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

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 NCT0079136

Characterisation of the MHC region in the Australian black flying fox, Pteropus alecto

Bats are widely recognised as natural reservoirs to numerous highly pathogenic zoonotic viruses. Their ability to remain clinically asymptomatic during most viral infection has presented a great challenge and opportunity to the very young field of bat immunology. The major histocompatibility complex (MHC) plays a central role in the innate and adaptive immune responses. This dissertation characterises the MHC region and MHC genes of the black flying fox (Pteropus alecto), providing the first insights into the MHC region of any species of bat. A partial MHC class I (MHC-I) region, a complete class II and complete class III region were identified from the current bat genome sequence assembly. All three bat MHC regions were highly contracted with conserved and syntenic gene content when compared to other mammals. Overall, the bat MHC resembles the ancestral architecture of the immune supercomplex. However, no MHC-I genes were identified in the bat genome. Sequencing of bacterial artificial chromosome (BAC) and cDNA clones resulted in the identification of 16 MHC-I loci, eight of which have preliminarily been classified as putative classical class I genes, more than any other species. Furthermore, a subset of the MHC-I genes contains a bat-specific five amino acid insertion within the α1 domain of the peptide-binding groove (PBG), potentially accommodating a larger and more diverse repertoire of antigens. A greater number of classical class I genes, together with the presence of a unique PBG, could potentially be one of the keys in the ability of bats to more effectively control viral infection. Twelve MHC class II genes, with orthology to class II genes from other mammals, were also identified in the bat genome. To our knowledge, this is also the first successful attempt at employing next generation sequencing technologies to resolve the highly complex and repetitive MHC region

The choice of obstetric care by low-risk pregnant women in the Netherlands: Implications for policy and management

In the Netherlands, pregnant women at low risk of complications during pregnancy, have the opportunity to choose freely between giving birth at home or in a hospital maternity unit. This study analyses how various attributes of obstetric care, socio-economic characteristics and attitudes influence the decisions that these women make with regard to obstetric care. The method of discrete-choice experiment was applied in the process of data collection and analysis. The data were collected among low-risk nulliparous pregnant women. The analysis suggests that there are strong preferences among some Dutch women for a home birth. Nevertheless, the absence of a medical pain-relief treatment during home birth, might provide incentives for some women to opt for a birth in a hospital, especially at the end of their pregnancy. If the attractiveness of home birth should be preserved in the Netherlands, specific attention should be paid on the approach to pain during a home birth. Efforts could also be made in offering a domestic atmosphere during hospital births to improve hospital-based obstetric care in view of women's preferences.Midwifery Obstetric care Preferences Discrete-choice experiment Netherlands

Characteristics of Patient Population, Intervention versus Control group.

<p>Characteristics of Patient Population, Intervention versus Control group.</p

Perceived goal attainment on plans concerning chronic care management¹.

1<p>Measured on a Likert scale (1–10).</p>a<p>plans concerning CVRM.</p>b<p>plans concerning chronic care management other than CVRM.</p><p>Perceived goal attainment on plans concerning chronic care management^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0114045#nt105" target="_blank">1</a>}.</p

Characteristics of Practice Population, Intervention vs. Control group.

<p><b>*</b>Regional organizations that have contracts with health insurers to coordinate CVRM-related care in a particular region with the objective to improve quality of care.</p><p>Characteristics of Practice Population, Intervention vs. Control group.</p

Physical therapists and importance of work participation in patients with musculoskeletal disorders: a focus group study

Abstract Background Musculoskeletal disorders are a major health problem resulting in negative effects on wellbeing and substantial costs to society. Work participation is associated with positive benefits for both mental and physical health. Potentially, generalist physical therapists (GPTs) can play an important role in reducing absenteeism, presenteeism and associated costs in patients with musculoskeletal disorders. However, work participation is often insufficiently addressed within generalist physical therapy practice (GPTP). Therefore, this study evaluates whether GPTs take work participation into account as a determining factor in patients with musculoskeletal disorders, and how this might be improved. Methods This qualitative study consisted of seven focus groups involving 30 participants: 21 GPTs and 9 occupational physical therapists (OPTs). Based on an interview guide, participants were asked how they integrate work participation within their practice, how they collaborate with other professionals, and how GPTs can improve integration of the patient’s work within their practice. Results Although participants recognized the importance of work participation, they mentioned that the integration of this item in their GPTP could be improved. Generally, GPTs place insufficient priority on work participation. Moreover, there is a lack of cooperation between the generalist physical therapist and (other) occupational healthcare providers (including OPTs), and the borderlines/differences between generalist physcial therapy and occupational health physcial therapy were sometimes unclear. GPTs showed a lack of knowledge and a need for additional information about several important work-related factors (e.g. work content, physical and psychosocial working conditions, terms of employment). Conclusions Although a patient’s work is important, GPTs take insufficient account of work participation as a determining factor in the treatment of patients with musculoskeletal disorders. GPTs often lack specific knowledge about work-related factors, and there is insufficient cooperation between OPTs and other occupational healthcare providers. The integration of work participation within GPTP, and the cooperation between GPTs and other occupational healthcare providers, show room for improvement