A cluster randomized controlled trial aimed at implementation of local quality improvement collaboratives to improve prescribing and test ordering performance of general practitioners: Study Protocol

<p>Abstract</p> <p>Background</p> <p>The use of guidelines in general practice is not optimal. Although evidence-based methods to improve guideline adherence are available, variation in physician adherence to general practice guidelines remains relatively high. The objective for this study is to transfer a quality improvement strategy based on audit, feedback, educational materials, and peer group discussion moderated by local opinion leaders to the field. The research questions are: is the multifaceted strategy implemented on a large scale as planned?; what is the effect on general practitioners' (GPs) test ordering and prescribing behaviour?; and what are the costs of implementing the strategy?</p> <p>Methods</p> <p>In order to evaluate the effects, costs and feasibility of this new strategy we plan a multi-centre cluster randomized controlled trial (RCT) with a balanced incomplete block design. Local GP groups in the south of the Netherlands already taking part in pharmacotherapeutic audit meeting groups, will be recruited by regional health officers. Approximately 50 groups of GPs will be randomly allocated to two arms. These GPs will be offered two different balanced sets of clinical topics. Each GP within a group will receive comparative feedback on test ordering and prescribing performance. The feedback will be discussed in the group and working agreements will be created after discussion of the guidelines and barriers to change. The data for the feedback will be collected from existing and newly formed databases, both at baseline and after one year.</p> <p>Discussion</p> <p>We are not aware of published studies on successes and failures of attempts to transfer to the stakeholders in the field a multifaceted strategy aimed at GPs' test ordering and prescribing behaviour. This pragmatic study will focus on compatibility with existing infrastructure, while permitting a certain degree of adaptation to local needs and routines.</p> <p>Trial registration</p> <p>Nederlands Trial Register ISRCTN40008171</p

Effects of storm events on mobilisaton and in-stream processing of dissolved organic matter (DOM) in a Welsh peatland catchment.

Peatlands are important contributors of dissolved organic matter (DOM) to downstream aquatic systems. We investigated the effects of storm events on dissolved organic carbon (DOC) concentrations and DOM quality in a stream draining a Welsh peatland catchment. Intensive stream samples were collected and analysed for pH, DOC, dissolved organic nitrogen (DON), absorbance and fluorescence. Soil water samples and samples of sphagnum pore water were also collected, and a simple end-member mixing model was applied to account for changes occurring during the events. Fluorescence data were interpreted using parallel factor analysis (PARAFAC). DOC concentrations increased and pH decreased during the storm events. The soil water data and the mixing model indicated that this was due to a change of flow paths and draining of the DOC-rich acrotelm. Absorbance indices and the DOC/DON ratio suggested that the DOM released during events was less degraded. There was a striking, inversely related diurnal pattern in absorbance and fluorescence after the discharge peak. The diurnal pattern and a lack of fit with the mixing model suggested that fluorescing DOM was mainly produced in-stream. Fluorescence has been found to peak in the morning and decline during day-time due to photo-bleaching. We hypothesise that the input of additional DOM during events causes a change in the diurnal pattern, giving a peak at mid-day, when the processing of the additional DOM is highest