A theoretical lens for revealing the complexity of chronic care

The increasing prevalence of co-occurring multiple chronic conditions in an aging population has influenced the debate on complexity in chronic care and nowadays provides an impetus to the reform of numerous health systems. This article presents a theoretical lens for understanding the complexity of chronic care based on research and debate conducted in the context of multiple quality improvement programs over the last five years in Belgium and The Netherlands. We consider four major components of complexity in chronic care against a background of complex adaptive systems: (1) case (patient) complexity; (2) care complexity; (3) quality assessment complexity; and (4) health systems complexity. Each of these components represents a range of elements that contribute to the picture of complexity in chronic care. We emphasize that planning for chronic care requires equal attention to the complexity of all four components. It also requires multifaceted interventions and implementation strategies that target improvements in multiple outcomes related to the structural, process, and outcome components of care. Further empirical research is needed to assess the validity of our complexity framework in the health-care environment

Patient health information materials in waiting rooms of family physicians: do patients care?

Background: Patient health information materials (PHIMs), such as leaflets and posters are widely used by family physicians to reinforce or illustrate information, and to remind people of information received previously. This facilitates improved health-related knowledge and self-management by patients. Objective: This study assesses the use of PHIMs by patient. It also addresses their perception of the quality and the impact of PHIMs on the interaction with their physician, along with changes in health-related knowledge and self-management. Methods: Questionnaire survey among patients of family practices of one town in Belgium, assessing: (1) the extent to which patients read PHIMs in waiting rooms (leaflets and posters) and take them home, (2) the patients' perception of the impact of PHIMs on interaction with their physician, their change in health-related knowledge and self-management, and (3) the patients judgment of the quality of PHIMs. Results: We included 903 questionnaires taken from ten practices. Ninety-four percent of respondents stated they read PHIMs (leaflets), 45% took the leaflets home, and 78% indicated they understood the content of the leaflets. Nineteen percent of respondents reportedly discussed the content of the leaflets with their physician and 26% indicated that leaflets allowed them to ask fewer questions of their physician. Thirty-four percent indicated that leaflets had previously helped them to improve their health-related knowledge and self-management. Forty-two percent reportedly discussed the content of the leaflets with others. Patient characteristics are of significant influence on the perceived impact of PHIMS in physician interaction, health-related knowledge, and self-management. Conclusion: This study suggests that patients value health information materials in the waiting rooms of family physicians and that they perceive such materials as being helpful in improving patient-physician interaction, health-related knowledge, and self-management

Association of objective health factors with self-reported health

Objectives. There is a strong relationship between subjective health and mortality, level of functional ability and medical con- sumption. The aim of this study was to describe the correlation of objective health-related factors with self-reported health (SRH) of a sample of the Belgian population. Methods. Participants were recruited during an exhibition at the Brussels Exhibition Centre. They completed a visual analogue scale assessing their SRH. Medical history and health related parameters of the participants were recorded. Results. In total 974 visitors participated. From the multivariate analysis we found an association between low SRH and diabe- tes (OR 0.23-0.80), increased body mass index (OR 0.52-0.74), coronary heart disease (OR 0.28-0.97), smoking (OR 0.38-0.89), speaking Dutch (OR 0.40-0.92), not knowing length (OR 0.36- 0.99), family history of breast cancer (OR 0.41-0.94), family history of coronary heart disease (OR 0.45-095) and aging (OR 0.84-0.99). Following a cholesterol-lowering diet was associated with a high SRH (OR 1.10-2.44). Conclusions. Most of the factors associated with low SRH are known and confirm what has previously been reported in literature. However, the associations between low SRH and not knowing your length, speaking Dutch or having a family history of breast or colon cancer, as well as the association between high SRH and being on a cholesterol-lowering diet are interesting new findings

Interdisciplinary diabetes care teams operating on the interface between primary and specialty care are associated with improved outcomes of care: findings from the Leuven Diabetes Project

<p>Abstract</p> <p>Background</p> <p>Type 2 diabetes mellitus is a complex, progressive disease which requires a variety of quality improvement strategies. Limited information is available on the feasibility and effectiveness of interdisciplinary diabetes care teams (IDCT) operating on the interface between primary and specialty care. A first study hypothesis was that the implementation of an IDCT is feasible in a health care setting with limited tradition in shared care. A second hypothesis was that patients who make use of an IDCT would have significantly better outcomes compared to non-users of the IDCT after an 18-month intervention period. A third hypothesis was that patients who used the IDCT in an Advanced quality Improvement Program (AQIP) would have significantly better outcomes compared to users of a Usual Quality Improvement Program (UQIP).</p> <p>Methods</p> <p>This investigation comprised a two-arm cluster randomized trial conducted in a primary care setting in Belgium. Primary care physicians (PCPs, n = 120) and their patients with type 2 diabetes mellitus (n = 2495) were included and subjects were randomly assigned to the intervention arms. The IDCT acted as a cornerstone to both the intervention arms, but the number, type and intensity of IDCT related interventions varied depending upon the intervention arm.</p> <p>Results</p> <p>Final registration included 67 PCPs and 1577 patients in the AQIP and 53 PCPs and 918 patients in the UQIP. 84% of the PCPs made use of the IDCT. The expected participation rate in patients (30%) was not attained, with 12,5% of the patients using the IDCT. When comparing users and non-users of the IDCT (irrespective of the intervention arm) and after 18 months of intervention the use of the IDCT was significantly associated with improvements in HbA1c, LDL-cholesterol, an increase in statins and anti-platelet therapy as well as the number of targets that were reached. When comparing users of the IDCT in the two intervention arms no significant differences were noted, except for anti-platelet therapy.</p> <p>Conclusion</p> <p>IDCT's operating on the interface between primary and specialty care are associated with improved outcomes of care. More research is required on what team and program characteristics contribute to improvements in diabetes care.</p> <p>Trial registration</p> <p>NTR 1369.</p

A cluster randomized trial to improve adherence to evidence-based guidelines on diabetes and reduce clinical inertia in primary care physicians in Belgium: study protocol [NTR 1369]

Contains fulltext : 70617.pdf (publisher's version ) (Open Access)ABSTRACT: BACKGROUND: Most quality improvement programs in diabetes care incorporate aspects of clinician education, performance feedback, patient education, care management, and diabetes care teams to support primary care physicians. Few studies have applied all of these dimensions to address clinical inertia. AIM: To evaluate interventions to improve adherence to evidence-based guidelines for diabetes and reduce clinical inertia in primary care physicians. DESIGN: Two-arm cluster randomized controlled trial. PARTICIPANTS: Primary care physicians in Belgium. INTERVENTIONS: Primary care physicians will be randomly allocated to 'Usual' (UQIP) or 'Advanced' (AQIP) Quality Improvement Programs. Physicians in the UQIP will receive interventions addressing the main physician, patient, and office system factors that contribute to clinical inertia. Physicians in the AQIP will receive additional interventions that focus on sustainable behavior changes in patients and providers. OUTCOMES: Primary endpoints are the proportions of patients within targets for three clinical outcomes: 1) glycosylated hemoglobin < 7%; 2) systolic blood pressure differences </=130 mmHg; and 3) low density lipoprotein/cholesterol < 100 mg/dl. Secondary endpoints are individual improvements in 12 validated parameters: glycosylated hemoglobin, low and high density lipoprotein/cholesterol, total cholesterol, systolic blood pressure, diastolic blood pressure, weight, physical exercise, healthy diet, smoking status, and statin and anti-platelet therapy. PRIMARY AND SECONDARY ANALYSIS: Statistical analyses will be performed using an intent-to-treat approach with a multilevel model. Linear and generalized linear mixed models will be used to account for the clustered nature of the data, i.e., patients clustered withinimary care physicians, and repeated assessments clustered within patients. To compare patient characteristics at baseline and between the intervention arms, the generalized estimating equations (GEE) approach will be used, taking the clustered nature of the data within physicians into account. We will also use the GEE approach to test for differences in evolution of the primary and secondary endpoints for all patients, and for patients in the two interventions arms, accounting for within-patient clustering. TRIAL REGISTRATION: number: NTR 1369

Barriers and facilitators to evidence based care of type 2 diabetes patients: experiences of general practitioners participating to a quality improvement program

Objective To evaluate the barriers and facilitators to high-quality diabetes care as experienced by general practitioners (GPs) who participated in an 18-month quality improvement program (QIP). This QIP was implemented to promote compliance with international guidelines. Methods Twenty out of the 120 participating GPs in the QIP underwent semi-structured interviews that focused on three questions: 'Which changes did you implement or did you observe in the quality of diabetes care during your participation in the QIP?' 'According to your experience, what induced these changes?' and 'What difficulties did you experience in making the changes?' Results Most GPs reported that enhanced knowledge, improved motivation, and a greater sense of responsibility were the key factors that led to greater compliance with diabetes care guidelines and consequent improvements in diabetes care. Other factors were improved communication with patients and consulting specialists and reliance on diabetes nurse educators. Some GPs were reluctant to collaborate with specialists, and especially with diabetes educators and dieticians. Others blamed poor compliance with the guidelines on lack of time. Most interviewees reported that a considerable minority of patients were unwilling to change their lifestyles. Conclusion Qualitative research nested in an experimental trial may clarify the improvements that a QIP may bring about in a general practice, provide insight into GPs' approach to diabetes care and reveal the program's limits. Implementation of a QIP encounters an array of cognitive, motivational, and relational obstacles that are embedded in a patient-healthcare provider relationshipGeert Goderis, Liesbeth Borgermans, Chantal Mathieu, Carine Van Den Broeke, Karen Hannes, Jan Heyrman and Richard Gro

Invloed van onafhankelijke artsenbezoekers op de praktijk van artsen in de eerste lijn

VI, 95 p.ill.Op vraag van het Geneesmiddelenagentschap (FAGG) onderzocht het Federaal Kenniscentrum voor de Gezondheidszorg (KCE), samen met de onderzoekers van Spiral (ULG) en het Leuvense Medsat , de impact van onafhankelijke huisartsenbezoeken. Doel van deze bezoeken is de huisartsen een onafhankelijke, wetenschappelijke boodschap te brengen. Het FAGG investeerde het afgelopen jaar meer dan 1 miljoen € in het project. Bij gebrek aan voldoende gegevens kon het KCE over de impact in België geen definitieve conclusie trekken. Als het project wordt voortgezet beveelt het KCE aan om het beter te integreren in de andere Belgische initiatieven inzake zorgkwaliteit . Daarnaast zou men gerichter moeten te werk gaan bij de selectie van de onderwerpen en de te bezoeken artsen. De methode van de individuele contacten wordt het beste uitgebreid met andere communicatie middelen. Tenslotte zijn een goede dataregistratie en evaluatie onontbeerlijk.Scientific summary -- Table of contents -- 1 BACKGROUND . 3 -- 1.1 ACADEMIC DETAILING . 3 -- 1.2 DEFINITIONS . 3 -- 1.3 ACADEMIC DETAILING IN BELGIUM . 4 -- 1.4 OBJECTIVE OF THE PROJECT . 4 -- 2 LITERATURE REVIEW ON ACADEMIC DETAILING . 5 -- 2.1 AIM OF THE LITERATURE REVIEW . 5 -- 2.2 METHODOLOGY . 5 -- 2.2.1 Population – Intervention - Comparison – Outcomes (PICO) . 5 -- 2.2.2 Search strategies . 5 -- 2.3 RESULTS . 8 -- 2.3.1 Systematic literature review . 8 -- 2.3.2 Academic Detailing programmes in other countries . 23 -- 2.4 DISCUSSION: RESULTS FROM THE INDEXED AND GREY LITERATURE . 33 -- 2.4.1 Widespread use of academic detailing . 33 -- 2.4.2 Rationale of academic detailing . 33 -- 2.4.3 The concept and content of academic detailing . 33 -- 2.4.4 Target population of caregivers . 34 -- 2.4.5 Professionals who provide academic detailing . 34 -- 2.4.6 Behaviour targeted by academic detailing programs . 34 -- 2.4.7 Conditions and diseases targeted by academic detailing programmes . 35 -- 2.4.8 Patients targeted by AD programmes: specific populations. 35 -- 2.4.9 Effectiveness of academic detailing on clinical outcomes . 35 -- 2.4.10 Cost-effectiveness of academic detailing . 36 -- 2.4.11 Effectiveness of AD programmes compared to other interventions . 36 -- 3 QUALITATIVE STUDY AMONG GENERAL PRACTITIONERS . 38 -- 3.1 OBJECTIVE OF THIS PART . 38 -- 3.2 METHODOLOGY . 38 -- 3.2.1 Tools for data collection: interviews and Mesydel methods . 38 -- 3.2.2 Methodological background: Grounded Theory . 39 -- 3.2.3 Population . 40 -- 3.2.4 Protocols . 41 -- 3.2.5 Sampling . 42 -- 3.2.6 Development of the Mesydel questions . 43 -- 3.2.7 Summary of the methodology . 43 -- 3.3 ANALYSIS . 44 -- 3.3.1 The GPs and their context . 44 -- 3.3.2 Perception of the Farmaka visit and visitor by the GPs . 49 -- 3.3.3 Impact of the Farmaka visit: what works . 51 -- 3.3.4 Impact of the Farmaka visit: what does not work . 53 -- 3.3.5 Wishes of interviewed GPs . 54 -- 3.4 CRITICAL DISCUSSION OF RESULTS AND ENHANCEMENT LINES . 57 -- 3.4.1 Biases . 57 -- 3.4.2 Discussion of some seemingly contradictory opinions in the analysis . 58 -- 3.4.3 Further research . 59 -- 3.5 IMPROVEMENT PATHS: SUGGESTIONS FOR IMPLEMENTATION . 60 -- 3.5.1 EBM for specialist physicians . 60 -- 3.5.2 Support of the medical information . 60 -- 3.5.3 Online forum and focus groups for GPs . 60 -- 3.5.4 Emerging problem: patients who misuse the Internet for self-diagnosis . 61 -- 3.5.5 Farmaka’s visitor profile . 61 -- 3.5.6 Choice of the topic of the visit by the GP . 61 -- 3.5.7 Better target group for the AD visits . 61 -- 3.5.8 Accreditation procedure linked to the Farmaka visit . 62 -- 3.5.9 Enhancing awareness of Farmaka amongst GPs . 62 -- 3.5.10 Life-long learning . 62 -- 4 PRESCRIPTION DATA OF A SELECTED SAMPLE OF BELGIAN GPS . 63 -- 4.1 BACKGROUND . 63 -- 4.1.1 Choice of the topics . 63 -- 4.1.2 Key messages of Farmaka AD visitors . 63 -- 4.2 METHODOLOGY . 64 -- 4.2.1 Data source . 64 -- 4.2.2 Planned Analyses . 64 -- 4.2.3 Statistics . 65 -- 4.2.4 Rules . 65 -- 4.3 RESULTS . 67 -- 4.3.1 Diabetes . 67 -- 4.3.2 Dementia . 83 -- 4.4 DISCUSSION: ANALYSIS OF THE GPS’ PRESCRIPTIONS . 88 -- 5 CONCLUSIONS . 90 -- 5.1 LITERATURE FINDINGS: MODERATE EFFECTIVENESS ON THE PRACTICE. 90 -- 5.2 EFFECTIVENESS NOT DEMONSTRATED IN THIS STUDY . 90 -- 5.3 ACADEMIC DETAILING IN BELGIUM: WHICH WAY FORWARD? . 91 -- 5.3.1 Choice of topic . 91 -- 5.3.2 Target population of physicians . 91 -- 5.3.3 Face-to-face or . ? . 91 -- 5.3.4 Background of the visitor . 92 -- 5.3.5 Other suggestions from GPs in Belgium . 92 -- 6 REFERENCES . 9

Impact of academic detailing on primary care physicians

VI, 95 p.ill.Scientific summary -- Table of contents -- 1 BACKGROUND . 3 -- 1.1 ACADEMIC DETAILING . 3 -- 1.2 DEFINITIONS . 3 -- 1.3 ACADEMIC DETAILING IN BELGIUM . 4 -- 1.4 OBJECTIVE OF THE PROJECT . 4 -- 2 LITERATURE REVIEW ON ACADEMIC DETAILING . 5 -- 2.1 AIM OF THE LITERATURE REVIEW . 5 -- 2.2 METHODOLOGY . 5 -- 2.2.1 Population – Intervention - Comparison – Outcomes (PICO) . 5 -- 2.2.2 Search strategies . 5 -- 2.3 RESULTS . 8 -- 2.3.1 Systematic literature review . 8 -- 2.3.2 Academic Detailing programmes in other countries . 23 -- 2.4 DISCUSSION: RESULTS FROM THE INDEXED AND GREY LITERATURE . 33 -- 2.4.1 Widespread use of academic detailing . 33 -- 2.4.2 Rationale of academic detailing . 33 -- 2.4.3 The concept and content of academic detailing . 33 -- 2.4.4 Target population of caregivers . 34 -- 2.4.5 Professionals who provide academic detailing . 34 -- 2.4.6 Behaviour targeted by academic detailing programs . 34 -- 2.4.7 Conditions and diseases targeted by academic detailing programmes . 35 -- 2.4.8 Patients targeted by AD programmes: specific populations. 35 -- 2.4.9 Effectiveness of academic detailing on clinical outcomes . 35 -- 2.4.10 Cost-effectiveness of academic detailing . 36 -- 2.4.11 Effectiveness of AD programmes compared to other interventions . 36 -- 3 QUALITATIVE STUDY AMONG GENERAL PRACTITIONERS . 38 -- 3.1 OBJECTIVE OF THIS PART . 38 -- 3.2 METHODOLOGY . 38 -- 3.2.1 Tools for data collection: interviews and Mesydel methods . 38 -- 3.2.2 Methodological background: Grounded Theory . 39 -- 3.2.3 Population . 40 -- 3.2.4 Protocols . 41 -- 3.2.5 Sampling . 42 -- 3.2.6 Development of the Mesydel questions . 43 -- 3.2.7 Summary of the methodology . 43 -- 3.3 ANALYSIS . 44 -- 3.3.1 The GPs and their context . 44 -- 3.3.2 Perception of the Farmaka visit and visitor by the GPs . 49 -- 3.3.3 Impact of the Farmaka visit: what works . 51 -- 3.3.4 Impact of the Farmaka visit: what does not work . 53 -- 3.3.5 Wishes of interviewed GPs . 54 -- 3.4 CRITICAL DISCUSSION OF RESULTS AND ENHANCEMENT LINES . 57 -- 3.4.1 Biases . 57 -- 3.4.2 Discussion of some seemingly contradictory opinions in the analysis . 58 -- 3.4.3 Further research . 59 -- 3.5 IMPROVEMENT PATHS: SUGGESTIONS FOR IMPLEMENTATION . 60 -- 3.5.1 EBM for specialist physicians . 60 -- 3.5.2 Support of the medical information . 60 -- 3.5.3 Online forum and focus groups for GPs . 60 -- 3.5.4 Emerging problem: patients who misuse the Internet for self-diagnosis . 61 -- 3.5.5 Farmaka’s visitor profile . 61 -- 3.5.6 Choice of the topic of the visit by the GP . 61 -- 3.5.7 Better target group for the AD visits . 61 -- 3.5.8 Accreditation procedure linked to the Farmaka visit . 62 -- 3.5.9 Enhancing awareness of Farmaka amongst GPs . 62 -- 3.5.10 Life-long learning . 62 -- 4 PRESCRIPTION DATA OF A SELECTED SAMPLE OF BELGIAN GPS . 63 -- 4.1 BACKGROUND . 63 -- 4.1.1 Choice of the topics . 63 -- 4.1.2 Key messages of Farmaka AD visitors . 63 -- 4.2 METHODOLOGY . 64 -- 4.2.1 Data source . 64 -- 4.2.2 Planned Analyses . 64 -- 4.2.3 Statistics . 65 -- 4.2.4 Rules . 65 -- 4.3 RESULTS . 67 -- 4.3.1 Diabetes . 67 -- 4.3.2 Dementia . 83 -- 4.4 DISCUSSION: ANALYSIS OF THE GPS’ PRESCRIPTIONS . 88 -- 5 CONCLUSIONS . 90 -- 5.1 LITERATURE FINDINGS: MODERATE EFFECTIVENESS ON THE PRACTICE. 90 -- 5.2 EFFECTIVENESS NOT DEMONSTRATED IN THIS STUDY . 90 -- 5.3 ACADEMIC DETAILING IN BELGIUM: WHICH WAY FORWARD? . 91 -- 5.3.1 Choice of topic . 91 -- 5.3.2 Target population of physicians . 91 -- 5.3.3 Face-to-face or . ? . 91 -- 5.3.4 Background of the visitor . 92 -- 5.3.5 Other suggestions from GPs in Belgium . 92 -- 6 REFERENCES . 9