Routinely collected general practice data: goldmines for research? A report of the European Federation for Medical Informatics Primary Care Informatics Working Group (EFMI PCIWG) from MIE2006, Maastricht, The Netherlands

Background Much of European primary care is computerised and many groups of practices pool data for research. Technology is making pooled general practice data widely available beyond the domain within which it is collected. Objective To explore the barriers and opportunities to exploiting routinely collected general practice data for research. Method Workshop, led by primary care and informatics academics experienced at working with clinical data from large databases, involving 23 delegates from eight countries. Email comments about the write-up from participants. Outputs The components of an effective process are: the input of those who have a detailed understanding of the context in which the data were recordedan assessment of the validity of these data and any denominator usedcreation of anonymised unique identifiers for each patient which can be decoded within the contributing practicesdata must be traceable back to the patient record from which it was extractedarchiving of the queries, the look-up tables of any coding systems used and the ethical constraints which govern the use of the data. Conclusions Explicit statements are needed to explain the source, context of recording, validity check and processing method of any routinely collected data used in research. Data lacking detailed methodological descriptors should not be published

The Efficacy of Education with the WHO Dengue Algorithm on Correct Diagnosing and Triaging of Dengue-Suspected Patients; Study in Public Health Centre

Background: Correct diagnosing and triaging dengue fever remains clinical, but is difficult because of unspecific flu-like symptoms. Best tool at the moment is the easy–to-use 2009 WHO guidelines. Objective: To investigate the efficacy of educational intervention with the (adapted and translated) algorithm from the 2009 WHO dengue guideline to healthcare providers in the Indonesian primary health care setting of Central Java. Methods: Quasi-randomized intervention study implemented in two Public Health Centres (PHCs), one being intervention and the other control. Intervention consisted of educational actions on healthcare providers with a presentation, hand-outs and posters. All patients with fever seen in policlinic or emergency department were included. Data were collected with a participatory observation using the WHO algorithm as a guidance. Results: Pre-intervention, a total of 88 patients (n=38 intervention group; n=50 in the control group), and post-intervention, a total of 231 patients (n=105 in the intervention group; n=126 in the control group) were included. Pre-intervention, correct diagnosing and triaging was not significantly different (63.2% vs 64.0% ; p=0.935), while post-intervention, the intervention group scored higher (75.2% vs 62.7% ; p=0.041). However, in both pre- and post-interventional phase, more than 50% of the cases in 19/22 domains were not investigated by the intervention group. Conclusion: Statistical analyses showed a significantly better outcome in correct diagnosis in the intervention group. However, results are considered inconclusive due to incompleteness of relevant information, which most probably leads to many false positive correct diagnoses and triaging

Green Care kuntoutumisen tukena mielenterveyskuntoutujien palvelukodissa

Tämän opinnäytetyön tavoitteena oli suunnitella ja toteuttaa Green Care-menetelmillä toiminnallisia ryhmiä. Ryhmien tavoitteena oli selvittää mielenterveyskuntoutujien kokemuksia eräässä mielenterveys- ja päihdekuntoutujien palvelukodissa. Opinnäytetyön tavoitteena oli myös tarkastella Green Care-menetelmien merkitystä palvelukodin asiakkaiden kuntoutumiseen. Opinnäytetyön tarkoituksena oli myös lisätä mielenterveys- ja päihdekuntoutujien palvelukodin palvelutarjontaa ja toimintatapoja Green Care-menetelmien avulla. Palvelukoti tarjoaa asumis-, kuntoutus- ja tukipalveluja 30:lle päihde- ja mielenterveyskuntoutujalle ja siellä noudatetaan yhteisöllisyyden periaatteita. Opinnäytetyön viitekehyksessä kuvaan erilaisia Green Care-menetelmiä ja niiden hyvinvointivaikutuksia sekä Green Caren etiikkaa. Kerron myös Green Care-käsitteestä, sen historiasta sekä esiintymisestä Suomessa. Green Care-toimintaa pidetään sateenvarjokäsitteenä erilaisille luontolähtöisille ja eläinavusteisille menetelmille, joilla pyritään edistämään ihmisten sosiaalista, fyysistä, psyykkistä ja koulutuksellista hyvinvointia. Green Care-toiminnan keskeisimmät elementit ovat luonto, luonnossa tapahtuva ja luontoelementtejä käyttävä toiminta sekä yhteisö, jossa toiminta tapahtuu. Teoriaosuudessa kerron myös mielenterveyskuntouksesta, sen käsitteistä ja kuntoutuksen prosessista. Kuvaan myös kuntoutusvalmiutta ja toimintakyvyn arviointia sekä mielenterveystyön etiikkaa. Mielenterveys on hyvinvoinnin tila, jossa ihminen näkee omat kykynsä selviytyä elämän haasteista ja työstä ja ottaa osaa yhteisönsä toimintaan. Opinnäytetyö on toiminnallinen opinnäytetyö, jonka tutkimuksellisessa osuudessa on käytetty osallistuvaa havainnointia ja avointa haastattelua. Haastattelut olivat ryhmähaastatteluja ja kolmelle asiakkaalle tehtiin myös yksilöhaastattelut. Tutkimuksen tulokset on analysoitu teemoittelun avulla. Sekä havaintojen että haastattelujen perusteella palvelukodin asiakkaat kokivat Green Care-menetelmät positiivisina, aktivoivina ja erilaisia hyvinvointivaikutuksia tuottavina. Yleisimmin koettu hyvinvointivaikutus oli menetelmien rauhoittava vaikutus. Green Care-toiminnan merkitystä palvelukodin mielenterveyskuntoutujille oli vaikea arvioida neljän toimintakerran avulla, mutta viitteitä antavana tuloksena voidaan pitää kahden asiakkaan toimintakyvyn lisääntymistä toiminnan aikana. Palvelukodin asiakkaat osallistuivat Green Care-menetelmillä toteutettuihin toimintaryhmiin aktiivisemmin kuin koskaan aikaisemmin ulkopuolisen tahon järjestämään toimintaan. Näiden kokemusten vuoksi palvelukoti aikoo hyödyntää jatkossa luontolähtöisiä menetelmiä enemmän palveluissaan. Opinnäytetyön tulokset ovat hyvin saman suuntaiset kuin Green Care-toiminnasta tehdyissä tutkimuksissa Suomessa ja ulkomailla. Menetelmien hyvinvointivaikutuksista on olemassa paljon näyttöä erilaisille asiakasryhmille. Mielenterveys- ja päihdekuntoutujien palvelukodissa, jossa opinnäytetyö tehtiin, ei ollut aikaisemmin juurikaan hyödynnetty luontoa asiakkaiden kuntoutumisen tukena. Neljä toimintakertaa oli melko lyhyt aika arvioida, miten Green Care-toiminnat tukevat asiakkaiden kuntoutumista palvelukodissa, joten toivon, että asiaa tutkitaan lisää, kun palvelukodissa on käytetty Green Care-toimintoja vähintään vuoden ajan.Using Green Care methods to support rehabilitation of mental health rehabilitees in a service flat. This thesis goal was to plan and help groups with certain functions and “Green Care” methods. The main goal of the groups was to find out about the experiences of mental health rehabilitees in one mental health and drug addict institution. The idea of the thesis was also to study the meaning of “Green Care” methods in the rehabilitation of rehabilitees in the institution. The goal was to increase the services and methods in the mental health and drug addict institution using “Green Care” methods. The service flats provide housing, rehabilitation and other support services to 30 mental health and drug addict rehabilitees and they try to bring a community spirit within the service. In the framework of the thesis I give information about the different “Green Care” methods, the welfare effects and the ethics of “Green Care”. I also described the concept of “Green Care”, its history and its appearance in Finland. “Green Care” methods are known as a rainbow concept of different methods were nature and animals play a part in advancing humans` social, physical, metal and educational welfare. The main elements in “Green Care” methods are nature, activities in nature and the use of nature elements. Also the community were the actions take place is important. In the theory part I wrote about mental health rehabilitation, concepts and the process of rehabilitation. I described the willingness for rehabilitation, the ability to function and the ethics of mental work. Mental health is a state of welfare where you can see your ability to survive the challenges of life and work and you can take part in a community’s functions. The thesis is a functional thesis in which there was used an examinational part, participating observation and open interviews. The interviews were group interviews and three customers also participated in the individual interviews. The results of the examination were analysed using the theme method. When analysing the results of the examination it was discovered that the customers of the mental health and drug addict institution found “Green Care” methods positive, activating and providing welfare. The customers found that the methods had a calming effect. The meaning of “Green Care” methods to the institutions rehabilitees was hard to estimate based on four visits to the service flats. But some progress was seen on two rehabilitees ability to function during the time “Green Care” methods were used. The customers in the service flats participated more willingly to functioning groups using “Green Care” methods than to any other functioning groups that were organized by an outsider. Because of these experiences the institution will use more nature based methods in its services. The results of the thesis are very similar to other examinations made in Finland and other countries about “Green Care” methods. The welfare effects of the methods used show various evidence using different customer groups. Nature was hardly ever used as a method of rehabilitation for the customers in the mental health and drug addict institution in which the thesis was made. Four times using the methods was quite a short time to evaluate how “Creen Care” methods was quite a short time to evaluate how “Green Care” methods support the rehabilitation of the customers in the service flat so I hope that there is a possibility to study the rehabilitees more when the methods are used at least for a year

Doctor-patient communication with people with intellectual disability - a qualitative study

<p>Abstract</p> <p>Background</p> <p>People with intellectual disability (ID) expressed dissatisfaction with doctor-patient communication and mentioned certain preferences for this communication (our research). Since many people with ID in the Netherlands have recently moved from residential care facilities to supported accommodations in the community, medical care for them was transferred from ID physicians (IDPs) to general practitioners (GPs) in the vicinity of the new accommodation. We addressed the following research question: 'What are the similarities and differences between the communication preferences of people with ID and the professional criteria for doctor-patient communication by GPs?'</p> <p>Methods</p> <p>A focus group meeting and interviews were used to identify the preferences of 12 persons with ID for good communication with their GP; these were compared with communication criteria used to assess trainee GPs, as described in the MAAS-Global manual.</p> <p>Results</p> <p>Eight preferences for doctor-patient communication were formulated by the people with ID. Six of them matched the criteria used for GPs. Improvements are required as regards the time available for consultation, demonstrating physical examinations before applying them and triadic communication.</p> <p>Conclusions</p> <p>People with ID hold strong views on communication with their doctors during consultations. GPs, people with ID and their support workers can further fine-tune their communication skills.</p

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

The SMILE study: a study of medical information and lifestyles in Eindhoven, the rationale and contents of a large prospective dynamic cohort study

<p>Abstract</p> <p>Background</p> <p>Health problems, health behavior, and the consequences of bad health are often intertwined. There is a growing need among physicians, researchers and policy makers to obtain a comprehensive insight into the mutual influences of different health related, institutional and environmental concepts and their collective developmental processes over time.</p> <p>Methods/Design</p> <p>SMILE is a large prospective cohort study, focusing on a broad range of aspects of disease, health and lifestyles of people living in Eindhoven, the Netherlands. This study is unique in its kind, because two data collection strategies are combined: first data on morbidity, mortality, medication prescriptions, and use of care facilities are continuously registered using electronic medical records in nine primary health care centers. Data are extracted regularly on an anonymous basis. Secondly, information about lifestyles and the determinants of (ill) health, sociodemographic, psychological and sociological characteristics and consequences of chronic disease are gathered on a regular basis by means of extensive patient questionnaires. The target population consisted of over 30,000 patients aged 12 years and older enrolled in the participating primary health care centers.</p> <p>Discussion</p> <p>Despite our relatively low response rates, we trust that, because of the longitudinal character of the study and the high absolute number of participants, our database contains a valuable set of information.</p> <p>SMILE is a longitudinal cohort with a long follow-up period (15 years). The long follow-up and the unique combination of the two data collection strategies will enable us to disentangle causal relationships. Furthermore, patient-reported characteristics can be related to self-reported health, as well as to more validated physician registered morbidity. Finally, this population can be used as a sampling frame for intervention studies. Sampling can either be based on the presence of certain diseases, or on specific lifestyles or other patient characteristics.</p

Clinical and cost-effectiveness of computerised cognitive behavioural therapy for depression in primary care: Design of a randomised trial

<p>Abstract</p> <p>Background</p> <p>Major depression is a common mental health problem in the general population, associated with a substantial impact on quality of life and societal costs. However, many depressed patients in primary care do not receive the care they need. Reason for this is that pharmacotherapy is only effective in severely depressed patients and psychological treatments in primary care are scarce and costly. A more feasible treatment in primary care might be computerised cognitive behavioural therapy. This can be a self-help computer program based on the principles of cognitive behavioural therapy. Although previous studies suggest that computerised cognitive behavioural therapy is effective, more research is necessary. Therefore, the objective of the current study is to evaluate the (cost-) effectiveness of online computerised cognitive behavioural therapy for depression in primary care.</p> <p>Methods/Design</p> <p>In a randomised trial we will compare (a) computerised cognitive behavioural therapy with (b) treatment as usual by a GP, and (c) computerised cognitive behavioural therapy in combination with usual GP care. Three hundred mild to moderately depressed patients (aged 18–65) will be recruited in the general population by means of a large-scale Internet-based screening (<it>N </it>= 200,000). Patients will be randomly allocated to one of the three treatment groups. Primary outcome measure of the clinical evaluation is the severity of depression. Other outcomes include psychological distress, social functioning, and dysfunctional beliefs. The economic evaluation will be performed from a societal perspective, in which all costs will be related to clinical effectiveness and health-related quality of life. All outcome assessments will take place on the Internet at baseline, two, three, six, nine, and twelve months. Costs are measured on a monthly basis. A time horizon of one year will be used without long-term extrapolation of either costs or quality of life.</p> <p>Discussion</p> <p>Although computerised cognitive behavioural therapy is a promising treatment for depression in primary care, more research is needed. The effectiveness of online computerised cognitive behavioural therapy without support remains to be evaluated as well as the effects of computerised cognitive behavioural therapy in combination with usual GP care. Economic evaluation is also needed. Methodological strengths and weaknesses are discussed.</p> <p>Trial registration</p> <p>The study has been registered at the Netherlands Trial Register, part of the Dutch Cochrane Centre (ISRCTN47481236).</p