TY - JOUR AU - Wensing, M. AU - Sales, A. AU - Armstrong, R. AU - Wilson, P. PY - 2020 UR - https://hdl.handle.net/2066/220984 AB - The emergence of SARS-CoV-2/Covid-19 affects all of us and is associated with rapid and massive changes in healthcare and societies. As a response, a range of interventions for patients and populations have been implemented in health and preventive settings, or need to be implemented in the short and long term. Implementation science offers a multidisciplinary perspective and systematic approach for the design, evaluation and analysis of programmes and policies to enhance implementation. The emergence of Covid-19 provides an urgent need to develop new perspectives and approaches in implementation science, such as the addition of innovative and rigorous approaches to the collection, use and analysis of 'real-world' data. Above all, we hope that implementation scientists will focus on what they can contribute to manage Covid-19 and its consequences for people, healthcare and society. TI - Implementation science in times of Covid-19 SN - 1748-5908 IS - iss. 1 JF - Implementation Science VL - vol. 15 DO - https://doi.org/10.1186/s13012-020-01006-x L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/220984/220984.pdf?sequence=1 ER - TY - JOUR AU - Rietbergen, T. van AU - Spoon, D. AU - Brunsveld-Reinders, A.H. AU - Schoones, J.W. AU - Huis, A.M.P. AU - Heinen, M.M. AU - Persoon, A. AU - Dijk, M. van AU - Vermeulen, H. AU - Ista, E. AU - Bodegom-Vos, L. van PY - 2020 UR - https://hdl.handle.net/2066/221015 AB - BACKGROUND: In the last decade, there is an increasing focus on detecting and compiling lists of low-value nursing procedures. However, less is known about effective de-implementation strategies for these procedures. Therefore, the aim of this systematic review was to summarize the evidence of effective strategies to de-implement low-value nursing procedures. METHODS: PubMed, Embase, Emcare, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar were searched till January 2020. Additionally, reference lists and citations of the included studies were searched. Studies were included that described de-implementation of low-value nursing procedures, i.e., procedures, test, or drug orders by nurses or nurse practitioners. PRISMA guideline was followed, and the 'Cochrane Effective Practice and Organisation of Care' (EPOC) taxonomy was used to categorize de-implementation strategies. A meta-analysis was performed for the volume of low-value nursing procedures in controlled studies, and Mantel-Haenszel risk ratios (95% CI) were calculated using a random effects model. RESULTS: Twenty-seven studies were included in this review. Studies used a (cluster) randomized design (n = 10), controlled before-after design (n = 5), and an uncontrolled before-after design (n = 12). Low-value nursing procedures performed by nurses and/or nurse specialists that were found in this study were restraint use (n = 20), inappropriate antibiotic prescribing (n = 3), indwelling or unnecessary urinary catheters use (n = 2), ordering unnecessary liver function tests (n = 1), and unnecessary antipsychotic prescribing (n = 1). Fourteen studies showed a significant reduction in low-value nursing procedures. Thirteen of these 14 studies included an educational component within their de-implementation strategy. Twelve controlled studies were included in the meta-analysis. Subgroup analyses for study design showed no statistically significant subgroup effect for the volume of low-value nursing procedures (p = 0.20). CONCLUSIONS: The majority of the studies with a positive significant effect used a de-implementation strategy with an educational component. Unfortunately, no conclusions can be drawn about which strategy is most effective for reducing low-value nursing care due to a high level of heterogeneity and a lack of studies. We recommend that future studies better report the effects of de-implementation strategies and perform a process evaluation to determine to which extent the strategy has been used. TRIAL REGISTRATION: The review is registered in Prospero (CRD42018105100). TI - Effects of de-implementation strategies aimed at reducing low-value nursing procedures: a systematic review and meta-analysis SN - 1748-5908 IS - iss. 1 JF - Implementation Science VL - vol. 15 DO - https://doi.org/10.1186/s13012-020-00995-z L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/221015/221015.pdf?sequence=1 ER - TY - JOUR AU - Sales, A.E. AU - Wilson, P.M. AU - Wensing, M. AU - Aarons, G.A. AU - Armstrong, R. AU - Flottorp, S. AU - Hutchinson, A.M. AU - Presseau, J. AU - Rogers, A. AU - Sevdalis, N. AU - Squires, J. AU - Straus, S. AU - Weiner, B.J. PY - 2019 UR - https://hdl.handle.net/2066/208510 AB - In the 13 years since the inception of Implementation Science, we have witnessed a continued rise in the number of submissions, reflecting the growing global interest in methods to enhance the uptake of research findings into healthcare practice and policy. We now receive over 800 submissions annually, and there is a large gap between what is submitted and what gets published. To better serve the needs of the research community, we announce our plans to introduce a new journal, Implementation Science Communications, which we believe will support publication of types of research reports currently not often published in Implementation Science. In this editorial, we state both journals' scope and current boundaries and set out our expectations for the scientific reporting, quality, and transparency of the manuscripts we receive. TI - Implementation Science and Implementation Science Communications: our aims, scope, and reporting expectations SN - 1748-5908 IS - iss. 1 SP - 77 JF - Implementation Science VL - vol. 14 DO - https://doi.org/10.1186/s13012-019-0922-2 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/208510/208510.pdf?sequence=1 ER - TY - JOUR AU - Scalia, Peter AU - Durand, Marie Anne AU - Forcino, Rachel C. AU - Schubbe, Danielle AU - Barr, Paul J. AU - O'Brien, Nancy AU - Aarts, J.W.M. AU - Cochran, N. AU - Elwyn, G. PY - 2019 UR - https://hdl.handle.net/2066/208006 TI - Implementation of the uterine fibroids Option Grid patient decision aids across five organizational settings: a randomized stepped-wedge study protocol SN - 1748-5908 IS - iss. 1 JF - Implementation Science VL - vol. 14 DO - https://doi.org/10.1186/s13012-019-0933-z L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/208006/208006.pdf?sequence=1 ER - TY - JOUR AU - Oosterveld-Vlug, M. AU - Onwuteaka-Philipsen, B. AU - Koppel, M. Ten AU - Hout, H. van AU - Smets, T. AU - Pivodic, L. AU - Tanghe, M. AU - Noortgate, N. Van Den AU - Hockley, J. AU - Payne, S. AU - Moore, D.C. AU - Kijowska, V. AU - Szczerbinska, K. AU - Kylanen, M. AU - Leppaaho, S. AU - Mercuri, C. AU - Rossi, P. AU - Mercuri, M. AU - Gambassi, G. AU - Bassal, C. AU - Paula, E.M. de AU - Engels, Y. AU - Deliens, L. AU - Block, L. Van den AU - Pasman, H. R. W. PY - 2019 UR - https://hdl.handle.net/2066/215612 AB - BACKGROUND: The PACE 'Steps to Success' programme is a complex educational and development intervention for staff to improve palliative care in long-term care facilities (LTCFs). In a cluster randomized controlled trial, this programme has been implemented in 37 LTCFs in 7 European countries. Alongside an effectiveness study, a process evaluation study was conducted. This paper reports on the results of this process evaluation, of which the aim was to provide a more detailed understanding of the implementation of the PACE Programme across and within countries. METHODS: The process evaluation followed the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework and involved various measures and tools, including diaries for country trainers, evaluation questionnaires for care staff, attendance lists and interviews (online and face-to-face, individual and in groups) with country trainers, managers, PACE coordinators and other staff members. Based on key elements of the PACE Programme, a priori criteria for a high, medium and low level of the RE-AIM components Reach, Adoption, Implementation and intention to Maintenance were defined. Qualitative data on factors affecting each RE-AIM component gathered in the online discussion groups and interviews were analysed according to the principles of thematic analysis. RESULTS: The performance of the PACE Programme on the RE-AIM components was highly variable within and across countries, with a high or medium score for in total 28 (out of 37) LTCFs on Reach, for 26 LTCFs on Adoption, for 35 LTCFs on Implementation and for 34 LTCFs on intention to Maintenance. The factors affecting performance on the different RE-AIM components could be classified into three major categories: (1) the PACE Programme itself and its way of delivery, (2) people working with the PACE Programme and (3) contextual factors. Several country-specific challenges in implementing the PACE Programme were identified. CONCLUSIONS: The implementation of the PACE Programme was feasible but leaves room for improvement. Our analysis helps to better understand the optimal levels of training and facilitation and provides recommendations to improve implementation in the LTC setting. The results of the process evaluation will be used to further adapt and improve the PACE Programme prior to its further dissemination. TRIAL REGISTRATION: The PACE study was registered at www.isrctn.com-ISRCTN14741671 (FP7-HEALTH-2013-INNOVATION-1 603111) July 30, 2015. TI - Evaluating the implementation of the PACE Steps to Success Programme in long-term care facilities in seven countries according to the RE-AIM framework SN - 1748-5908 IS - iss. 1 SP - 107 JF - Implementation Science VL - vol. 14 DO - https://doi.org/10.1186/s13012-019-0953-8 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/215612/215612.pdf?sequence=1 ER - TY - JOUR AU - Kamradt, M. AU - Kaufmann-Kolle, P. AU - Andres, E. AU - Brand, T. van den AU - Klingenberg, A. AU - Glassen, K. AU - Poss-Doering, R. AU - Uhlmann, L. AU - Hees, K. AU - Weber, D. AU - Gutscher, A. AU - Wambach, V. AU - Szecsenyi, J. AU - Wensing, M. PY - 2018 UR - https://hdl.handle.net/2066/190981 AB - BACKGROUND: Despite many initiatives to enhance the rational use of antibiotics, there remains substantial room for improvement. The overall aim of this study is to optimise the appropriate use of antibiotics in German ambulatory care in patients with acute non-complicated infections (respiratory tract infections, such as bronchitis, sinusitis, tonsillitis and otitis media), community-acquired pneumonia and non-complicated cystitis, in order to counter the advancing antimicrobial resistance development. METHODS: A three-armed cluster randomised trial will be conducted in 14 practice networks in two German federal states (Bavaria and North Rhine-Westphalia) and an added cohort that reflects standard care. The trial is accompanied by a process evaluation. Each arm will receive a different set of implementation strategies. Arm A receives a standard set, comprising of e-learning on communication with patients and quality circles with data-based feedback for physicians, information campaigns for the public, patient information material and performance-based additional reimbursement. Arm B receives this standard set plus e-learning on communication with patients and quality circles with data-based feedback tailored for non-physician health professionals of the practice team and information material for tablet computers (culture sensitive). Arm C receives the standard set as well as a computerised decision support system and quality circles in local multidisciplinary groups. The study aims to recruit 193 practices which will provide data on 23,934 patients each year (47,867 patients in total). The outcome evaluation is based on claims data and refers to established indicators of the European Surveillance of Antimicrobial Consumption Network (ESAC-Net). Primary and secondary outcomes relate to prescribing of antibiotics, which will be analysed in multivariate regression models. The process evaluation is based on interviews with surveys among physicians, non-physician health professionals of the practice team and stakeholders. A patient survey is conducted in one of the study arms. Interview data will be qualitatively analysed using thematic framework analysis. Survey data of physicians, non-physician health professionals of the practice team and patients will use descriptive and exploratory statistics for analysis. DISCUSSION: The ARena trial will examine the effectiveness of large scale implementation strategies and explore their delivery in routine practice. TRIAL REGISTRATION: ISRCTN, ISRCTN58150046 . Registered 24 August 2017. TI - Sustainable reduction of antibiotic-induced antimicrobial resistance (ARena) in German ambulatory care: study protocol of a cluster randomised trial SN - 1748-5908 IS - iss. 1 SP - 23 JF - Implementation Science VL - vol. 13 DO - https://doi.org/10.1186/s13012-018-0722-0 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/190981/190981.pdf?sequence=1 ER - TY - JOUR AU - Wilson, P.M. AU - Sales, A. AU - Wensing, M. AU - Aarons, G.A. AU - Flottorp, S. AU - Glidewell, L. AU - Hutchinson, A. AU - Presseau, J. AU - Rogers, A. AU - Sevdalis, N. AU - Squires, J. AU - Straus, S. PY - 2017 UR - https://hdl.handle.net/2066/170009 AB - In the 10 years since the inception of Implementation Science, we have witnessed a continued rise in the number of submissions received, reflecting the continued global interest in methods to enhance the uptake of research findings into healthcare practice and policy. We receive over 750 submissions annually, and there is now a large gap between what is submitted and what gets published. In this editorial, we restate the journal scope and current boundaries. We also identify some specific reporting issues that if addressed will help enhance the scientific reporting quality and transparency of the manuscripts we receive. We hope that this editorial acts as a further guide to researchers seeking to publish their work in Implementation Science. TI - Enhancing the reporting of implementation research SN - 1748-5908 IS - iss. 1 SP - 13 JF - Implementation Science VL - vol. 12 DO - https://doi.org/10.1186/s13012-017-0546-3 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/170009/170009.pdf?sequence=1 ER - TY - JOUR AU - Ullrich, C. AU - Mahler, C. AU - Forstner, J. AU - Szecsenyi, J. AU - Wensing, M. PY - 2017 UR - https://hdl.handle.net/2066/174305 AB - BACKGROUND: Implementation science in healthcare is an evolving discipline in German-speaking countries. In 2015, the Medical Faculty of the University of Heidelberg, Germany, implemented a two-year full-time Master of Science program Health Services Research and Implementation Science. The curriculum introduces implementation science in the context of a broader program that also covers health services research, healthcare systems, research methods, and generic academic skills. Our aim was to assess the expectations of different stakeholder groups regarding the master's program. METHODS: An online survey listing desired competencies of prospective graduates was developed and administered to four groups: national experts in the field (including potential employers of graduates), teaching staff, enrolled students, and prospective students (N = 169). Competencies were extracted from the curriculum's module handbook. A five-point Likert scale was used for the assessment of 42 specific items. Data were analyzed descriptively. RESULTS: A total of 83 people participated in the survey (response rate 49%). The online survey showed a strong agreement across the groups concerning the desired competencies of graduates. About two-thirds of the listed competencies (27 items) were felt to be crucial or very important by 80% or more of participants, with little difference between stakeholder groups. Of the eight items specifically related to implementation in practice, six were in this category. Knowledge of implementation strategies (90% very important), knowledge of barriers and enablers of implementation (89%), and knowledge of evidence-based practice (89%) were the top priorities. CONCLUSIONS: The master's program is largely orientated towards the desired competencies of graduates according to students, teaching staff, and national experts. TI - Teaching implementation science in a new Master of Science Program in Germany: a survey of stakeholder expectations SN - 1748-5908 IS - iss. 1 JF - Implementation Science VL - vol. 12 DO - https://doi.org/10.1186/s13012-017-0583-y L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/174305/174305.pdf?sequence=1 ER - TY - JOUR AU - Heijmans, N. AU - Lieshout, J. van AU - Wensing, M. PY - 2017 UR - https://hdl.handle.net/2066/170071 AB - BACKGROUND: Although a wide range of preventive and clinical interventions has targeted cardiovascular risk management (CVRM), outcomes remain suboptimal. Therefore, the question is what additional determinants of CVRM and outcomes can be identified and addressed to optimize CVRM. In this study, we aimed to identify new perspectives for improving healthcare delivery and explored associations between information exchange networks of health care providers and evidence-based CVRM. METHODS: This observational study was performed parallel to a randomized clinical trial which aimed to improve professional performance of practice nurses in the Netherlands. Information exchange on medical policy for CVRM ("general information networks") and CVRM for individual patients ("specific information networks") of 180 health professionals in 31 general practices was measured with personalized questionnaires. Medical record audit was performed concerning 1620 patients in these practices to document quality of care delivery and two risk factors (systolic blood pressure (SBP) and LDL cholesterol level). Hypothesized effects of five network characteristics (density, frequency of contact, centrality of CVRM-coordinators, homophily on positive attitudes for treatment target achievement, and presence of an opinion leader for CVRM) constructed on both general and specific information exchange networks were tested and controlled for practice and patient factors using logistic multilevel analyses. RESULTS: Odds for adequate performance were enhanced in practices with an opinion leader for CVRM (OR 2.75, p < .05). Odds for achievement of SBP targets were reduced in practices who had networks with low homophily on positive attitudes for SBP and LDL targets (homophily for SBP targets OR 0.57, p < .05 and OR 0.60, p < .05, homophily for LDL targets OR 0.59, p < .05 and OR 0.61, p < .05 in general and specific information networks, respectively). No effects of network characteristics on cholesterol were found. CONCLUSIONS: Delivery of evidence-based CVRM is associated with homophily of clinical attitudes and presence of opinion leaders in primary care teams. These results signal the potential of social networks to be taken into account in further attempts to improve the implementation of evidence-based care for CVRM. Future research is needed to identify and formulate optimal strategies for using opinion leaders to improve CVRM. Future interventions may be more effective if they target a common vision on CVRM within practices. TI - Information exchange networks of health care providers and evidence-based cardiovascular risk management: an observational study SN - 1748-5908 IS - iss. 1 SP - 7 JF - Implementation Science VL - vol. 12 DO - https://doi.org/10.1186/s13012-016-0532-1 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/170071/170071.pdf?sequence=1 ER - TY - JOUR AU - Powell, B.J. AU - Stanick, C.F. AU - Halko, H.M. AU - Dorsey, C.N. AU - Weiner, B.J. AU - Barwick, M.A. AU - Damschroder, L.J. AU - Wensing, M. AU - Wolfenden, L. AU - Lewis, C.C. PY - 2017 UR - https://hdl.handle.net/2066/182408 AB - BACKGROUND: Advancing implementation research and practice requires valid and reliable measures of implementation determinants, mechanisms, processes, strategies, and outcomes. However, researchers and implementation stakeholders are unlikely to use measures if they are not also pragmatic. The purpose of this study was to establish a stakeholder-driven conceptualization of the domains that comprise the pragmatic measure construct. It built upon a systematic review of the literature and semi-structured stakeholder interviews that generated 47 criteria for pragmatic measures, and aimed to further refine that set of criteria by identifying conceptually distinct categories of the pragmatic measure construct and providing quantitative ratings of the criteria's clarity and importance. METHODS: Twenty-four stakeholders with expertise in implementation practice completed a concept mapping activity wherein they organized the initial list of 47 criteria into conceptually distinct categories and rated their clarity and importance. Multidimensional scaling, hierarchical cluster analysis, and descriptive statistics were used to analyze the data. FINDINGS: The 47 criteria were meaningfully grouped into four distinct categories: (1) acceptable, (2) compatible, (3) easy, and (4) useful. Average ratings of clarity and importance at the category and individual criteria level will be presented. CONCLUSIONS: This study advances the field of implementation science and practice by providing clear and conceptually distinct domains of the pragmatic measure construct. Next steps will include a Delphi process to develop consensus on the most important criteria and the development of quantifiable pragmatic rating criteria that can be used to assess measures. TI - Toward criteria for pragmatic measurement in implementation research and practice: a stakeholder-driven approach using concept mapping SN - 1748-5908 IS - iss. 1 JF - Implementation Science VL - vol. 12 DO - https://doi.org/10.1186/s13012-017-0649-x L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/182408/182408.pdf?sequence=1 ER - TY - JOUR AU - Jager, C. AU - Steinhauser, J. AU - Freund, T. AU - Kuse, S. AU - Szecsenyi, J. AU - Wensing, M. PY - 2017 UR - https://hdl.handle.net/2066/169995 AB - BACKGROUND: We developed and evaluated a tailored programme to implement three evidence-based recommendations for multimorbid patients with polypharmacy into primary care practices: structured medication counselling including brown bag reviews, the use of medication lists and medication reviews. No effect on the primary outcome was found. This process evaluation aimed to identify factors associated with outcomes by exploring nine hypotheses specified in the logic model of the tailored programme. METHODS: The tailored programme was developed with respect to identified determinants of practice and consisted of a workshop for practice teams, elaboration of implementation action plans, aids for medication reviews, a multilingual info-tool for patients on a tablet PC, posters and brown paper bags as reminders for patients. The tailored programme was evaluated in a cluster randomized trial. The process evaluation was based on various data sources: interviews with general practitioners and medical assistants of the intervention group and a survey with general practitioners of the intervention and control group, written reports on the implementation action plans, documentation forms for structured medication counselling and the log file of the info-tool. RESULTS: We analyzed 12 interviews, 21 questionnaires, 120 documentation forms for medication counselling, 5 implementation action plans and one log file of the info-tool. The most frequently reported effect of the tailored programme was the increase of awareness for the health problem and the recommendations, while implementation of routine processes was only reported for structured medication counselling. The survey largely confirmed the usefulness of the applied strategies, yet the interviews provided a more detailed understanding of the actual use of the strategies and several suggestions for modifications of the tailored programme. CONCLUSIONS: The tailored programme seemed to have induced awareness as a first step of behaviour change. Several modifications of the tailored programme may enhance its effectiveness such as conducting outreach visits instead of a workshop, improved targeting, provision of evidence, integration of tools into the practice software and information materials in tailored formats. TRIAL REGISTRATION: This study is linked to an outcome evaluation study with the registration ISRCTN34664024 , assigned 14/08/2013. TI - A tailored programme to implement recommendations for multimorbid patients with polypharmacy in primary care practices-process evaluation of a cluster randomized trial SN - 1748-5908 IS - iss. 1 SP - 31 JF - Implementation Science VL - vol. 12 DO - https://doi.org/10.1186/s13012-017-0559-y L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/169995/169995.pdf?sequence=1 ER - TY - JOUR AU - Jager, C. AU - Freund, T. AU - Steinhauser, J. AU - Stock, C. AU - Krisam, J. AU - Kaufmann-Kolle, P. AU - Wensing, M. AU - Szecsenyi, J. PY - 2017 UR - https://hdl.handle.net/2066/170022 AB - BACKGROUND: Multimorbid patients receiving polypharmacy represent a growing population at high risk for negative health outcomes. Tailoring is an approach of systematic intervention development taking account of previously identified determinants of practice. The aim of this study was to assess the effect of a tailored program to improve the implementation of three important processes of care for this patient group: (a) structured medication counseling including brown bag reviews, (b) the use of medication lists, and (c) structured medication reviews to reduce potentially inappropriate medication. METHODS: We conducted a cluster-randomized controlled trial with a follow-up time of 9 months. Participants were general practitioners (GPs) organized in quality circles and participating in a GP-centered care contract of a German health insurance. Patients aged >50 years, suffering from at least 3 chronic diseases, receiving more than 4 drugs, and being at high risk for medication-related events according to the assessment of the treating GP were enrolled. The tailored program consisted of a workshop for GPs and health care assistants, educational materials and reminders for patients, and the elaboration of implementation action plans. The primary outcome was the change in the degree of implementation between baseline and follow-up, measured by a summary score of 10 indicators. The indicators were based on structured surveys with patients and GPs. RESULTS: We analyzed the data of 21 GPs (10 - intervention group, 11 - control group) and 273 patients (130 - intervention group, 143 - control group). The increase in the degree of implementation was 4.2 percentage points (95% confidence interval: -0.3, 8.6) higher in the intervention group compared to the control group (p = 0.1). Two of the 10 indicators were significantly improved in the intervention group: medication counseling (p = 0.017) and brown bag review (p = 0.012). Secondary outcomes showed an effect on patients' self-reported use of medication lists when buying drugs in the pharmacy (p = 0.03). CONCLUSIONS: The tailored program may improve implementation of medication counseling and brown bag review whereas the use of medication lists and medication reviews did not improve. No effect of the tailored program on the combined primary outcome could be substantiated. Due to limitations of the study, results have to be interpreted carefully. The factors facilitating and hindering successful implementation will be examined in a comprehensive process evaluation. TRIAL REGISTRATION NUMBER: ISRCTN34664024 , assigned 14/08/2013. TI - Impact of a tailored program on the implementation of evidence-based recommendations for multimorbid patients with polypharmacy in primary care practices-results of a cluster-randomized controlled trial SN - 1748-5908 IS - iss. 1 SP - 8 JF - Implementation Science VL - vol. 12 DO - https://doi.org/10.1186/s13012-016-0535-y L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/170022/170022.pdf?sequence=1 ER - TY - JOUR AU - Wensing, M. PY - 2017 UR - https://hdl.handle.net/2066/170092 AB - BACKGROUND: The Tailored Implementation in Chronic Diseases (TICD) project aims to contribute knowledge on how to improve healthcare for patients with chronic diseases and, at the same time, knowledge on concepts and methods of tailoring interventions to local conditions. In this contribution, the project is briefly introduced and its main findings are discussed. DISCUSSION: The tailored implementation programs in the TICD project had little impact, for which we provide a range of potential explanations. Structured group interviews with informed stakeholders, such as clinicians and researchers, were used to generate perceived determinants of practice and suggestions for tailored implementation strategies. They were productive and valid, yet incomplete, if compared to perceptions of healthcare providers who received the tailored implementation programs. Ongoing monitoring of determinants of practice during intervention delivery seems required to adapt the interventions to emerging needs and opportunities. TI - The Tailored Implementation in Chronic Diseases (TICD) project: introduction and main findings SN - 1748-5908 IS - iss. 1 SP - 5 JF - Implementation Science VL - vol. 12 DO - https://doi.org/10.1186/s13012-016-0536-x L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/170092/170092.pdf?sequence=1 ER - TY - JOUR AU - Adang, E.M.M. AU - Gerritsma, A. AU - Nouwens, E.S. AU - Lieshout, J. van AU - Wensing, M. PY - 2016 UR - https://hdl.handle.net/2066/172445 AB - BACKGROUND: This study aimed to document the variation in technical efficiency of primary care (PC) practices in delivering evidence-based cardiovascular risk management (CVRM) and to identify associated factors. METHODS: This observational study was based on the follow-up measurements in a cluster randomized trial. Patients were recruited from 41 general practices in the Netherlands, involving 106 GPs and 1671 patients. Data on clinical performance were collected from patient records. The analysis focused on PC practices and used a two-stage data envelopment analysis (DEA) approach. Bias-corrected DEA technical efficiency scores for each PC practice were generated, followed by regression analysis with practice efficiency as outcomes and organizational features of general practice as predictors. RESULTS: Not all PC practices delivered recommended CVRM with the same technical efficiency; a significant difference from the efficient frontier was found (p < .000; 95 % CI 1.018-1.041). The variation in technical efficiency between PC practices was associated with training practice status (p = .026). Whether CVRM clinical tasks were performed by a practice nurse or a GP did not influence technical efficiency in a statistical significant way neither did practice size. CONCLUSIONS: Technical efficiency in delivering evidence-based CVRM increased with having a training practice status. Nurse involvement and practice size showed no statistical impact. TI - Efficiency of the implementation of cardiovascular risk management in primary care practices: an observational study SN - 1748-5908 IS - iss. 1 SP - 67 JF - Implementation Science VL - vol. 11 DO - http://dx.doi.org/10.1186/s13012-016-0434-2 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/172445/172445.pdf?sequence=1 ER - TY - JOUR AU - Jager, C. AU - Steinhauser, J. AU - Freund, T. AU - Baker, R. AU - Agarwal, S. AU - Godycki-Cwirko, M. AU - Kowalczyk, A. AU - Aakhus, E. AU - Granlund, I. AU - Lieshout, J. van AU - Szecsenyi, J. AU - Wensing, M. PY - 2016 UR - https://hdl.handle.net/2066/171266 AB - BACKGROUND: Although there is evidence that tailored implementation strategies can be effective, there is little evidence on which methods of tailoring improve the effect. We designed and evaluated five tailored programs (TPs) each consisting of various strategies. The aim of this study was to examine (a) how determinants of practice prioritized in the design phase of the TPs were perceived by health care professionals who had been exposed to the TPs and whether they suggested other important determinants of practice and (b) how professionals used the offered strategies and whether they suggested other strategies that might have been more effective. METHODS: We conducted a mixed-method process evaluation linked to five cluster-randomized trials carried out in five European countries to implement recommendations for five chronic conditions in primary care settings. The five TPs used a total of 28 strategies which aimed to address 38 determinants of practice. Interviews of professionals in the intervention groups and a survey of professionals in the intervention and control groups were performed. Data collection was conducted by each research team in the respective national language. The interview data were first analyzed inductively by each research team, and subsequently, a meta-synthesis was conducted. The survey was analyzed descriptively. Results : We conducted 71 interviews; 125 professionals completed the survey. The survey showed that 76 % (n = 29) of targeted determinants of practice were perceived as relevant and 95 % (n = 36) as being modified by the implementation interventions by 66 to 100 % of professionals. On average, 47 % of professionals reported using the strategies and 51 % considered them helpful, albeit with substantial variance between countries and strategies. In the interviews, 89 determinants of practice were identified, of which 70 % (n = 62) had been identified and 45 % (n = 40) had been prioritized in the design phase. The interviewees suggested 65 additional strategies, of which 54 % (n = 35) had been identified and 20 % (n = 13) had been prioritized, but not selected in the final programs. CONCLUSIONS: This study largely confirmed the perceived relevance of the targeted determinants of practice. This contrasts with the fact that no impact of the trials on the implementation of the recommendations could be observed. The findings suggest that better methods for prioritization of determinants and strategies are needed. TRIAL REGISTRATION: Each of the five trials was registered separately in recognized trial registries. Details are given in the respective trial outcome papers. TI - Process evaluation of five tailored programs to improve the implementation of evidence-based recommendations for chronic conditions in primary care SN - 1748-5908 IS - iss. 1 SP - 123 JF - Implementation Science VL - vol. 11 DO - http://dx.doi.org/10.1186/s13012-016-0473-8 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/171266/171266.pdf?sequence=1 ER - TY - JOUR AU - Elwyn, G. AU - Frosch, D.L. AU - Kobrin, S. PY - 2016 UR - https://hdl.handle.net/2066/172770 AB - BACKGROUND: The ethical argument that shared decision-making is "the right" thing to do, however laudable, is unlikely to change how healthcare is organized, just as evidence alone will be an insufficient factor: practice change is governed by factors such as cost, profit margin, quality, and efficiency. It is helpful, therefore, when evaluating new approaches such as shared decision-making to conceptualize potential consequences in a way that is broad, long-term, and as relevant as possible to multiple stakeholders. Yet, so far, evaluation metrics for shared decision-making have been mostly focused on short-term outcomes, such as cognitive or affective consequences in patients. The goal of this article is to hypothesize a wider set of consequences, that apply over an extended time horizon, and include outcomes at interactional, team, organizational and system levels, and to call for future research to study these possible consequences. MAIN ARGUMENT: To date, many more studies have evaluated patient decision aids rather than other approaches to shared decision-making, and the outcomes measured have typically been focused on short-term cognitive and affective outcomes, for example knowledge and decisional conflict. From a clinicians perspective, the shared decision-making process could be viewed as either intrinsically rewarding and protective, or burdensome and impractical, yet studies have not focused on the impact on professionals, either positive or negative. At interactional levels, group, team, and microsystem, the potential long-term consequences could include the development of a culture where deliberation and collaboration are regarded as guiding principles, where patients are coached to assess the value of interventions, to trade-off benefits versus harms, and assess their burdens-in short, to new social norms in the clinical workplace. At organizational levels, consistent shared decision-making might boost patient experience evaluations and lead to fewer complaints and legal challenges. In the long-term, shared decision-making might lead to changes in resource utilization, perhaps to reductions in cost, and to modification of workforce composition. Despite the gradual shift to value-based payment, some organizations, motivated by continued income derived from achieving high volumes of procedures and contacts, will see this as a negative consequence. CONCLUSION: We suggest that a broader conceptualization and measurement of shared decision-making would provide a more substantive evidence base to guide implementation. We outline a framework which illustrates a hypothesized set of proximal, distal, and distant consequences that might occur if collaboration and deliberation could be achieved routinely, proposing that well-informed preference-based patient decisions might lead to safer, more cost-effective healthcare, which in turn might result in reduced utilization rates and improved health outcomes. TI - Implementing shared decision-making: consider all the consequences SN - 1748-5908 JF - Implementation Science VL - vol. 11 DO - http://dx.doi.org/10.1186/s13012-016-0480-9 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/172770/172770.pdf?sequence=1 ER - TY - JOUR AU - Sales, A. AU - Wensing, M. PY - 2016 UR - https://hdl.handle.net/2066/171427 AB - CONTRIBUTING REVIEWERS: The editors of Implementation Science would like to thank all our reviewers who have contributed to the journal in Volume 10 (2015). TI - Annual acknowledgement of manuscript reviewers SN - 1748-5908 IS - iss. 1 SP - 34 JF - Implementation Science VL - vol. 11 DO - https://doi.org/10.1186/s13012-016-0391-9 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/171427/171427.pdf?sequence=1 ER - TY - JOUR AU - Keurhorst, M.N. AU - Anderson, P. AU - Heinen, M.M. AU - Bendtsen, P. AU - Baena, B. AU - Brzozka, K. AU - Colom, J. AU - Deluca, P. AU - Drummond, C. AU - Kaner, E. AU - Kloda, K. AU - Mierzecki, A. AU - Newbury-Birch, D. AU - Okulicz-Kozaryn, K. AU - Palacio-Vieira, J. AU - Parkinson, K. AU - Reynolds, J. AU - Ronda, G. AU - Segura, L. AU - Slodownik, L. AU - Spak, F. AU - Steenkiste, B. van AU - Wallace, P. AU - Wolstenholme, A. AU - Wojnar, M. AU - Gual, A. AU - Laurant, M.G. AU - Wensing, M. PY - 2016 UR - https://hdl.handle.net/2066/172760 AB - BACKGROUND: Brief interventions in primary healthcare are cost-effective in reducing drinking problems but poorly implemented in routine practice. Although evidence about implementing brief interventions is growing, knowledge is limited with regard to impact of initial role security and therapeutic commitment on brief intervention implementation. METHODS: In a cluster randomised factorial trial, 120 primary healthcare units (PHCUs) were randomised to eight groups: care as usual, training and support, financial reimbursement, and the opportunity to refer patients to an internet-based brief intervention (e-BI); paired combinations of these three strategies, and all three strategies combined. To explore the impact of initial role security and therapeutic commitment on implementing brief interventions, we performed multilevel linear regression analyses adapted to the factorial design. RESULTS: Data from 746 providers from 120 PHCUs were included in the analyses. Baseline role security and therapeutic commitment were found not to influence implementation of brief interventions. Furthermore, there were no significant interactions between these characteristics and allocated implementation groups. CONCLUSIONS: The extent to which providers changed their brief intervention delivery following experience of different implementation strategies was not determined by their initial attitudes towards alcohol problems. In future research, more attention is needed to unravel the causal relation between practitioners' attitudes, their actual behaviour and care improvement strategies to enhance implementation science. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01501552. TI - Impact of primary healthcare providers' initial role security and therapeutic commitment on implementing brief interventions in managing risky alcohol consumption: a cluster randomised factorial trial SN - 1748-5908 SP - 96 JF - Implementation Science VL - vol. 11 DO - https://doi.org/10.1186/s13012-016-0468-5 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/172760/172760.pdf?sequence=1 ER - TY - JOUR AU - Lieshout, J. van AU - Huntink, E. AU - Koetsenruijter, J. AU - Wensing, M. PY - 2016 UR - https://hdl.handle.net/2066/171616 AB - BACKGROUND: Counselling on health-related lifestyles is key to the prevention and management of chronic diseases. After comprehensive study of determinants of its delivery in general practice and strategies to improve, we composed a tailored improvement program, which included communication skills training, online patient information, and a clinical protocol for managing depressive symptoms. Our aim was to assess the effectiveness of this program on professional performance and outcomes in cardiovascular patients. METHODS: A two-arm cluster randomized trial in 34 general practices involving 34 nurses was conducted. The primary outcome was an aggregated score of a positive score on lifestyle counselling delivered and an appropriate action on depressive symptoms. Secondary outcomes included the various elements of the primary outcome, vascular risk factors (extracted from patient records), and patient-reported lifestyle behaviors. Data were collected from medical records and a written survey among included patients. RESULTS: A sample of 1782 patients with recorded cardiovascular disease or high cardiovascular risk was available at follow-up at 6 months. No impact on the primary outcome was found; lifestyle counselling was recorded in a minority of patients (11.4 % in the intervention group and 10.3 % in the control group). An effect was found on a secondary outcome: patients' physical activity level increased (B 0.18; 95 % CI 0.02-0.35) on a seven-point scale. CONCLUSIONS: The tailored improvement program showed no effect on the primary outcome. This challenges the methodology of tailoring. More involvement of the targeted health care professionals might offer ways to develop more effective implementation programs. Physical activity might be the lifestyle issue that can be more easily changed than smoking or dietary habits. TRIAL REGISTRATION: Nederlands Trial register NTR4069. TI - Tailored implementation of cardiovascular risk management in general practice: a cluster randomized trial SN - 1748-5908 SP - 115 JF - Implementation Science VL - vol. 11 DO - https://doi.org/10.1186/s13012-016-0460-0 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/171616/171616.pdf?sequence=1 ER - TY - JOUR AU - Huntink, E. AU - Wensing, M. AU - Timmers, I.M. AU - Lieshout, J. van PY - 2016 UR - https://hdl.handle.net/2066/171265 AB - BACKGROUND: A tailored implementation programme to improve cardiovascular risk management (CVRM) in general practice had little impact on outcomes. The questions in this process evaluation concerned (1) impact on counselling skills and CVRM knowledge of practice nurses, (2) their use of the various components of the intervention programme and adoption of recommended practices and (3) patients' perceptions of counselling for CVRM. METHODS: A mixed-methods process evaluation was conducted. We assessed practice nurses' motivational interviewing skills on audio-taped consultations using Motivational Interviewing Treatment Integrity (MITI). They also completed a clinical knowledge test. Both practice nurses and patients reported on their experiences in a written questionnaire and interviews. A multilevel regression analysis and an independent sample t test were used to examine motivational interviewing skills and CVRM knowledge. Framework analysis was applied to analyse qualitative data. RESULTS: Data from 34 general practices were available, 19 intervention practices and 14 control practices. No improvements were measured on motivational interviewing skills in both groups. There appeared to be better knowledge of CVRM in the control group. On average half of the practice nurses indicated that they adopted the recommended interventions, but stated that they did not necessarily record this in patients' medical files. The tailored programme was perceived as too large. Time, follow-up support and reminders were felt to be lacking. About 20% of patients in the intervention group visited the general practice during the intervention period, yet only a small number of these patients were referred to recommended options. CONCLUSIONS: The tailored programme was only partly used by practice nurses and had little impact on either their clinical knowledge and communication skills or on patient reported healthcare. If the assumed logical model of change is valid, a more intensive programme is needed to have an impact on CVRM in general practice at all. TI - Process evaluation of a tailored intervention programme of cardiovascular risk management in general practices SN - 1748-5908 IS - iss. 1 SP - 164 JF - Implementation Science VL - vol. 11 DO - https://doi.org/10.1186/s13012-016-0526-z L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/171265/171265.pdf?sequence=1 ER - TY - JOUR AU - Ament, S.M. AU - Kok, M. de AU - Velde, C.J. van de AU - Roukema, J.A. AU - Bell, T.V. AU - Ent, F.W. van der AU - Weijden, T.T. van der AU - Meyenfeldt, M.F. von AU - Dirksen, C.D. PY - 2015 UR - https://hdl.handle.net/2066/152095 AB - BACKGROUND: Despite the increased attention for assessing the effectiveness of implementation strategies, most implementation studies provide little or no information on its associated costs. The focus of the current study was to provide a detailed report of the resource use and costs associated with implementation of a short stay programme for breast cancer surgery in four Dutch hospitals. METHODS: The analysis was performed alongside a multi-centre implementation study. The process of identification, measurement and valuation of the implementation activities was based on recommendations for the design, analysis and reporting of health technology assessments. A scoring form was developed to prospectively determine the implementation activities at professional and implementation expert level. A time horizon of 5 years was used to calculate the implementation costs per patient. Results : Identified activities were consisted of development and execution of the implementation strategy during the implementation project. Total implementation costs over the four hospitals were euro83.293. Mean implementation costs, calculated for 660 patients treated over a period of 5 years, were euro25 per patient. Subgroup analyses showed that the implementation costs ranged from euro3.942 to euro32.000 on hospital level. From a local hospital perspective, overall implementation costs were euro21 per patient, after exclusion of the costs made by the expert centre. CONCLUSIONS: We provided a detailed case description of how implementation costs can be determined. Notable differences in implementation costs between hospitals were observed. TRIAL REGISTRATION: ISRCTN: ISRCTN77253391. TI - A detailed report of the resource use and costs associated with implementation of a short stay programme for breast cancer surgery SN - 1748-5908 SP - 78 JF - Implementation Science VL - vol. 10 DO - http://dx.doi.org/10.1186/s13012-015-0270-9 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/152095/152095.pdf?sequence=1 ER - TY - JOUR AU - Straus, S.E. AU - Sales, A. AU - Wensing, M. AU - Michie, S. AU - Kent, B. AU - Foy, R. PY - 2015 UR - https://hdl.handle.net/2066/155115 AB - Alongside the growth in interest in implementation science, there has been a marked increase in training programs, educational courses, degrees, and other offerings in implementation research and practice to meet the demand for this expertise. We believe that the science of capacity building has matured but that we can advance it further by shining light on excellent work in this area and by highlighting gaps for future research. At Implementation Science, we regularly receive manuscripts that describe or evaluate training materials, competencies, and competency development in implementation curricula. We are announcing a renewed interest in manuscripts in this area, with specifications described below. TI - Education and training for implementation science: our interest in manuscripts describing education and training materials SN - 1748-5908 IS - iss. 1 SP - 136 JF - Implementation Science VL - vol. 10 DO - https://doi.org/10.1186/s13012-015-0326-x L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/155115/155115.pdf?sequence=1 ER - TY - JOUR AU - Sales, A. AU - Wensing, M.J.P. PY - 2015 UR - https://hdl.handle.net/2066/154255 AB - CONTRIBUTING REVIEWERS: The editors of Implementation Science would like to thank all our reviewers and editors who have contributed to the journal in Volume 9 (2014). TI - Annual acknowledgement of manuscript reviewers SN - 1748-5908 IS - iss. 1 SP - 86 JF - Implementation Science VL - vol. 10 DO - https://doi.org/10.1186/s13012-015-0253-x L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/154255/154255.pdf?sequence=1 ER - TY - JOUR AU - Foy, R. AU - Sales, A. AU - Wensing, M.J. AU - Aarons, G.A. AU - Flottorp, S. AU - Kent, B. AU - Michie, S. AU - O'Connor, D. AU - Rogers, A. AU - Sevdalis, N. AU - Straus, S. AU - Wilson, P. PY - 2015 UR - https://hdl.handle.net/2066/153105 AB - The implementation of research findings into healthcare practice has become increasingly recognised as a major priority for researchers, service providers, research funders and policymakers over the past decade. Nine years after its establishment, Implementation Science, an international online open access journal, currently publishes over 150 articles each year. This is fewer than 30% of those submitted for publication. The majority of manuscript rejections occur at the point of initial editorial screening, frequently because we judge them to fall outside of journal scope. There are a number of common reasons as to why manuscripts are rejected on grounds of scope. Furthermore, as the field of implementation research has evolved and our journal submissions have risen, we have, out of necessity, had to become more selective in what we publish. We have also expanded our scope, particularly around patient-mediated and population health interventions, and will monitor the impact of such changes. We hope this editorial on our evolving priorities and common reasons for rejection without peer review will help authors to better judge the relevance of their papers to Implementation Science. TI - Implementation science: a reappraisal of our journal mission and scope SN - 1748-5908 SP - 51 JF - Implementation Science VL - vol. 10 DO - https://doi.org/10.1186/s13012-015-0240-2 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/153105/153105.pdf?sequence=1 ER - TY - JOUR AU - Groot, J.J.A.M. de AU - Maessen, J.M. AU - Slangen, B.F. AU - Winkens, B. AU - Dirksen, C.D. AU - Weijden, T.T. van der PY - 2015 UR - https://hdl.handle.net/2066/152306 AB - BACKGROUND: Enhanced Recovery After Surgery (ERAS) programmes aim at an early recovery after surgical trauma and consequently at a reduced length of hospitalisation. This paper presents the protocol for a study that focuses on large-scale implementation of the ERAS programme in major gynaecological surgery in the Netherlands. The trial will evaluate effectiveness and costs of a stepped implementation approach that is characterised by tailoring the intensity of implementation activities to the needs of organisations and local barriers for change, in comparison with the generic breakthrough strategy that is usually applied in large-scale improvement projects in the Netherlands. METHODS: All Dutch hospitals authorised to perform major abdominal surgery in gynaecological oncology patients are eligible for inclusion in this cluster randomised controlled trial. The hospitals that already fully implemented the ERAS programme in their local perioperative management or those who predominantly admit gynaecological surgery patients to an external hospital replacement care facility will be excluded. Cluster randomisation will be applied at the hospital level and will be stratified based on tertiary status. Hospitals will be randomly assigned to the stepped implementation strategy or the breakthrough strategy. The control group will receive the traditional breakthrough strategy with three educational sessions and the use of plan-do-study-act cycles for planning and executing local improvement activities. The intervention group will receive an innovative stepped strategy comprising four levels of intensity of support. Implementation starts with generic low-cost activities and may build up to the highest level of tailored and labour-intensive activities. The decision for a stepwise increase in intensive support will be based on the success of implementation so far. Both implementation strategies will be completed within 1 year and evaluated on effect, process, and cost-effectiveness. The primary outcome is length of postoperative hospital stay. Additional outcome measures are length of recovery, guideline adherence, and mean implementation costs per patient. DISCUSSION: This study takes up the challenge to evaluate an efficient strategy for large-scale implementation. Comparing effectiveness and costs of two different approaches, this study will help to define a preferred strategy for nationwide dissemination of best practices. TRIAL REGISTRATION: Dutch Trial Register NTR4058. TI - A stepped strategy that aims at the nationwide implementation of the Enhanced Recovery After Surgery programme in major gynaecological surgery: study protocol of a cluster randomised controlled trial SN - 1748-5908 SP - 106 JF - Implementation Science VL - vol. 10 DO - https://doi.org/10.1186/s13012-015-0298-x L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/152306/152306.pdf?sequence=1 ER - TY - JOUR AU - Vos, M.L. de AU - Veer, S.N. van der AU - Wouterse, B. AU - Graafmans, W.C. AU - Peek, N. AU - Keizer, N.F. de AU - Jager, K.J. AU - Westert, G.P. AU - Voort, P.H. van der PY - 2015 UR - https://hdl.handle.net/2066/155179 AB - BACKGROUND: Organizational data such as bed occupancy rate and nurse-to-patient ratio are related to clinical outcomes and to the efficient use of intensive care unit (ICU) resources. Standards for these performance indicators are provided in guidelines. We studied the effects of a multifaceted feedback strategy to improve the adherence to these standards. METHODS: In a cluster randomized controlled study design the intervention ICUs received extensive monthly feedback reports, they received outreach visits and initiated a quality improvement team. The control ICUs received limited quarterly feedback reports only. We collected primary data prospectively within the setting of a Dutch national ICU registry over a 14-month study period. The target indicators were bed occupancy rate (aiming at 80 % or below) and nurse-to-patient ratio (aiming at 0.5 or higher). Data were collected per 8-h nursing shift. Logistic regression analysis was performed. For both study end points, the odds ratios (OR) for improvements at follow-up versus at baseline were calculated separately for control and intervention ICUs. RESULTS: We analyzed data on 67,237 nursing shifts. The bed occupancy rate did not improve in the intervention group compared to baseline (adjusted OR 0.88; 95 % confidence interval (CI), 0.62-1.27) or compared to control group (OR 0.67; 95 % CI 0.39-1.15). The nurse-to-patient ratio did not improve (OR 0.72; 95 % CI 0.41-1.26 compared to baseline and OR 0.65; 95 % CI 0.35-1.19 compared to control group). CONCLUSIONS: A multifaceted feedback intervention did not improve the adherence to guideline-based standards on the organizational issues bed occupancy rate and nurse-to-patient ratio in the ICU. The reasons may be a limited confidence in data quality, the lack of practical tools for improvement, and the relatively short follow-up. TRIAL REGISTRATION: ISRCTN: ISRCTN50542146. TI - A multifaceted feedback strategy alone does not improve the adherence to organizational guideline-based standards: a cluster randomized trial in intensive care SN - 1748-5908 SP - 95 JF - Implementation Science VL - vol. 10 DO - https://doi.org/10.1186/s13012-015-0285-2 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/155179/155179.pdf?sequence=1 ER - TY - JOUR AU - Brantnell, A. AU - Baraldi, E. AU - Achterberg, T. van AU - Winblad, U. PY - 2015 UR - https://hdl.handle.net/2066/153867 AB - BACKGROUND: Implementation of clinical research results is challenging, yet the responsibility for implementation is seldom addressed. The process from research to the use of clinical research results in health care can be facilitated by research funders. In this paper, we report the roles of ten Swedish research funders in relation to implementation and their views on responsibilities in implementation. FINDINGS: Ten cases were studied and compared using semi-structured interviews. In addition, websites and key documents were reviewed. Eight facilitative roles for research funders in relation to the implementation of clinical research results were identified. Three of them were common for several funders: "Advocacy work," "Monitoring implementation outcomes," and "Dissemination of knowledge." Moreover, the research funders identified six different actors responsible for implementation, five of which belonged to the healthcare setting. Collective and organizational responsibilities were the most common forms of responsibilities among the identified actors responsible for implementation. CONCLUSIONS: The roles commonly identified by the Swedish funders, "Advocacy work," "Monitoring implementation outcomes," and "Dissemination of knowledge," seem feasible facilitative roles in relation to the implementation of clinical research results. However, many actors identified as responsible for implementation together with the fact that collective and organizational responsibilities were the most common forms of responsibilities entail a risk of implementation becoming no one's responsibility. TI - Research funders' roles and perceived responsibilities in relation to the implementation of clinical research results: a multiple case study of Swedish research funders SN - 1748-5908 SP - 100 JF - Implementation Science VL - vol. 10 DO - https://doi.org/10.1186/s13012-015-0290-5 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/153867/153867.pdf?sequence=1 ER - TY - JOUR AU - Sinnema, H. AU - Majo, M.C. AU - Volker, D. AU - Hoogendoorn, A. AU - Terluin, B. AU - Wensing, M.J. AU - Balkom, A. van PY - 2015 UR - https://hdl.handle.net/2066/155133 AB - BACKGROUND: Anxiety and depression are not always diagnosed and treated in primary care as has been recommended. A tailored implementation programme, which addresses key barriers for change by targeted interventions, may help to remedy this. METHODS: The effectiveness of an individually tailored implementation programme, additional to standardised training and feedback on the recognition and treatment of patients with anxiety or depression in general practice, was examined in a cluster randomised controlled trial. Participants were 46 general practitioners (GPs) from 23 general practices (12 intervention, 11 control) and 444 patients aged 18 years or older (198 intervention, 246 control) who screened positive on the extended Kessler 10. In the control group, GPs received a 1-day training in guidelines for recognition and stepped treatment for anxiety and depression. Ten months after the training session, GPs received feedback on their performance over the preceding 6 months. In the intervention group, GPs received the same training and feedback as those in the control condition; in addition, they were offered support, tailored to perceived local barriers to change. The support was delivered in the format of peer group supervisions and personalised telephone consultations. Data were based on an audit of patient records and patient surveys at baseline and after 3 and 6 months. RESULTS: The tailored implementation programme led to recognition of a higher proportion of patients presenting with anxiety and depression (42% versus 31%; odds ratio (OR) = 1.60; 95% CI: 1.01-2.53), more consultations after recognition (IRR = 1.78; 95% CI: 1.14-2.78) and did not lead to more prescription of antidepressants (OR = 1.07; 95% CI: 0.52-2.19) or referral to specialist mental health services (OR = 1.62; 95% CI: 0.72-3.64). Patients in the intervention group reported better accessibility of care (effect size (ES) = 0.4; p < 0.05) and provision of information and advice (ES = 0.5; p < 0.05). CONCLUSIONS: A tailored implementation programme may enhance the recognition and treatment of patients with anxiety or depression. Further development and evaluation of the programme is warranted to determine its cost-effectiveness. TRAIL REGISTRATION: Dutch Trial Register identifier NTR1912 . TI - Effectiveness of a tailored implementation programme to improve recognition, diagnosis and treatment of anxiety and depression in general practice: a cluster randomised controlled trial SN - 1748-5908 IS - iss. 1 SP - 210 JF - Implementation Science VL - vol. 10 DO - https://doi.org/10.1186/s13012-015-0210-8 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/155133/155133.pdf?sequence=1 ER - TY - JOUR AU - Riet Paap, J.C. van AU - Vernooij-Dassen, M.J.F.J. AU - Sommerbakk, R. AU - Moyle, W. AU - Hjermstad, M.J. AU - Leppert, W. AU - Vissers, K. AU - Engels, Y. PY - 2015 UR - https://hdl.handle.net/2066/153102 AB - BACKGROUND: The European population is ageing, and as a consequence, an increasing number of patients are in need of palliative care, including those with dementia. Although a growing number of new insights and best practices in palliative care have been published, they are often not implemented in daily practice. The aim of this integrative review is to provide an overview of implementation strategies that have been used to improve the organisation of palliative care. METHODS: Using an integrative literature review, we evaluated publications with strategies to improve the organisation of palliative care. Qualitative analysis of the included studies involved categorisation of the implementation strategies into subgroups, according to the type of implementation strategy. RESULTS: From the 2379 publications identified, 68 studies with an experimental or quasi-experimental design were included. These studies described improvements using educational strategies (n = 14), process mapping (n = 1), feedback (n = 1), multidisciplinary meetings (n = 1) and multi-faceted implementation strategies (n = 51). Fifty-three studies reported positive outcomes, 11 studies reported mixed effects and four studies showed a limited effect (two educational and two multi-faceted strategies). CONCLUSIONS: This review is one of the first to provide an overview of the available literature in relation to strategies used to improve the organisation of palliative care. Since most studies reported positive results, further research is needed to identify and improve the effects of strategies aiming to improve the organisation of palliative care. TI - Implementation of improvement strategies in palliative care: an integrative review SN - 1748-5908 SP - 103 JF - Implementation Science VL - vol. 10 DO - https://doi.org/10.1186/s13012-015-0293-2 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/153102/153102.pdf?sequence=1 ER - TY - JOUR AU - Ijsbrandy, C. AU - Ottevanger, P.B. AU - Groen, W.G. AU - Gerritsen, W.R. AU - Harten, W.H. van AU - Hermens, R.P.M.G. PY - 2015 UR - https://hdl.handle.net/2066/154018 AB - BACKGROUND: The need for physical cancer rehabilitation programmes (PCRPs), addressing adverse effects from cancer, is growing. Implementing these programmes into daily practice is still a challenge. Since barriers for successful implementation often arise at different levels in healthcare, multi-faceted strategies focusing on multiple levels are likely more effective than single-faceted strategies. Nevertheless, most studies implementing PCRPs used strategies directed at patients only. The aim of this study is to develop and identify the most effective strategy to implement PCRPs into daily care. We want to assess the added value of a multi-faceted strategy compared with a single-faceted patient-directed strategy. METHODS/DESIGN: We will conduct a clustered controlled before and after study (CBA) in the Netherlands that compares two strategies to implement PCRPs. The patient-directed (PD) strategy (five hospitals) will focus on change at the patient level. The multi-faceted (MF) strategy (five hospitals) will focus on change at the patient, professional and organizational levels. Eligibility criteria are as follows: (A) patients: adults; preferably (history of) cancer in the gastro-intestinal, reproductive and/or urological system; successful primary treatment; and without recurrence/metastases. (B) Healthcare professionals: involved in cancer care. A stepwise approach will be followed: Step 1: Analysis of the current implementation of PCRPs and the examination of barriers and facilitators for implementation, via a qualitative study with patients (four focus groups n = 10-12) and their healthcare workers (four focus groups n = 10-12 and individual interviews n = 30-40) and collecting data on adherence to quality indicators (n = 500 patients, 50 per hospital). Step 2: Selection and development of interventions to create a PD and MF strategy during expert roundtable discussions, using the knowledge gained in step 1 and a literature search of the effect of strategies for implementing PCRPs. Step 3: Test and compare both strategies with a clustered CBA (effectiveness, process evaluation and costs), by data extraction from existing registration systems, questionnaires and interviews. For the effectiveness and cost-effectiveness, n = 500 patients, 50 per hospital. For the process evaluation, n = 50 patients, 5 per hospital, and n = 40 healthcare professionals, 4 per hospital. MAIN OUTCOME MEASURES: % screened patients, % referrals to PCRPs, incremental costs and incremental cost-effectiveness ratios (ICERs). TRAIL REGISTRATION: NCT02205853 (ClinicalTrials.gov). TI - Study protocol: an evaluation of the effectiveness, experiences and costs of a patient-directed strategy compared with a multi-faceted strategy to implement physical cancer rehabilitation programmes for cancer survivors in a European healthcare system; a controlled before and after study SN - 1748-5908 SP - 128 JF - Implementation Science VL - vol. 10 DO - https://doi.org/10.1186/s13012-015-0312-3 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/154018/154018.pdf?sequence=1 ER - TY - JOUR AU - Emond, Y. AU - Calsbeek, H. AU - Teerenstra, S. AU - Bloo, G.J.A. AU - Westert, G.P. AU - Damen, J. AU - Wolff, A.P. AU - Wollersheim, H.C.H. PY - 2015 UR - https://hdl.handle.net/2066/153123 AB - BackgroundThis study is initiated to evaluate the effects, costs, and feasibility at the hospital and patient level of an evidence-based strategy to improve the use of Dutch perioperative safety guidelines. Based on current knowledge, expert opinions and expertise of the project team, a multifaceted implementation strategy has been developed.Methods/designThis is a stepped wedge cluster randomized trial including nine representative hospitals across The Netherlands. Hospitals are stratified into three groups according to hospital type and geographical location and randomized in terms of the period for receipt of the intervention. All adult surgical patients meeting the inclusion criteria are assessed for patient outcomes. The implementation strategy includes education, audit and feedback, organizational interventions (e.g., local embedding of the guidelines), team-directed interventions (e.g., multi-professional team training), reminders, as well as patient-mediated interventions (e.g., patient safety cards). To tailor the implementation activities, we developed a questionnaire to identify barriers for effective guideline adherence, based on (a) a theoretical framework for classifying barriers and facilitators, (b) an instrument for measuring determinants of innovations, and (c) 19 semi-structured interviews with perioperative key professionals. Primary outcome is guideline adherence measured at the hospital (i.e., cluster) and patient levels by a set of perioperative Patient Safety Indicators (PSIs), which was developed parallel to the perioperative guidelines. Secondary outcomes at the patient level are in-hospital complications, postoperative wound infections and mortality, length of hospital stay, and unscheduled transfer to the intensive care unit, non-elective readmission to the hospital and unplanned reoperation, all within 30 days after the initial surgery. Also, patient safety culture and team climate will be studied as potential determinants. Finally, a process evaluation is conducted to identify the compliance with the implementation strategy, as well as an economic evaluation to assess the costs. Data sources are registered clinical data and surveys. There is no form of blinding.DiscussionThe perioperative setting is an unexplored area with respect to implementation issues. This study is expected to yield important new evidence about the effects of a multifaceted approach on guideline adherence in the perioperative care setting.Trial registrationDutch trial registry: NTR3568. TI - Improving the implementation of perioperative safety guidelines using a multifaceted intervention approach: protocol of the IMPROVE study, a stepped wedge cluster randomized trial SN - 1748-5908 IS - iss. 1 SP - 3 JF - Implementation Science VL - vol. 10 DO - https://doi.org/10.1186/s13012-014-0198-5 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/153123/153123.pdf?sequence=1 ER - TY - JOUR AU - Ekirapa-Kiracho, E. AU - Walugembe, D.R. AU - Tetui, M. AU - Kisakye, A.N. AU - Rutebemberwa, E. AU - Sengooba, F. AU - Kananura, R.M. AU - Wensing, M. AU - Kiwanuka, S.N. PY - 2014 UR - https://hdl.handle.net/2066/139099 AB - BackgroundDespite the increasing investment in health-related research in Sub-Saharan Africa, a large gulf remains between what is known and what is practiced in health systems. Knowledge translation programs aim to ensure that a wide range of stakeholders are aware of and use research evidence to inform their health and health-care decision-making. The purpose of this study is to provide insight into the impacts on capacity building for knowledge translation and knowledge translation activities by a coalition of eight research groups in Africa.Methods/designWe will use a mixed methods approach. Key informant interviews and document reviews will be employed to evaluate changes in knowledge translation capacity and to evaluate the effects of knowledge translation on potential users of research. Quarterly teleconferences will be done to evaluate the impacts of knowledge translation activities on users of research. Using website tracking, we will be able to explore the influence of knowledge translation networking and dynamics of the knowledge translation network.DiscussionWe have adopted the dynamic knowledge transfer model and the Landry framework to come up with a framework for this study so as to explore the capacity of producers and users of research to generate, disseminate, and use research findings, while highlighting their strengths and weaknesses. This information will be useful for guiding implementers that seek to build capacity on knowledge translation so as to promote the utilization of research findings for informing programs, practice, and policy. TI - Evaluation of a health systems knowledge translation network for Africa (KTNET): a study protocol SN - 1748-5908 IS - iss. 1 SP - 170 JF - Implementation Science VL - vol. 9 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/139099/139099.pdf?sequence=1 ER - TY - JOUR AU - Breton, M. AU - Brousselle, A. AU - Boivin, A. AU - Loignon, C. AU - Touati, N. AU - Dubois, C.A. AU - Nour, K. AU - Berbiche, D. AU - Roberge, D. PY - 2014 UR - https://hdl.handle.net/2066/139101 AB - BACKGROUND: Most national and provincial commissions on healthcare services in Canada over the past decade have recommended that primary care services be strengthened in order to guarantee each citizen access to a family physician. Despite these recommendations, finding a family physician continues to be problematic. The issue of enrollment with a family physician is worrying in Canada, where nearly 21% of the country's population reported not having a family physician in the last Commonwealth Fund survey.To respond to this important need, centralized waiting lists have been implemented in four Canadian provinces to help 'orphan,' or unaffiliated, patients find a family physician. These organizational mechanisms are intended to better coordinate the demand for and supply of family physicians. The objectives of this study are: to assess the effects of centralized waiting lists for orphan patients (GACOs) implemented in the province of Quebec and to explain the variation among their effects by analyzing factors influencing implementation process. METHODS: This study is based on two complementary and sequential research strategies. The first (objective 1) is a quantitative longitudinal design to assess the effects of all the GACOs (n = 93) in Quebec using clinical-administrative data. The second (objective 2) involves using four case studies to explain variations in effects through in-depth analysis of the various factors contributing to the observed effects. The primary source of data will be key actors involved in the GACOs. We expect to conduct around 40 semi-structured interviews. DISCUSSION: This will be the first study in Canada to evaluate the implementation of this innovation. It will provide an exhaustive picture of the effects of GACO implementation in Quebec and to assess their potential for generalization elsewhere in Canada. At the theoretical level, this study will produce new knowledge on the factors having the greatest influence on the implementation of primary care innovations in professional environments. TI - Evaluation of the implementation of centralized waiting lists for patients without a family physician and their effects across the province of Quebec SN - 1748-5908 SP - 117 JF - Implementation Science VL - vol. 9 DO - http://dx.doi.org/10.1186/s13012-014-0117-9 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/139101/139101.pdf?sequence=1 ER - TY - JOUR AU - Ista, E. AU - Trogrlic, Z. AU - Bakker, J. AU - Osse, R. AU - Achterberg, T. van AU - Jagt, M. van der PY - 2014 UR - https://hdl.handle.net/2066/139121 AB - BackgroundDelirium in critically ill patients has a strong adverse impact on prognosis. In spite of its recognized importance, however, delirium screening and treatment procedures are often not in accordance with current guidelines. This implementation study is designed to assess barriers and facilitators for guideline adherence and next to develop a multifaceted tailored implementation strategy. Effects of this strategy on guideline adherence as well as important clinical outcomes will be described.MethodsCurrent practices and guideline deviations will be assessed in a prospective baseline measurement. Barriers and facilitators will be identified from a survey among intensive care health care professionals (intensivists and nurses) and focus group interviews with selected health care professionals (n inverted question mark= inverted question mark60). Findings will serve as a foundation for a tailored guideline implementation strategy. Adherence to the guideline and effects of the implementation strategies on relevant clinical outcomes will be piloted in a before-after study in six intensive care units (ICUs) in the southwest Netherlands. The primary outcomes are adherence to screening and treatment in line with the Dutch ICU delirium guideline. Secondary outcomes are process measures (e.g. attendance to training and knowledge) and clinical outcomes (e.g. incidence of delirium, hospital-mortality changes, and length of stay). Primary and secondary outcome data will be collected at four time points including at least 460 patients. Furthermore, a process evaluation will be done, including an economical evaluation.DiscussionLittle is known on effective implementation of delirium management in the critically ill. The proposed multifaceted implementation strategy is expected to improve process measures such as screening adherence in line with the guideline and may improve clinical outcomes, such as mortality and length of stay. This ICU Delirium in Clinical Practice Implementation Evaluation study (iDECePTIvE-study) will generate important knowledge for ICU health care providers on how to improve their clinical practice to establish optimum care for delirious patients.Trials registrationClinical Trials NCT01952899. TI - Improvement of care for ICU patients with delirium by early screening and treatment: study protocol of iDECePTIvE study SN - 1748-5908 IS - iss. 1 SP - 143 JF - Implementation Science VL - vol. 9 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/139121/139121.pdf?sequence=1 ER - TY - JOUR AU - Beljouw, I.M.J. van AU - Laurant, M.G. AU - Heerings, M. AU - Stek, M.L. AU - Marwijk, H.W. van AU - Exel, E. van PY - 2014 UR - https://hdl.handle.net/2066/138248 AB - BACKGROUND: Depressive symptoms are highly prevalent in old age, but they remain mostly untreated. Several clinical trials have shown promising results in preventing or reducing depressive symptoms. However, it is not clear how robust these effects are in the real world of day-to-day care. Therefore, we have implemented the 'Lust for Life' programme, which significantly reduced depressive symptoms in community-dwelling older adults in the first three months after implementation. This mixed-methods study was conducted alongside the trial to develop a contextualised understanding of factors affecting the implementation. METHODS: A total of 263 persons of 65 years and older with depressive symptoms were recruited from 18 general practices and home care organizations in the Netherlands. We used qualitative data (in-depth interviews and focus group discussions with participants with depressive symptoms and healthcare professionals) as well as quantitative data (longitudinal data on the severity of depressive symptoms) to explore hindering and facilitating factors to the implementation of the 'Lust for Life' programme. Results : The uptake of the routine screening was poor and imposed significant burdens on participants and healthcare professionals, and drop-out rates were high. Participants' perceived mental problems and need for care played a key role in their decision to participate in the programme and to step up to consequent interventions. Older people preferred interventions that focused on interpersonal contact. The programme was only effective when delivered by mental healthcare nurses, compared to home care nurses with limited experience in providing mental healthcare. CONCLUSIONS: The intervention programme was effective in reducing depressive symptoms, and valuable lessons can be learned from this implementation trial. Given the low uptake and high investment, we advise against routine screening for depressive symptoms in general healthcare. Further, agreement between the participant and healthcare professional on perceived need for care and intervention is vital. Rather than providing a stepped care intervention programme, we showed that offering only one single preference-led intervention is effective. Lastly, since the provision of the interventions seems to ask for specific skills and experiences, it might require mental healthcare nurses to offer the programme. TRIAL REGISTRATION: Dutch trial register NTR2241. TI - Implementing an outreaching, preference-led stepped care intervention programme to reduce late life depressive symptoms: results of a mixed-methods study SN - 1748-5908 SP - 107 JF - Implementation Science VL - vol. 9 DO - http://dx.doi.org/10.1186/s13012-014-0107-y L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/138248/138248.pdf?sequence=1 ER - TY - JOUR AU - Boivin, A. AU - Lehoux, P. AU - Lacombe, R. AU - Burgers, J. AU - Grol, R.P. PY - 2014 UR - https://hdl.handle.net/2066/138353 AB - BACKGROUND: Patients are increasingly seen as active partners in healthcare. While patient involvement in individual clinical decisions has been extensively studied, no trial has assessed how patients can effectively be involved in collective healthcare decisions affecting the population. The goal of this study was to test the impact of involving patients in setting healthcare improvement priorities for chronic care at the community level. METHODS: Design: Cluster randomized controlled trial. Local communities were randomized in intervention (priority setting with patient involvement) and control sites (no patient involvement). Setting: Communities in a canadian region were required to set priorities for improving chronic disease management in primary care, from a list of 37 validated quality indicators. Intervention: Patients were consulted in writing, before participating in face-to-face deliberation with professionals. Control: Professionals established priorities among themselves, without patient involvement. Participants: A total of 172 individuals from six communities participated in the study, including 83 chronic disease patients, and 89 health professionals. Outcomes: The primary outcome was the level of agreement between patients' and professionals' priorities. Secondary outcomes included professionals' intention to use the selected quality indicators, and the costs of patient involvement. RESULTS: Priorities established with patients were more aligned with core generic components of the Medical Home and Chronic Care Model, including: access to primary care, self-care support, patient participation in clinical decisions, and partnership with community organizations (p < 0.01). Priorities established by professionals alone placed more emphasis on the technical quality of single disease management. The involvement intervention fostered mutual influence between patients and professionals, which resulted in a 41% increase in agreement on common priorities (95%CI: +12% to +58%, p < 0.01). Professionals' intention to use the selected quality indicators was similar in intervention and control sites. Patient involvement increased the costs of the prioritization process by 17%, and required 10% more time to reach consensus on common priorities. CONCLUSIONS: Patient involvement can change priorities driving healthcare improvement at the population level. Future research should test the generalizability of these findings to other contexts, and assess its impact on patient care. TRIAL REGISTRATION: The Netherlands National Trial Register #NTR2496. TI - Involving patients in setting priorities for healthcare improvement: a cluster randomized trial SN - 1748-5908 IS - iss. 1 SP - 24 JF - Implementation Science VL - vol. 9 DO - http://dx.doi.org/10.1186/1748-5908-9-24 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/138353/138353.pdf?sequence=1 ER - TY - JOUR AU - Huntink, E. AU - Lieshout, J. van AU - Aakhus, E. AU - Baker, R. AU - Flottorp, S. AU - Godycki-Cwirko, M. AU - Jager, C. AU - Kowalczyk, A. AU - Szecsenyi, J. AU - Wensing, M. PY - 2014 UR - https://hdl.handle.net/2066/138998 AB - BackgroundTailored strategies to implement evidence-based practice can be generated in several ways. In this study, we explored the usefulness of group interviews for generating these strategies, focused on improving healthcare for patients with chronic diseases.MethodsParticipants included at least four categories of stakeholders (researchers, quality officers, health professionals, and external stakeholders) in five countries. Interviews comprised brainstorming followed by a structured interview and focused on different chronic conditions in each country. We compared the numbers and types of strategies between stakeholder categories and between interview phases. We also determined which strategies were actually used in tailored intervention programs.ResultsIn total, 127 individuals participated in 25 group interviews across five countries. Brainstorming generated 8 to 120 strategies per group; structured interviews added 0 to 55 strategies. Healthcare professionals and researchers provided the largest numbers of strategies. The type of strategies for improving healthcare practice did not differ systematically between stakeholder groups in four of the five countries. In three out of five countries, all components of the chosen intervention programs were mentioned by the group of researchers.ConclusionsGroup interviews with different stakeholder categories produced many strategies for tailored implementation of evidence-based practice, of which the content was largely similar across stakeholder categories. TI - Stakeholders inverted question mark contributions to tailored implementation programs: an observational study of group interview methods SN - 1748-5908 IS - iss. 1 SP - 185 JF - Implementation Science VL - vol. 9 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/138998/138998.pdf?sequence=1 ER - TY - JOUR AU - Krause, J. AU - Lieshout, J. van AU - Klomp, R. AU - Huntink, E. AU - Aakhus, E. AU - Flottorp, S. AU - Jaeger, C. AU - Steinhaeuser, J. AU - Godycki-Cwirko, M. AU - Kowalczyk, A. AU - Agarwal, S. AU - Wensing, M. AU - Baker, R. PY - 2014 UR - https://hdl.handle.net/2066/138215 AB - BACKGROUND: The tailoring of implementation interventions includes the identification of the determinants of, or barriers to, healthcare practice. Different methods for identifying determinants have been used in implementation projects, but which methods are most appropriate to use is unknown. METHODS: The study was undertaken in five European countries, recommendations for a different chronic condition being addressed in each country: Germany (polypharmacy in multimorbid patients); the Netherlands (cardiovascular risk management); Norway (depression in the elderly); Poland (chronic obstructive pulmonary disease--COPD); and the United Kingdom (UK) (obesity). Using samples of professionals and patients in each country, three methods were compared directly: brainstorming amongst health professionals, interviews of health professionals, and interviews of patients. The additional value of discussion structured through reference to a checklist of determinants in addition to brainstorming, and determinants identified by open questions in a questionnaire survey, were investigated separately. The questionnaire, which included closed questions derived from a checklist of determinants, was administered to samples of health professionals in each country. Determinants were classified according to whether it was likely that they would inform the design of an implementation intervention (defined as plausibly important determinants). RESULTS: A total of 601 determinants judged to be plausibly important were identified. An additional 609 determinants were judged to be unlikely to inform an implementation intervention, and were classified as not plausibly important. Brainstorming identified 194 of the plausibly important determinants, health professional interviews 152, patient interviews 63, and open questions 48. Structured group discussion identified 144 plausibly important determinants in addition to those already identified by brainstorming. CONCLUSIONS: Systematic methods can lead to the identification of large numbers of determinants. Tailoring will usually include a process to decide, from all the determinants that are identified, those to be addressed by implementation interventions. There is no best buy of methods to identify determinants, and a combination should be used, depending on the topic and setting. Brainstorming is a simple, low cost method that could be relevant to many tailored implementation projects. TI - Identifying determinants of care for tailoring implementation in chronic diseases: an evaluation of different methods SN - 1748-5908 SP - 102 JF - Implementation Science VL - vol. 9 DO - https://doi.org/10.1186/s13012-014-0102-3 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/138215/138215.pdf?sequence=1 ER - TY - JOUR AU - Rietpaap, J. AU - Dassen, M.J.F.J. AU - Brouwer, F. AU - Meiland, F. AU - Iliffe, S. AU - Davies, N. AU - Leppert, W. AU - Jaspers, B. AU - Mariani, E. AU - Sommerbakk, R. AU - Vissers, K. AU - Engels, Y.M. PY - 2014 UR - https://hdl.handle.net/2066/135931 TI - Improving the organization of palliative care: identification of barriers and facilitators in five European countries EP - 110 SN - 1748-5908 IS - iss. 130 SP - 130 JF - Implementation Science VL - vol. 9 DO - https://doi.org/10.1186/s13012-014-0130-z L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/135931/135931.pdf?sequence=1 ER - TY - JOUR AU - Breejen, E.M. den AU - Hilbink, M.A. AU - Nelen, W.L.D.M. AU - Wiersma, Tj. AU - Burgers, J.S. AU - Kremer, J.A. AU - Hermens, R.P. PY - 2014 UR - https://hdl.handle.net/2066/137918 AB - BACKGROUND: Guideline development and uptake are still suboptimal; they focus on clinical aspects of diseases rather than on improving the integration of care. We used a patient-centered network approach to develop five harmonized guidelines (one multidisciplinary and four monodisciplinary) around clinical pathways in fertility care. We assessed the feasibility of this approach with a detailed process evaluation of the guideline development, professionals' experiences, and time invested. METHODS: The network structure comprised the centrally located patients and the steering committee; a multidisciplinary guideline development group (gynecologists, physicians, urologists, clinical embryologists, clinical chemists, a medical psychologist, an occupational physician, and two patient representatives); and four monodisciplinary guideline development groups. The guideline development addressed patient-centered, organizational, and medical-technical key questions derived from interviews with patients and professionals. These questions were elaborated and distributed among the groups. We evaluated the project performance, participants' perceptions of the approach, and the time needed, including time for analysis of secondary sources, interviews with eight key figures, and a written questionnaire survey among 35 participants. RESULTS: Within 20 months, this approach helped us develop a multidisciplinary guideline for treating infertility and four related monodisciplinary guidelines for general infertility, unexplained infertility, male infertility, and semen analysis. The multidisciplinary guideline included recommendations for the main medical-technical matters and for organizational and patient-centered issues in clinical care pathways. The project was carried out as planned except for minor modifications and three extra consensus meetings. The participants were enthusiastic about the approach, the respect for autonomy, the project coordinator's role, and patient involvement. Suggestions for improvement included timely communication about guideline formats, the timeline, participants' responsibilities, and employing a librarian and more support staff. The 35 participants spent 4497 hours in total on this project. CONCLUSIONS: The novel patient-centered network approach is feasible for simultaneously and collaboratively developing a harmonized set of multidisciplinary and monodisciplinary guidelines around clinical care pathways for patients with fertility problems. Further research is needed to compare the efficacy of this approach with more traditional approaches. TI - A patient-centered network approach to multidisciplinary-guideline development: a process evaluation SN - 1748-5908 SP - 68 JF - Implementation Science VL - vol. 9 DO - https://doi.org/10.1186/1748-5908-9-68 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/137918/137918.pdf?sequence=1 ER - TY - JOUR AU - Lugtenberg, M. AU - Westert, G.P. AU - Pasveer, D. AU - Weijden, T. van der AU - Kool, R.B. PY - 2014 UR - https://hdl.handle.net/2066/139098 AB - BackgroundComputerized decision support systems (CDSSs) are increasingly used to improve quality of care. There is evidence for moderate to large effects from randomized controlled trials (RCTs), but evidence on their effectiveness when implemented at a national level is lacking. In the Netherlands, the Dutch College of General Practitioners (NHG) initiated their successful guideline program already 30 years ago. NHGDoc, a CDSS based on these NHG guidelines, covering multiple disease areas for general practice, was developed in 2006 with the aim to improve quality of primary care. In this paper, a protocol is presented to evaluate the uptake and effects of NHGDoc.MethodsA cluster RCT will be conducted among 120 general practices in the Netherlands. Eligible general practices will be randomized to receive either the regular NHGDoc decision support modules (control arm) or the regular modules plus an additional module on heart failure (intervention arm). The heart failure module consists of patient-specific alerts concerning the treatment of patients with heart failure. The effect evaluation will focus on performance indicators (e.g., prescription behavior) as well as on patient outcomes (e.g., hospital admissions) relevant in the domain of heart failure. Additionally, a process evaluation will be conducted to gain insight into the barriers and facilitators that affect the uptake and impact of NHGDoc.DiscussionResultsof this study will provide insight in the uptake and impact of a multiple-domain covering CDSS for primary care implemented by a national guideline organization to improve the quality of primary care. Whereas the trial focuses on a specific domain of care inverted question markheart failure inverted question markconclusions of this study will shed light on the functioning of CDSSs covering multiple disease areas for primary care, particularly as this study also explores the factors contributing to the system inverted question marks uptake and effectiveness.Trial registrationClinical trials NCT01773057. TI - Evaluating the uptake and effects of the computerized decision support system NHGDoc on quality of primary care: protocol for a large-scale cluster randomized controlled trial SN - 1748-5908 IS - iss. 1 SP - 145 JF - Implementation Science VL - vol. 9 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/139098/139098.pdf?sequence=1 ER - TY - JOUR AU - Gagliardi, A.R. AU - Brouwers, M.C. AU - Bhattacharyya, O.K. AU - Wees, P.J. van der AU - et al. PY - 2014 UR - https://hdl.handle.net/2066/137719 AB - BACKGROUND: Guidelines are the foundation for healthcare planning, delivery and quality improvement but are not consistently implemented. Few guidelines are accompanied by guideline implementation tools (GItools). Users have requested GItools, and developers have requested guidance on how to develop GItools. First it is necessary to characterize GItools. The purpose of this research was to generate a framework of desirable features of GItools. METHODS: Items representing desirable GItool features were generated by a cross-sectional survey of the international guideline community. Items were confirmed by 31 guideline developers, implementers and researchers in a two-round Delphi survey administered on the Internet. The resulting GItool framework was applied with a sample of GItools accompanying guidelines identified in the National Guideline Clearinghouse. RESULTS: The cross-sectional survey was completed by 96 respondents from Australia, Canada, the United Kingdom, the United States, The Netherlands, and various other countries. Seven of nine items were rated by the majority as desirable. A total of 31 panelists from 10 countries including Australia, Canada, Germany, New Zealand, Peru, Saudi Arabia, Spain, the United Kingdom, and the United States took part in a two-round Delphi survey. Ten items achieved consensus as desirable GItool features in round #1, and two additional items in round #2. A total of 13 GItools for Resource Planning, Implementation and Evaluation were identified among 149 guidelines on a variety of clinical topics (8.7%). Many GItools did not possess features considered desirable. CONCLUSIONS: Inclusion of higher quality GItools in guidelines is needed to support user adoption of guidelines. The GItool framework can serve as the basis for evaluating and adapting existing GItools, or developing new GItools. Further research is needed to validate the framework, develop and implement instruments by which developers can apply the framework, and specify which guidelines should be accompanied by GItools. TI - A framework of the desirable features of guideline implementation tools (GItools): Delphi survey and assessment of GItools SN - 1748-5908 SP - 98 JF - Implementation Science VL - vol. 9 DO - https://doi.org/10.1186/s13012-014-0098-8 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/137719/137719.pdf?sequence=1 ER - TY - JOUR AU - Hilbink, M.A. AU - Ouwens, M.M.T.J. AU - Burgers, J.S. AU - Kool, R.B. PY - 2014 UR - https://hdl.handle.net/2066/137830 AB - BACKGROUND: In the last decade, guideline organizations faced a number of problems, including a lack of standardization in guideline development methods and suboptimal guideline implementation. To contribute to the solution of these problems, we produced a toolbox for guideline development, implementation, revision, and evaluation. METHODS: All relevant guideline organizations in the Netherlands were approached to prioritize the topics. We sent out a questionnaire and discussed the results at an invitational conference. Based on consensus, twelve topics were selected for the development of new tools. Subsequently, working groups were composed for the development of the tools. After development of the tools, their draft versions were pilot tested in 40 guideline projects. Based on the results of the pilot tests, the tools were refined and their final versions were presented. RESULTS: The vast majority of organizations involved in pilot testing of the tools reported satisfaction with using the tools. Guideline experts involved in pilot testing of the tools proposed a variety of suggestions for the implementation of the tools. The tools are available in Dutch and in English at a web-based platform on guideline development and implementation (http://www.ha-ring.nl). CONCLUSIONS: A collaborative approach was used for the development and evaluation of a toolbox for development, implementation, revision, and evaluation of guidelines. This approach yielded a potentially powerful toolbox for improving the quality and implementation of Dutch clinical guidelines. Collaboration between guideline organizations within this project led to stronger linkages, which is useful for enhancing coordination of guideline development and implementation and preventing duplication of efforts. Use of the toolbox could improve quality standards in the Netherlands, and might facilitate the development of high-quality guidelines in other countries as well. TI - A new impetus for guideline development and implementation: construction and evaluation of a toolbox SN - 1748-5908 IS - iss. 1 SP - 34 JF - Implementation Science VL - vol. 9 DO - https://doi.org/10.1186/1748-5908-9-34 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/137830/137830.pdf?sequence=1 ER - TY - JOUR AU - Janssen, M. AU - Wensing, M. AU - Gaag, R.J. van der AU - Cornelissen, I. AU - Deurzen, P.A. van AU - Buitelaar, J.K. PY - 2014 UR - https://hdl.handle.net/2066/135930 AB - BackgroundImplementation of clinical guidelines for diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents is a challenge in practice due to insufficient availability of mental health specialists and lack of effective cooperation with primary care physicians. The Tornado program aims to reduce time between referral and start of treatment in eligible patients. This study aims to assess the effectiveness and efficiency of this program.Methods/designThis is a non-randomized controlled before-after study involving 90 outpatients (6 inverted question mark18 years old) suspected of uncomplicated ADHD, which were recruited by ten mental health teams. The Tornado program, provided by three teams, combines accelerated-track diagnosis and treatment planning. This is followed by psychoeducation at a mental health center and pharmacological treatment by primary care physicians, who received an online e-learning module for this purpose. The control group consists of patients of seven other teams, who receive care as usual. Primary outcome is the patients inverted question mark time between referral to the mental health or pediatric center and start of treatment. Secondary outcomes include severity of ADHD symptoms; functional status; health-related quality of life; treatment adherence; indicators of diagnostic procedures and treatments; patient, parent, and professional experiences and satisfaction with care; and an economic evaluation. The study is powered to detect a difference of 36 days.DiscussionThis study will provide insight into the effectiveness and efficiency of the Tornado program, an accelerated-track program in mental healthcare.Trial registrationNetherlands Trial Register NTR2505. Trial status: active data collection. TI - Improving patient care for attention deficit hyperactivity disorder in children by organizational redesign (Tornado program) and enhanced collaboration between psychiatry and general practice: a controlled before and after study SN - 1748-5908 IS - iss. 1 SP - 155 JF - Implementation Science VL - vol. 9 DO - https://doi.org/10.1186/s13012-014-0155-3 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/135930/135930.pdf?sequence=1 ER - TY - JOUR AU - Lloyd, A. AU - Joseph-Williams, N. AU - Edwards, A. AU - Rix, A. AU - Elwyn, G. PY - 2013 UR - https://hdl.handle.net/2066/125742 AB - BACKGROUND: Implementing shared decision making into routine practice is proving difficult, despite considerable interest from policy-makers, and is far more complex than merely making decision support interventions available to patients. Few have reported successful implementation beyond research studies. MAking Good Decisions In Collaboration (MAGIC) is a multi-faceted implementation program, commissioned by The Health Foundation (UK), to examine how best to put shared decision making into routine practice. In this paper, we investigate healthcare professionals' perspectives on implementing shared decision making during the MAGIC program, to examine the work required to implement shared decision making and to inform future efforts. METHODS: The MAGIC program approached implementation of shared decision making by initiating a range of interventions including: providing workshops; facilitating development of brief decision support tools (Option Grids); initiating a patient activation campaign ('Ask 3 Questions'); gathering feedback using Decision Quality Measures; providing clinical leads meetings, learning events, and feedback sessions; and obtaining executive board level support. At 9 and 15 months (May and November 2011), two rounds of semi-structured interviews were conducted with healthcare professionals in three secondary care teams to explore views on the impact of these interventions. Interview data were coded by two reviewers using a framework derived from the Normalization Process Theory. RESULTS: A total of 54 interviews were completed with 31 healthcare professionals. Partial implementation of shared decision making could be explained using the four components of the Normalization Process Theory: 'coherence,' 'cognitive participation,' 'collective action,' and 'reflexive monitoring.' Shared decision making was integrated into routine practice when clinical teams shared coherent views of role and purpose ('coherence'). Shared decision making was facilitated when teams engaged in developing and delivering interventions ('cognitive participation'), and when those interventions fit with existing skill sets and organizational priorities ('collective action') resulting in demonstrable improvements to practice ('reflexive monitoring'). The implementation process uncovered diverse and conflicting attitudes toward shared decision making; 'coherence' was often missing. CONCLUSIONS: The study showed that implementation of shared decision making is more complex than the delivery of patient decision support interventions to patients, a portrayal that often goes unquestioned. Normalizing shared decision making requires intensive work to ensure teams have a shared understanding of the purpose of involving patients in decisions, and undergo the attitudinal shifts that many health professionals feel are required when comprehension goes beyond initial interpretations. Divergent views on the value of engaging patients in decisions remain a significant barrier to implementation. TI - Patchy 'coherence': using normalization process theory to evaluate a multi-faceted shared decision making implementation program (MAGIC) SN - 1748-5908 IS - iss. 1 SP - 102 JF - Implementation Science VL - vol. 8 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/125742/125742.pdf?sequence=1 ER - TY - JOUR AU - Flottorp, S.A. AU - Oxman, A.D. AU - Krause, J. AU - Musila, N.R. AU - Wensing, M. AU - Godycki-Cwirko, M. AU - Baker, R. AU - Eccles, M.P. PY - 2013 UR - https://hdl.handle.net/2066/118059 AB - BACKGROUND: Determinants of practice are factors that might prevent or enable improvements. Several checklists, frameworks, taxonomies, and classifications of determinants of healthcare professional practice have been published. In this paper, we describe the development of a comprehensive, integrated checklist of determinants of practice (the TICD checklist). METHODS: We performed a systematic review of frameworks of determinants of practice followed by a consensus process. We searched electronic databases and screened the reference lists of key background documents. Two authors independently assessed titles and abstracts, and potentially relevant full text articles. We compiled a list of attributes that a checklist should have: comprehensiveness, relevance, applicability, simplicity, logic, clarity, usability, suitability, and usefulness. We assessed included articles using these criteria and collected information about the theory, model, or logic underlying how the factors (determinants) were selected, described, and grouped, the strengths and weaknesses of the checklist, and the determinants and the domains in each checklist. We drafted a preliminary checklist based on an aggregated list of determinants from the included checklists, and finalized the checklist by a consensus process among implementation researchers. RESULTS: We screened 5,778 titles and abstracts and retrieved 87 potentially relevant papers in full text. Several of these papers had references to papers that we also retrieved in full text. We also checked potentially relevant papers we had on file that were not retrieved by the searches. We included 12 checklists. None of these were completely comprehensive when compared to the aggregated list of determinants and domains. We developed a checklist with 57 potential determinants of practice grouped in seven domains: guideline factors, individual health professional factors, patient factors, professional interactions, incentives and resources, capacity for organisational change, and social, political, and legal factors. We also developed five worksheets to facilitate the use of the checklist. CONCLUSIONS: Based on a systematic review and a consensus process we developed a checklist that aims to be comprehensive and to build on the strengths of each of the 12 included checklists. The checklist is accompanied with five worksheets to facilitate its use in implementation research and quality improvement projects. TI - A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice SN - 1748-5908 SP - 35 JF - Implementation Science VL - vol. 8 DO - https://doi.org/10.1186/1748-5908-8-35 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/118059/118059.pdf?sequence=1 ER - TY - JOUR AU - Ludt, S. AU - Campbell, S.M. AU - Petek, D. AU - Rochon, J. AU - Szecsenyi, J. AU - Lieshout, J. van AU - Wensing, M.J.P. AU - Ose, D. PY - 2013 UR - https://hdl.handle.net/2066/117949 AB - BACKGROUND: Prevention of cardiovascular diseases (CVD) is a major health issue worldwide. Primary care plays an important role in cardiovascular risk management (CVRM). Guidelines and quality of care measures to assess CVRM in primary care practices are available. In this study, we assessed the relationship between structural and organisational practice characteristics and the quality of care provided in individuals at high risk for developing CVD in European primary care. METHODS: An observational study was conducted in 267 general practices from 9 European countries. Previously developed quality indicators were abstracted from medical records of randomly sampled patients to create a composite quality measure. Practice characteristics were collected by a practice questionnaire and face to face interviews. Data were aggregated using factor analysis to four practice scores representing structural and organisational practice features. A hierarchical multilevel analysis was performed to examine the impact of practice characteristics on quality of CVRM. RESULTS: The final sample included 4223 individuals at high risk for developing CVD (28% female) with a mean age of 66.5 years (SD 9.1). Mean indicator achievement was 59.9% with a greater variation between practices than between countries. Predictors at the patient level (age, gender) had no influence on the outcome. At the practice level, the score 'Preventive Services' (13 items) was positively associated with clinical performance (r = 1.92; p = 0.0058). Sensitivity analyses resulted in a 5-item score (PrevServ_5) that was also positively associated with the outcome (r = 4.28; p < 0.0001). CONCLUSIONS: There was a positive association between the quality of CVRM in individuals at high risk for developing CVD and the availability of preventive services related to risk assessment and lifestyle management supported by information technology. TI - Which practice characteristics are associated with the quality of cardiovascular disease prevention in European primary care? SN - 1748-5908 SP - 27 JF - Implementation Science VL - vol. 8 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/117949/117949.pdf?sequence=1 ER - TY - JOUR AU - Keurhorst, M.N. AU - Anderson, P. AU - Spak, F. AU - Bendtsen, P. AU - Segura, L. AU - Colom, J. AU - Reynolds, J. AU - Drummond, C. AU - Deluca, P. AU - Steenkiste, B.C. van AU - Mierzecki, A. AU - Kloda, K. AU - Wallace, P. AU - Newbury-Birch, D. AU - Kaner, E. AU - Gual, T. AU - Laurant, M.G.H. PY - 2013 UR - https://hdl.handle.net/2066/118617 AB - BACKGROUND: The European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers. METHODS/DESIGN: In a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals' role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling. DISCUSSION: Effective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers. TI - Implementing training and support, financial reimbursement, and referral to an internet-based brief advice program to improve the early identification of hazardous and harmful alcohol consumption in primary care (ODHIN): study protocol for a cluster randomized factorial trial SN - 1748-5908 SP - 11 JF - Implementation Science VL - vol. 8 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/118617/118617.pdf?sequence=1 ER - TY - JOUR AU - Huis, A.M.P. AU - Holleman, G.J.M. AU - Achterberg, T. van AU - Grol, R.P.T.M. AU - Schoonhoven, L. AU - Hulscher, M. PY - 2013 UR - https://hdl.handle.net/2066/118412 AB - BACKGROUND: There is only limited understanding of why hand hygiene improvement strategies are successful or fail. It is therefore important to look inside the 'black box' of such strategies, to ascertain which components of a strategy work well or less well. This study examined which components of two hand hygiene improvement strategies were associated with increased nurses' hand hygiene compliance. METHODS: A process evaluation of a cluster randomised controlled trial was conducted in which part of the nursing wards of three hospitals in the Netherlands received a state-of-the-art strategy, including education, reminders, feedback, and optimising materials and facilities; another part received a team and leaders-directed strategy that included all elements of the state-of-the-art strategy, supplemented with activities aimed at the social and enhancing leadership. This process evaluation used four sets of measures: effects on nurses' hand hygiene compliance, adherence to the improvement strategies, contextual factors, and nurses' experiences with strategy components. Analyses of variance and multiple regression analyses were used to explore changes in nurses' hand hygiene compliance and thereby better understand trial effects. RESULTS: Both strategies were performed with good adherence to protocol. Two contextual factors were associated with changes in hand hygiene compliance: a hospital effect in long term (p < 0.05), and high hand hygiene baseline scores were associated with smaller effects (p < 0.01). In short term, changes in nurses' hand hygiene compliance were positively correlated with experienced feedback about their hand hygiene performance (p < 0.05). In the long run, several items of the components 'social influence' (i.e., addressing each other on undesirable hand hygiene behaviour p < 0.01), and 'leadership' (i.e., ward manager holds team members accountable for hand hygiene performance p < 0.01) correlated positively with changes in nurses' hand hygiene compliance. CONCLUSION: This study illustrates the use of a process evaluation to uncover mechanisms underlying change in hand hygiene improvement strategies. Our study results demonstrate the added value of specific aspects of social influence and leadership in hand hygiene improvement strategies, thus offering an interpretation of the trial effects. TRIAL REGISTRATION: The study is registered in ClinicalTrials.gov, dossier number: NCT00548015. TI - Explaining the effects of two different strategies for promoting hand hygiene in hospital nurses: a process evaluation alongside a cluster randomised controlled trial SN - 1748-5908 SP - 41 JF - Implementation Science VL - vol. 8 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/118412/118412.pdf?sequence=1 ER - TY - JOUR AU - Boogaard, N.M. van den AU - Kersten, F.A.M. AU - Goddijn, M. AU - Bossuyt, P.M. AU - Veen, F. van der AU - Hompes, P.G. AU - Hermens, R.P.M.G. AU - Braat, D.D.M. AU - Mol, B.W. AU - Nelen, W.L.D.M. AU - et al. PY - 2013 UR - https://hdl.handle.net/2066/118626 AB - BACKGROUND: Prognostic models in reproductive medicine can help to identify subfertile couples who would benefit from fertility treatment. Expectant management in couples with a good chance of natural conception, i.e., tailored expectant management (TEM), prevents unnecessary treatment and is therefore recommended in international fertility guidelines. However, current implementation is not optimal, leaving room for improvement. Based on barriers and facilitators for TEM that were recently identified among professionals and subfertile couples, we have developed a multifaceted implementation strategy. The goal of this study is to assess the effects of this implementation strategy on the guideline adherence on TEM. METHODS/DESIGN: In a cluster randomized trial, 25 clinics and their allied practitioners units will be randomized between the multifaceted implementation strategy and care as usual. Randomization will be stratified for in vitro fertilization (IVF) facilities (full licensed, intermediate/no IVF facilities). The effect of the implementation strategy, i.e., the percentage guideline adherence on TEM, will be evaluated by pre- and post-randomization data collection. Furthermore, there will be a process and cost evaluation of the strategy. The implementation strategy will focus on subfertile couples and their care providers i.e., general practitioners (GPs), fertility doctors, and gynecologists. The implementation strategy addresses three levels: patient level: education materials in the form of a patient information leaflet and a website; professional level: audit and feedback, educational outreach visit, communication training, and access to a digital version of the prognostic model of Hunault on a website; organizational level: providing a protocol based on the guideline. The primary outcome will be the percentage guideline adherence on TEM. Additional outcome measures will be treatment-, patient-, and process-related outcome measures. DISCUSSION: This study will provide evidence about the effectiveness and costs of a multifaceted implementation strategy to improve guideline adherence on TEM. TRIAL REGISTRATION: http://www.trialregister.nlNTR3405. This study is sponsored by ZonMW. TI - Improving the implementation of tailored expectant management in subfertile couples: protocol for a cluster randomized trial SN - 1748-5908 SP - 53 JF - Implementation Science VL - vol. 8 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/118626/118626.pdf?sequence=1 ER - TY - JOUR AU - Dopp, C.M.E. AU - Graff, M.J.L. AU - Olde Rikkert, M.G.M. AU - Nijhuis-van der Sanden, M.W.G. AU - Vernooij-Dassen, M.J.F.J. PY - 2013 UR - https://hdl.handle.net/2066/125315 AB - BACKGROUND: A multifaceted implementation (MFI) strategy was used to implement an evidence-based occupational therapy program for people with dementia (COTiD program). This strategy was successful in increasing the number of referrals, but not in improving occupational therapists' (OTs) adherence. Therefore, a process evaluation was conducted to identify factors that influenced the effectiveness of the MFI strategy. METHODS: A mixed-method approach of qualitative and quantitative research was used to evaluate the implementation process. The MFI strategy as planned and as executed were reported and evaluated based on the framework of Hulscher et al. (2003; 2006). Data on OTs attitudes and expected barriers were collected at baseline from 94 OTs using a 19-item questionnaire. Data on the experiences were collected after finishing the implementation using focus groups with OTs and telephone interviews with physicians and managers. For quantitative data, frequencies and correlations were calculated and qualitative data were analyzed using inductive content analysis. RESULTS: The implementation strategy as executed had a stronger focus than planned on increasing OTs promotional skills due to an initial lack of referrals. This resulted in less attention for increasing OTs' skills in using the COTiD program as initially intended. At baseline, OTs had a positive attitude toward the program, however, 75% did not feel experienced enough and only 14.3% felt competent in using the program. Focus groups and interviews revealed various determinants that influenced implementation. Most managers were positive about the program. However, the degree of operational support of managers for OTs regarding the implementation was not always adequate. Managers stated that a well-defined place for occupational therapy within the dementia care network was lacking although this was perceived necessary for successful implementation. Several physicians perceived psychosocial interventions not to be in their area of expertise or not their responsibility. All professionals perceived inter-professional collaboration to be a facilitator for effective implementation, and general practitioners were perceived as key partners in this collaboration. However, collaboration was not always optimal. OTs indicated that increasing the referral rate was most effective when promoting OT via other disciplines within a physician's network. CONCLUSION: Our data suggests that a first step in successful implementation should be to make sure that individual and organizational barriers are resolved. In addition, implementation should be network-based and encourage inter-professional collaboration. Initial promotion of COTiD should focus on physicians that have a positive attitude toward non-pharmacological interventions. TI - Determinants for the effectiveness of implementing an occupational therapy intervention in routine dementia care SN - 1748-5908 IS - iss. 1 SP - 131 JF - Implementation Science VL - vol. 8 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/125315/125315.pdf?sequence=1 ER - TY - JOUR AU - Sluisveld, P.H. van AU - Zegers, M. AU - Westert, G.P. AU - Hoeven, J.G. van der AU - Wollersheim, H.C. PY - 2013 UR - https://hdl.handle.net/2066/118558 AB - BACKGROUND: To use intensive care unit (ICU) facilities efficiently and ensure high quality of care, an optimal patient flow is necessary. Discharging patients relieves the pressure on ICU beds but the risk of premature discharge must be managed carefully. Suboptimal patient discharge may result in ICU readmissions and in patients' death.The aim of this study is to obtain insight into the safety and efficiency of current ICU discharge practices and into barriers and facilitators to the implementation of effective ICU discharge interventions, and to develop an implementation strategy tailored to the barriers and facilitators identified. METHODS/DESIGN: This study exists of five phases. Phase A: analysis of routinely registered data on variation in ICU readmissions and hospital mortality after ICU discharge of all ICUs participating in the Dutch National Intensive Care Evaluation registry (n=83). Phase B: systematic review of effective interventions aiming to improve the efficiency and safety of the ICU discharge process. Phase C: assessing the intervention adherence with a questionnaire survey among all Dutch ICUs (n=90). Phase D: assessing barriers and facilitators to the implementation of effective ICU discharge interventions with a questionnaire survey among all Dutch intensivists (n=700). The questionnaire will be based on barriers and facilitators identified by focus groups (n=4) and individual interviews with professionals of ICUs and general wards and adult discharged ICU patients (n=25 to 30). Phase E: systematic development of an implementation strategy based on the sampled data in phase A to D, and effective implementation strategies from the literature using the intervention mapping method. DISCUSSION: Using theory and empirical data, an implementation strategy will be developed to improve the safety and efficiency of the ICU discharge process. The developed strategy will be evaluated in a subsequent study. The knowledge obtained in this study should be used for further implementation of ICU discharge interventions, and can be used for implementation of handover interventions in other healthcare transition settings. TI - A strategy to enhance the safety and efficiency of handovers of ICU patients: study protocol of the pICUp study EP - 67 SN - 1748-5908 SP - 67 JF - Implementation Science VL - vol. 8 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/118558/118558.pdf?sequence=1 ER - TY - JOUR AU - Melman, S. AU - Schoorel, E.N. AU - Dirksen, C. AU - Kwee, A. AU - Smits, L. AU - Boer, F. de AU - Jonkers, M. AU - Woiski, M.D. AU - Mol, B.W. AU - Doornbos, J.P. AU - Visser, H. AU - Huisjes, A.J.M. AU - Porath, M.M. AU - Delemarre, F.M.C. AU - Kuppens, S.M. AU - Aardenburg, R. AU - Dooren, I.M. van AU - Vrouenraets, F.P. AU - Lim, F.T. AU - Kleiverda, G. AU - Salm, P.C. van der AU - Boer, K. de AU - Sikkema, M.J. AU - Nijhuis, J.G. AU - Hermens, R.P.M.G. AU - Scheepers, H.C.J. PY - 2013 UR - https://hdl.handle.net/2066/117613 AB - BACKGROUND: Caesarean section (CS) rates are rising worldwide. In the Netherlands, the most significant rise is observed in healthy women with a singleton in vertex position between 37 and 42 weeks gestation, whereas it is doubtful whether an improved outcome for the mother or her child was obtained. It can be hypothesized that evidence-based guidelines on CS are not implemented sufficiently. Therefore, the present study has the following objectives: to develop quality indicators on the decision to perform a CS based on key recommendations from national and international guidelines; to use the quality indicators in order to gain insight into actual adherence of Dutch gynaecologists to guideline recommendations on the performance of a CS; to explore barriers and facilitators that have a direct effect on guideline application regarding CS; and to develop, execute, and evaluate a strategy in order to reduce the CS incidence for a similar neonatal outcome (based on the information gathered in the second and third objectives). METHODS: An independent expert panel of Dutch gynaecologists and midwives will develop a set of quality indicators on the decision to perform a CS. These indicators will be used to measure current care in 20 hospitals with a population of 1,000 women who delivered by CS, and a random selection of 1,000 women who delivered vaginally in the same period. Furthermore, by interviewing healthcare professionals and patients, the barriers and facilitators that may influence the decision to perform a CS will be measured. Based on the results, a tailor-made implementation strategy will be developed and tested in a controlled before-and-after study in 12 hospitals (six intervention, six control hospitals) with regard to effectiveness, experiences, and costs. DISCUSSION: This study will offer insight into the current CS care and into the hindering and facilitating factors influencing obstetrical policy on CS. Furthermore, it will allow definition of patient categories or situations in which a tailor-made implementation strategy will most likely be meaningful and cost effective, without negatively affecting the outcome for mother and child. TRIAL REGISTRATION: http://www.clinicaltrials.gov: NCT01261676. TI - SIMPLE: implementation of recommendations from international evidence-based guidelines on caesarean sections in the Netherlands. Protocol for a controlled before and after study SN - 1748-5908 SP - 3 JF - Implementation Science VL - vol. 8 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/117613/117613.pdf?sequence=1 ER - TY - JOUR AU - Dirksen, C.D. AU - Utens, C.M. AU - Joore, M.A. AU - Barneveld, T.A. van AU - Boer, B. AU - Dreesens, D.H. AU - Laarhoven, H. van AU - Smit, C. AU - Stiggelbout, A.M. AU - Weijden, T.T. van der PY - 2013 UR - https://hdl.handle.net/2066/125985 AB - BACKGROUND: Despite a strong movement towards active patient involvement in healthcare policy decisions, systematic and explicit consideration of evidence of this research on patient preferences seems limited. Furthermore, little is known about the opinions of several stakeholders towards consideration of research evidence on patient preferences in healthcare policy decisions. This paper describes the protocol for an explorative study on the integration of research on patient preferences in healthcare policy decisions. The study questions: to what extent research evidence on patient preferences is considered in current procedures for healthcare policy decisions; opinions of stakeholders regarding the integration of this type of evidence in healthcare policy decisions; and what could be a decision framework for the integration of such research evidence in healthcare policy decisions. METHODS/DESIGN: The study is divided in three sub-studies, predominantly using qualitative methods. The first sub-study is a scoping review in five European countries to investigate whether and how results of research on patient preferences are considered in current procedures for coverage decisions and clinical practice guideline development. The second sub-study is a qualitative study to explore the opinions of stakeholders with regard to the possibilities for integrating evidence on patient preferences in the process of healthcare decision-making in the Netherlands. The third sub-study is the development of a decision framework for research on patient preferences. The framework will consist of: a process description regarding the place of evidence on patient preferences in the decision-making process; and a taxonomy describing different terminologies and conceptualisations of 'preferences' and an overview of existing methodologies for investigating preferences. The concept framework will be presented to and discussed with experts. DISCUSSION: This study will create awareness regarding the existence and potential value of research evidence on patient preferences for healthcare policy decision-making and provides insight in the methods for investigating patient preferences and the barriers and facilitators for integration of such research in healthcare policy decisions. Results of the study will be useful for researchers, clinical practice guideline developers, healthcare policy makers, and patient representatives. TI - Integrating evidence on patient preferences in healthcare policy decisions: protocol of the patient-VIP study SN - 1748-5908 SP - 64 JF - Implementation Science VL - vol. 8 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/125985/125985.pdf?sequence=1 ER - TY - JOUR AU - Stienen, J.J.C. AU - Hermens, R.P.M.G. AU - Wennekes, L. AU - Schans, S.A. van de AU - Dekker, H.M. AU - Blijlevens, N.M.A. AU - Maazen, R.W.M. van der AU - Adang, E.M.M. AU - Krieken, J.H.J.M. van AU - Ottevanger, P.B. PY - 2013 UR - https://hdl.handle.net/2066/118620 AB - BACKGROUND: Malignant lymphomas constitute a diverse group of cancers of lymphocytes. One well-known disease is Hodgkin's lymphoma; the others are classified as non-Hodgkin's lymphoma (NHL). NHLs are the most common hematologic neoplasms in adults worldwide, and in 2012 over 170,000 new cases were estimated in the United States and Europe.In previous studies, several practice gaps in hospital care for patients with NHL have been identified. To decrease this variation in care, the present study aims to perform a problem analysis in which barriers to and facilitators for optimal NHL care will be identified and, based on these findings, to develop (tailored) improvement strategies. Subsequently, we will assess the effectiveness, feasibility and costs of the improvement strategies. METHODS/DESIGN: Barriers and facilitators will be explored using the literature, using interviews and questionnaires among physicians involved in NHL care, and patients diagnosed with NHL. The results will be used to develop a tailored improvement strategy. A cluster randomized controlled trial involving 19 Dutch hospitals will be conducted. Hospitals will be randomized to receive either an improvement strategy tailored to the barriers and facilitators found or, a standard strategy of audit and feedback.The effects of both strategies will be evaluated using previously developed quality indicators. Adherence to the indicators will be measured before and after the intervention period based on medical records from newly diagnosed NHL patients. To study the feasibility of both strategies, a process evaluation will be additionally performed. Data about exposure to the different elements of the strategies will be collected using questionnaires. Economic evaluation from a healthcare perspective will compare the two implementation strategies, where the costs of the implementation strategy and changes in healthcare consumption will be assessed. DISCUSSION: The presence of variation in the use of diagnostic tests, treatment, and follow-up between different physicians in different hospitals in the Netherlands is important for patients. To reduce the existing variation in care, implementation of tailored interventions to improve NHL care is necessary. TRIAL REGISTRATION: This trial is registered at ClinicalTrial.gov as the PEARL study, registration number NCT01562509. TI - Improvement of hospital care for patients with non-Hodgkin's lymphoma: protocol for a cluster randomized controlled trial (PEARL study) SN - 1748-5908 IS - iss. 1 SP - 77 JF - Implementation Science VL - vol. 8 DO - https://doi.org/10.1186/1748-5908-8-77 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/118620/118620.pdf?sequence=1 ER - TY - JOUR AU - Versteeg, M.H. AU - Laurant, M.G.H. AU - Franx, G.C. AU - Jacobs, A.J.M AU - Wensing, M.J.P. PY - 2012 UR - https://hdl.handle.net/2066/107878 AB - BACKGROUND: Quality improvement collaboratives (QICs) bring together groups of healthcare professionals to work in a structured manner to improve the quality of healthcare delivery within particular domains. We explored which characteristics of the composition, participation, functioning, and organization of these collaboratives related to changes in the healthcare for patients with anxiety disorders, dual diagnosis, or schizophrenia. METHODS: We studied three QICs involving 29 quality improvement (QI) teams representing a number of mental healthcare organizations in the Netherlands. The aims of the three QICs were the implementation of multidisciplinary practice guidelines in the domains of anxiety disorders, dual diagnosis, and schizophrenia, respectively. We used eight performance indicators to assess the impact of the QI teams on self-reported patient outcomes and process of care outcomes for 1,346 patients. The QI team members completed a questionnaire on the characteristics of the composition, participation in a national program, functioning, and organizational context for their teams. It was expected that an association would be found between these team characteristics and the quality of care for patients with anxiety disorders, dual diagnosis, and schizophrenia. RESULTS: No consistent patterns of association emerged. Theory-based factors did not perform better than practice-based factors. However, QI teams that received support from their management and both active and inspirational team leadership showed better results. Rather surprisingly, a lower average level of education among the team members was associated with better results, although less consistently than the management and leadership characteristics. Team views with regard to the QI goals of the team and attitudes towards multidisciplinary practice guidelines did not correlate with team success. CONCLUSIONS: No general conclusions about the impact of the characteristics of QI teams on the quality of healthcare can be drawn, but support of the management and active, inspirational team leadership appear to be important. Not only patient outcomes but also the performance indicators of monitoring and screening/assessment showed improvement in many but not all of the QI teams with such characteristics. More studies are needed to identify factors associated with the impact of multidisciplinary practice guidelines in mental healthcare. TI - Factors associated with the impact of quality improvement collaboratives in mental healthcare: an exploratory study. EP - 1 SN - 1748-5908 SP - 1 JF - Implementation Science VL - vol. 7 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/107878/107878.pdf?sequence=1 ER - TY - JOUR AU - Wensing, M.J. AU - Grimshaw, J.M. AU - Eccles, M.P. PY - 2012 UR - https://hdl.handle.net/2066/110957 AB - In this editorial, we reflect on the arguments for starting a scientific society focused on research on how to improve healthcare. This society would take an inclusive approach to what constitutes healthcare. For instance, it should include mental health healthcare, treatment for substance abuse, the work of allied health professions, and preventive healthcare. The society would be open to researchers from all traditions. Thus, we take an inclusive approach to what constitutes scientific research, as long as it uses rigorous methods, is focused on improving healthcare, and aims at knowledge that can be transferred across settings. The society would primarily target scientific researchers but would invite others with an interest in this area of research, regardless of their discipline, position, field of application, or group affiliation (e.g., improvement science, behavioral medicine, knowledge translation). A society would need fruitful collaboration with related societies and organizations, which may include having combined meetings. Special links may be developed with one or more journals. A website to provide information on relevant resources, events, and training opportunities is another key activity. It would also provide a voice for the field at funding agencies, political arenas, and similar institutions. An organizational structure and financial resources are required to develop and run these activities. Our aim is to start an international debate, to discover if we can establish a shared vision across academics and stakeholders engaged with creating scientific knowledge on how to improve healthcare. We invite readers to express their views in the online questionnaire accessed by following the URL link provided at the end of the editorial. TI - Does the world need a scientific society for research on how to improve healthcare? EP - 10 SN - 1748-5908 SP - 10 JF - Implementation Science VL - vol. 7 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/110957/110957.pdf?sequence=1 ER - TY - JOUR AU - Nouwens, E. AU - Lieshout, J. van AU - Adang, E.M. AU - Bouma, M. AU - Braspenning, J.C. AU - Wensing, M.J.P. PY - 2012 UR - https://hdl.handle.net/2066/111061 AB - ABSTRACT: 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 NCT00791362. TI - Effectiveness and efficiency of a practice accreditation program on cardiovascular risk management in primary care: study protocol of a clustered randomized trial EP - 94 SN - 1748-5908 SP - 94 JF - Implementation Science VL - vol. 7 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/111061/111061.pdf?sequence=1 ER - TY - JOUR AU - Eccles, M.P. AU - Foy, R. AU - Sales, A. AU - Wensing, M.J.P. AU - Mittman, B. PY - 2012 UR - https://hdl.handle.net/2066/108250 AB - ABSTRACT: Implementation Science has been published for six years and over that time has gone from receiving 100 articles in 2006 to receiving 354 in 2011; our impact factor has risen from 2.49 in June 2010 to 3.10 in June 2012. Whilst our article publication rate has also risen, it has risen much less slowly than our submission rate-we published 29 papers in 2006 and 134 papers in 2011 and we now publish only around 40 % of submissions. About one-half of submitted manuscripts are rejected without being sent out for peer review; it has become clear that there are a number of common issues that result in manuscripts being rejected at this stage. We hope that by publishing this editorial on our common reasons for rejection without peer review we can help authors to better judge the relevance of their papers to Implementation Science. TI - Implementation Science six years on-our evolving scope and common reasons for rejection without review. EP - 71 SN - 1748-5908 SP - 71 JF - Implementation Science VL - vol. 7 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/108250/108250.pdf?sequence=1 ER - TY - JOUR AU - Franx, G.C. AU - Oud, M. AU - Lange, J. AU - Wensing, M.J. AU - Grol, R.P. PY - 2012 UR - https://hdl.handle.net/2066/108260 AB - BACKGROUND: Since 2004, 'stepped-care models' have been adopted in several international evidence-based clinical guidelines to guide clinicians in the organisation of depression care. To enhance the adoption of this new treatment approach, a Quality Improvement Collaborative (QIC) was initiated in the Netherlands. METHODS: Alongside the QIC, an intervention study using a controlled before-and-after design was performed. Part of the study was a process evaluation, utilizing semi-structured group interviews, to provide insight into the perceptions of the participating clinicians on the implementation of stepped care for depression into their daily routines. Participants were primary care clinicians, specialist clinicians, and other healthcare staff from eight regions in the Netherlands. Analysis was supported by the Normalisation Process Theory (NPT). RESULTS: The introduction of a stepped-care model for depression to primary care teams within the context of a depression QIC was generally well received by participating clinicians. All three elements of the proposed stepped-care model (patient differentiation, stepped-care treatment, and outcome monitoring), were translated and introduced locally. Clinicians reported changes in terms of learning how to differentiate between patient groups and different levels of care, changing antidepressant prescribing routines as a consequence of having a broader treatment package to offer to their patients, and better working relationships with patients and colleagues. A complex range of factors influenced the implementation process. Facilitating factors were the stepped-care model itself, the structured team meetings (part of the QIC method), and the positive reaction from patients to stepped care. The differing views of depression and depression care within multidisciplinary health teams, lack of resources, and poor information systems hindered the rapid introduction of the stepped-care model. The NPT constructs 'coherence' and 'cognitive participation' appeared to be crucial drivers in the initial stage of the process. CONCLUSIONS: Stepped care for depression is received positively in primary care. While it is difficult for the implementation of a full stepped-care approach to occur within a short time frame, clinicians can make progress towards achieving a stepped-care approach, particularly within the context of a QIC. Creating a shared understanding within multidisciplinary teams of what constitutes depression, reaching a consensus about the content of depression care, and the division of tasks are important when addressing the implementation process. TI - Implementing a stepped-care approach in primary care: results of a qualitative study. EP - 8 SN - 1748-5908 SP - 8 JF - Implementation Science VL - vol. 7 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/108260/108260.pdf?sequence=1 ER - TY - JOUR AU - Bokhoven, M.A. van AU - Koch, H. AU - Weijden, T. van der AU - Weekers-Muyres, A.H. AU - Bindels, P.J. AU - Grol, R.P.T.M. AU - Dinant, G.J. PY - 2012 UR - https://hdl.handle.net/2066/109800 AB - BACKGROUND: Immediate blood testing for patients presenting with unexplained complaints in family practice is superfluous from a diagnostic point of view. However, many general pracitioners (GPs) order tests immediately. Watchful waiting reduces the number of patients to be tested and the number of false-positive results. The objectives of this study are: to determine the feasibility of watchful waiting compared to immediate test ordering; to determine if a special quality improvement strategy can improve this feasibility; and to determine if watchful waiting leads to testing at a later time. METHODS: The study is a cluster-randomized clinical trial with three groups, on blood test ordering strategies in patients with unexplained complaints. GPs in group one were instructed to order tests immediately and GPs in group two to apply a watchful waiting approach. GPs in group three received the same instruction as group two, but they were supported by a systematically designed quality improvement strategy. A total of 498 patients with unexplained complaints from 63 practices of Dutch GPs participated. We measured: the percentage of patients for whom tests were ordered and number of tests ordered at the first consultation; performance on the strategy's performance objectives (i.e., ordering fewer tests and specific communication skills); the number of tests ordered after four weeks; and GP and patient characteristics. RESULTS: Immediate test ordering proved feasible in 92% of the patients; watchful waiting in 86% and 84%, respectively, for groups two and three. The two watchful waiting groups did not differ significantly in the achievement of any of the performance objectives. Of the patients who returned after four weeks, none from group one and six from the two watchful waiting groups had tests ordered for them. CONCLUSIONS: Watchful waiting is a feasible approach. It does not lead to testing immediately afterwards. Furthermore, watchful waiting was not improved by the quality improvement strategy. TRIAL REGISTRATION: Clinical trial registration: ISRCTN55755886. TI - The effect of watchful waiting compared to immediate test ordering instructions on general practitioners' blood test ordering behaviour for patients with unexplained complaints; a randomized clinical trial (ISRCTN55755886). EP - 29 SN - 1748-5908 SP - 29 JF - Implementation Science VL - vol. 7 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/109800/109800.pdf?sequence=1 ER - TY - JOUR AU - Glind, I.M. van de AU - Heinen, M.M. AU - Evers, A.W.M. AU - Wensing, M.J.P. AU - Achterberg, T. van PY - 2012 UR - https://hdl.handle.net/2066/107883 AB - ABSTRACT: BACKGROUND: Implementation of lifestyle interventions in patient care is a major challenge. Understanding factors that influence implementation is a first step in programs to enhance uptake of these interventions. A lifestyle-counseling intervention, Lively Legs, delivered by trained nurses, can effectively improve the lifestyle in patients with venous leg ulcers. The aim of this study was to identify factors that hindered or facilitated implementation of this intervention in outpatient dermatology clinics and in home care. METHODS: A mixed-methods multiple case study in five purposefully selected healthcare settings in the Netherlands was conducted. Measurements to identify influencing factors before and after implementation of Lively Legs included interviews, focus groups, questionnaires, and nurses' registration. Analyses focused on qualitative data as the main data source. All data were compared across multiple cases to draw conclusions from the study as a whole. RESULTS: A total of 53 patients enrolled in the Lively Legs program, which was delivered by 12 trained nurses. Barriers for implementation were mainly organizational. It was difficult to effectively organize reaching and recruiting patients for the program, especially in home care. Main barriers were a lack of a standardized healthcare delivery process, insufficient nursing time, and a lack of motivated nurses to deliver the program. Facilitating factors were nurse-driven coordination of care and a standardized care process to tie Lively Legs into, as this resulted in better patient recruitment and better program implementation. CONCLUSIONS: This study identified a range of factors influencing the implementation of a lifestyle-counseling program, mainly related to the organization of healthcare. Using a case study method proved valuable in obtaining insight into influencing factors for implementation. This study also shed light on a more general issue, which is that leg ulcer care is often fragmented, indicating that quality improvement is needed. TI - Factors influencing the implementation of a lifestyle counseling program in patients with venous leg ulcers: a multiple case study EP - 104 SN - 1748-5908 SP - 104 JF - Implementation Science VL - vol. 7 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/107883/107883.pdf?sequence=1 ER - TY - JOUR AU - Huis, A.M.P. AU - Achterberg, T. van AU - de Bruin, M. AU - Grol, R.P.T.M. AU - Schoonhoven, L. AU - Hulscher, M.E.J.L. PY - 2012 UR - https://hdl.handle.net/2066/108114 AB - ABSTRACT: BACKGROUND: Many strategies have been designed and evaluated to address the problem of low hand hygiene (HH) compliance. Which of these strategies are most effective and how they work is still unclear. Here we describe frequently used improvement strategies and related determinants of behaviour change that prompt good HH behaviour to provide a better overview of the choice and content of such strategies. METHODS: Systematic searches of experimental and quasi-experimental research on HH improvement strategies were conducted in Medline, Embase, CINAHL, and Cochrane databases from January 2000 to November 2009. First, we extracted the study characteristics using the EPOC Data Collection Checklist, including study objectives, setting, study design, target population, outcome measures, description of the intervention, analysis, and results. Second, we used the Taxonomy of Behavioural Change Techniques to identify targeted determinants. RESULTS: We reviewed 41 studies. The most frequently addressed determinants were knowledge, awareness, action control, and facilitation of behaviour. Fewer studies addressed social influence, attitude, self-efficacy, and intention. Thirteen studies used a controlled design to measure the effects of HH improvement strategies on HH behaviour. The effectiveness of the strategies varied substantially, but most controlled studies showed positive results. The median effect size of these strategies increased from 17.6 (relative difference) addressing one determinant to 49.5 for the studies that addressed five determinants. CONCLUSIONS: By focussing on determinants of behaviour change, we found hidden and valuable components in HH improvement strategies. Addressing only determinants such as knowledge, awareness, action control, and facilitation is not enough to change HH behaviour. Addressing combinations of different determinants showed better results. This indicates that we should be more creative in the application of alternative improvement activities addressing determinants such as social influence, attitude, self-efficacy, or intention. TI - A systematic review of hand hygiene improvement strategies: a behavioural approach EP - 92 SN - 1748-5908 SP - 92 JF - Implementation Science VL - vol. 7 DO - https://doi.org/10.1186/1748-5908-7-92 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/108114/108114.pdf?sequence=1 ER - TY - JOUR AU - Gaal, S. AU - Verstappen, W.H.J.M. AU - Wolters, R.J. AU - Lankveld, H. AU - Weel, C. van AU - Wensing, M.J.P. PY - 2011 UR - https://hdl.handle.net/2066/97252 AB - BACKGROUND: Patient safety can be at stake in both hospital and general practice settings. While severe patient safety incidents have been described, quantitative studies in large samples of patients in general practice are rare. This study aimed to assess patient safety in general practice, and to show areas where potential improvements could be implemented. METHODS: We conducted a retrospective review of patient records in Dutch general practice. A random sample of 1,000 patients from 20 general practices was obtained. The number of patient safety incidents that occurred in a one-year period, their perceived underlying causes, and impact on patients' health were recorded. RESULTS: We identified 211 patient safety incidents across a period of one year (95% CI: 185 until 241). A variety of types of incidents, perceived causes and consequences were found. A total of 58 patient safety incidents affected patients; seven were associated with hospital admission; none resulted in permanent disability or death. CONCLUSIONS: Although this large audit of medical records in general practices identified many patient safety incidents, only a few had a major impact on patients' health. Improving patient safety in this low-risk environment poses specific challenges, given the high numbers of patients and contacts in general practice. TI - Prevalence and consequences of patient safety incidents in general practice in the Netherlands: a retrospective medical record review study EP - 37 SN - 1748-5908 SP - 37 JF - Implementation Science VL - vol. 6 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/97252/97252.pdf?sequence=1 ER - TY - JOUR AU - Looijmans-van den Akker, I. AU - Hulscher, M.E.J.L. AU - Verheij, T.J. AU - Riphagen-Dalhuisen, J. AU - Delden, J.J.M. van AU - Hak, E. PY - 2011 UR - https://hdl.handle.net/2066/95966 AB - BACKGROUND: Apart from direct protection and reduced productivity loss during epidemics, the main reason to immunize healthcare workers (HCWs) against influenza is to provide indirect protection of frail patients through reduced transmission in healthcare settings. Because the vaccine uptake among HCWs remains far below the health objectives, systematic programs are needed to take full advantage of such vaccination. In an earlier report, we showed a mean 9% increase of vaccine uptake among HCWs in nursing homes that implemented a systematic program compared with control homes, with higher rates in those homes that implemented more program elements. Here, we report in detail the process of the development of the implementation program to enable researchers and practitioners to develop intervention programs tailored to their setting. METHODS: We applied the intervention mapping (IM) method to develop a theory- and evidence-based intervention program to change vaccination behaviour among HCWs in nursing homes. RESULTS: After a comprehensive needs assessment, we were able to specify proximal program objectives and selected methods and strategies for inducing behavioural change. By consensus, we decided on planning of three main program components, i.e., an outreach visit to all nursing homes, plenary information meetings, and the appointment of a program coordinator -- preferably a physician -- in each home. Finally, we planned program adoption, implementation, and evaluation. CONCLUSION: The IM methodology resulted in a systematic, comprehensive, and transparent procedure of program development. A potentially effective intervention program to change influenza vaccination behaviour among HCWs was developed, and its impact was assessed in a clustered randomised controlled trial. TI - How to develop a program to increase influenza vaccine uptake among workers in health care settings? EP - 47 SN - 1748-5908 SP - 47 JF - Implementation Science VL - vol. 6 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/95966/95966.pdf?sequence=1 ER - TY - JOUR AU - Veer, S.N. van der AU - Vos, M.L. de AU - Jager, K.J. AU - Voort, P.H. van der AU - Peek, N. AU - Westert, G.P. AU - Graafmans, W.C. AU - Keizer, N.F. de PY - 2011 UR - https://hdl.handle.net/2066/95871 AB - ABSTRACT: BACKGROUND: Feedback is potentially effective in improving the quality of care. However, merely sending reports is no guarantee that performance data are used as input for systematic quality improvement (QI). Therefore, we developed a multifaceted intervention tailored to prospectively analyzed barriers to using indicators: the Information Feedback on Quality Indicators (InFoQI) program. This program aims to promote the use of performance indicator data as input for local systematic QI. We will conduct a study to assess the impact of the InFoQI program on patient outcome and organizational process measures of care, and to gain insight into barriers and success factors that affected the program's impact. The study will be executed in the context of intensive care. This paper presents the study's protocol. METHODS/DESIGN: We will conduct a cluster randomized controlled trial with intensive care units (ICUs) in the Netherlands. We will include ICUs that submit indicator data to the Dutch National Intensive Care Evaluation (NICE) quality registry and that agree to allocate at least one intensivist and one ICU nurse for implementation of the intervention. Eligible ICUs (clusters) will be randomized to receive basic NICE registry feedback (control arm) or to participate in the InFoQI program (intervention arm). The InFoQI program consists of comprehensive feedback, establishing a local, multidisciplinary QI team, and educational outreach visits. The primary outcome measures will be length of ICU stay and the proportion of shifts with a bed occupancy rate above 80%. We will also conduct a process evaluation involving ICUs in the intervention arm to investigate their actual exposure to and experiences with the InFoQI program. DISCUSSION: The results of this study will inform those involved in providing ICU care on the feasibility of a tailored multifaceted performance feedback intervention and its ability to accelerate systematic and local quality improvement. Although our study will be conducted within the domain of intensive care, we believe our conclusions will be generalizable to other settings that have a quality registry including an indicator set available. TRIAL REGISTRATION: Current Controlled Trials ISRCTN50542146. TI - Evaluating the effectiveness of a tailored multifaceted performance feedback intervention to improve the quality of care: protocol for a cluster randomized trial in intensive care EP - 119 SN - 1748-5908 SP - 119 JF - Implementation Science VL - vol. 6 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/95871/95871.pdf?sequence=1 ER - TY - JOUR AU - Lieshout, J. van AU - Steenkamer, B. AU - Knippenberg, M. AU - Wensing, M.J.P. PY - 2011 UR - https://hdl.handle.net/2066/97992 AB - BACKGROUND: Many patients with chronic heart failure (CHF), a common condition with high morbidity and mortality rates, receive treatment in primary care. To improve the management of CHF in primary care, we developed an implementation programme comprised of educational and organisational components, with support by a practice visitor and focus both on drug treatment and lifestyle advice, and on organisation of care within the practice and collaboration with other healthcare providers. Tailoring has been shown to improve the success of implementation programmes, but little is known about what would be best methods for tailoring, specifically with respect to CHF in primary care. METHODS/DESIGN: We describe the study protocol of a cluster randomised controlled trial to examine the effectiveness of tailoring a CHF implementation programme to general practices compared to a standardised way of delivering a programme. The study population will consist of 60 general practitioners (GPs) and the CHF patients they include. GPs are randomised in blocks of four, stratified according to practice size. With a tailored implementation programme GPs prioritise the issues that will form the bases of the support for the practice visits. These may comprise several issues, both educational and organizational.The primary outcome measures are patient's experience of receiving structured primary care for CHF (PACIC, a questionnaire related to the Chronic Care Model), patients' health-related utilities (EQ-5D), and drugs prescriptions using the guideline adherence index. Patients being clustered in practices, multilevel regression analyses will be used to explore the effect of practice size and type of intervention programme. In addition we will examine both changes within groups and differences at follow-up between groups with respect to drug dosages and advice on lifestyle issues. Furthermore, in interviews the feasibility of the programme and goal attainment, organisational changes in CHF care, and formalised cooperation with other disciplines will be assessed. DISCUSSION: In the tailoring of the programme we will present the GPs a list with barriers; GPs will assess relevance and possibility to solve these barriers. The list is rigorously developed and tested in various projects. The factors for ordering the barriers are related to the innovation, the healthcare professional, the patient, and the context.CHF patients do not form a homogeneous group. Subgroup analyses will be performed based on the distinction between systolic CHF and CHF with preserved left ventricular function (diastolic CHF). TRIAL REGISTRATION: ISRCTN: ISRCTN18812755. TI - Improvement of primary care for patients with chronic heart failure: A study protocol for a cluster randomised trial comparing two strategies. EP - 28 SN - 1748-5908 SP - 28 JF - Implementation Science VL - vol. 6 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/97992/97992.pdf?sequence=1 ER - TY - JOUR AU - Wensing, M.J.P. AU - Oxman, A. AU - Baker, R. AU - Godycki-Cwirko, M. AU - Flottorp, S. AU - Szecsenyi, J. AU - Grimshaw, J. AU - Eccles, M. PY - 2011 UR - https://hdl.handle.net/2066/98393 AB - ABSTRACT: BACKGROUND: The assumption underlying tailoring is that implementation interventions are most helpful if these effectively address the most important determinants of practice for improvement in the targeted setting. The aim of the Tailored Implementation For Chronic Diseases (TICD) project is to develop valid and efficient methods of tailoring implementation interventions to determinants of practice for knowledge implementation in chronic illness care. METHODS: The TICD project has organized the planned empirical research in three work packages that follow the three main steps of tailoring: identification of determinants of healthcare practice, matching implementation interventions to identified determinants of practice, and applying and assessing the tailored implementation interventions. These three key steps of tailored implementation will be applied to targeted chronic conditions in five different healthcare systems: cardiovascular disease in the Netherlands, obesity in England, depression in Norway, chronic obstructive pulmonary disease in Poland, and multimorbidity in Germany. The design and interpretation of empirical research will be informed by systematic reviews of previous research on tailoring implementation interventions. DISCUSSION: The TICD project will provide much needed evidence on the advantages and disadvantages of different methods of identifying important determinants of practice and selecting implementation strategies that take account of those. It will also provide five rigorous evaluations of tailored implementation interventions for five different chronic conditions. TI - Tailored implementation for chronic diseases (TICD): A project protocol EP - 103 SN - 1748-5908 SP - 103 JF - Implementation Science VL - vol. 6 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/98393/98393.pdf?sequence=1 ER - TY - JOUR AU - Dijk, L.J. van AU - Nelen, W.L.D.M. AU - D'Hooghe, T.M. AU - Dunselman, G.A. AU - Hermens, R.P.M.G. AU - Bergh, C. AU - Nygren, K.G. AU - Simons, A.H. AU - Sutter, P. de AU - Marshall, C. AU - Burgers, J.S. AU - Kremer, J.A.M. PY - 2011 UR - https://hdl.handle.net/2066/97413 AB - BACKGROUND: Clinical guidelines are intended to improve healthcare. However, even if guidelines are excellent, their implementation is not assured. In subfertility care, the European Society of Human Reproduction and Embryology (ESHRE) guidelines have been inventoried, and their methodological quality has been assessed. To improve the impact of the ESHRE guidelines and to improve European subfertility care, it is important to optimise the implementability of guidelines. We therefore investigated the implementation barriers of the ESHRE guideline with the best methodological quality and evaluated the used instrument for usability and feasibility. METHODS: We reviewed the ESHRE guideline for the diagnosis and treatment of endometriosis to assess its implementability. We used an electronic version of the guideline implementability appraisal (eGLIA) instrument. This eGLIA tool consists of 31 questions grouped into 10 dimensions. Seven items address the guideline as a whole, and 24 items assess the individual recommendations in the guideline. The eGLIA instrument identifies factors that influence the implementability of the guideline recommendations. These factors can be divided into facilitators that promote implementation and barriers that oppose implementation. A panel of 10 experts from three European countries appraised all 36 recommendations of the guideline. They discussed discrepancies in a teleconference and completed a questionnaire to evaluate the ease of use and overall utility of the eGLIA instrument. RESULTS: Two of the 36 guideline recommendations were straightforward to implement. Five recommendations were considered simply statements because they contained no actions. The remaining 29 recommendations were implementable with some adjustments. We found facilitators of the guideline implementability in the quality of decidability, presentation and formatting, apparent validity, and novelty or innovation of the recommendations. Vaguely defined actions, lack of facilities, immeasurable outcomes, and inflexibility within the recommendations formed barriers to implementation. The eGLIA instrument was generally useful and easy to use. However, assessment with the eGLIA instrument is very time-consuming. CONCLUSIONS: The ESHRE guideline for the diagnosis and treatment of endometriosis could be improved to facilitate its implementation in daily practice. The eGLIA instrument is a helpful tool for identifying obstacles to implementation of a guideline. However, we recommend a concise version of this instrument. TI - The European Society of Human Reproduction and Embryology guideline for the diagnosis and treatment of endometriosis: an electronic guideline implementability appraisal EP - 7 SN - 1748-5908 SP - 7 JF - Implementation Science VL - vol. 6 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/97413/97413.pdf?sequence=1 ER - TY - JOUR AU - Huis, A.M.P. AU - Schoonhoven, L. AU - Grol, R.P.T.M. AU - Borm, G.F. AU - Adang, E.M.M. AU - Hulscher, M.E.J.L. AU - Achterberg, T. van PY - 2011 UR - https://hdl.handle.net/2066/95948 AB - ABSTRACT: 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: NCT00548015. TI - Helping hands: A cluster randomised trial to evaluate the effectiveness of two different strategies for promoting hand hygiene in hospital nurses EP - 101 SN - 1748-5908 SP - 101 JF - Implementation Science VL - vol. 6 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/95948/95948.pdf?sequence=1 ER - TY - JOUR AU - Boivin, A. AU - Lehoux, P. AU - Lacombe, R. AU - Lacasse, A. AU - Burgers, J.S. AU - Grol, R.P.T.M. PY - 2011 UR - https://hdl.handle.net/2066/98395 AB - BACKGROUND: Public priorities for improvement often differ from those of clinicians and managers. Public involvement has been proposed as a way to bridge the gap between professional and public clinical care priorities but has not been studied in the context of quality-indicator choice. Our objective is to assess the feasibility and impact of public involvement on quality-indicator choice and agreement with public priorities. METHODS: We will conduct a cluster randomised controlled trial comparing quality-indicator prioritisation with and without public involvement. In preparation for the trial, we developed a 'menu' of quality indicators, based on a systematic review of existing validated indicator sets. Participants (public representatives, clinicians, and managers) will be recruited from six participating sites. In intervention sites, public representatives will be involved through direct participation (public representatives, clinicians, and managers will deliberate together to agree on quality-indicator choice and use) and consultation (individual public recommendations for improvement will be collected and presented to decision makers). In control sites, only clinicians and managers will take part in the prioritisation process. Data on quality-indicator choice and intended use will be collected. Our primary outcome will compare quality-indicator choice and agreement with public priorities between intervention and control groups. A process evaluation based on direct observation, videorecording, and participants' assessment will be conducted to help explain the study's results. The marginal cost of public involvement will also be assessed. DISCUSSION: We identified 801 quality indicators that met our inclusion criteria. An expert panel agreed on a final set of 37 items containing validated quality indicators relevant for chronic disease prevention and management in primary care. We pilot tested our public-involvement intervention with 27 participants (11 public representatives and 16 clinicians and managers) and our study instruments with an additional 21 participants, which demonstrated the feasibility of the intervention and generated important insights and adaptations to engage public representatives more effectively. To our knowledge, this study is the first trial of public involvement in quality-indicator prioritisation, and its results could foster more effective upstream engagement of patients and the public in clinical practice improvement. TRIAL REGISTRATION: NTR2496 (Netherlands National Trial Register, http://www.trialregister.nl). TI - Target for improvement: a cluster randomised trial of public involvement in quality-indicator prioritisation (intervention development and study protocol) EP - 45 SN - 1748-5908 SP - 45 JF - Implementation Science VL - vol. 6 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/98395/98395.pdf?sequence=1 ER - TY - JOUR AU - Alonso-Coello, P. AU - Garcia, L.M. AU - Gimeno, J.M. AU - Sola, I. AU - Qureshi, S. AU - Burgers, J.S. PY - 2011 UR - https://hdl.handle.net/2066/98466 AB - BACKGROUND: Clinical practice guidelines (CPGs) have become increasingly popular, and the methodology to develop guidelines has evolved enormously. However, little attention has been given to the updating process, in contrast to the appraisal of the available literature. We conducted an international survey to identify current practices in CPG updating and explored the need to standardize and improve the methods. METHODS: We developed a questionnaire (28 items) based on a review of the existing literature about guideline updating and expert comments. We carried out the survey between March and July 2009, and it was sent by email to 106 institutions: 69 members of the Guidelines International Network who declared that they developed CPGs; 30 institutions included in the U.S. National Guideline Clearinghouse database that published more than 20 CPGs; and 7 institutions selected by an expert committee. RESULTS: Forty-four institutions answered the questionnaire (42% response rate). In the final analysis, 39 completed questionnaires were included. Thirty-six institutions (92%) reported that they update their guidelines. Thirty-one institutions (86%) have a formal procedure for updating their guidelines, and 19 (53%) have a formal procedure for deciding when a guideline becomes out of date. Institutions describe the process as moderately rigorous (36%) or acknowledge that it could certainly be more rigorous (36%). Twenty-two institutions (61%) alert guideline users on their website when a guideline is older than three to five years or when there is a risk of being outdated. Twenty-five institutions (64%) support the concept of "living guidelines," which are continuously monitored and updated. Eighteen institutions (46%) have plans to design a protocol to improve their guideline-updating process, and 21 (54%) are willing to share resources with other organizations. CONCLUSIONS: Our study is the first to describe the process of updating CPGs among prominent guideline institutions across the world, providing a comprehensive picture of guideline updating. There is an urgent need to develop rigorous international standards for this process and to minimize duplication of effort internationally. TI - The updating of clinical practice guidelines: insights from an international survey. EP - 107 SN - 1748-5908 SP - 107 JF - Implementation Science VL - vol. 6 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/98466/98466.pdf?sequence=1 ER - TY - JOUR AU - Sinnema, H. AU - Franx, G.C. AU - Volker, D. AU - Majo, C. AU - Terluin, B. AU - Wensing, M.J.P. AU - Balkom, A. van PY - 2011 UR - https://hdl.handle.net/2066/96261 AB - ABSTRACT: BACKGROUND: Anxiety and depressive disorders are highly prevalent disorders and are mostly treated in primary care. The management of these disorders by general practitioners is not always consistent with prevailing guidelines because of a variety of factors. Designing implementation strategies tailored to prospectively identified barriers could lead to more guideline-recommended care. Although tailoring of implementation strategies is promoted in practice, little is known about the effect on improving the quality of care for the early recognition, diagnosis, and stepped care treatment allocation in patients with anxiety or depressive disorders in general practice. This study examines whether the tailored strategy supplemented with training and feedback is more effective than providing training and feedback alone. METHODS: In this cluster randomised controlled trial, a total of 22 general practices will be assigned to one of two conditions: (1) training, feedback, and tailored interventions and (2) training and feedback. The primary outcome measure is the proportion of patients who have been recognised to have anxiety and/or depressive disorder. The secondary outcome measures in patients are severity of anxiety and depressive symptoms, level of functioning, expectation towards and experience with care, quality of life, and economic costs. Measures are taken after the start of the intervention at baseline and at three- and six-month follow-ups. Secondary outcome measures in general practitioners are adherence to guideline-recommended care in care that has been delivered, the proportion of antidepressant prescriptions, and number of referrals to specialised mental healthcare facilities. Data will be gathered from the electronic medical patient records from the patients included in the study. In a process evaluation, the identification of barriers to change and the relations between prospectively identified barriers and improvement interventions selected for use will be described, as well as the factors that influence the provision of guideline-recommended care. DISCUSSION: It is hypothesised that the adherence to guideline recommendations will be improved by designing implementation interventions that are tailored to prospectively identified barriers in the local context of general practitioners. Currently, there is insufficient evidence on the most effective and efficient approaches to tailoring, including how barriers should be identified and how interventions should be selected to address the barriers. TRIAL REGISTRATION: NTR1912. TI - Randomised controlled trial of tailored interventions to improve the management of anxiety and depressive disorders in primary care EP - 75 SN - 1748-5908 SP - 75 JF - Implementation Science VL - vol. 6 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/96261/96261.pdf?sequence=1 ER - TY - JOUR AU - Boveldt, N.D. te AU - Engels, Y.M.P. AU - Besse, K. AU - Vissers, K.C.P. AU - Vernooij-Dassen, M.J.F.J. PY - 2011 UR - https://hdl.handle.net/2066/98286 AB - ABSTRACT: BACKGROUND: One-half of patients with cancer have pain. In nearly one out of two cancer patients with pain, this was undertreated. Inadequate pain control still remains an important problem in this group of patients. Therefore, in 2008 a national, evidence-based multidisciplinary clinical practice guideline 'pain in patients with cancer' has been developed. Yet, publishing a guideline is not enough. Implementation is needed to improve pain management. An innovative implementation strategy, Short Message Service with Interactive Voice Response (SVS-IVR), has been developed and pilot tested. This study aims to evaluate on effectiveness of this strategy to improve pain reporting, pain measurement and adequate pain therapy. In addition, whether the active role of the patient and involvement of caregivers in pain management may change. METHODS/DESIGN: A cluster randomised controlled trial with two arms will be performed in six oncology outpatient clinics of hospitals in the Southeastern region of the Netherlands, with three hospitals in the intervention and three in the control condition. Follow-up measurements will be conducted in all hospitals to study the long-term effect of the intervention. The intervention includes training of professionals (medical oncologists, nurses, and general practitioners) and SMS-IVR to report pain in patients with cancer to improve pain reporting by patients, pain management by medical oncologists, nurses, and general practitioners, and decrease pain intensity. DISCUSSION: This innovative implementation strategy with technical tools and the involvement of patients, may enhance the use of the guideline 'pain in patients with cancer' for pain management. Short Message Service alerts may serve as a tool to support self-management of patients. Therefore, the SMS-IVR intervention may increase the feeling of having control over one's life. TRAIL REGISTRATION: Netherlands Trial Register (NTR): NTR2739. TI - Rationale, design, and implementation protocol of the Dutch clinical practice guideline Pain in patients with cancer: a cluster randomised controlled trial with short message service (SMS) and interactive voice response (IVR). EP - 126 SN - 1748-5908 SP - 126 JF - Implementation Science VL - vol. 6 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/98286/98286.pdf?sequence=1 ER - TY - JOUR AU - Weenink, J.W. AU - Lieshout, J. van AU - Jung, H.P. AU - Wensing, M.J.P. PY - 2011 UR - https://hdl.handle.net/2066/97203 AB - ABSTRACT: BACKGROUND: Patient care teams have an important role in providing medical care to patients with chronic disease, but insight into how to improve their performance is limited. Two potentially relevant determinants are the presence of a central care provider with a coordinating role and an active role of the patient in the network of care providers. In this study, we aimed to develop and test measures of these factors related to the network of care providers of an individual patient. METHODS: We performed an observational study in patients with type 2 diabetes or chronic heart failure, who were recruited from three primary care practices in The Netherlands. The study focused on medical treatment, advice on physical activity, and disease monitoring. We used patient questionnaires and chart review to measure connections between the patient and care providers, and a written survey among care providers to measure their connections. Data on clinical performance were extracted from the medical records. We used network analysis to compute degree centrality coefficients for the patient and to identify the most central health professional in each network. A range of other network characteristics were computed including network centralization, density, size, diversity of disciplines, and overlap among activity-specific networks. Differences across the two chronic conditions and associations with disease monitoring were explored. RESULTS: Approximately 50% of the invited patients participated. Participation rates of health professionals were close to 100%. We identified 63 networks of 25 patients: 22 for medical treatment, 16 for physical exercise advice, and 25 for disease monitoring. General practitioners (GPs) were the most central care providers for the three clinical activities in both chronic conditions. The GP's degree centrality coefficient varied substantially, and higher scores seemed to be associated with receiving more comprehensive disease monitoring. The degree centrality coefficient of patients also varied substantially but did not seem to be associated with disease monitoring. CONCLUSIONS: Our method can be used to measure connections between care providers of an individual patient, and to examine the association between specific network parameters and healthcare received. Further research is needed to refine the measurement method and to test the association of specific network parameters with quality and outcomes of healthcare. TI - Patient Care Teams in treatment of diabetes and chronic heart failure in primary care: an observational networks study. EP - 66 SN - 1748-5908 SP - 66 JF - Implementation Science VL - vol. 6 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/97203/97203.pdf?sequence=1 ER - TY - JOUR AU - Wensing, M.J.P. AU - Eijk, M. van der AU - Koetsenruijter, J. AU - Bloem, B.R. AU - Munneke, M. AU - Faber, M.J. PY - 2011 UR - https://hdl.handle.net/2066/96760 AB - ABSTRACT: BACKGROUND: Patients with chronic illness typically receive ambulatory treatment from multiple health professionals. Connectedness between these professionals may influence their clinical decisions and the coordination of patient care. We aimed to describe and analyze connectedness in a regional network of health professionals involved in ambulatory treatment of patients with Parkinson's disease (PD). METHODS: Observational study with 104 health professionals who had joined a newly established network (ParkinsonNet) were asked to complete a pre-structured form to report on their professional contacts with others in the network. Using social networks methods, network measures were calculated for the total network and for the networks of individual health professionals. We planned to test differences between subgroups of health professionals regarding 12 network measures, using a random permutation method. RESULTS: Ninety-six health professionals (92%) provided data on 101 professionals. The reciprocity of reported connections was 0.42 in the network of professional contacts. Measures characterizing the individual networks showed a wide variation; e.g., density varied between 0 and 100% (mean value 28.4%). Health professionals with >/=10 PD patients had higher values on 7 out of 12 network measures compare to those with < 10 PD patients (size, number of connections, two step reach, indegree centrality, outdegree centrality, inreach centrality, betweenness centrality). Primary care professionals had lower values on 11 out of 12 network measures (all but reach efficiency) compared to professionals who were affiliated with a hospital. CONCLUSIONS: Our measure of professional connectedness proved to be feasible in a regional disease-specific network of health professionals. Network measures describing patterns in the professional contacts showed relevant variation across professionals. A higher caseload and an affiliation with a hospital were associated with stronger connectedness with other health professionals. TI - Connectedness of healthcare professionals involved in the treatment of patients with Parkinson's disease: a social networks study EP - 67 SN - 1748-5908 SP - 67 JF - Implementation Science VL - vol. 6 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/96760/96760.pdf?sequence=1 ER - TY - JOUR AU - Schouten, L.M.T. AU - Grol, R.P.T.M. AU - Hulscher, M.E.J.L. PY - 2010 UR - https://hdl.handle.net/2066/88630 AB - ABSTRACT: BACKGROUND: To increase the effectiveness of quality-improvement collaboratives (QICs), it is important to explore factors that potentially influence their outcomes. For this purpose, we have developed and tested the psychometric properties of an instrument that aims to identify the features that may enhance the quality and impact of collaborative quality-improvement approaches. The instrument can be used as a measurement instrument to retrospectively collect information about perceived determinants of success. In addition, it can be prospectively applied as a checklist to guide initiators, facilitators, and participants of QICs, with information about how to perform or participate in a collaborative with theoretically optimal chances of success. Such information can be used to improve collaboratives. METHODS: We developed an instrument with content validity based on literature and the opinions of QIC experts. We collected data from 144 healthcare professionals in 44 multidisciplinary improvement teams participating in two QICs and used exploratory factor analysis to assess the construct validity. We used Cronbach's alpha to ascertain the internal consistency. RESULTS: The 50-item instrument we developed reflected expert-opinion-based determinants of success in a QIC. We deleted nine items after item reduction. On the basis of the factor analysis results, one item was dropped, which resulted in a 40-item questionnaire. Exploratory factor analysis showed that a three-factor model provided the best fit. The components were labeled 'sufficient expert team support', 'effective multidisciplinary teamwork', and 'helpful collaborative processes'. Internal consistency reliability was excellent (alphas between .85 and .89). CONCLUSIONS: This newly developed instrument seems a promising tool for providing healthcare workers and policy makers with useful information about determinants of success in QICs. The psychometric properties of the instrument are satisfactory and warrant application either as an objective measure or as a checklist. TI - Factors influencing success in quality-improvement collaboratives: development and psychometric testing of an instrument. EP - 84 SN - 1748-5908 SP - 84 JF - Implementation Science VL - vol. 5 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/88630/88630.pdf?sequence=1 ER - TY - JOUR AU - Schouten, L.M.T. AU - Hulscher, M.E.J.L. AU - Everdingen, J.J. van AU - Huijsman, R. AU - Niessen, L.W. AU - Grol, R.P.T.M. PY - 2010 UR - https://hdl.handle.net/2066/89239 AB - ABSTRACT: INTRODUCTION: This study examined the short- and long-term effects of a quality improvement collaborative on patient outcomes, professional performance, and structural aspects of chronic care management of type 2 diabetes in an integrated care setting. METHODS: Controlled pre- and post-intervention study assessing patient outcomes (hemoglobin A1c, cholesterol, blood pressure, weight, blood lipid levels, and smoking status), professional performance (guideline adherence), and structural aspects of chronic care management from baseline up to 24 months. Analyses were based on 1,861 patients with diabetes in six intervention and nine control regions representing 37 general practices and 13 outpatient clinics. RESULTS: Modest but significant improvement was seen in mean systolic blood pressure (decrease by 4.0 mm Hg versus 1.6 mm Hg) and mean high density lipoprotein levels (increase by 0.12 versus 0.03 points) at two-year follow up. Positive but insignificant differences were found in hemoglobin A1c (0.3%), cholesterol, and blood lipid levels. The intervention group showed significant improvement in the percentage of patients receiving advice and instruction to examine feet, and smaller reductions in the percentage of patients receiving instruction to monitor blood glucose and visiting a dietician annually. Structural aspects of self-management and decision support also improved significantly. CONCLUSIONS: At a time of heightened national attention toward diabetes care, our results demonstrate a modest benefit of participation in a multi-institutional quality improvement collaborative focusing on integrated, patient-centered care. The effects persisted for at least 12 months after the intervention was completed. TRIAL NUMBER: http://clinicaltrials.gov Identifier: NCT 00160017. TI - Short- and long-term effects of a quality improvement collaborative on diabetes management. EP - 94 SN - 1748-5908 SP - 94 JF - Implementation Science VL - vol. 5 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/89239/89239.pdf?sequence=1 ER - TY - JOUR AU - Wensing, M.J.P. AU - Lieshout, J. van AU - Koetsenruiter, J. AU - Reeves, D. PY - 2010 UR - https://hdl.handle.net/2066/88018 AB - BACKGROUND: Information exchange networks for chronic illness care may influence the uptake of innovations in patient care. Valid and feasible methods are needed to document and analyse information exchange networks in healthcare settings. This observational study aimed to examine the usefulness of methods to study information exchange networks in primary care practices, related to chronic heart failure, diabetes and chronic obstructive pulmonary disease. METHODS: The study was linked to a quality improvement project in the Netherlands. All health professionals in the practices were asked to complete a short questionnaire that documented their information exchange relations. Feasibility was determined in terms of response rates and reliability in terms of reciprocity of reports of receiving and providing information. For each practice, a number of network characteristics were derived for each of the chronic conditions. RESULTS: Ten of the 21 practices in the quality improvement project agreed to participate in this network study. The response rates were high in all but one of the participating practices. For the analysis, we used data from 67 health professionals from eight practices. The agreement between receiving and providing information was, on average, 65.6%. The values for density, centralization, hierarchy, and overlap of the information exchange networks showed substantial variation between the practices as well as between the chronic conditions. The most central individual in the information exchange network could be a nurse or a physician. CONCLUSIONS: Further research is needed to refine the measure of information networks and to test the impact of network characteristics on the uptake of innovations. TI - Information exchange networks for chronic illness care in primary care practices: an observational study. EP - 3 SN - 1748-5908 SP - 3 JF - Implementation Science VL - vol. 5 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/88018/88018.pdf?sequence=1 ER - TY - JOUR AU - Freund, T. AU - Wensing, M.J.P. AU - Mahler, C. AU - Gensichen, J. AU - Erler, A. AU - Beyer, M. AU - Gerlach, F.M. AU - Szecsenyi, J. AU - Peters-Klimm, F. PY - 2010 UR - https://hdl.handle.net/2066/88513 AB - ABSTRACT: BACKGROUND: Complex care management is seen as an approach to face the challenges of an ageing society with increasing numbers of patients with complex care needs. The Medical Research Council in the United Kingdom has proposed a framework for the development and evaluation of complex interventions that will be used to develop and evaluate a primary care-based complex care management program for chronically ill patients at high risk for future hospitalization in Germany. METHODS AND DESIGN: We present a multi-method procedure to develop a complex care management program to implement interventions aimed at reducing potentially avoidable hospitalizations for primary care patients with type 2 diabetes mellitus, chronic obstructive pulmonary disease, or chronic heart failure and a high likelihood of hospitalization. The procedure will start with reflection about underlying precipitating factors of hospitalizations and how they may be targeted by the planned intervention (pre-clinical phase). An intervention model will then be developed (phase I) based on theory, literature, and exploratory studies (phase II). Exploratory studies are planned that entail the recruitment of 200 patients from 10 general practices. Eligible patients will be identified using two ways of 'case finding': software based predictive modelling and physicians' proposal of patients based on clinical experience. The resulting subpopulations will be compared regarding healthcare utilization, care needs and resources using insurance claims data, a patient survey, and chart review. Qualitative studies with healthcare professionals and patients will be undertaken to identify potential barriers and enablers for optimal performance of the complex care management program. DISCUSSION: This multi-method procedure will support the development of a primary care-based care management program enabling the implementation of interventions that will potentially reduce avoidable hospitalizations. TI - Development of a primary care-based complex care management intervention for chronically ill patients at high risk for hospitalization: a study protocol. EP - 70 SN - 1748-5908 SP - 70 JF - Implementation Science VL - vol. 5 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/88513/88513.pdf?sequence=1 ER - TY - JOUR AU - Dekker, N. AU - Hermens, R.P.M.G. AU - Elwyn, G. AU - Weijden, G.D.E.M. van der AU - Nagengast, F.M. AU - Duijvendijk, P. van AU - Salemink, S. AU - Adang, E.M.M. AU - Krieken, J.H.J.M. van AU - Ligtenberg, M.J.L. AU - Hoogerbrugge-van der Linden, N. PY - 2010 UR - https://hdl.handle.net/2066/88114 AB - BACKGROUND: Individuals with multiple relatives with colorectal cancer (CRC) and/or a relative with early-onset CRC have an increased risk of developing CRC. They are eligible for preventive measures, such as surveillance by regular colonoscopy and/or genetic counselling. Currently, most at-risk individuals do not follow the indicated follow-up policy. In a new guideline on familial and hereditary CRC, clinicians have new tasks in calculating, interpreting, and communicating familial CRC risk. This will lead to better recognition of individuals at an increased familial CRC risk, enabling them to take effective preventive measures. This trial compares two implementation strategies (a common versus an intensive implementation strategy), focussing on clinicians' risk calculation, interpretation, and communication, as well as patients' uptake of the indicated follow-up policy. METHODS: A clustered randomized controlled trial including an effect, process, and cost evaluation will be conducted in eighteen hospitals. Nine hospitals in the control group will receive the common implementation strategy (i.e., dissemination of the guideline). In the intervention group, an intensive implementation strategy will be introduced. Clinicians will receive education and tools for risk calculation, interpretation, and communication. Patients will also receive these tools, in addition to patient decision aids. The effect evaluation includes assessment of the number of patients for whom risk calculation, interpretation, and communication is performed correctly, and the number of patients following the indicated follow-up policy. The actual exposure to the implementation strategies and users' experiences will be assessed in the process evaluation. In a cost evaluation, the costs of the implementation strategies will be determined. DISCUSSION: The results of this study will help determine the most effective method as well as the costs of improving the recognition of individuals at an increased familial CRC risk. It will provide insight into the experiences of both patients and clinicians with these strategies.The knowledge gathered in this study can be used to improve the recognition of familial and hereditary CRC at both the national and international level, and will serve as an example to improve care for patients and their relatives worldwide. Our results may also be useful in improving healthcare in other diseases. TRIAL REGISTRATION: ClinicalTrials.gov NCT00929097. TI - Improving calculation, interpretation and communication of familial colorectal cancer risk: protocol for a randomized controlled trial. EP - 6 SN - 1748-5908 IS - iss. 28 january SP - 6 JF - Implementation Science VL - vol. 5 DO - https://doi.org/10.1186/1748-5908-5-6 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/88114/88114.pdf?sequence=1 ER - TY - JOUR AU - Weijden, G.D.E.M. van der AU - Légaré, F. AU - Boivin, A. AU - Burgers, J.S. AU - Veenendaal, H. van AU - Stiggelbout, A.M. AU - Faber, M.J. AU - Elwyn, G. PY - 2010 UR - https://hdl.handle.net/2066/88291 AB - BACKGROUND: Clinical practice guidelines are largely conceived as tools that will inform health professionals' decisions rather than foster patient involvement in decision making. The time now seems right to adapt clinical practice guidelines in such a way that both the professional's perspective as care provider and the patients' preferences and characteristics are being weighed equally in the decision-making process. We hypothesise that clinical practice guidelines can be adapted to facilitate the integration of individual patients' preferences in clinical decision making. This research protocol asks two questions: How should clinical practice guidelines be adapted to elicit patient preferences and to support shared decision making? What type of clinical decisions are perceived as most requiring consideration of individual patients' preferences rather than promoting a single best choice? METHODS: Stakeholders' opinions and ideas will be explored through an 18-month qualitative study. Data will be collected from in-depth individual interviews. A purposive sample of 20 to 25 key-informants will be selected among three groups of stakeholders: health professionals using guidelines (e.g., physicians, nurses); experts at the macro- and meso-level, including guideline and decision aids developers, policy makers, and researchers; and patient representatives. Ideas and recommendations expressed by stakeholders will be prioritized by nominal group technique in expert meetings. DISCUSSION: One-for-all guidelines do not account for differences in patients' characteristics and for their preferences for medical interventions and health outcomes, suggesting a need for flexible guidelines that facilitate patient involvement in clinical decision making. The question is how this can be achieved. This study is not about patient participation in guideline development, a closely related and important issue that does not however substitute for, or guarantee individual patient involvement in clinical decisions. The study results will provide the needed background for recommendations about potential effective and feasible strategies to ensure greater responsiveness of clinical practice guidelines to individual patient's preferences in clinical decision-making. TI - How to integrate individual patient values and preferences in clinical practice guidelines? A research protocol. EP - 10 SN - 1748-5908 SP - 10 JF - Implementation Science VL - vol. 5 DO - https://doi.org/10.1186/1748-5908-5-56 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/88291/88291.pdf?sequence=1 ER - TY - JOUR AU - Harmsen, M. AU - Gaal, S. AU - Dulmen, A.M. van AU - Feijter, E.P. de AU - Giesen, P.H.J. AU - Jacobs, A. AU - Martijn, L.M. AU - Mettes, T.G.P.H. AU - Verstappen, W.H.J.M. AU - Nijhuis-van der Sanden, M.W.G. AU - Wensing, M.J.P. PY - 2010 UR - https://hdl.handle.net/2066/89811 AB - ABSTRACT: BACKGROUND: Insight into the frequency and seriousness of potentially unsafe situations may be the first step towards improving patient safety. Most patient safety attention has been paid to patient safety in hospitals. However, in many countries, patients receive most of their healthcare in primary care settings. There is little concrete information about patient safety in primary care in the Netherlands. The overall aim of this study was to provide insight into the current patient safety issues in Dutch general practices, out-of-hours primary care centres, general dental practices, midwifery practices, and allied healthcare practices. The objectives of this study are: to determine the frequency, type, impact, and causes of incidents found in the records of primary care patients; to determine the type, impact, and causes of incidents reported by Dutch healthcare professionals; and to provide insight into patient safety management in primary care practices. DESIGN AND METHODS: The study consists of three parts: a retrospective patient record study of 1,000 records per practice type was conducted to determine the frequency, type, impact, and causes of incidents found in the records of primary care patients (objective one); a prospective component concerns an incident-reporting study in each of the participating practices, during two successive weeks, to determine the type, impact, and causes of incidents reported by Dutch healthcare professionals (objective two); to provide insight into patient safety management in Dutch primary care practices (objective three), we surveyed organizational and cultural items relating to patient safety. We analysed the incidents found in the retrospective patient record study and the prospective incident-reporting study by type of incident, causes (Eindhoven Classification Model), actual harm (severity-of-outcome domain of the International Taxonomy of Medical Errors in Primary Care), and probability of severe harm or death. DISCUSSION: To estimate the frequency of incidents was difficult. Much depended on the accuracy of the patient records and the professionals' consensus about which types of adverse events have to be recognized as incidents. TI - Patient safety in Dutch primary care: a study protocol. EP - 50 SN - 1748-5908 SP - 50 JF - Implementation Science VL - vol. 5 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/89811/89811.pdf?sequence=1 ER - TY - JOUR AU - Luitjes, S.H. AU - Wouters, M.G.A.J. AU - Franx, A. AU - Scheepers, H.C.J. AU - Coupe, V.M. AU - Wollersheim, H.C.H. AU - Steegers, E.A.P. AU - Heringa, M.P. AU - Hermens, R.P.M.G. AU - Tulder, M.W. van PY - 2010 UR - https://hdl.handle.net/2066/89141 AB - ABSTRACT: BACKGROUND: Hypertensive disease in pregnancy remains the leading cause of maternal mortality in the Netherlands. Seventeen percent of the clinical pregnancies are complicated by hypertension and 2% by preeclampsia. The Dutch Society of Obstetrics and Gynaecology (NVOG) has developed evidence-based guidelines on the management of hypertension in pregnancy and chronic hypertension. Previous studies showed a low adherence rate to other NVOG guidelines and a large variation in usual care in the different hospitals. An explanation is that the NVOG has no general strategy of practical implementation and evaluation of its guidelines. The development of an effective and cost effective implementation strategy to improve adherence to the guidelines on hypertension in pregnancy is needed. METHODS/DESIGN: The objective of this study is to assess the cost effectiveness of an innovative implementation strategy of the NVOG guidelines on hypertension including a computerised decision support system (BOS) compared to a common strategy of professional audit and feedback. A cluster randomised controlled trial with an economic evaluation alongside will be performed. Both pregnant women who develop severe hypertension or pre-eclampsia and professionals involved in the care for these women will participate. The main outcome measures are a combined rate of major maternal complications and process indicators extracted from the guidelines. A total of 472 patients will be included in both groups. For analysis, descriptive as well as regression techniques will be used. A cost effectiveness and cost utility analysis will be performed according to the intention-to-treat principle and from a societal perspective. Cost effectiveness ratios will be calculated using bootstrapping techniques. TI - Study protocol: Cost effectiveness of two strategies to implement the NVOG guidelines on hypertension in pregnancy: An innovative strategy including a computerised decision support system compared to a common strategy of professional audit and feedback, a randomized controlled trial. EP - 68 SN - 1748-5908 SP - 68 JF - Implementation Science VL - vol. 5 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/89141/89141.pdf?sequence=1 ER - TY - JOUR AU - Helvoort-Postulart, D. van AU - Weijden, G.D.E.M. van der AU - Dellaert, B.G. AU - Kok, M. de AU - Meyenfeldt, M.F. von AU - Dirksen, C.D. PY - 2009 UR - https://hdl.handle.net/2066/80094 AB - ABSTRACT: BACKGROUND: The potential barriers and facilitators to change should guide the choice of implementation strategy. Implementation researchers believe that existing methods for the evaluation of potential barriers and facilitators are not satisfactory. Discrete choice experiments (DCE) are relatively new in the health care sector to investigate preferences, and may be of value in the field of implementation research. The objective of our study was to investigate the complementary value of DCE for the evaluation of barriers and facilitators in implementation research. METHODS: Clinical subject was the implementation of the guideline for breast cancer surgery in day care. We identified 17 potential barriers and facilitators to the implementation of this guideline. We used a traditional questionnaire that was made up of statements about the potential barriers and facilitators. Respondents answered 17 statements on a five-point scale ranging from one (fully disagree) to five (fully agree). The potential barriers and facilitators were included in the DCE as decision attributes. Data were gathered among anaesthesiologists, surgical oncologists, and breast care nurses by means of a paper-and-pencil questionnaire. RESULTS: The overall response was 10%. The most striking finding was that the responses to the traditional questionnaire hardly differentiated between barriers. Forty-seven percent of the respondents thought that DCE is an inappropriate method. These respondents considered DCE too difficult and too time-consuming. Unlike the traditional questionnaire, the results of a DCE provide implementation researchers and clinicians with a relative attribute importance ranking that can be used to prioritize potential barriers and facilitators to change, and hence to better fine-tune the implementation strategies to the specific problems and challenges of a particular implementation process. CONCLUSION: The results of our DCE and traditional questionnaire would probably lead to different implementation strategies. Although there is no 'gold standard' for prioritising potential barriers and facilitators to the implementation of change, theoretically, DCE would be the method of choice. However, the feasibility of using DCE was less favourable. Further empirical applications should investigate whether DCE can really make a valuable contribution to the implementation science. TI - Investigating the complementary value of discrete choice experiments for the evaluation of barriers and facilitators in implementation research: a questionnaire survey. EP - 10 SN - 1748-5908 SP - 10 JF - Implementation Science VL - vol. 4 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/80094/80094.pdf?sequence=1 ER - TY - JOUR AU - Goderis, G. AU - Borgermans, L.D.A. AU - Mathieu, C. AU - Broeke, C. Van Den AU - Hannes, K. AU - Heyrman, J. AU - Grol, R.P.T.M. PY - 2009 UR - https://hdl.handle.net/2066/80434 AB - ABSTRACT: 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 relationship. TI - Barriers and facilitators to evidence based care of type 2 diabetes patients: experiences of general practitioners participating to a quality improvement program. EP - 41 SN - 1748-5908 SP - 41 JF - Implementation Science VL - vol. 4 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/80434/80434.pdf?sequence=1 ER - TY - JOUR AU - Elwyn, G. AU - Frosch, D. AU - Rollnick, S. PY - 2009 UR - https://hdl.handle.net/2066/80919 AB - ABSTRACT: BACKGROUND: There is increasing interest in interventions that can support patients who face difficult decisions and individuals who need to modify their behaviour to achieve better outcomes. Evidence for effectiveness is used to categorise patients care. Effective care is where evidence of benefit outweighs harm: patients should always receive this type of care, where indicated. Preference-sensitive care describes a situation where the evidence for the superiority of one treatment over another is either not available or does not allow differentiation; in this situation, there are two or more valid approaches, and the best choice depends on how individuals value the risks and benefits of treatments. DISCUSSION: Preference-sensitive decisions are defined by equipoise: situations where options need to be deliberated. Moreover, where both healthcare professionals and patients agree that equipoise exists, situations may be regarded as having 'dual equipoise'. Such conditions are ideal for shared decision making. However, there are many situations in medicine where dual equipoise does not exist, where health professionals hold the view that scientific evidence for benefit strongly outweighs harm. This is often the case where people suffer from chronic conditions, and where behaviour change is recommended to improve outcomes. However, some patients, are either ambivalent or find it difficult to sustain optimal behaviours, i.e., patients will be in varying degrees of equipoise. Therefore, situations where dual equipoise exists (or not) help to clarify the definitions of two classes of support, namely, decision and behaviour change support interventions. Decision support interventions help people think about choices they face; they describe where and why choice exists, in short, conditions of dual equipoise; they provide information about options, including, where reasonable, the option of taking no action. These interventions help people to deliberate, independently or in collaboration with others, about options by considering relevant attributes; they support people to forecast how they might feel about short, intermediate, and long-term outcomes that have relevant consequences, in ways that help the process of constructing preferences and eventual decision making appropriate to their individual situation. Whereas, behavioural support interventions describe, justify, and recommend actions that, over time, lead to predictable outcomes over short, intermediate, and long-term timeframes, and that have relevant and important consequences for those who are considering behaviour change. SUMMARY: Decision and behaviour support interventions have divergent aims, different relationships to equipoise, and form two classes of interventions. TI - Dual equipoise shared decision making: definitions for decision and behaviour support interventions. EP - 75 SN - 1748-5908 SP - 75 JF - Implementation Science VL - vol. 4 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/80919/80919.pdf?sequence=1 ER - TY - JOUR AU - Wensing, M.J.P. AU - Ludt, S. AU - Campbell, S.M. AU - Lieshout, J. van AU - Volbracht, E. AU - Grol, R.P.T.M. PY - 2009 UR - https://hdl.handle.net/2066/80788 TI - European Practice Assessment of Cardiovascular risk management (EPA Cardio): protocol of an international observational study in primary care. EP - 3 SN - 1748-5908 IS - iss. 1 SP - 3 JF - Implementation Science VL - vol. 4 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/80788/80788.pdf?sequence=1 ER - TY - JOUR AU - Trietsch, J. AU - Weijden, G.D.E.M. van der AU - Verstappen, W.H.J.M. AU - Janknegt, R. AU - Muijrers, P.E. AU - Winkens, R.A.G. AU - Steenkiste, B.C. van AU - Grol, R.P.T.M. AU - Metsemakers, J.F.M. PY - 2009 UR - https://hdl.handle.net/2066/81599 AB - ABSTRACT: BACKGROUND: 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? METHODS: 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. DISCUSSION: 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. TRIAL REGISTRATION: Nederlands Trial Register ISRCTN40008171. TI - 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. EP - 6 SN - 1748-5908 SP - 6 JF - Implementation Science VL - vol. 4 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/81599/81599.pdf?sequence=1 ER - TY - JOUR AU - Eccles, M.P. AU - Hrisos, S. AU - Francis, J.J. AU - Steen, N AU - Bosch, M.C. AU - Johnston, M. PY - 2009 UR - https://hdl.handle.net/2066/80339 TI - Can the collective intentions of individual professionals within healthcare teams predict the team's performance: developing methods and theory. EP - 24 SN - 1748-5908 SP - 24 JF - Implementation Science VL - vol. 4 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/80339/80339.pdf?sequence=1 ER - TY - JOUR AU - Lugtenberg, M. AU - Zegers-van Schaick, J.M. AU - Westert, G.P. AU - Burgers, J.S. PY - 2009 UR - https://hdl.handle.net/2066/79840 AB - ABSTRACT: BACKGROUND: Despite wide distribution and promotion of clinical practice guidelines, adherence among Dutch general practitioners (GPs) is not optimal. To improve adherence to guidelines, an analysis of barriers to implementation is advocated. Because different recommendations within a guideline can have different barriers, in this study we focus on key recommendations rather than guidelines as a whole, and explore the barriers to implementation perceived by Dutch GPs. METHODS: A qualitative study using six focus groups was conducted, in which 30 GPs participated, with an average of seven per session. Fifty-six key recommendations were derived from twelve national guidelines. In each focus group, barriers to the implementation of the key recommendations of two clinical practice guidelines were discussed. Focus group discussions were audiotaped and transcribed verbatim. Data was analysed by using an existing framework of barriers. RESULTS: The barriers varied largely within guidelines, with each key recommendation having a unique pattern of barriers. The most perceived barriers were lack of agreement with the recommendations due to lack of applicability or lack of evidence (68% of key recommendations), environmental factors such as organisational constraints (52%), lack of knowledge regarding the guideline recommendations (46%), and guideline factors such as unclear or ambiguous guideline recommendations (43%). CONCLUSION: Our study findings suggest a broad range of barriers. As the barriers largely differ within guidelines, tailored and barrier-driven implementation strategies focusing on key recommendations are needed to improve adherence in practice. In addition, guidelines should be more transparent concerning the underlying evidence and applicability, and further efforts are needed to address complex issues such as comorbidity in guidelines. Finally, it might be useful to include focus groups in continuing medical education as an innovative medium for guideline education and implementation. TI - Why don't physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners. EP - 54 SN - 1748-5908 SP - 54 JF - Implementation Science VL - vol. 4 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/79840/79840.pdf?sequence=1 ER - TY - JOUR AU - May, C.R. AU - Mair, F. AU - Finch, T. AU - Macfarlane, A. AU - Dowrick, C. AU - Treweek, S. AU - Rapley, T. AU - Ballini, L. AU - Ong, B.N. AU - Rogers, A. AU - Murray, E. AU - Elwyn, G. AU - Légaré, F. AU - Gunn, J. AU - Montori, V.M. PY - 2009 UR - https://hdl.handle.net/2066/80316 AB - ABSTRACT: BACKGROUND: Theories are important tools in the social and natural sciences. The methods by which they are derived are rarely described and discussed. Normalization Process Theory explains how new technologies, ways of acting, and ways of working become routinely embedded in everyday practice, and has applications in the study of implementation processes. This paper describes the process by which it was built. METHODS: Between 1998 and 2008, we developed a theory. We derived a set of empirical generalizations from analysis of data collected in qualitative studies of healthcare work and organization. We developed an applied theoretical model through analysis of empirical generalizations. Finally, we built a formal theory through a process of extension and implication analysis of the applied theoretical model. RESULTS: Each phase of theory development showed that the constructs of the theory did not conflict with each other, had explanatory power, and possessed sufficient robustness for formal testing. As the theory developed, its scope expanded from a set of observed regularities in data with procedural explanations, to an applied theoretical model, to a formal middle-range theory. CONCLUSION: Normalization Process Theory has been developed through procedures that were properly sceptical and critical, and which were opened to review at each stage of development. The theory has been shown to merit formal testing. TI - Development of a theory of implementation and integration: Normalization Process Theory. EP - 29 SN - 1748-5908 SP - 29 JF - Implementation Science VL - vol. 4 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/80316/80316.pdf?sequence=1 ER - TY - JOUR AU - Frosch, D. AU - Légaré, F. AU - Fishbein, M. AU - Elwyn, G. PY - 2009 UR - https://hdl.handle.net/2066/79881 AB - ABSTRACT: BACKGROUND: A growing body of literature documents the efficacy of decision support interventions (DESI) in helping patients make informed clinical decisions. DESIs are frequently described as an adjunct to shared decision-making between a patient and healthcare provider, however little is known about the effects of DESIs on patients' interactional behaviors-whether or not they promote the involvement of patients in decisions. DISCUSSION: Shared decision-making requires not only a cognitive understanding of the medical problem and deliberation about the potential options to address it, but also a number of communicative behaviors that the patient and physician need to engage in to reach the goal of making a shared decision. Theoretical models of behavior can guide both the identification of constructs that will predict the performance or non-performance of specific behaviors relevant to shared decision-making, as well as inform the development of interventions to promote these specific behaviors. We describe how Fishbein's Integrative Model (IM) of behavior can be applied to the development and evaluation of DESIs. There are several ways in which the IM could be used in research on the behavioral effects of DESIs. An investigator could measure the effects of an intervention on the central constructs of the IM - attitudes, normative pressure, self-efficacy, and intentions related to communication behaviors relevant to shared decision-making. However, if one were interested in the determinants of these domains, formative qualitative research would be necessary to elicit the salient beliefs underlying each of the central constructs. Formative research can help identify potential targets for a theory-based intervention to maximize the likelihood that it will influence the behavior of interest or to develop a more fine-grained understanding of intervention effects. SUMMARY: Behavioral theory can guide the development and evaluation of DESIs to increase the likelihood that these will prepare patients to play a more active role in the decision-making process. Self-reported behavioral measures can reduce the measurement burden for investigators and create a standardized method for examining and reporting the determinants of communication behaviors necessary for shared decision-making. TI - Adjuncts or adversaries to shared decision-making? Applying the Integrative Model of behavior to the role and design of decision support interventions in healthcare interactions. EP - 73 SN - 1748-5908 SP - 73 JF - Implementation Science VL - vol. 4 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/79881/79881.pdf?sequence=1 ER - TY - JOUR AU - Légaré, F. AU - Stewart, M. AU - Frosch, D. AU - Grimshaw, J. AU - Labrecque, M. AU - Magnan, M. AU - Ouimet, M. AU - Rousseau, M. AU - Stacey, D. AU - Weijden, G.D.E.M. van der AU - Elwyn, G. PY - 2009 UR - https://hdl.handle.net/2066/80882 AB - ABSTRACT: BACKGROUND: While the evidence suggests that the way physicians provide information to patients is crucial in helping patients decide upon a course of action, the field of knowledge translation and exchange (KTE) is silent about how the physician and the patient influence each other during clinical interactions and decision-making. Consequently, based on a novel relationship-centered model, EXACKTE2 (EXploiting the clinicAl Consultation as a Knowledge Transfer and Exchange Environment), this study proposes to assess how patients and physicians influence each other in consultations. METHODS: We will employ a cross-sectional study design involving 300 pairs of patients and family physicians from two primary care practice-based research networks. The consultation between patient and physician will be audio-taped and transcribed. Following the consultation, patients and physicians will complete a set of questionnaires based on the EXACKTE2 model. All questionnaires will be similar for patients and physicians. These questionnaires will assess the key concepts of our proposed model based on the essential elements of shared decision-making (SDM): definition and explanation of problem; presentation of options; discussion of pros and cons; clarification of patient values and preferences; discussion of patient ability and self-efficacy; presentation of doctor knowledge and recommendation; and checking and clarifying understanding. Patients will be contacted by phone two weeks later and asked to complete questionnaires on decisional regret and quality of life. The analysis will be conducted to compare the key concepts in the EXACKTE2 model between patients and physicians. It will also allow the assessment of how patients and physicians influence each other in consultations. DISCUSSION: Our proposed model, EXACKTE2, is aimed at advancing the science of KTE based on a relationship process when decision-making has to take place. It fosters a new KTE paradigm by putting forward a relationship-centered perspective and has the potential to reveal unknown mechanisms that underline effective KTE in clinical contexts. This will result in better understanding of the mechanisms that may promote a new generation of knowledge transfer strategies. TI - EXACKTE2: Exploiting the clinical consultation as a knowledge transfer and exchange environment: a study protocol. EP - 14 SN - 1748-5908 SP - 14 JF - Implementation Science VL - vol. 4 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/80882/80882.pdf?sequence=1 ER - TY - JOUR AU - Légaré, F. AU - Boivin, A. AU - Weijden, G.D.E.M. van der AU - Packenham, C. AU - Tapp, S. AU - Burgers, J.S. PY - 2009 UR - https://hdl.handle.net/2066/81288 AB - ABSTRACT: BACKGROUND: Failure to reconcile patient preferences and values as well as social norms with clinical practice guidelines (CPGs) recommendations may hamper their implementation in clinical practice. However, little is known about patients and public involvement programs (PPIP) in CPGs development and implementation. This study aims at identifying what it is about PPIP that works, in which contexts are PPIP most likely to be effective, and how are PPIP assumed to lead to better CPGs development and implementation. METHODS AND DESIGN: A knowledge synthesis will be conducted in four phases. In phase one, literature on PPIP in CPGs development will be searched through bibliographic databases. A call for bibliographic references and unpublished reports will also be sent via the mailing lists of relevant organizations. Eligible publications will include original qualitative, quantitative, or mixed methods study designs reporting on a PPIP pertaining to CPGs development or implementation. They will also include documents produced by CPGs organizations to describe their PPIP. In phase two, grounded in the program's logic model, two independent reviewers will extract data to collect information on the principal components and activities of PPIP, the resources needed, the contexts in which PPIP were developed and tested, and the assumptions underlying PPIP. Quality assessment will be made for all retained publications. Our literature search will be complemented with interviews of key informants drawn from of a purposive sample of CPGs developers and patient/public representatives. In phase three, we will synthesize evidence from both the publications and interviews data using template content analysis to organize the identified components in a meaningful framework of PPIP theories. During a face-to-face workshop, findings will be validated with different stakeholder and a final toolkit for CPGs developers will be refined. DISCUSSION: The proposed research project will be among the first to explore the PPIP in CPGs development and implementation based on a wide range of publications and key informants interviews. It is anticipated that the results generated by the proposed study will significantly contribute to the improvement of the reconciliation of CPGs with patient preferences and values as well as with social norms. TI - A knowledge synthesis of patient and public involvement in clinical practice guidelines: study protocol. EP - 30 SN - 1748-5908 IS - iss. 4 SP - 30 JF - Implementation Science VL - vol. 4 L1 - https://repository.ubn.ru.nl/bitstream/handle/2066/81288/81288.pdf?sequence=1 ER - TY - JOUR AU - Borgermans, L.D.A. AU - Goderis, G. AU - Broeke, C.V. AU - Mathieu, C. AU - Aertgeerts, B. AU - Verbeke, G. AU - Carbonez, A. AU - Ivanova, A. AU - Grol, R.P.T.M. AU - Heyrman, J. PY - 2008 UR - https://hdl.handle.net/2066/70617 AB - 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