Does a joint development and dissemination of multidisciplinary guidelines improve prescribing behaviour: a pre/post study with concurrent control group and a randomised trial

BACKGROUND: It is difficult to keep control over prescribing behaviour in general practices. The purpose of this study was to assess the effects of a dissemination strategy of multidisciplinary guidelines on the volume of drug prescribing. METHODS: The study included two designs, a quasi-experimental pre/post study with concurrent control group and a random sample of GPs within the intervention group. The intervention area with 53 GPs was compared with a control group of 54 randomly selected GPs in the south and centre of the Netherlands. Additionally, a randomisation was executed in the intervention group to create two arms with 27 GPs who were more intensively involved in the development of the guideline and 26 GPs in the control group. A multidisciplinary committee developed prescription guidelines. Subsequently these guidelines were disseminated to all GPs in the intervention region. Additional effects were studied in the subgroup trial in which GPs were invited to be more intensively involved in the guideline development procedure. The guidelines contained 14 recommendations on antibiotics, asthma/COPD drugs and cholesterol drugs The main outcome measures were prescription data of a three-year period (one year before and 2 years after guideline dissemination) and proportion of change according to recommendations. RESULTS: Significant short-term improvements were seen for one recommendation: mupirocin. Long-term changes were found for cholesterol drug prescriptions. No additional changes were seen for the randomised controlled study in the subgroup. GPs did not take up the invitation for involvement. CONCLUSION: Disseminating multidisciplinary guidelines that were developed within a region, has no clear effect on prescribing behaviour even though GPs and specialists were involved more intensively in their development. Apparently, more effort is needed to bring about change

Helping hands: A cluster randomised trial to evaluate the effectiveness of two different strategies for promoting hand hygiene in hospital nurses

Background: hand hygiene prescriptions are the most important measure in the prevention of hospital-acquired infections. Yet, compliance rates are generally below 50% of all opportunities for hand hygiene. This study aims at evaluating the short- and long-term effects of two different strategies for promoting hand hygiene in hospital nurses.Methods/design: this study is a cluster randomised controlled trial with inpatient wards as the unit of randomisation. Guidelines for hand hygiene will be implemented in this study. Two strategies will be used to improve the adherence to guidelines for hand hygiene. The state-of-the-art strategy is derived from the literature and includes education, reminders, feedback, and targeting adequate products and facilities. The extended strategy also contains activities aimed at influencing social influence in groups and enhancing leadership. The unique contribution of the extended strategy is built upon relevant behavioural science theories. The extended strategy includes all elements of the state-of-the-art strategy supplemented with gaining active commitment and initiative of ward management, modelling by informal leaders at the ward, and setting norms and targets within the team. Data will be collected at four points in time, with six-month intervals. An average of 3,000 opportunities for hand hygiene in approximately 900 nurses will be observed at each time point.Discussion: performing and evaluating an implementation strategy that also targets the social context of teams may considerably add to the general body of knowledge in this field. Results from our study will allow us to draw conclusions on the effects of different strategies for the implementation of hand hygiene guidelines, and based on these results we will be able to define a preferred implementation strategy for hospital based nursing.Trial registration: the study is registered as a Clinical Trial in ClinicalTrials.gov, dossier number: NCT0054801

Physical functioning and quality of life after cancer rehabilitation

Physical functioning and quality of life after cancer rehabilitation van Weert, E; Hoekstra-Weebers, JEHM; Grol, BMF; Otter, R; Arendzen, JH; Postema, K; van der Schans, CP Con el fin de superar los problemas relacionados con el cá ncer y mejorar la calidad de vida, se desarrolló un programa de rehabilitació n multifocal intensiva para pacientes oncoló gicos. Nuestra hipó tesis era que un programa de rehabilitació n intensiva de seis semanas de duració n se traduciría en mejorías fisioló gicas y de la calidad de vida. Treinta y cuatro pacientes con problemas físicos y psicosociales relacionados con el cá ncer. A´mbito: Centro de rehabilitació n. Disen˜o: Estudio observacional prospectivo. Intervencio´n: Un programa de rehabilitació n multifocal intensiva de seis semanas constituido por cuatro componentes: ejercicio individual, deportes, psicoeducació n e informació n. Criterios de valoracio´n: Ejercicio en bicicleta ergomé trica limitado por los síntomas, fuerza muscular y calidad de vida (RAND-36, RSCL y MFI). Las mediciones se hicieron antes (T0) y despué s de seis semanas de rehabilitació n (T1). Despué s del programa de rehabilitació n intensiva se observaron mejorías estadísti-camente significativas en el ejercicio en bicicleta ergomé trica limitado por los síntomas, en la fuerza muscular y en varios dominios del RAND-36, RSCL y MFI. El programa de rehabilitació n multifocal intensiva de seis semanas tuvo efectos beneficiosos inmediatos sobre las variables fisioló gicas, la calidad de vida y la fatiga

From postpartum haemorrhage guideline to local protocol: a study of protocol quality

Objective: Postpartum hemorrhage (PPH) has a continuously rising incidence worldwide, suggesting suboptimal care. An important step in optimizing care is the translation of evidence-based guidelines into comprehensive hospital protocols. However, knowledge about the quality of these protocols is lacking. The objective of this study was to evaluate the quality of PPH-protocols on structure and content in the Netherlands. Methods: We performed an observational multicenter study. Eighteen PPH-protocols from 3 University Hospitals (UH), 8 Teaching Hospitals (TH) and 7 Non-Teaching hospitals (NTH) throughout the Netherlands were acquired. The structure of the PPH-protocols was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE-II) Instrument. The content was appraised using previously developed quality indicators, based on international guidelines and Advance-Trauma-Life-Support (ATLS)-based course instructions. Results: The quality of the protocols for postpartum hemorrhage for both structure and content varied widely between different hospitals, but all of them showed room for improvement. The protocols scored mainly below average on the different items of the AGREE-II instrument (8 of the 10 items scored <4 on a 1-7 scale). Regarding the content, adoption of guideline recommendations in protocols was 46 %. In addition, a timely indication of 'when to perform' a recommendation was lacking in three-fourths of the items. Conclusion: This study shows that the quality of the PPH-protocols for both structure and content in the Netherlands is suboptimal. This makes adherence to the guideline and ATLS-based course instructions difficult.Mallory D. Woiski, Helena C. van Vugt, Anneke Dijkman, Richard P. Grol, Abraham Marcus, Johanna M. Middeldorp, Ben W. Mol, Femke Mols, Martijn A. Oudijk, Martina Porath, Hubertina J. Scheepers, Rosella P. Hermen

Potential barriers and facilitators for implementation of an integrated care pathway for hearing-impaired persons: an exploratory survey among patients and professionals

BACKGROUND: Because of the increasing costs and anticipated shortage of Ear Nose and Throat (ENT) specialists in the care for hearing-impaired persons, an integrated care pathway that includes direct hearing aid provision was developed. While this direct pathway is still under investigation, in a survey we examined expectations and potential barriers and facilitators towards this direct pathway, of patients and professionals involved in the pathway. METHODS: Two study populations were assessed: members of the health professions involved in the care pathway for hearing-impaired persons (general practitioners (GPs), hearing aid dispensers, ENT-specialists and clinical audiologists) and persons with hearing complaints. We developed a comprehensive semi-structured questionnaire for the professionals, regarding expectations, barriers, facilitators and conditions for implementation. We developed two questionnaires for persons with hearing complaints, both regarding evaluations and preferences, and administered them after they had experienced two key elements of the direct pathway: the triage and the hearing aid fitting. RESULTS: On average GPs and hearing aid dispensers had positive expectations towards the direct pathway, while ENT-specialists and clinical audiologists had negative expectations. Professionals stated both barriers and facilitators towards the direct pathway. Most professionals either supported implementation of the direct pathway, provided that a number of conditions were satisfied, or did not support implementation, unless roughly the same conditions were satisfied. Professionals generally agreed on which conditions need to be satisfied. Persons with hearing complaints evaluated the present referral pathway and the new direct pathway equally. Many, especially older, participants stated however that they would still visit the GP and ENT-specialist, even when this would not be necessary for reimbursement of the hearing aid, and found it important that the ENT-specialist or Audiological Centre evaluated their hearing aid. CONCLUSION: This study identified professional concerns about the direct pathway for hearing-impaired persons. Gaps exist in expectations amongst professions. Also gaps exist between users of the pathway, especially between age groups and regions. Professionals are united in the conditions that need to be fulfilled for a successful implementation of the direct pathway. Implementation on a regional level is recommended to best satisfy these conditions

Nurses' perceived barriers to the implementation of a Fall Prevention Clinical Practice Guideline in Singapore hospitals

BackgroundTheories of behavior change indicate that an analysis of barriers to change is helpful when trying to influence professional practice. The aim of this study was to assess the perceived barriers to practice change by eliciting nurses\u27 opinions with regard to barriers to, and facilitators of, implementation of a Fall Prevention clinical practice guideline in five acute care hospitals in Singapore.MethodsNurses were surveyed to identify their perceptions regarding barriers to implementation of clinical practice guidelines in their practice setting. The validated questionnaire, \u27Barriers and facilitators assessment instrument\u27, was administered to nurses (n = 1830) working in the medical, surgical, geriatric units, at five acute care hospitals in Singapore.ResultsAn 80.2% response rate was achieved. The greatest barriers to implementation of clinical practice guidelines reported included: knowledge and motivation, availability of support staff, access to facilities, health status of patients, and, education of staff and patients.ConclusionNumerous barriers to the use of the Fall Prevention Clinical Practice Guideline have been identified. This study has laid the foundation for further research into implementation of clinical practice guidelines in Singapore by identifying barriers to change in acute care settings.<br /

Construction and psychometric testing of the EMPATHIC questionnaire measuring parent satisfaction in the pediatric intensive care unit

Abstract PURPOSE: To construct and test the reliability and validity of the EMpowerment of PArents in THe Intensive Care (EMPATHIC) questionnaire measuring parent satisfaction in the pediatric intensive care unit (PICU). METHODS: Structured development and psychometric testing of a parent satisfaction-with-care instrument with the results of two cohorts of parents (n = 2,046) from eight PICUs in the Netherlands. RESULTS: In the first cohort, 667/1,055 (63%) parents participated followed by 551/991 (56%) parents in the second cohort. The empirical structure of the instrument was established by confirmatory factor analysis with the first sample of parents confirming 65 statements within five theoretically conceptualized domains: information, care and cure, organization, parental participation, and professional attitude. The standardized factor loadings were greater than 0.40 in 63 statements. Cronbach's α, a measure of reliability, per domain ranged from 0.73 to 0.93 in both cohorts with no significant difference documenting the reliability over time. Beside rigorous content and face validity, the congruent validity of the instrument showed adequate correlation with four gold standard questions measuring overall satisfaction. The non-differential validity was confirmed with no significant differences between the population characteristics and the domains, except that parents with a child for a surgical admission were more satisfied on information issues. CONCLUSIONS: The final EMPATHIC questionnaire incorporates 65 statements. The empirical structure of the satisfaction statements and domains was satisfactory. The reliability and validity proved to be adequate. The EMPATHIC questionnaire is a valid quality performance indicator to measure quality of care as perceived by parents

Pattern Recognition Based Speed Forecasting Methodology for Urban Traffic Network

A full methodology of short-term traffic prediction is proposed for urban road traffic network via Artificial Neural Network (ANN). The goal of the forecasting is to provide speed estimation forward by 5, 15 and 30 min. Unlike similar research results in this field, the investigated method aims to predict traffic speed for signalized urban road links and not for highway or arterial roads. The methodology contains an efficient feature selection algorithm in order to determine the appropriate input parameters required for neural network training. As another contribution of the paper, a built-in incomplete data handling is provided as input data (originating from traffic sensors or Floating Car Data (FCD)) might be absent or biased in practice. Therefore, input data handling can assure a robust operation of speed forecasting also in case of missing data. The proposed algorithm is trained, tested and analysed in a test network built-up in a microscopic traffic simulator by using daily course of real-world traffic

Intervention mapping for the development of a strategy to implement the insurance medicine guidelines for depression

<p>Abstract</p> <p>Background</p> <p>This article describes the development of a strategy to implement the insurance medicine guidelines for depression. Use of the guidelines is intended to result in more transparent and uniform assessment of claimants with depressive symptoms.</p> <p>Methods</p> <p>The implementation strategy was developed using the Intervention Mapping (IM) method for alignment with insurance-medical practice. The ASE behavioural explanation model (Attitude, Social Influence and Self-Efficacy) was used as theoretical basis for the development work. A literature study of implementation strategies and interviews with insurance physicians were performed to develop instruments for use with the guideline. These instruments were designed to match the needs and the working circumstances of insurance physicians. Performance indicators to measure the quality of the assessment and the adherence to the guidelines were defined with input from insurance physicians.</p> <p>Results</p> <p>This study resulted in the development of a training course to teach insurance physicians how to apply the guidelines for depression, using the aforementioned instruments. The efficacy of this training course will be evaluated in a Randomized Controlled Trial.</p> <p>Conclusions</p> <p>The use of IM made it possible to develop guideline support instruments tailored to insurance medical practice.</p