Interview With Mary Barrett (Nee Dettmann)

OBJECTIVE: Randomized trials showed that changes in healthcare organization improved diabetes care. This study aimed to identify which organizational determinants were associated with patient outcomes in routine diabetes care. DESIGN: Observational study, in which multilevel regression analyses were applied to examine the impact of 12 organizational determinants on diabetes care as separate measures and as a composite score. SETTING: Primary care practices in the Netherlands. SUBJECTS: 11,751 patients with diabetes in 354 practices. MAIN OUTCOME MEASURES: Patients' recorded glycated hemoglobin (HbA1c), systolic blood pressure, and serum cholesterol levels. RESULTS: A higher score on the composite measure of organizational determinants was associated with better control of systolic blood pressure (p = 0.017). No effects on HbA1C or cholesterol levels were found. Exploration of specific organizational factors found significant impact of use of an electronic patient registry on HbA1c (OR = 1.80, 95% CI 1.12-2.88), availability of patient leaflets on systolic blood pressure control (OR = 2.59, 95% CI 1.06-6.35), and number of hours' nurse education on cholesterol control (OR = 2.51, 95% CI 1.02-6.15). CONCLUSION: In routine primary care, it was found that favorable healthcare organization was associated with a number of intermediate outcomes in diabetes care. This finding lends support to the findings of trials on organizational changes in diabetes care. Notably, the composite measure of organizational determinants had most impact

Response to the letter to the editor

Contains fulltext : 125871.pdf (publisher's version ) (Open Access

Patient reported outcome measures (PROMs) in primary care: an observational pilot study of seven generic instruments

Contains fulltext : 136484.pdf (publisher's version ) (Open Access)BACKGROUND: Patient reported outcome measures (PROMs) have been introduced in studies to assess healthcare performance. The development of PROMs for primary care poses specific challenges, including a preference for generic measures that can be used across diseases, including early phases or mild conditions. This pilot study aimed to explore the potential usefulness of seven generic measures for assessing health outcomes in primary care patients. METHODS: A total of 300 patients in three general practices were invited to participate in the study, shortly after their visit to the general practitioner. Patients received a written questionnaire, containing seven validated instruments, focused on patient empowerment (PAM-13 or EC-17), quality of life (EQ-5D or SF-12), mental health (GHQ-12), enablement (PEI) and perceived treatment effect (GPE). Furthermore, questions on non-specific symptoms and number of GP contacts were included. After 4 weeks patients received a second, identical, questionnaire. Response and missing items, total scores and dispersion, responsiveness, and associations between instruments and other measures were examined. RESULTS: A total of 124 patients completed the questionnaire at baseline, of whom 98 completed it both at baseline and 4 weeks later (response rate: 32.7%). The instruments had a full completion rate of 80% or higher. Differences between baseline and follow up were significant for the EQ-5D (p = 0.026), SF-12 PCS (p = 0.026) and the GPE (p = 0.006). A strong correlation (r >/= 0.6) was found between the SF-12 MCS and GHQ-12, at both baseline measurement and after four weeks. Other observed associations between instruments were moderately strong. No strong correlations were found between instruments and non-specific symptoms or number of GP contacts. CONCLUSIONS: The present study is among the first to explore the use of generic patient-reported outcome measures in primary care. It provides several leads for developing a generic PROM questionnaire in primary care as well as for potential limitations of such instruments

Patients inverted question mark expectations of variation in quality of care relates to their search for comparative performance information

Contains fulltext : 138965.pdf (publisher's version ) (Open Access)BackgroundChoice of hospital based on comparative performance information (CPI) was introduced for Dutch healthcare consumers at least 5 years ago, but CPI use has not yet become commonplace. Our aim was to assess the role of patients inverted question mark expectations regarding variation in the quality of hospital care in determining whether they search for CPI.MethodsA questionnaire (for a cross-sectional survey) was distributed to 475 orthopaedic patients in a consecutive sample, who underwent primary hip or knee replacement in a university, teaching, or community hospital between September 2009 and July 2010.ResultsOf the 302 patients (63%) who responded, 13% reported searching for CPI to help them choose a hospital. People who expected quality differences between hospitals (67%) were more likely to search for CPI (OR =3.18 [95% CI: 1.02 inverted question mark9.89]; p <0.04) than those who did not. Quality differences were most often expected in hospital reputation, distance, and accessibility. Patients who did not search for CPI stated that they felt no need for this type of information.ConclusionPatients inverted question mark expectations regarding variation in quality of care are positively related to their reported search for CPI. To increase the relevance of CPI for patients, future studies should explore the underlying reasoning of patients about meaningful quality-of-care variation between hospitals

The development of a collective quality system: challenges and lessons learned; a qualitative study

Contains fulltext : 177269.pdf (publisher's version ) (Open Access)BACKGROUND: The ongoing professionalization of medical education means that quality systems (QSs) aimed at improving medical education also continuously have to improve. The aim of this paper is to describe the development of a collective QS for eight Dutch General Practitioner (GP) specialty training institutes to provide insights into the considerations that are involved in developing a QS in medical education. METHODS: Experts in the field of GP education and quality assurance developed the QS. They studied the literature, prior QSs and involved stakeholders. The team interviewed the directors, and all meetings and steps in the development process were transcribed. All interviews and relevant documentation were analyzed. Results were checked by the developers. RESULTS: Stakeholders agreed on the goals, the relevance of the resulting domains, and the methods to assess. However, one major theme emerged. To enable benchmarking, the team developed detailed quantifiable indicators. Especially the development of these indicators gave discussion. CONCLUSIONS: Involving stakeholders was crucial as they directed the development of the QS. The framework of the World Federation for Medical Education (WFME) provided guidance in covering all the relevant processes. The major challenge consisted of formulating indicators. Our experience indicates that the process of quantifying indicators is not straightforward. The detailed level of the indicators chosen is perhaps not always suitable for QSs in the field of medical education

The prevalence of disease clusters in older adults with multiple chronic diseases - a systematic literature review

Contains fulltext : 126145.pdf (publisher's version ) (Open Access)BACKGROUND: Since most clinical guidelines address single diseases, treatment of patients with multimorbidity, the co-occurrence of multiple (chronic) diseases within one person, can become complicated. Information on highly prevalent combinations of diseases can set the agenda for guideline development on multimorbidity. With this systematic review we aim to describe the prevalence of disease combinations (i.e. disease clusters) in older patients with multimorbidity, as assessed in available studies. In addition, we intend to acquire information that can be supportive in the process of multimorbidity guideline development. METHODS: We searched MEDLINE, Embase and the Cochrane Library for all types of studies published between January 2000 and September 2012. We included empirical studies focused on multimorbidity or comorbidity that reported prevalence rates of combinations of two or more diseases. RESULTS: Our search yielded 3070 potentially eligible articles, of which 19 articles, representing 23 observational studies, turned out to meet all our quality and inclusion criteria after full text review. These studies provided prevalence rates of 165 combinations of two diseases (i.e. disease pairs). Twenty disease pairs, concerning 12 different diseases, were described in at least 3 studies. Depression was found to be the disease that was most commonly clustered, and was paired with 8 different diseases, in the available studies. Hypertension and diabetes mellitus were found to be the second most clustered diseases, both with 6 different diseases. Prevalence rates for each disease combination varied considerably per study, but were highest for the pairs that included hypertension, coronary artery disease, and diabetes mellitus. CONCLUSIONS: Twenty disease pairs were assessed most frequently in patients with multimorbidity. These disease combinations could serve as a first priority setting towards the development of multimorbidity guidelines, starting with the diseases with the highest observed prevalence rates and those with potential interacting treatment plans

Quality of physical therapy from a patient's perspective; factor analysis on web-based survey data revealed three dimensions on patient experiences with physical therapy

Contains fulltext : 136040.pdf (publisher's version ) (Open Access)BACKGROUND: Assessing quality of care from the patient's perspective has changed from patient satisfaction to the more general term patient experience, as satisfaction measures turned out to be less discriminative due to high scores. Literature describes four to ten dimensions of patient experience, tailored to specific conditions or types of care. Given the administrative burden on patients, less dimensions and items could increase feasibility. Ten dimensions of patient experiences with physical therapy (PT) were proposed in the Netherlands in a consensus-based process with patients, physical therapists, health insurers, and policy makers. The aim of this paper is to detect the number of dimensions from data of a field study using factor analysis at item level. METHODS: A web-based survey yielded data of 2,221 patients from 52 PT practices on 41 items. Principal component factor analysis at item level was used to assess the proposed distinction between the ten dimensions. RESULTS: Factor analysis revealed two dimensions: 'personal interaction' and 'practice organisation'. The dimension 'patient reported outcome' was artificially established. The three dimensions 'personal interaction' (14 items) (median(practice level) = 91.1; IQR = 2.4), 'practice organisation' (9 items) (median(practice level) = 88.9; IQR = 6.0) and 'outcome' (3 items) (median(practice level) = 80.6; IQR = 19.5) reduced the number of dimensions from ten to three and the number of items by more than a third. CONCLUSIONS: Factor analysis revealed three dimensions and achieved an item reduction of more than a third. It is a relevant step in the development process of a quality measurement tool to reduce respondent burden, increase clarity, and promote feasibility

The implementation of a quality system in the Dutch GP specialty training: barriers and facilitators; a qualitative study

Contains fulltext : 177274.pdf (publisher's version ) (Open Access)BACKGROUND: Quality assurance programs in medical education are introduced to gain insight into the quality of such programs and to trigger improvements. Although of utmost importance, research on the implementation of such programs is scarce. The Dutch General Practice (GP) specialty training institutes used an implementation strategy to implement a quality system (QS), and we aimed to study the success of this strategy and to learn about additional facilitators and barriers. METHODS: Seventeen structured interviews were conducted with the directors and quality coordinators (QCs) of the eight Dutch GP training institutes. A five-stage process model of implementation was used to structure these interviews and analyze the data. Two researchers analyzed the data with a framework approach. RESULTS: The strategy supported the institutes in implementing the QS. However, after the introduction of the QS, staff experienced the QS as demanding, although they noticed almost no concrete short-term results. Moreover, they experienced difficulties in integrating the QS into their local situation. Collectively working with the QS and following common deadlines did create a sense of commitment towards each other that appeared to be a true stimulus to the introduction of the QS. CONCLUSIONS: The implementation strategy focused mainly on the introduction of the QS in the GP specialty training, and it was, as such, rather successful. An important barrier concerned the acceptance of the QS and the integration of the QS into local structures, which suggests that there is a need for guidance on the translation of the QS to local contexts. All in all, we recommend more focus on the benefits of a QS

Effectiveness and efficiency of a practice accreditation program on cardiovascular risk management in primary care: study protocol of a clustered randomized trial

Contains fulltext : 111061.pdf (publisher's version ) (Open Access)ABSTRACT: BACKGROUND: Cardiovascular risk management is largely provided in primary healthcare, but not all patients with established cardiovascular diseases receive preventive treatment as recommended. Accreditation of healthcare organizations has been introduced across the world with a range of aims, including the improvement of clinical processes and outcomes. The Dutch College of General Practitioners has launched a program for accreditation of primary care practices, which focuses on chronic illness care. This study aims to determine the effectiveness and efficiency of a practice accreditation program, focusing on patients with established cardiovascular diseases. METHODS/DESIGN: We have planned a two-arm cluster randomized trial with a block design. Seventy primary care practices will be recruited from those who volunteer to participate in the practice accreditation program. Primary care practices will be the unit of randomization. A computer list of random numbers will be generated by an independent statistician. The intervention group (n = 35 practices) will be instructed to focus improvement on cardiovascular risk management. The control group will be instructed to focus improvement on other domains in the first year of the program. Baseline and follow-up measurements at 12 months after receiving the accreditation certificate are based on a standardized version of the audit in the practice accreditation program. Primary outcomes include controlled blood pressure, serum cholesterol, and prescription of recommended preventive medication. Secondary outcomes are 15 process indicators and two outcome indicators of cardiovascular risk management, self-reported achievement of improvement goals and perceived unintended consequences. The intention to treat analysis is statistically powered to detect a difference of 10% on primary outcomes. The economic evaluation aims to determine the efficiency of the program and investigates the relationship between costs, performance indicators, and accreditation. DISCUSSION: It is important to gain more information about the effectiveness and efficiency of the practice accreditation program to assess if participation is worthwhile regarding the quality of cardiovascular risk management. The results of this study will help to develop the practice accreditation program for primary care practices. TRIAL REGISTRATION: This cluster randomized trial is registered at ClinicalTrials.gov nr NCT00791362