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 - 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 - 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 -