this date.Once the list of laureates and their publications was generated, the funding sources for US recipients (based on the address listed on the publication) were determined. Of the 96 Nobel Prize winners, 59 recipients (62% of the group) were from the United States. Each US publication was examined for specific funding information in the acknowledgment section of the laureate's paper. If possible, the NIH RePORT grant information database . Sixteen (more than one-third) of the 45 American Nobel laureates did not receive funding from the NIH for the early scientific work that won them the prize. The work of seven of these recipients was funded through NIH grants, with others listed as the PI. For instance, Dr. Carol W. Greider's early work was funded under Dr. Elizabeth H. Blackburn, her Ph.D. adviser. The remaining recipients were funded through private institutions—PEW, the March of Dimes, the American Cancer Society, the American Heart Association, their university or a company—or other governmental agencies, specifically the Atomic Energy Commission or the US Public Health Service. These results are similar to findings from other researchers who looked at Nobel funding from 2000 to 2008 in the fields of chemistry, physics, and medicine As scientific research becomes more competitive, it is crucial to fund the most promising research and promote innovative and creative thinking. In this paper, we used the Nobel Prize as a measure for innovation or innovative thinking to try to estimate when novel and revolutionary ideas are formed, specifically in biomedical research. This study suggested that Nobel Prize winners conducted their groundbreaking research at an average age that was lower than the average age of an NIH PI or a first-time NIH grantee. Our data also suggested that while innovative research can occur at any age (the Nobel researchers surveyed ranged in age from 24 to 72 years), investigators under 40 years old seemed to dominate the projects. While many of the young investigators collaborated with more senior scientists, the fact that they were singled out by the Nobel committee indicated their personal contribution was great, and the field may not have advanced without them.The peer-review process can be the best way to determine good projects, but it can also be conservative and risk-averse. This can harms both high-risk, high-impact ideas as well as new investigators who have not established a track record. First-time investigators are historically funded at lower rates due to their perceived higher risk. In 2006, 14.8% of proposals from first-time investigators received funding, compared to 17.5% for previously funded investigators There are also other possible reasons for the lower average age of Nobel winners compared to first-time grantees. Young researchers might have fewer management obligations and grant writing pressures than senior faculty members, and might therefore spend more time in the lab on experiments. They also have access to reagents and equipment through their mentors, which might be missing in later stages of their careers. They could also benefit from associating with a mature PI and receiving increased mentoring.www.nih.gov).In the limited survey of Nobel Prize winners, we found that in several cases, the NIH did not fund the researchers directly for their work leading to the award. Responses to our emails uncovered multiple grant proposal rejections due to the researcher's inexperience or the peer reviewer's reluctance to fund high-risk projects. By raising barriers to funding, the NIH could be stifling innovative projects by deterring young scientists from entering the field. The NIH budget has been boosted nearly tenfold in the past 30 years, indicating that more resources are available and could be allocated differently to support early-career scientists . In addition, a careful survey of the impact of NIH's new policy granting exceptions for new investigators should be pursued to ascertain if these researchers are more, less, or equally as successful as their colleagues in future rounds of funding, when privileged status is not granted.If nothing is done to reverse the rising age of PIs and first-time grantees, the scientific community could lose a generation of researchers, leading to an unsustainable biomedical research infrastructure and a dearth of talent participating in NIH-funded projects in the near future. In approximately 20 years, this gap will be more apparent as senior leadership enters retirement. Without change, biomedical research will be poised to falter as the next generation of scientists and innovations fails to emerge. Increasing the commitment to fund young scientists and providing career advancement opportunities will help ensure a steady flow of ingenuity for years to come.


Systems to exempt the indigent from user fees have been put in place to prevent the worst-off from being excluded from health care services for lack of funds. Yet the implementation of these mechanisms is as rare as the operational research on this topic. This article analyzes an action research project aimed at finding an appropriate solution to make health care accessible to the indigent in a rural district of Burkina Faso.This action research project was initiated in 2007 to study the feasibility and effectiveness of a community-based, participative and financially sustainable process for exempting the indigent from user fees. A interdisciplinary team of researchers from Burkina Faso and Canada was mobilized to document this action research project.The action process was very well received. Indigent selection was effective and strengthened local solidarity, but coverage was reduced by the lack of local financial resources. Furthermore, the indigent have many other needs that cannot be addressed by exemption from user fees. Several knowledge transfer strategies were implemented to share research findings with residents and with local and national decision-makers.Using a mixed and interdisciplinary research approach was critical to grasping the complexity of this community-based process. The adoption of the process and the partnership with local decision-makers were very effective. Therefore, at the instigation of an NGO, four other districts in Burkina Faso and Niger reproduced this experiment. However, national decision-makers showed no interest in this action and still seem unconcerned about finding solutions that promote access to health care for the indigent.The lessons learned with regard to knowledge transfer and partnerships between researchers and associated decision-makers are: i) involve potential users of the research results from the research planning stage; ii) establish an ongoing partnership between researchers and users; iii) ensure that users can participate in certain research activities; iv) use a variety of strategies to disseminate results; and v) involve users in dissemination activities. Access to health care is restricted particularly by geographic, sociocultural and financial factors . In AfriIn light of this, health policies in Africa have always advocated exempting the indigent, who are consistently unable to pay for care , from poTo satisfy this need for knowledge, an action research project was initiated in 2005. Our previous research showed that: i) villagers’ knowledge about each other can be used to identify the indigent; ii) health centre management committees (COGESs), which manage the money paid by users, have a certain financial capacity to exempt the indigent from user fees; and iii) trials need to be conducted in the national context to generate local knowledge with significant potential to influence national decision-makers ,9.This action research project  was launBetween 2005 and 2007, a participative process was carried out to plan the outlines of the action project and the study. All central and peripheral actors from the Ministry of Health and the Ministry of Social Action, as well as community representatives and other local leaders, were invited to take part in this planning process.The action project, carried out in partnership with the team from the health district and the provincial social action department, consisted in asking villagers in half of the district's health centres (n = 10) to identify the people whom they considered to be indigent . In 2007Because health care workers found it difficult to identify the indigent based on a list of 20 criteria that we provided, those working in other health centres in the district that were not involved in the trial asked that it be reproduced. Therefore, in 2010, the trial was expanded to include all villages (n = 257) and health centres (n = 26) in the district. The village selection committees then identified 2,650 indigent people, of which the COGESs retained 1,100, or 41%. Also, following a study trip to Ouargaye in 2008, teams from two other districts in the country (Dori and Sebba) and from two districts in neighbouring Niger (Mayahi and Tera) tested the action project in 2009. In early 2011, it was extended to all the villages in Dori and Sebba. The village selection committees identified 1,400 and 865 indigents, respectively, of whom the COGESs retained 292 and 312. In Niger, the pilot project in nine health centres resulted in indigence cards being distributed to 244 people.A number of research activities were carried out in conjunction with this action project. While space constraints do not allow us to describe in detail here all the methods used, the fundamental point to note is that we employed both qualitative and quantitative methods and assessed not only the appropriateness of the action project, but also its processes and effectiveness. A multidisciplinary team from Canada and Burkina Faso was set up to answer three main questions: i) Was the action project adapted to the social context, well received by stakeholders, and non-stigmatizing of the indigent? ii) What process was used to implement the action, and what were its strengths, weaknesses and local adaptations? and iii) Did the action project make it possible to reduce both inclusion (selecting non-indigent people) and exclusion (leaving out indigent people) biases?The research results showed that the community-based selection process was perfectly adapted to the social context and well received by residents and health care workers. Thus, we showed that communities are able to identify the indigent in their villages. In rural areas, therefore, it is not necessarily useful to wait for a list of indigence criteria to be defined. However, the request from nurses, who have been asking for these criteria for the past 20 years, to scale up this pre-identification method to the entire district is additional proof of the relevance of the community-based approach.He doesn't care about health care; he's thinking about where he'll get his next meal and where he'll sleep."While indigence status did not lead to social stigmatization, the process revealed that access to health care was just one of many needs , even though the action research focused solely on that aspect. Indeed, the research action project focused on financial access to health care as a gateway to understanding why health services are used very little, if at all, by the indigent. It responded to a need that had long been widely expressed by those working in Burkina Faso’s health system and by residents, but never studied . In factThe scientific literature has long shown that geographic or social distance between patients and health care workers also affects use of services . The researchers were clearly aware of these facts but could not attempt to resolve all access issues in a single action research project because of the difficulty in finding ways to conduct research in this area and because of the chosen approach. However, the research in Ouargaye helped bring to light once again the two limitations of actions centred solely on financial access to health care: i) the use of services is constrained by aspects other than just payment for health care, and ii) the health of indigent people is affected by multiple factors outside of the health care system. While this is by no means a new scientific discovery, these results argue for the organization of more holistic and interdisciplinary action research projects to improve the living conditions of the worst-off. However, there again, we come up against the constraints of health research funding methods, which hardly favour this type of approach.The fact that the principle of solidarity was brought to light again through this endogenous funding was welcomed by all stakeholders. However, this local solidarity obviously has limits. Remember that in Burkina Faso, nearly half of the population (46%) lives on less than 280 F CFA (0.50 USD) per day. The communities made very few inclusion errors because they selected people who were truly very poor. On the other hand, in Ouargaye, they selected only a tiny portion of the poor population (0.36%) and the extremely poor population (0.78%), whereas the proportion of people in the country living below the extreme poverty line is 9% . The resTo ensure the results would be both useful and used, we developed multiple knowledge transfer strategies:Very early involvement of potential users of the results in defining the action project and the outlines of the study: Beginning in the planning stage, all the main potential stakeholders in the action research project were involved , and health centre management committees).i) Involvement of local partners of the action research project in the processes of research and results presentation: Some members of the district management team and managers in the social action department were involved in many activities .ii) Presentation of results to communities and at national meetings of the Ministry of Health and stakeholders: It was not enough to present the results in scientific arenas; the research results were also shared at community forums , among others.iii) s Figure , at distPresentation of results at national, regional and international scientific conferences: To increase the number of dissemination processes, scientific presentations were given in Burkina Faso, Senegal, France, Canada, Switzerland, Belgium, etc. A workshop was specifically organized at the First Global Symposium on Health Systems Research held in Montreux in November 2010.iv) Organization of an international workshop in Burkina Faso: A workshop was organized in October 2010 to encourage stakeholders in the field to share their experiences and to increase the likelihood of getting decision-makers to integrate this issue into public policy. More than 60 people participated in the two-day workshop, and presentations were made on similar experiences in Burkina Faso, Cambodia, Ivory Coast, Ghana, Mali, Mauritania and Niger.v) Preparation and distribution of a policy brief: We know decision-makers do not always have time to read long reports or scientific articles. Therefore, we also prepared a short 1,500-word text (four pages with illustrations) summarizing the main results of this action research project. The document was translated into English and widely distributed, both as a hard copy version in Burkina Faso (In French) and as an electronic version across the networks interested in this topic.vi) Production of a 26-minute documentary: We produced a documentary film to raise awareness of the issue of indigence and to have a visual tool that would attract attention. A film director from Niger, who had also produced a documentary on the issue of free health care for another one of our research projects, came to Ouargaye to give all the stakeholders involved an opportunity to express themselves. The film will be broadcast within the country and may also be used by the director in international competitions.vii) http://www.medsp.umontreal.ca/vesa-tc/indigents.htm.All of these knowledge transfer products are available online at: The challenges involved in the partnership between researchers were more of an interdisciplinary nature than about North-South differences. The lessons learned were mutual, and the focus was on the complementarity of theoretical and methodological approaches. For example, anthropologists most often use a very inductive process in conducting their research, whereas researchers in evaluation and public health generally organize their data using an analytical framework. In this case, the processes were evaluated based on the intervention theory (elements describing the logic of the action) without necessarily restricting the collection of qualitative data to this aspect alone. Using mixed methods to evaluate the action and to understand the process was very useful . The stuMore relevant to this text is a discussion of the partnership between the researchers, decision-makers and communities, in which lies the originality of the action research project.The researchers involved in this project and concerned about how the knowledge would be used  saw the Clearly, the closeness of the relationships between researchers and local decision-makers or practitioners was a positive factor for the application of knowledge . Their iOn the other hand, the adoption of the strategy by central decision-makers, those who write policies, was more problematic despite several attempts and presentations of the study’s evidentiary data. Like the inter-ministerial committee on support for the indigent created in 2005 that rarely manages to meet, we ourselves, after two years of trying to organize a national forum on the subject, were unable to involve the central decision-makers. They never wanted to assume the leadership on this issue. We eventually decided to take it upon ourselves by inviting them (with little success) to the abovementioned international workshop (see v) without involving them in its organization. The observation made several years ago regarding the decision-makers’ lack of interest in this issue appears to still apply ,22. A reWith regard to the knowledge updated by this study about support for indigent people, our experience has shown that:• Communities are able to select indigent people;• The community-based, participative process adopted did not lead to social stigmatization of the indigent;• Lowering the financial barrier to health care access is not enough in itself to satisfy the many needs of the indigent;• Conflicts of interest between providing free health care and having inadequate revenue-generating capacity reduce the coverage potential of the community-based approach for indigent selection;• National decision-makers’ have no interest in supporting indigent people.With regard to the application of knowledge and the partnership between researchers and peripheral decision-makers, we have learned the importance of:• Involving potential users of the results from the start, when planning the organization of the research project;• Ensuring a continuous and sustained partnership between researchers and users;• Making sure users are able to participate in some research activities;• Using a variety of strategies to disseminate the research results;• Involving users in the dissemination activities.The authors declare that they have no competing interests.VR, SH, MY and AB wrote the research protocols. YK and KK coordinated the action project with MS and NC. MY organized the collection of qualitative data with VR, YK, KK and AB. MO organized the collection of quantitative data with AB, VR and YK, and the initial analyses with SH and VR. The quantitative analyses were performed by SH and VR with the help of Béatrice Nikiema. The qualitative analyses were conducted by MY and VR. VR wrote the draft versions of the article. All of the authors read, revised and approved the final article.


The literature indicated that the majority of professional ballet dancers present static and active dynamic range of motion difference between left and right lower limbs, however, no previous study focused this difference in non-professional ballet dancers. In this study we aimed to evaluate active movements of the hip in non-professional classical dancers.We evaluated 10 non professional ballet dancers (16-23 years old). We measured the active range of motion and flexibility through Well Banks. We compared active range of motion between left and right sides (hip flexion and abduction) and performed correlation between active movements and flexibility.st and the 3rd measurement. There was no correlation between the movements of the hip  with the three test measurements of the bank of Wells.There was a small difference between the right and left sides of the hip in relation to the movements of flexion and abduction, which suggest the dominant side of the subjects, however, there was no statistical significance. Bank of Wells test revealed statistical difference only between the 1There is no imbalance between the sides of the hip with respect to active abduction and flexion movements in non-professional ballet dancers. Dance is a healthy activity which helps people to improve their life quality -3. DanceDance is a "high-risk" activity with high incidence of musculoskeletal impairments. Yearly injury rates at ballet companies range from 67-95% . OveruseA previous review  indicateThe literature suggests a relationship between hamstring flexibility and hip range of motion . PreviouAs mentioned above, although it is indicated that the majority of professional ballet dancers present static and active dynamic range of motion difference between left and right lower limbs -21, no pConsidering the difference between male and female subjects with respect to muscle movement and mass, we selected only female non-professional ballet dancers (n = 10) between 16 and 23 years old, non-smokers without cardiorespiratory compromise, non-sedentary and dancing ballet twice or three times a week and at least with 7 years of practice . We included subjects that considered ballet as a recreational activity undertaken for relaxation or pleasure, typically done during one's leisure time, not as a primary activity. The study protocol was approved by the ethics committees of our University (number 004/08) and written informed consent was obtained from all voluntaries prior to enrolment.One researcher measured the active range of motion (ROM) of classical non professional dancers at the supine position; we studied active hip abduction and flexion. The right side was the first side to be measured, each movement was measured three times; we calculated the mean of the three measurements. The movement of the hip abduction was carried out in rotation side, because most of the ballet exercises are held at that position, known as "en dehor", a position which requires the maximum lateral rotation of the hip, which further complicates and specifies ballet training  Figure . The ROMIn order to analyze the flexibility of the volunteers, we applied the bank of Wells test, an indirect method to measure hip flexibility. The subject was positioned with the spine and hip on a wall or support, forming an angle of 90° with the legs, which were maintained extended. At that position, the subject extended her arms in front of the body, with the shoulders parallel to the ground and protruded hands outstretched fingers touching the tip of the piece of wood moves, without losing contact with the wall or with support. This position is the zero point in ruler for measuring the bank of Wells test. Thereafter, the subject pushed the piece of wood moving at the point closest to the platform in three attempts, trying to reach the highest distance point in the box of wood Figure . We consWe applied the Kolmorogov Smirnov normality test for analysis of the distribution of the study population. In order to compare left and right sides of the hip in relation to flexion and abduction we applied the paired Student t test. For comparison of 3 values of the bank of Wells test, we applied one way ANOVA followed by Newmans-Keuls posttest. In order to verify the correlation between active ROM and bank of Wells performance, we applied the Pearson correlation coefficient; the highest value of ROM was correlated to each value of the bank of Wells. We also performed the Pearson correlation test between years practicing and the highest value of each subject in the Bank of Wells. The significance was considered only for p < 0.05.Table st and the 3rd measurement (p < 0.05).As shown in Figure We may observe in Table In order to verify if the long-term ballet practice may lead to overuse injuries or range of motion deficits we performed a correlation test between years practicing and the highest value of each subject in the bank of Wells. We observed no significant correlation between those variables .Our investigation aimed to evaluate active hip abduction and flexion in female non-professional ballet dancers. The group was composed by ballet dancers with at least 7 years of experience. We expected that due to the load that non-professional ballet dancers are exposed, even though it is lower compared to professional ballet dancers, we would find significant differences between the right and left sides regarding hip flexion and abduction. Nonetheless, when we compared the two sides of the hip as the movement of flexion and abduction we noticed a slight difference between the sides, which suggested the dominant side of each dancer. Nevertheless, these results did not reach statistical significance. With respect to flexibility, we used the bank of Wells test and we observed that the third measurement was significantly higher than the first. We believe that it was observed because after warming up and stretch-out of muscle/ligament it gradually increases. On the other hand, dancers work very hard to improve their flexibility, so we wonder if it compensates any potential adaptations to long-term dance practice.Our data suggest that non-professional ballet dancers are exposed to lower load compared to professional ballet dancers. According to Hincapié et al , there wIn order to verify if the posterior muscle chain  was associated with active hip abduction and flexion, we performed a correlation between left and right hip abduction and flexion with the three measurements of the bank of Wells. There was no significant association between hip movements and the bank of Wells test performance. Nevertheless, it was previously suggested that the concentric contraction of gluteus maximus, which is prolonged during important ballet movements at standing, is expected to control hip flexion or stabilize pelvis and prevent stance leg collapse by acting to extend the hip ,18. TherWe measured the correlation between range of motion of the hips and hamstring and low-back flexibility (bank of Wells test) in order to verify if hip abduction and hip flexion are associated with indirect flexibility tested in the bank of Wells test. We believe that a positive association between range of motion and hamstring and low-back flexibility would provide important information in order to direct ballet training. Nonetheless, our findings suggest that flexibility measured by the indirect bank of Wells test is not associated with active hip abduction and flexion.In our study we examined non-professional ballet as a recreational activity that is undertaken for pleasure or relaxation, typically done during one's leisure time; hence, this population is of great interest. If we consider the implications of ballet practice for overuse injuries, we should also consider how much a professional dancer practices compared to a non-professional dancer. While professional ballet dancers practice at least five days per week, eight hours per day, non-professional ballet dancers practice around two-three days per week, up to three hours per day. Thus, professional ballet dancers are exposed to lower limbs overload in a higher intensity.Our report presents interesting findings, although non professional ballet dancers are exposed to lower limbs overload and previous investigations indicated that the majority of professional ballet dancers present range of motion difference between left and right lower limb passive and active movements ,19,20, sThere is no imbalance between the sides of the hip with respect to the active movements of abduction and flexion in non professional ballet dancers. Future studies may also consider the effect of gender and age and influence of other muscles that act on the hip movements in non professional ballet dancers.The authors declare that they have no competing interests.EEV, VEV and LCA participated in the acquisition of data and revision of the manuscript. EEV, VEV, CF, OFMF, LCMV, TDC, NT, MP, CL, ENF, HMJ, CBMM, ILM, ACCR and LCA conceived of the study, determined the design, performed the statistical analysis, interpreted the data and drafted the manuscript. All authors read and gave final approval for the version submitted for publication.


Integrated care is considered as a strategy to improve the delivery, efficiency, client outcomes and satisfaction rates of health care. To integrate the care from multiple providers into a coherent client-focused service, a large number of activities and agreements have to be implemented like streamlining information flows and patient transfers. The Development Model for Integrated care (DMIC) describes nine clusters containing in total 89 elements that contribute to the integration of care. We have empirically validated this model in practice by assessing the relevance, implementation and plans of the elements in three integrated care service settings in The Netherlands: stroke, acute myocardial infarct (AMI), and dementia.Based on the DMIC, a survey was developed for integrated care coordinators. We invited all Dutch stroke and AMI-services, as well as the dementia care networks to participate, of which 84 did (response rate 83%). Data were collected on relevance, presence, and year of implementation of the 89 elements. The data analysis was done by means of descriptive statistics, Chi Square, ANOVA and Kruskal-Wallis H tests.The results indicate that the integrated care practice organizations in all three care settings rated the nine clusters and 89 elements of the DMIC as highly relevant. The average number of elements implemented was 50 ± 18, 42 ± 13, and 45 ± 22 for stroke, acute myocardial infarction, and dementia care services, respectively. Although the dementia networks were significantly younger, their numbers of implemented elements were comparable to those of the other services. The analyses of the implementation timelines showed that the older integrated care services had fewer plans for further implementation than the younger ones. Integrated care coordinators stated that the DMIC helped them to assess their integrated care development in practice and supported them in obtaining ideas for expanding their integrated care activities.Although the patient composites and the characteristics of the 84 participating integrated care services differed considerably, the results confirm that the clusters and the vast majority of DMIC elements are relevant to all three groups. Therefore, the DMIC can serve as a general quality management tool for integrated care. Applying the model in practice can help in steering further implementations as well as the development of new integrated care practices. When a patient's needs cannot be covered by one professional or health care provider alone, collaboration between different providers is required. The collaborative efforts and commitment to organize care for a specific patient group in a streamlined way are generally referred to as 'integrated care,' 'coordinated care', 'collaborative care' or 'chronic disease management' programmes. An integrated care service is defined as a coherent and coordinated set of services which are planned, managed and delivered to individual service users across a range of organizations and by a range of co-operating professionals and informal carers . The avaThe need for integrated care has grown in the past decade. There is an increasing interest in how health care workers, managers and policy makers could implement effective integrated care services. This situation can be explained by multiple developments. Firstly, the increasing numbers of elderly people and those with chronic illnesses require a shift in focus from acute to chronic care. Further, for many diseases the amount of hospital time has declined which raises the need for close and early connections with long term and social care ,9. In adWhereas the rationale for integrated care has been recognized, the implementation of this type of care is often complex. Although much research has been conducted on integrated care, the studies available only address specific settings and patient groups, while their conclusions regarding which elements should be implemented are partially incompatible -16. SystThe evidence- and expert-based Development Model for Integrated Care consists of 89 elements grouped in nine clusters. The elements represent a wide range of activities considered as relevant to the realization of integrated care. The clusters are named as follows: 'patient-centeredness', 'delivery system', 'performance management', 'quality of care', 'result-focused learning', 'interprofessional teamwork', 'roles and tasks', 'commitment', and 'transparant entrepreneurship'  of the questionnaire focused on general information about the integrated care practice, such as the year when the collaboration had started, the number of patients in the year prior to that year, the number and type of health care providers involved, the current agreements among the care providers, infrastructures for cooperation improvement, the availability of a coordinator on the care chain level, and the commitment on a strategic level. The second part of the questionnaire (B) concerned the clusters and elements of the model. The respondents were asked to rate whether each element was relevant to their specific integrated care practice  and if so, whether and in which year this element was implemented. The maximum relevance score on a cluster level for the total group was 1, the elements having equal weights. If elements were not implemented, there was an option by which to indicate that there were intentions to implement this element shortly (this year or the next). At the end of section B respondents had the option to add general comments or make suggestions for missing elements. Project leaders or coordinators of integrated stroke services as well as AMI and dementia care networks were invited to fill in the questionnaire. To assure that the right respondents took part, we clearly explained the criteria for participation via personal contact or sometimes by visiting them. The rationale for investigating these three different patient groups was based on multiple criteria. Firstly, we wanted variance among the participating integrated care services to assess the generalizability of the model. This variety had to apply to both the different client groups and their different care providers from the various sectors . The AMI group has a strong focus on acute care settings, while the stroke group covers the entire continuum from acute to chronic care. The slow and progressive syndrome of dementia also includes mental health care and social care. Next, to include integrated care services in different stages of development, the years had to vary when the integration had been started. This was indeed the case for the three groups: dementia has only more recently received attention in The Netherlands, whereas AMI and stroke services have already been offered for a longer period of time. Another criterion was the inclusion of collaborative national networks that were willing to stimulate participation. The National Stroke Service Network, the National Network on Dementia, and the National Society for Trauma Centers all recommended participation in a letter to their members. Another criterion was geographical spread. This criterion was met since the national networks operate in most parts of the country. Finally, a coordinator on the tactical level was required. In all three sectors this criterion was met by a majority of the integrated care services. We contacted these coordinators and asked for their participation in the study. Each service was asked to fill in one questionnaire. The criteria for the respondents were that they had a good overview of the current state, history, and future plans of the integrated care service as a whole. The respondents had to participate on behalf of all integrated care providers involved and were allowed to contact colleagues in their integrated care setting to help them answer the questions. For this study, no ethical approval was needed. The collected data did not address any individual nor group wise patient data. The focus was on organisational aspects of integrated care (the 89 elements) which were delivered on a voluntary basis by the integrated care coordinators.Ultimately 36 stroke services, 50 dementia care networks, and 12 myocard services were invited to participate in our study. Upon acceptation of our invitation, the respondents received the Excel-based questionnaire and an instruction sheet by e-mail. Non-responders were reminded twice, by telephone and by e-mail. Due to its smaller scale, the organizations in the AMI service sectors were visited beforehand by one of the researchers to introduce them to the questionnaire. Non-responders to our first call were telephoned by the researchers to explain the purpose of the study, after which they asked again for their participation. If indicated on the questionnaire, the reasons for the non-response as well as additional remarks were documented.The data analyses were executed per service and for the total group by means of descriptive statistics, frequency analyses, Chi Square, ANOVA and Kruskal-Wallis H, using SPSS software, version 16.0.The overall response rate to the questionnaire was 83%; 32 of the 36 stroke services participated (89%), 9 of the 12 AMI services (75%) and 43 of the 50 dementia services (86%). Reasons for non-response were a lack of time to answer the questionnaire or absense of the service coordinator. Respondents stated that filling in the questionnaire took about 30 to 45 minutes. Table For all 89 elements relevance scores (RS) were calculated. Overall, the relevance of the elements was high in the case of all three integrated care settings. As regards stroke and dementia, all elements could be classified as relevant at a cut-off point of 80%, as in our previous Delphi study  for the total group was 46 ± 20 items (range 3-82). For the three subgroups, the amounts ranged from 50 ± 18 (10-77) elements for stroke, 42 ± 13 (20-61) elements for AMI, and 45 ± 22 (3-82) for dementia. Figure The results of this study indicate that the integrated care practice widely recognizes the Development Model for Integrated Care with its evidence- and expert-based elements and clusters. Regardless of the differences among the three integrated care services  who differed in age, client groups, size, focus on either acute or chronic care, collaboration infrastructure, and the care providers involved, they all rated the elements of the Development model for Integrated Care as highly relevant. Based on these results we may conclude that the empirical test of our theoretical model has been successful and that this tool has the potential to effectively support multiple integrated care practices.In addition to the useful information gathered regarding the relevance and implementation of the elements of integrated care, a large number of respondents gave feedback on the model's applicability. The integrated care coordinators indicated that filling in the questionnaire was a good exercise to reflect upon the current situation. Discussing the implementation of the elements gave new ideas for the improvement and further development of their integrated care practice. The respondents used the elements and clusters for their quality management systems, improvement plans or even wrote a discussion paper for their steering committee based on the questionnaire results.Although the relevance scores were all (very) high, some important differences were observed among the nine clusters. For the AMI services three elements of cluster 2 ('delivery system') had the lowest relevance scores (< 50%). The average priority score of these four elements was 1.94, which is markedly lower than the average of 2.23 of the whole set . We assume that national initiatives, such as the National Dementia Program, the Front Runner Program, and a strong nationwide network of client federations have accelerated the development of this service. In addition, there are many plans for the near future, which has raised the expectation for the coming years. The newness of the concept of integrated care to the people working in the dementia sector may stimulate their enthusiasm in making plans to further develop the service. In other words, the biggest growth of the system possibly lies in the beginning of it.Our study has some limitations. First, the number of research participants per patient group differed, which was due to the nature of the current situation. The AMI services were only represented by nine of the twelve services because the number of hospitals with interventional capacities was limited, which means that there were only a few networks. The treatment of a stroke, however, can be initiated in almost any hospital. Second, although a number of respondents consulted partners in the care chain when filling in the questionnaire, it would be interesting to invite more care workers in the three integrated care service to add additional perspectives. Third, the respondents' answers were based on self-reported data. Whenever elements were implemented, these decisions were based on the judgement of the integrated care service representatives themselves without consulting other sources, such as documentation or interviews. Finally, we focused our research on integrated care services in the Netherlands, while it would also be interesting to expand this study internationally.We have multiple suggestions for further research to further assess the generalizability of the model. Firstly, we suggest to broaden the assessment of the implemented elements by involving multiple professionals, managers and also client representatives per integrated care setting. Adding these perspectives can provide interesting information about how the implementation is being experienced and if consensus is available. Secondly, we suggest repeating the study in integrated care services which focus on other client groups like for instance clients with diabetes, COPD, depression or other groups like frail elderly who need support on broader life domains. This kind of research could provide knowledge about the further applicability of the model, because of our aim was to develop a generic model. A third option could be expanding our research to other countries. Next to changes on the 'meso- or organisational level' of integrated care where our research focuses on, the 'also macro- or system level' characteristics and differences are being taken into account. These characteristics address for instance other political, demographical, legal and professional or educational contexts.Another suggestion is further research on the different phases of development of integrated care services and the implemented elements in each phase. Previous research revealed different phases of development, but the relation between these phases and the implementation of elements in each phase is less clear. Also, the implementation process of the elements asks for different roles, needed expertises and strategies of integrated care coordinators, professionals and managers. These are interesting topics for further research.Finally, we suggest follow-up research on the relation between the implementation of the elements and clusters of the DMIC and the delivered results. Do more 'mature' integrated care practices or practices that implemented more elements achieve better results in quality of care, quality of life, client related indicators (or client experiences) and costs?Our study has a number of practical implications. Coordinators and managers may use the Development model for Integrated Care as a quality management tool in their integrated care practices. The model with its elements and clusters is suitable for different patients groups and can be used as an assessment instrument to monitor the integrated care activities. Moreover, the respondents indicated that the model also worked as a self-evaluation tool and helped them in the formulation of improvement plans. Further use in practice could be enhanced by developing a DMIC-based user-friendly (web based) tool, in which not only integrated care coordinators but also multiple partners working in integrated care services could score the elements on relevance and implementation. By presenting the (consensus) results found, clusters and elements with lower scores could be further discussed and prioritised as a basis for an improvement plan. Managers can use the model in broadening their vision on integrated care and improving their quality management. Furthermore, the model can be used for benchmarking by comparing the (absolute) implementation scores between integrated care practices. Practices can mirror their own results with comparable others and get input for improvement activities. The National Stroke Service network has plans to use the model for auditing its stroke services in The Netherlands in the coming years.This study has assessed the practical relevance and implementation of the Development Model for Integrated Care, consisting of nine clusters with in total 89 elements, in three integrated care settings: AMI, stoke, and dementia. These segments varied considerably. The AMI services can be characterized as acute care, while stroke services range from acute to chronic care. Finally, the dementia services merely focus on chronic care. In all three integrated care settings the relevance of the elements was considered high. We can therefore conclude that the Development Model for Integrated Care has a generic character and can serve as a useful tool for assessment, evaluation or improvement in both the research on integrated care and its development in the practical field.In addition, the study has provided a detailed analysis to what extent integrated care has been implemented within each service and on which topics. The average number of implemented elements was 50 ± 18, 42 ± 13, and 45 ± 22 for stroke, acute myocardial infarction, and dementia care services, respectively. Although the dementia services were significantly newer, the number of implemented elements was comparable to that of the other segments. The average number of planned elements told us that the integrated care services are still developing, although the intensity differs significantly among the three groups. With respect to new initiatives and plans the dementia services take the lead, which might be explained by the national initiatives and incentives in this area and the actions of client federations. Research to further assess the generalizability of the model for other  client groups and the relation between integrated care development and the DMIC elements is suggested.The authors declare that they have no competing interests.All authors contributed to the study. MM, KA and RH designed the questionnaire on the basis of previous research. MM and RV collected and analyzed the data, supervised by KA and RH. MM led the writing process, while all authors commented on the sequential drafts before approving the final version of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/177/prepubImplementation of integrated care elements. This file presents the percentages of implemented elements (PI), the average year of implementation (Ayr), and the percentage of planned elements (PP) of services which have not implemented the element yet. The data were gathered from 32 stroke service (Str), nine AMI-services, and 43 dementia services. PI is based on attainable elements: attainable elements are all services minus those which rated the element as not relevant (see also table Click here for file


Objectives. To examine the impact of active student participation on quality of care in an integrative inpatient setting. Methods. Over a two-year period, we surveyed all patients treated on the Clinical Education Ward for Integrative Medicine (CEWIM), where final-year medical students are integrated into an internal medicine ward complementing conventional medicine with anthroposophic medicine. Patients treated on the regular wards of the same internal medicine department served as the control group (CG). General quality of care was studied with the Picker Inpatient Questionnaire, physician empathy with the Consultation and Relational Empathy measure, and patient enablement with the Patient Enablement Index. ANCOVA was used to control for covariates while examining significant differences between both patient groups. Results. Comparison of the CG wards and the CEWIM revealed no significant differences in medical treatment success. The CEWIM, however, achieved better results for physician-patient interaction, physician empathy, and patient enablement. Eighty Percent of the CEWIM patients rated student participation as positively impacting quality of care. Conclusion. Our results indicate that incorporating students in an integrative healthcare setting may result in greater patient centeredness. Further studies are needed to determine whether this is due to organizational advantages, students' empathic activity, the impact of teaching, or learner-teacher interaction. Over the last two decades, increased attention has been given to the concept of active learner participation in the so-called “community of practice” , 2. StudIn the field of medicine, active student participation (ASP) typically takes place during clinical clerkships and final-year rotations. However, from different studies, we know that participation in clinical rotations alone does not necessarily automatically result in the professional development of learners. Instead, it is the degree of active participation (as opposed to being involved in primarily passive learning experiences) together with certain qualities of the learning environment that determine the success of clinical education , 4. In GIn response to these deficits and in order to offer students a structured clinical learning environment tailored to their learning needs, the Clinical Education Ward for Integrative Medicine (CEWIM) was established in 2007 and implemented into one of the wards of the Department of Internal Medicine at the Gemeinschaftskrankenhaus Herdecke (GKH), an academic teaching hospital of Witten/Herdecke University in Germany. The two main aims of the CEWIM are ). physician-patient interaction,physician empathy, defined as a specific ability to communicate and help patients based on a deeper understanding of their situation, their perspectives, and their feelings ,patient enablement, defined as the extent to which a patient feels empowered after a medical consultation, in terms of being able to cope with, understand, and manage their illness ). While most studies investigating ASP focus on its educational value for learners, few have explored its potential influence on the community of practice and on the learners' work, including quality of care. The findings of such studies have indicated that ASP may also be of benefit to patients, since they gain a better understanding of their disease  and are short-term ward with 20 beds, which is mainly for patients with fewer symptoms and less severe diseases (average stay: 4.5 days), and two long-term wards for patients with more complex and severe diseases. Particularly on these long-term wards, there are patients with specific interest in complementary medicine. One of the two long-term wards is more specialized in oncological and palliative care ; the other is focused on gastroenterological and cardiological care . The CEWIM was incorporated into the latter medical ward, using 10 to 12 of the ward's 36 beds. On the CEWIM, four to five students take over the work of one house officer on the ward, meaning that together they are responsible for the care of a total of 10 to 12 patients. The students are supported and supervised by the house officer and a consultant. Important decisions, such as making changes to a patient's medication or arranging diagnostic interventions, may only be made after consultation and in agreement with the two supervising physicians. Students' care of the patients on the ward involves the usual diagnostic and therapeutic procedures performed on a conventional medical ward as well as complementary medicine being offered to interested patients. Based on a holistic view of the patient, students provide conventional and specific complementary treatments, such as natural remedies, rhythmic massage, external applications, art therapy, therapeutic eurythmy (a form of meditative movement), and biographic counseling [The Department of Internal Medicine at the GKH, which offers the same diagnostic and interventional services as a regional hospital (including an intensive care unit), is divided into three different wards: one unseling . StudentESPRI2T approach, which combines exploratory learning, supported participation, patient-oriented learning, reflective practice, integrated learning, an integrative approach, and team-oriented learning [Students learn how to integrate the different perspectives and treatment options of conventional medicine and complementary anthroposophic medicine and to appreciate the specific values and limitations of each approach. Students are involved in interprofessional learning by being fully integrated into the healthcare team and by working together with nurses and healthcare practitioners practicing art therapy, music therapy, therapeutic eurythmy, massage, physiotherapy, and psychotherapy. Interprofessional learning is enhanced by an interprofessional module (held during Week 1), weekly team meetings with therapists, and monthly meetings with the nursing team. Reflective practice is promoted through a clinical reflection training seminar  held eveOriginally launched as a pilot project in 2007, the CEWIM became a permanent program in 2009. The CEWIM is part of the Integrated Curriculum of Anthroposophic Medicine (ICURAM), an optional program in anthroposophic medicine that is integrated into the full six-year program of the regular undergraduate medical curriculum at Witten/Herdecke University . The mailearning . The CEWThe Picker Inpatient Questionnaire (PIQ). Originally developed in the USA by Cleary et al., the PIQ was accredited in 1997 by the Joint Commission for Accreditation of Health Care Organizations [izations , 17. PatThe Consultation and Relational Empathy (CARE) Questionnaire. Developed by Mercer et al. [r et al.  as a patr et al. . Evaluatr et al. . The Patient Enablement Instrument (PEI). Developed by Howie et al. [e et al. , this sie et al. .Patients of the CEWIM were also asked to rate whether student participation on the ward had a positive, neutral, or negative impact on their care.The following instruments were used to evaluate and compare the perceived quality of care received by patients of the CEWIM and by patients of the regular “nonstudent” wards of the Department of Internal Medicine at the GKH.To ensure that medical students were included in the patients' assessments of the quality of care they received, the word “physician” was replaced with the phrase “the team of physicians” in all relevant questions. A note was also made that students should be considered a part of this team.n = 215, see To evaluate the perceived quality of care received on the CEWIM, a survey was conducted of all patients that had been treated by four cohorts of medical students between the fall of 2010 and the summer of 2012. All patients meeting the inclusion criteria (n = 250) was assessed using results taken from the most recently conducted routine evaluation of the GKH. Every two years, the GKH undergoes an evaluation, the last of which was conducted in the fall of 2011 over a period of two months. The data collection procedure and the questionnaires used for the routine GKH evaluation are the same as those used for the CEWIM patient survey. The perceived quality of care received by patients of the regular internal medicine wards  were included as covariates in a univariate ANCOVA where the outcomes of the PIQ, the CARE, and the PEI were compared. IBM SPSS 20.0 was used for these analyses. A P value <0.05 was considered to indicate a significant statistical difference.The patient characteristics of each patient group were calculated and compared using the Mann-Whitney Of the 215 CEWIM patients, 103 returned the questionnaire (response rate 47.9%), whereas in the control group, this was 94 out of 250 (37.6%). Patients of the CEWIM were, on average, six years younger (60.7 versus 66.6 years), had a better education , were more often very interested in anthroposophic medicine (55% versus 29.6%), and obtained more often nonphysician therapies (59.8% versus 40.5%) than patients in the control group. No significant differences were found between the two patient groups for the other characteristics assessed, including sex, possession of private health insurance, duration of disease, and health status see . While the results of the PIQ see  revealedEighty Percent of the CEWIM patients reported that student participation on the ward had a somewhat positive or very positive impact on the quality of care they received. Only one percent felt it had a somewhat negative impact on the quality of care received. None considered it to have had a very negative impact see . The aim of our study was to determine whether there is a difference in the quality of care experienced by patients on the CEWIM, where students actively participate in patient care, and wards of the same department where students are not involved in care. In particular, we were interested in whether ASP has an impact on certain qualities of patient centeredness, namely, patient-physician interaction in general, perceived physician empathy, and patient enablement.The results of our study indicate that while ASP—as implemented on the CEWIM—has no significant impact on the success of medical treatment in terms of the improvement of complaints or the rate of reported complications after discharge, it does improve patient-physician interaction, physician empathy, and patient enablement. The CEWIM also fared better than the control group wards in other areas which are specific to integrative medicine; namely, the practice of holistic and humanistic medicine, a noticeable anthroposophic orientation, and collaboration between healthcare professionals. A preliminary study of the initial two-rotation pilot phase of the CEWIM  had founBy including a greater number of patients and students in the present study, it was possible to detect a significant difference between the CEWIM and the GKH medical wards without ASP, in particular with regard to certain qualities of patient centeredness. The results of our study seem surprising given that patients tend to prefer to be treated by experienced professionals rather than by students still in medical school. This preference is, of course, understandable, since students tend to be more uncertain of themselves, slower, overstrained at an earlier stage, and need more time and attempts to perform most procedures and practical tasks . It is also assumed that resident physicians and fully licensed physicians have greater practical knowledge and are better in other areas, such as time management, clinical thinking, and clinical decision making. Organizational Advantages. Since students are responsible for the care of fewer patients than regular physicians, they can dedicate more time to their patients. In addition, unlike physicians on the regular wards, students on the CEWIM do not have night shifts and are continuously on the ward. These two organizational advantages may be reflected in the better PIQ scores for “physician availability” and “having a clearly assigned physician.” Similarly, another study found time and physician availability to have a comparable positive effect on patients' assessments of physician empathy among patients with private health insurance [nsurance . Specific Qualities of Student Communication with Patients. The results of the CARE questionnaire suggest that patients on the CEWIM found students to be better at letting them tell their story, at really listening, and at being interested in them as a whole person. These aspects require not only dedicating more time to patients but also motivation, an open interest in another person, and a high level of commitment. These outcomes on empathy are supported by the better PIQ scores for “enough friendliness,” “relationship of trust,” and “possibility to talk about fears” in the CEWIM group. Moreover, patients on the CEWIM more frequently reported receiving “understandable answers to important questions,” which could be explained by the fact that students still tend to use more everyday language instead of medical terms. The Impact of Teaching and Supervision. On the CEWIM, student learning is promoted through reflection and discussion on the daily problems and tasks associated with each of the students' patients. In addition to the usual ward rounds and seminars, students participate in weekly teaching rounds and integrative case conferences. These activities give students opportunities to dedicate greater focus to individual patient cases and find optimal solutions to their problems. In other words, they have more time to work through cases thoroughly and conscientiously than a regular physician would have. This may further be supported by the reflective practice module held every two weeks, which offers students opportunities to reflect on challenging interactions with their patients. Students' Impact on the Healthcare Team. It is possible that, by asking relevant questions, students may encourage healthcare professionals to reassess and improve the usual procedures on the ward and to work with greater mindfulness and reflection. Being asked to act as a role model may also promote better and more comprehensive performance. Several hypotheses can be offered to explain why patients' ratings of patient centeredness were higher on the CEWIM. The results of our study correspond with those of other studies, which have found ASP to have a positive impact on patient care. A study by Coleman and Murray, for example, found that patients enjoyed being involved in a community-based teaching program, had acquired greater knowledge about their disease, had enhanced self-esteem, and felt that the service they received was better . PatientAlthough, as this study has shown, ASP plays a significant role in perceived quality of care, it is also vital to provide the proper learning environment that supports students during their participation on the ward. Various studies have shown that empathy and patient centeredness tend to decline during participation in clinical education and in residency . While tBoth the CEWIM patient group and the control group were comparable in size (103 versus 94 patients), sex, insurance status, health status, and duration of disease. A possible explanation for the lower response rate of the control group compared to the CEWIM patient groups (38% versus 48%) may be that this group had more older age patients and more patients with dementia, making it more difficult for them to complete a written survey. The fact that more of the CEWIM patients were satisfied with their care may have also contributed to a higher response rate. The lower percentage of patients in the control group with an interest in anthroposophic medicine reflects the fact that two of the three internal medicine wards at the GKH offer a greater range of complementary therapies. The “short-term ward” does not offer so many art therapies and other nonphysician therapies. The number of patients with an interest in anthroposophic medicine was therefore higher on the CEWIM than on the control group wards, one of the reasons why it was important to control for different patient characteristics as part of our study.Since the long-term wards have more patients with a specific interest in anthroposophic medicine, it may be that the resulting higher amount of patients obtaining more complementary nonphysician therapies led to greater satisfaction with the CEWIM. However, inclusion of the patient characteristic “number of nonphysician therapies obtained” as a covariate did not change the significance of the differences in quality of care found between the two patient groups. Furthermore, 80% of the CEWIM patients rated the impact of student participation on their care as positive while only one out of the 103 CEWIM patients reported it to have a somewhat negative influence.The results of this study suggest that ASP has a positive effect on perceived patient centeredness. Further studies are needed to determine whether similar results can be observed in other contexts, such as in other clinical specialties or in conventional hospitals. A comprehensive economic analysis is also desired to assess cost intensiveness of the CEWIM compared to a regular ward. Also, more research is necessary to analyze the specific conditions of the learning environment enabling a positive influence of ASP on the quality of care. Our study shows that ASP may enhance patient-physician interaction, physician empathy, and patient enablement. In addition, our findings suggest that the relationship between students and the community of practice is not just a one-way street. Active student participation in the community is of benefit both to students and to the healthcare team and patients. Student participation and the establishment of a favorable and supportive learning environment may therefore be considered factors which can be used to improve the care provided by future healthcare teams practicing integrative medicine.