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1.  Human Factors Barriers to the Effective Use of Ten HIV Clinical Reminders 
Objective: Substantial variations in adherence to guidelines for human immunodeficiency virus (HIV) care have been documented. To evaluate their effectiveness in improving quality of care, ten computerized clinical reminders (CRs) were implemented at two pilot and eight study sites. The aim of this study was to identify human factors barriers to the use of these CRs.
Design: Observational study was conducted of CRs in use at eight outpatient clinics for one day each and semistructured interviews were conducted with physicians, pharmacists, nurses, and case managers.
Measurements: Detailed handwritten field notes of interpretations and actions using the CRs and responses to interview questions were used for measurement.
Results: Barriers present at more than one site were (1) workload during patient visits (8 of 8 sites), (2) time to document when a CR was not clinically relevant (8 of 8 sites), (3) inapplicability of the CR due to context-specific reasons (9 of 26 patients), (4) limited training on how to use the CR software for rotating staff (5 of 8 sites) and permanent staff (3 of 8 sites), (5) perceived reduction of quality of provider–patient interaction (3 of 23 permanent staff), and (6) the decision to use paper forms to enable review of resident physician orders prior to order entry (2 of 8 sites).
Conclusion: Six human factors barriers to the use of HIV CRs were identified. Reducing these barriers has the potential to increase use of the CRs and thereby improve the quality of HIV care.
PMCID: PMC305458  PMID: 14527974
2.  Is bowling workload a risk factor for injury to Australian junior cricket fast bowlers? 
British Journal of Sports Medicine  2005;39(11):843-846.
Objectives: To examine whether bowling workload is a risk factor for overuse injury to Australian junior cricket fast bowlers and to evaluate the appropriateness of current bowling workload guidelines.
Methods: Forty four male fast bowlers (mean (standard deviation) age 14.7 (1.4) years) were monitored prospectively over the 2002–2003 season. Bowlers completed a daily diary to record bowling workloads and self reported injuries, which were validated by a physiotherapist. Bowling workload prior to the first injury (for those bowlers who were injured) was compared to workload across the whole season for uninjured bowlers.
Results: Eleven (25%) bowlers reported an overuse-type injury, with seven of these sustaining a back injury. Injured bowlers had been bowling significantly more frequently than uninjured bowlers (median number of days since the previous bowling day: 3.2 v 3.9 days, Mann-Whitney U = 105.0, p = 0.038). Compared with bowlers with an average of ⩾3.5 rest days between bowling, bowlers with an average of <3.5 rest days were at a significantly increased risk of injury (risk ratio (RR) = 3.1, 95% confidence interval (CI) 1.1 to 8.9). There were also trends towards an increased risk of injury for those who bowled an average of ⩾2.5 days per week (RR = 2.5, 95% CI 0.9 to 7.4) or ⩾50 deliveries per day (RR = 2.0, 95% CI 0.7 to 5.4).
Conclusions: This study has identified high bowling workload as a risk factor for overuse injury to junior fast bowlers. Continued research is required to provide scientific evidence for bowling workload guidelines that are age-specific for junior fast bowlers.
PMCID: PMC1725068  PMID: 16244195
3.  Grip on challenging behaviour: a multidisciplinary care programme for managing behavioural problems in nursing home residents with dementia. Study protocol 
Behavioural problems are common in nursing home residents with dementia and they often are burdensome for both residents and nursing staff. In this study, the effectiveness and cost-effectiveness of a new care programme for managing behavioural problems will be evaluated.
The care programme is based on Dutch national guidelines. It will consist of four steps: detection, analysis, treatment and evaluation. A stepped wedge design will be used. A total of 14 dementia special care units will implement the care programme. The primary outcome is behavioural problems. Secondary outcomes will include quality of life, prescription rate of antipsychotics, use of physical restraints and workload and job satisfaction of nursing staff. The effect of the care programme will be estimated using multilevel linear regression analysis. An economic evaluation from a societal perspective will also be carried out.
The care programme is expected to be cost-effective and effective in decreasing behavioural problems, workload of nursing staff and in increasing quality of life of residents.
Trial registration
The Netherlands National Trial Register (NTR). Trial number: NTR 2141
PMCID: PMC3051882  PMID: 21338502
4.  Impact of remuneration on guideline adherence: Empirical evidence in general practice 
Background and objective. Changes in the Dutch GP remuneration system provided the opportunity to study the effects of changes in financial incentives on the quality of care. Separate remuneration systems for publicly insured patients (capitation) and privately insured patients (fee-for-service) were replaced by a combined system of capitation and fee-for-service for all in 2006. The effects of these changes on the quality of care in terms of guideline adherence were investigated. Design and setting. A longitudinal study from 2002 to 2009 using data from patient electronic medical records in general practice. A multilevel (patient and practice) approach was applied to study the effect of changes in the remuneration system on guideline adherence. Subjects. 21 421 to 39 828 patients from 32 to 52 general practices (dynamic panel of GPs). Main outcome measures. Sixteen guideline adherence indicators on prescriptions and referrals for acute and chronic conditions. Results. Guideline adherence increased between 2002 and 2008 by 7% for (formerly) publicly insured patients and 10% for (formerly) privately insured patients. In general, no significant differences in the trends for guideline adherence were found between privately and publicly insured patients, indicating the absence of an effect of the remuneration system on guideline adherence. Adherence to guidelines involving more time investment in terms of follow-up contacts was affected by changes in the remuneration system. For publicly insured patients, GPs showed a higher trend for guideline adherence for guidelines involving more time investment in terms of follow-up contacts compared with privately insured patients. Conclusion. The change in the remuneration system had a limited impact on guideline adherence.
PMCID: PMC3587301  PMID: 23330604
General practice; guideline adherence; quality of care; remuneration system; The Netherlands
5.  Local guidelines for the transfer of women from midwifery unit to obstetric unit during labour in England: a systematic appraisal of their quality 
A proportion of women planning to give birth in a midwifery unit will experience complications during labour that necessitate transfer to an obstetric unit. Local guidelines for the transfer of women in labour have the potential to impact on quality of care and the safety of the transfer process.
To systematically appraise the quality of local NHS guidelines on the transfer of women from midwifery unit to obstetric unit during labour.
Guidelines were requested from all 52 NHS hospital trusts in England with midwifery units. The Appraisal of Guidelines for Research and Evaluation Instrument was used to evaluate the quality of the guidelines received.
Relevant guidelines were received from 34 (65%) trusts. No guidelines scored on the ‘editorial independence’ domain. The mean score on ‘scope and purpose’ (56.2%), concerned with the aims, clinical questions and target patient population of the guideline, was higher than for other domains: ‘clarity and presentation’ (language and format) 45.3%, ‘stakeholder involvement’ (representation of users’ views) 15.3%, ‘rigour of development’ (process used to develop guideline) 15.0%, ‘applicability’ (organisational, behavioural and cost implications of applying guideline) 7.1%. Only three guidelines were recommended for use in clinical practice.
We believe this to be the first systematic appraisal of the quality of local NHS guidelines. Overall these local guidelines were of poor quality. It is not clear whether the quality of these midwifery guidelines is typical of local guidelines in other clinical areas, but this study raises fundamental questions about the appropriate development of high-quality local clinical guidelines.
PMCID: PMC2929588  PMID: 20351156
6.  Cost-effectiveness of monitoring glaucoma patients in shared care: an economic evaluation alongside a randomized controlled trial 
Population aging increases the number of glaucoma patients which leads to higher workloads of glaucoma specialists. If stable glaucoma patients were monitored by optometrists and ophthalmic technicians in a glaucoma follow-up unit (GFU) rather than by glaucoma specialists, the specialists' workload and waiting lists might be reduced.
We compared costs and quality of care at the GFU with those of usual care by glaucoma specialists in the Rotterdam Eye Hospital (REH) in a 30-month randomized clinical trial. Because quality of care turned out to be similar, we focus here on the costs.
Stable glaucoma patients were randomized between the GFU and the glaucoma specialist group. Costs per patient year were calculated from four perspectives: those of patients, the Rotterdam Eye Hospital (REH), Dutch healthcare system, and society. The outcome measures were: compliance to the protocol; patient satisfaction; stability according to the practitioner; mean difference in IOP; results of the examinations; and number of treatment changes.
Baseline characteristics (such as age, intraocular pressure and target pressure) were comparable between the GFU group (n = 410) and the glaucoma specialist group (n = 405).
Despite a higher number of visits per year, mean hospital costs per patient year were lower in the GFU group (€139 vs. €161). Patients' time and travel costs were similar. Healthcare costs were significantly lower for the GFU group (€230 vs. €251), as were societal costs (€310 vs. €339) (p < 0.01). Bootstrap-, sensitivity- and scenario-analyses showed that the costs were robust when varying hospital policy and the duration of visits and tests.
We conclude that this GFU is cost-effective and deserves to be considered for implementation in other hospitals.
PMCID: PMC3006381  PMID: 21083880
7.  Adherence to guidelines on cervical cancer screening in general practice: programme elements of successful implementation. 
BACKGROUND: There is still only limited understanding of whether and why interventions to facilitate the implementation of guidelines for improving primary care are successful. It is therefore important to look inside the 'black box' of the intervention, to ascertain which elements work well or less well. AIM: To assess the associations of key elements of a nationwide multifaceted prevention programme with the successful implementation of cervical screening guidelines in general practice. DESIGN OF STUDY: A nationwide prospective cohort study. SETTING: A random sample of one-third of all 4,758 general practices in The Netherlands (n = 1,586). METHOD: General practitioners (GPs) in The Netherlands were exposed to a two-and-a-half-year nationwide multifaceted prevention programme to improve the adherence to national guidelines for cervical cancer screening. Adherence to guidelines at baseline and after the intervention and actual exposure to programme elements were assessed in the sample using self-administered questionnaires. RESULTS: Both baseline and post-measurement questionnaires were returned by 988 practices (response rate = 62%). No major differences in baseline practice characteristics between study population, non-responders, and all Netherlands practices were observed. After the intervention all practices improved markedly (P<0.001) in their incorporation of nine out of 10 guideline indicators for effective cervical screening into practice. The most important elements for successful implementation were: specific software modules (odds ratios and 95% confidence intervalsfor all nine indicators ranged from OR = 1.85 [95% CI = 1.24-2.77] to OR = 10.2 [95% CI = 7.58-14.1]); two or more 'practice visits' by outreach visitors (ORs and 95% CIs for six indicators ranged from OR = 1.46 [95% CI= 1.01-2.12] to OR = 2.35 [95% CI = 1.63-3.38]); and an educational programme for practice assistants (ORs and 95% CIs for four indicators ranged from OR = 1.57 [95% CI = 1.00-1.92] to OR = 1.90 [95% CI = 1.25-2.88]). CONCLUSION: A multifaceted programme targeting GPs, including facilitating software modules, outreach visits, and educational sessions for PAs, contributes to the successful implementation of national guidelines for cervical screening.
PMCID: PMC1314146  PMID: 11761203
8.  Characteristics of effective clinical guidelines for general practice. 
BACKGROUND: The use of clinical guidelines in general practice is often limited. Research on barriers to guideline adherence usually focuses on attitudinal factors. Factors linked to the guideline itself are much less studied. AIM: To identify characteristics of effective clinical guidelines for general practice, and to explore whether these differ between therapeutic and diagnostic recommendations. DESIGN OF STUDY: Analysis of performance data from an audit study of 200 general practitioners (GPs) in The Netherlands conducted in 1997. SETTING: Panel of 12 GPs in The Netherlands who were familiar with guideline methodology. METHOD: A set of 12 attributes, including six potential facilitators and six potential barriers to guideline use, was formulated. The panel assessed the presence of these attributes in 96 guideline recommendations formulated by the Dutch College of General Practitioners. The attributes of recommendations with high compliance rates (70% to 100%) were compared with those with low compliance rates (0% to 60%). RESULTS: Recommendations with high compliance rates were to a lesser extent those requiring new skills (7% compared with 22% in recommendations with low compliance rates), were less often part of a complex decision tree (12% versus 25%), were more compatible with existing norms and values in practice (87% versus 76%), and more often supported with evidence (47% versus 31%). For diagnostic recommendations, the ease of applying them and the potential (negative) reactions of patients were more relevant than for therapeutic recommendations. CONCLUSION: To bridge the gap between research and practice, the evidence as well as the applicability should be considered when formulating recommendations. If the recommendations are not compatible with existing norms and values, not easy to follow or require new knowledge and skills, appropriate implementation strategies should be designed to ensure change in daily practice.
PMCID: PMC1314503  PMID: 12569898
9.  Adherence to Referral Criteria for Burns in the Emergency Department 
Eplasty  2008;8:e26.
Objective: To audit the referral patterns of burns in an emergency department compared with national referral guidelines. Methods: A retrospective case note audit of patients attending an emergency department with a diagnosis of “burn” in a 1-year period. Results: Only one quarter of the patients were managed according to the suggested national referral criteria for burns. Large and full thickness burns were managed appropriately but those at important anatomical sites and in patients at the extremes of age were managed less well. Conclusion: Increased awareness of the national referral guidelines, along with further education of staff within this department, may improve management of burn injuries. It is likely that referral patterns are similar in other emergency departments and may be improved by training staff in the assessment and management of burns. Increased adherence to the guidelines is likely to improve patient outcome at the expense of increased patient numbers and workloads in regional burns units that have implications for funding and service provision.
PMCID: PMC2380084  PMID: 18536778
10.  An Organized Approach to Improvement in Guideline Adherence for Acute Myocardial Infarction Results With the Get With The Guidelines Quality Improvement Program 
Archives of internal medicine  2008;168(16):1813-1819.
Evidence-based guidelines from the American Heart Association are voluntary, and adherence is highly variable across the country. Get With The Guidelines (GWTG) is a national quality improvement program sponsored and developed by the American Heart Association. The objective of this study was to evaluate whether participation in GWTG is associated with greater adherence to guidelines for coronary artery disease (CAD).
Data on adherence to guidelines were obtained from Hospital Compare, grouping hospitals according to participation in the GWTG-CAD program on January 1, 2004: GWTG-CAD hospitals, n=223; non–GWTG-CAD hospitals, n=3407. The GWTG program uses a patient management tool, education, and benchmarked quality reports to improve guideline adherence. Adherence to 8 national measures, including the use of aspirin and β-blockers early and at discharge and timeline reperfusion, was analyzed. A composite score was also calculated. Multivariable logistic regression was performed for comparing composite adherence rates between groups.
Adherence to the overall Hospital Compare composite measure was higher in GWTG-CAD hospitals than in non–GWTG-CAD hospitals (mean [SD], 89.7% [10.0%] vs 85.0 [15.0%]; absolute increase, 4.7%; P<.001). Adherence to the GWTG-CAD performance measures (PM) composite was also higher (89.5% [11.0%] vs 83.0% [18.0%]; P<.001). In multivariate analysis, GWTG-CAD participation was associated with a modest absolute increase in adherence to the PM composite by 2.52% (95% confidence interval [CI], 0.19%–4.85%). Larger acute myocardial infarction volume by quartile (absolute increase, 14.2%; 95% CI, 12.2%–16.3%), geographic location in the Northeast, and teaching hospital status (absolute increase, 2.87%; 95% CI, 0.43–5.32) were also associated with improved adherence to the PM composite. As a control, evaluation of unrelated quality measures for pneumonia, showed lower adherence among GWTG-CAD participating hospitals (74.8% [7.3%] vs 76.1% [9.7%]; P=.005).
Participation in GWTG-CAD was independently associated with improvements in guideline adherence beyond that associated with public reporting.
PMCID: PMC3086550  PMID: 18779470
11.  Use of medical informatics to implement and develop clinical practice guidelines. 
Western Journal of Medicine  1998;168(3):166-175.
Clinical practice guidelines have enormous potential to improve the quality of and accountability in health care. Making the most of this potential should become easier as guideline developers integrate guidelines within information systems and electronic medical records. A major barrier to such integration is the lack of computing infrastructure in many clinical settings. To successfully implement guidelines in information systems, developers must create more specific recommendations than those that have been required for traditional guidelines. Using reusable software components to create guidelines can make the development of protocols faster and less expensive. In addition, using decision models to produce guidelines enables developers to structure guideline problems systematically, to prioritize information acquisition, to develop site-specific guidelines, and to evaluate the cost-effectiveness of the explicit incorporation of patient preferences into guideline recommendations. Ongoing research provides a foundation for the use of guideline development tools that can help developers tailor guidelines appropriately to their practice settings. This article explores how medical informatics can help clinicians find, use, and create practice guidelines.
PMCID: PMC1304856  PMID: 9549415
12.  Effectiveness of nurse-delivered cardiovascular risk management in primary care: a randomised trial 
A substantial part of cardiovascular disease prevention is delivered in primary care. Special attention should be paid to the assessment of cardiovascular risk factors. According to the Dutch guideline for cardiovascular risk management, the heavy workload of cardiovascular risk management for GPs could be shared with advanced practice nurses.
To investigate the clinical effectiveness of practice nurses acting as substitutes for GPs in cardiovascular risk management after 1 year of follow-up.
Design of study
Prospective pragmatic randomised trial.
Primary care in the south of the Netherlands. Six centres (25 GPs, six nurses) participated.
A total of 1626 potentially eligible patients at high risk for cardiovascular disease were randomised to a practice nurse group (n = 808) or a GP group (n = 818) in 2006. In total, 701 patients were included in the trial. The Dutch guideline for cardiovascular risk management was used as the protocol, with standardised techniques for risk assessment. Changes in the following risk factors after 1 year were measured: lipids, systolic blood pressure, and body mass index. In addition, patients in the GP group received a brief questionnaire.
A larger decrease in the mean level of risk factors was observed in the practice nurse group compared with the GP group. After controlling for confounders, only the larger decrease in total cholesterol in the practice nurse group was statistically significant (P = 0.01, two-sided).
Advanced practice nurses are achieving results, equal to or better than GPs for the management of risk factors. The findings of this study support the involvement of practice nurses in cardiovascular risk management in Dutch primary care.
PMCID: PMC2801783  PMID: 20040167
cardiovascular diseases; general practice; general practitioners; prevention; primary care; risk factors
13.  Quality of cardiovascular disease care in Ontario, Canada: missed opportunities for prevention - a cross sectional study 
Primary care plays a key role in the prevention and management of cardiovascular disease (CVD). We examined primary care practice adherence to recommended care guidelines associated with the prevention and management of CVD for high risk patients.
We conducted a secondary analysis of cross-sectional baseline data collected from 84 primary care practices participating in a large quality improvement initiative in Eastern Ontario from 2008 to 2010. We collected medical chart data from 4,931 patients who either had, or were at high risk of developing CVD to study adherence rates to recommended guidelines for CVD care and to examine the proportion of patients at target for clinical markers such as blood pressure, lipid levels and hemoglobin A1c.
Adherence to preventive care recommendations was poor. Less than 10% of high risk patients received a waistline measurement, half of the smokers received cessation advice, and 7.7% were referred to a smoking cessation program. Gaps in care exist for diabetes and kidney disease as 54.9% of patients with diabetes received recommended hemoglobin-A1c screenings, and only 55.8% received an albumin excretion test. Adherence rates to recommended guidelines for coronary artery disease, hypertension, and dyslipidemia were high (>75%); however <50% of patients were at target for blood pressure or LDL-cholesterol levels (37.1% and 49.7% respectively), and only 59.3% of patients with diabetes were at target for hemoglobin-A1c.
There remain significant opportunities for primary care providers to engage high risk patients in prevention activities such as weight management and smoking cessation. Despite high adherence rates for hypertension, dyslipidemia, and coronary artery disease, a significant proportion of patients failed to meet treatment targets, highlighting the complexity of caring for people with multiple chronic conditions.
Trial Registration
PMCID: PMC3477034  PMID: 22970753
Cardiovascular disease; Primary care; Diabetes; Evidence-based care; Preventive care; Quality of care
14.  Age and Receipt of Guideline-Recommended Medications for Heart Failure: A Nationwide Study of Veterans 
Journal of General Internal Medicine  2011;26(10):1152-1159.
Older patients often receive less guideline-concordant care for heart failure than younger patients.
To determine whether age differences in heart failure care are explained by patient, provider, and health system characteristics and/or by chart-documented reasons for non-adherence to guidelines.
Design and Patients
Retrospective cohort study of 2,772 ambulatory veterans with heart failure and left ventricular ejection fraction <40% from a 2004 nationwide medical record review program (the VA External Peer Review Program).
Main Measures
Ambulatory use of ACE inhibitors, angiotensin receptor blockers (ARBs), and beta blockers.
Among 2,772 patients, mean age was 73 +/− 10 years, 87% received an ACE inhibitor or ARB, and 82% received a beta blocker. When patients with explicit chart-documented reasons for not receiving these drugs were excluded, 95% received an ACE inhibitor or ARB and 89% received a beta blocker. In multivariable analyses controlling for a variety of patient and health system characteristics, the adjusted odds ratio for ACE-inhibitor and ARB use was 0.43 (95% CI 0.24–0.78) for patients age 80 and over vs. those age 50–64 years, and the adjusted odds ratio for beta blocker use was 0.66 (95% CI 0.48–0.93) between the two age groups. The magnitude of these associations was similar but not statistically significant after excluding patients with chart-documented reasons for not prescribing ACE inhibitors or ARBs and beta blockers.
A high proportion of veterans receive guideline-recommended medications for heart failure. Older veterans are consistently less likely to receive these drugs, although these differences were no longer significant when accounting for patients with chart-documented reasons for not prescribing these drugs. Closely evaluating reasons for non-prescribing in older adults is essential to assessing whether non-treatment represents good clinical judgment or missed opportunities to improve care.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1745-2) contains supplementary material, which is available to authorized users.
PMCID: PMC3181303  PMID: 21604076
guideline adherence; heart failure; aging; health services research; quality of care
15.  Implications of the California Nurse Staffing Mandate for Other States 
Health services research  2010;45(4):904-921.
To determine whether nurse staffing in California hospitals, where state mandated minimum nurse to patient ratios are in effect, differs from two states without legislation and whether those differences are associated with nurse and patient outcomes.
Data Sources
Primary survey data from 22,336 hospital staff nurses in California, Pennsylvania, and New Jersey in 2006 and state hospital discharge databases.
Study Design
Nurse workloads are compared across the three states and we examine how nurse and patient outcomes, including patient mortality and failure-to rescue, are affected by the differences in nurse workloads across the hospitals in these states.
Principal Findings
California hospital nurses cared for one less patient on average than nurses in the other states and two fewer patients on medical and surgical units. Lower ratios are associated with significantly lower mortality. When nurses’ workloads were in line with California mandated ratios in all 3 states, nurses’ burnout and job dissatisfaction were lower, and nurses reported consistently better quality of care.
Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California and in other states where they occur.
PMCID: PMC2908200  PMID: 20403061
nurse staffing; California nurse ratios
16.  Implications of the California Nurse Staffing Mandate for Other States 
Health Services Research  2010;45(4):904-921.
To determine whether nurse staffing in California hospitals, where state-mandated minimum nurse-to-patient ratios are in effect, differs from two states without legislation and whether those differences are associated with nurse and patient outcomes.
Data Sources
Primary survey data from 22,336 hospital staff nurses in California, Pennsylvania, and New Jersey in 2006 and state hospital discharge databases.
Study Design
Nurse workloads are compared across the three states and we examine how nurse and patient outcomes, including patient mortality and failure-to-rescue, are affected by the differences in nurse workloads across the hospitals in these states.
Principal Findings
California hospital nurses cared for one less patient on average than nurses in the other states and two fewer patients on medical and surgical units. Lower ratios are associated with significantly lower mortality. When nurses' workloads were in line with California-mandated ratios in all three states, nurses' burnout and job dissatisfaction were lower, and nurses reported consistently better quality of care.
Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California and in other states where they occur.
PMCID: PMC2908200  PMID: 20403061
Nurse staffing; California nurse ratios
17.  Health workers, quality of care, and child health: Simulating the relationships between increases in health staffing and child length 
One in three children globally is stunted in growth. Many of the conditions that promote child stunting are amenable to quality care provided by skilled health workers.
The study uses household and facility data from the Indonesian Family Life Surveys in 1993 and 1997. The first set of multivariate regression models evaluate whether the number of medical doctors (MDs), nurses, and midwives predict quality of care as measured by adherence to clinical guidelines. The second set explains the relationships between quality and length among children less than 36 months. Using the information generated from these two sets of regressions, we simulate the effect of increasing the number of MDs, nurses, and midwives on child length and stunting.
Increases in the number of MDs and nurses predict increases in the quality of care. Higher quality care is associated with child length in centimeters and stunting. Simulations suggest that large health gains among children under 24 months of age result by placing MDs where none are available.
Improvements in child health could be made by increasing the number of qualified health staff. The returns to investing in improvements in human resources for health are high.
PMCID: PMC2819476  PMID: 19147250
Health personnel; Medical staff; Quality of healthcare; Growth; Public policy; Public health
18.  Does the attention General Practitioners pay to their patients' mental health problems add to their workload? A cross sectional national survey 
BMC Family Practice  2006;7:71.
The extra workload induced by patients with mental health problems may sometimes cause GPs to be reluctant to become involved in mental health care. It is known that dealing with patients' mental health problems is more time consuming in specific situations such as in consultations. But it is unclear if GPs who are more often involved in patients' mental health problems, have a higher workload than other GPs. Therefore we investigated the following: Is the attention GPs pay to their patients' mental health problems related to their subjective and objective workload?
Secondary analyses were made using data from the Second Dutch National Survey of General Practice, a cross sectional study conducted in the Netherlands in 2000–2002. A nationally representative selection of 195 GPs from 104 general practices participated in this National Survey. Data from: 1) a GP questionnaire; 2) a detailed log of the GP's time use during a week and; 3) an electronic medical registration system, including all patients' contacts during a year, were used. Multiple regression analyses were conducted with the GP's workload as an outcome measure, and the GP's attention for mental health problems as a predictor. GP, patient, and practice characteristics were included in analyses as potential confounders.
Results show that GPs with a broader perception of their role towards mental health care do not have more working hours or patient contacts than GPs with a more limited perception of their role. Neither are they more exhausted or dissatisfied with the available time. Also the number of patient contacts in which a psychological or social diagnosis is made is not related to the GP's objective or subjective workload.
The GP's attention for a patient's mental health problems is not related to their workload. The GP's extra workload when dealing in a consultation with patients' mental health problems, as is demonstrated in earlier research, is not automatically translated into a higher overall workload. This study does not confirm GPs' complaints that mental health care is one of the components of their job that consumes a lot of their time and energy. Several explanations for these results are discussed.
PMCID: PMC1693554  PMID: 17147799
19.  Patterns of Care in Community-Based Oncology Practices for Anemia Associated With Myelosuppressive Chemotherapy 
Journal of Oncology Practice  2009;5(5):236-243.
Use of erythropoiesis-stimulating agents in the treatment of myelosuppresive chemotherapy–induced anemia has been shown to increase hemoglobin levels and reduce the need for transfusions in patients with cancer.
Adherence to anemia guidelines may improve patient outcomes. The objectives of this retrospective analysis were to examine baseline guideline adherence and patient characteristics associated with receiving treatment for chemotherapy-induced anemia (CIA) in community-based oncology practices.
National guidelines at time of data collection, including those from ASCO, National Comprehensive Cancer Network, and McKesson Corporation (San Francisco, CA), were used to measure adherence. Guidelines recommended treatment with erythropoiesis-stimulating agents (ESAs) or transfusions when hemoglobin (Hb) levels were less than 11 g/dL or from 11 to 12 g/dL with presence of anemia symptoms or risk factors for development of symptomatic anemia. Medical records of patients age 18 years or older receiving myelosuppressive chemotherapy between June 2005 and August 2006 for multiple solid tumors, Hodgkin's lymphoma, or non-Hodgkin's lymphoma at 47 oncology practices were abstracted.
There were 2,874 patients receiving chemotherapy (mean age, 62 years; 66% female). The most common malignancies were breast cancer (36.5%), non–small-cell lung cancer (19%), and colorectal cancer (18%). Treatment patterns in 2,175 (75.7%) of 2,874 patients followed guideline recommendations. In 310 patients (10.8%), treatment was not initiated when guidelines recommended it, and in 389 patients (13.5%), treatment initiated was inconsistent with guideline recommendations. Among patients for whom treatment was recommended, prior chemotherapy and lower Hb levels were associated with higher likelihood of receiving treatment. Patients with colorectal, breast, and head and neck cancer and non-Hodgkin's lymphoma were less likely than patients with other cancers to receive CIA treatment.
The majority of patients received treatment consistent with guidelines. Cancer type, prior chemotherapy, and lower Hb levels were associated with receiving CIA treatment among patients for whom treatment was recommended.
PMCID: PMC2790673  PMID: 20856735
20.  Application of Statistical Process Control Methods to Monitor Guideline Adherence: A Case Study 
Control charts are tools from the field of statistical process control for visualizing the longitudinal development of quality indicators, and detecting whether the underlying process is changing. They have been used in critical care and disease management settings to monitor and improve patient outcomes. This paper investigates the application of control charts to monitor adherence to clinical practice guidelines by healthcare professionals. Data were used from a recent trial on computerized decision support in outpatient cardiac aftercare. Guideline adherence increased in clinics that started using decision support. A gradual drop in adherence was seen in clinics that continued using decision support over a longer period. Control charts are more sensitive to detect changes in adherence than summary comparisons in before-after designs.
PMCID: PMC2656072  PMID: 18999047
21.  Adherence to Stage-Specific Treatment Guidelines for Patients With Colon Cancer 
Journal of Clinical Oncology  2012;30(9):972-979.
Adherence to evidence-based treatment guidelines has been proposed as a measure of cancer care quality. We sought to determine rates of and factors associated with adherence to the National Comprehensive Cancer Network (NCCN) treatment guidelines for colon cancer.
Patients and Methods
Patients within the National Cancer Data Base treated for colon adenocarcinoma (2003 to 2007) were identified. Adherence to stage-specific NCCN guidelines was determined based on disease stage. Hierarchical regression analyses were performed to identify factors predictive of adherence, overtreatment, and undertreatment.
A total of 173,243 patients were included in the final cohort, 123,953 (71%) of whom were treated according to NCCN guidelines. Patients with stage I disease were more likely to receive guideline-based treatment (96%) than patients with stage II (low risk, 66%; high risk, 36%), III (71%), or IV (73%) disease (P < .001). Adherence to consensus-based guidelines increased over time. Factors associated with adherence across all stages included age, Charlson-Deyo comorbidity index score, later year of diagnosis, and insurance status. Among patients with high-risk stage II or stage III disease, older patients with pre-existing comorbidities and patients with lower socioeconomic status were less likely to be offered adjuvant chemotherapy. Among patients with stage I and II disease, young, healthy patients were more likely to be recommended chemotherapy, in discordance with NCCN guidelines.
Significant variation exists in the treatment of colon cancer, particularly in treatment of high-risk stage II and stage III disease. The impact of nonadherence to guidelines on patient outcomes needs to be further elucidated.
PMCID: PMC3341110  PMID: 22355049
22.  What will a primary care led NHS mean for GP workload? The problem of the lack of an evidence base. 
BMJ : British Medical Journal  1997;314(7090):1337-1341.
Ongoing negotiations on the general practitioner contract raise the question of remunerating general practitioners for increased workload resulting from the shift from secondary to primary care. A review of the literature shows that there is little evidence on whether a shift of services from secondary to primary care is responsible for general practitioners' increased workload, and scope for making generalisations is limited. The implication is that general practitioners have little more than anecdotal evidence to support their claims of greatly increased workloads, and there is insufficient evidence to make informed decisions about remunerating general practitioners for the extra work resulting from the changes. Lack of evidence does not, however, mean that there is no problem with workload. It will be increasingly important to identify mechanisms for ensuring that resources follow workload.
PMCID: PMC2126579  PMID: 9158473
23.  Evaluation of the theory-based Quality Improvement in Physical Therapy (QUIP) programme: a one-group, pre-test post-test pilot study 
Guideline adherence in physical therapy is far from optimal, which has consequences for the effectiveness and efficiency of physical therapy care. Programmes to enhance guideline adherence have, so far, been relatively ineffective. We systematically developed a theory-based Quality Improvement in Physical Therapy (QUIP) programme aimed at the individual performance level (practicing physiotherapists; PTs) and the practice organization level (practice quality manager; PQM). The aim of the study was to pilot test the multilevel QUIP programme’s effectiveness and the fidelity, acceptability and feasibility of its implementation.
A one-group, pre-test, post-test pilot study (N = 8 practices; N = 32 PTs, 8 of whom were also PQMs) done between September and December 2009. Guideline adherence was measured using clinical vignettes that addressed 12 quality indicators reflecting the guidelines’ main recommendations. Determinants of adherence were measured using quantitative methods (questionnaires). Delivery of the programme and management changes were assessed using qualitative methods (observations, group interviews, and document analyses). Changes in adherence and determinants were tested in the paired samples T-tests and expressed in effect sizes (Cohen’s d).
Overall adherence did not change (3.1%; p = .138). Adherence to three quality indicators improved (8%, 24%, 43%; .000 ≤ p ≤ .023). Adherence to one quality indicator decreased (−15.7%; p = .004). Scores on various determinants of individual performance improved and favourable changes at practice organizational level were observed. Improvements were associated with the programme’s multilevel approach, collective goal setting, and the application of self-regulation; unfavourable findings with programme deficits. The one-group pre-test post-test design limits the internal validity of the study, the self-selected sample its external validity.
The QUIP programme has the potential to change physical therapy practice but needs considerable revision to induce the ongoing quality improvement process that is required to optimize overall guideline adherence. To assess its value, the programme needs to be tested in a randomized controlled trial.
PMCID: PMC3688482  PMID: 23705912
Guideline implementation; Quality improvement; Multilevel programme; Individual professional; Practice management; Physical therapy
24.  Computerizing guidelines: factors for success. 
Clinical practice guidelines are being touted as a cure for the tension between health care cost and quality. Rather than being just a means of controlling clinicians, guidelines also offer the chance to improve the quality of care by reducing practice variation and adherence to standards of good care. To be operationalized via computers, guidelines must be accepted by the clinicians, who must fully intend to follow them. They must be timely and use available data with minimal additional data entry by clinicians. Finally, they should have a measurable effect and be shown to improve care processes and/or outcomes.
PMCID: PMC2233160  PMID: 8947708
25.  Is the methodological quality of guidelines declining in the US? Comparison of the quality of US Agency for Health Care Policy and Research (AHCPR) guidelines with those published subsequently 
Quality & safety in health care  2003;12(6):428-434.
Objective: To determine whether North American guidelines published subsequent to and in the same topic areas as those developed by the US Agency for Health Care Policy and Research (AHCPR) meet the same methodological criteria.
Study design: A guideline appraisal instrument containing 30 criteria was used to evaluate the methodological quality of the AHCPR guidelines, "updates" of the AHCPR guidelines authored by others, and guidelines that referenced or were adapted from the AHCPR guidelines. The frequency with which the criteria appeared in each guideline was compared and an analysis was performed to determine guidelines with two key features of the ACHPR guidelines—multidisciplinary guideline development panels and systematic reviews of the literature. Data were extracted from the guidelines by one investigator and then checked for accuracy by the other.
Results: Fifty two guidelines identified by broad based searches were evaluated. 50% of the criteria were present in every AHCPR guideline. The AHCPR guidelines scored 80% or more on 24 of the 30 criteria compared with 14 for the "updates" and 11 for those that referenced/adapted the AHCPR guidelines. All of the 17 AHCPR guidelines had both multidisciplinary development panels and systematic reviews of the literature compared with five from the other two categories (p<0.05).
Conclusions: North American guidelines developed subsequent to and in the same topic areas as the AHCPR guidelines are of substantially worse methodological quality and ignore key features important to guideline development. This finding contrasts with previously published conclusions that guideline methodological quality is improving over time.
PMCID: PMC1758044  PMID: 14645758

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