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1.  Retrospective Evaluation of Control Measures for Contacts of Patient with Marburg Hemorrhagic Fever 
Emerging Infectious Diseases  2012;18(7):1107-1114.
Measures had substantial effects on contacts and household members.
After an imported case of Marburg hemorrhagic fever was reported in 2008 in the Netherlands, control measures to prevent transmission were implemented. To evaluate consequences of these measures, we administered a structured questionnaire to 130 contacts classified as either having high-risk or low-risk exposure to body fluids of the case-patient; 77 (59.2%) of 130 contacts responded. A total of 67 (87.0%) of 77 respondents agreed that temperature monitoring and reporting was necessary, significantly more often among high-risk than low-risk contacts (p<0.001). Strict compliance with daily temperature monitoring decreased from 80.5% (62/77) during week 1 to 66.2% (51/77) during week 3. Contacts expressed concern about development of Marburg hemorrhagic fever (58.4%, 45/77) and infecting a family member (40.2%, 31/77). High-risk contacts had significantly higher scores on psychological impact scales (p<0.001) during and after the monitoring period. Public health authorities should specifically address consequences of control measures on the daily life of contacts.
PMCID: PMC3376788  PMID: 22710186
retrospective evaluation; temperature monitoring; control measures; Marburg hemorrhagic fever; Marburg virus; viruses; contacts; daily life; the Netherlands
2.  How to develop a program to increase influenza vaccine uptake among workers in health care settings? 
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.
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.
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.
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.
PMCID: PMC3115899  PMID: 21595877
3.  Barriers to optimal antibiotic use for community‐acquired pneumonia at hospitals: a qualitative study 
Quality & Safety in Health Care  2007;16(2):143-149.
Physician adherence to key recommendations of guidelines for community‐acquired pneumonia (CAP) is often not optimal. A better understanding of factors influencing optimal performance is needed to plan effective change.
The authors used semistructured interviews with care providers in three Dutch medium‐sized hospitals to qualitatively study and understand barriers to appropriate antibiotic use in patients with CAP. They discussed recommendations about the prescription of empirical antibiotic therapy that adheres to the guidelines, timely administration of antibiotics, adjusting antibiotic dosage to accommodate decreased renal function, switching and streamlining therapy, and blood and sputum culturing. The authors then classified the barriers each recommendation faced into categories using a conceptual framework (Cabana).
Eighteen interviews were performed with residents and specialists in pulmonology and internal medicine, with medical microbiologists and a clinical pharmacist. Two additional multidisciplinary small group interviews which included nurses were performed. Each guideline recommendation elicited a different type of barrier. Regarding the choice of guideline‐adherent empirical therapy, treating physicians said that they worried about patient outcome when prescribing narrow‐spectrum antibiotic therapy. Regarding the timeliness of antibiotic administration, barriers such as conflicting guidelines and organisational factors (for example, delayed laboratory results, antibiotics not directly available, lack of time) were reported. Not streamlining therapy after culture results became available was thought to be due to the physicians' attitude of “never change a winning team”.
Efforts to improve the use of antibiotics for patients with CAP should consider the range of barriers that care providers face. Each recommendation meets its own barriers. Interventions to improve adherence should be tailored to these factors.
PMCID: PMC2653154  PMID: 17403764
4.  Evidence for the impact of quality improvement collaboratives: systematic review 
BMJ : British Medical Journal  2008;336(7659):1491-1494.
Objective To evaluate the effectiveness of quality improvement collaboratives in improving the quality of care.
Data sources Relevant studies through Medline, Embase, PsycINFO, CINAHL, and Cochrane databases.
Study selection Two reviewers independently extracted data on topics, participants, setting, study design, and outcomes.
Data synthesis Of 1104 articles identified, 72 were included in the study. Twelve reports representing nine studies (including two randomised controlled trials) used a controlled design to measure the effects of the quality improvement collaborative intervention on care processes or outcomes of care. Systematic review of these nine studies showed moderate positive results. Seven studies (including one randomised controlled trial) reported an effect on some of the selected outcome measures. Two studies (including one randomised controlled trial) did not show any significant effect.
Conclusions The evidence underlying quality improvement collaboratives is positive but limited and the effects cannot be predicted with great certainty. Considering that quality improvement collaboratives seem to play a key part in current strategies focused on accelerating improvement, but may have only modest effects on outcomes at best, further knowledge of the basic components effectiveness, cost effectiveness, and success factors is crucial to determine the value of quality improvement collaboratives.
PMCID: PMC2440907  PMID: 18577559
5.  Control Measures Used during Lymphogranuloma Venereum Outbreak, Europe 
Emerging Infectious Diseases  2008;14(4):573-578.
The degree of preparedness may affect the ability to respond quickly and to control an outbreak.
To assess the response to the reemergence of lymphogranuloma venereum, we conducted a cross-sectional survey by administering a structured questionnaire to representatives from 26 European countries. Responses were received from 18 countries. The ability to respond quickly and the measures used for outbreak detection and control varied. Evidence-based criteria were not consistently used to develop recommendations. We did not develop criteria to determine the effectiveness of the recommendations. The degree of preparedness for an unexpected outbreak, as well as the ability of countries to respond quickly to alerts, varied, which indicates weaknesses in the ability to control an outbreak. More guidance is needed to implement and evaluate control measures used during international outbreaks.
PMCID: PMC2570903  PMID: 18394274
Lymphogranuloma venereum; outbreaks; response; alert; quality; research
6.  Multifaceted support to improve preventive cardiovascular care: a nationwide, controlled trial in general practice. 
BACKGROUND: Multifaceted interventions improve the quality of preventive cardiovascular care in general practice when applied in small-scale research trials. AIM: To test the transferability of observations from research trials on preventive cardiovascular care to a real-world situation and, therefore, evaluate the effectiveness of a nationwide project with a large number of practices. The intervention comprised a combination of conferences, dissemination of manuals, and support from trained non-physicians during outreach visits. DESIGN OF STUDY: A controlled before-and-after trial with two arms: multifaceted support versus no special attention. Analysis after 2 years. SETTING: 617 general practices in The Netherlands. METHOD: Outcomes measures were the compliance rates for 15 indicators. Structure-of-care indicators included the use of reminders, specific computer files, written protocols, and special clinics. Process-of-care indicators included the assessment of modifiable risk factors and use of a minimal contact intervention (MCI) for smoking cessation. Compliance of general practitioners (GPs) was assessed using self-administered questionnaires. RESULTS: The intervention group improved on all eight of the structure-of-care indicators when compared to the control group. A positive effect was also found on the extent to which the GPs measured blood pressure in 60-year-old patients and on the use of an MCI for smoking cessation. No effect was found on the completeness of the risk-factor profiles that the GPs assessed in specific groups of high-risk patients. CONCLUSION: The nationwide intervention appeared to improve certain aspects of preventive cardiovascular care. Nevertheless, the National Association of GPs decided to stop the project. This decision was made within the context of discussions about the heavy workloads and insufficient incomes being experienced by GPs.
PMCID: PMC1314746  PMID: 14960217

Results 1-6 (6)