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1.  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
2.  Reasons for ordering laboratory tests and relationship with frequency of abnormal results 
Laboratory tests are ordered on a daily basis, even though disease probability is often very low. Abnormal results, especially mildly abnormal results, can be difficult to interpret in these circumstances. Further insights into the occurrence of abnormalities can help improve rational test ordering and test interpretation. The objective was therefore to examine the frequency of mildly and markedly abnormal results and their relationship with physicians' reasons for ordering tests.
Prospective study.
A total of 87 primary care physicians in the Netherlands collected data on 1775 patients.
Main outcome measures
The physicians recorded the reason for ordering the tests, the most probable diagnosis and the pretest probability. The laboratories' reference values and specified “action limits” were used to assess the number of abnormal results and markedly abnormal results, respectively.
Laboratory results were received for 1621 patients and 15,603 tests were reported (mean 9.6). The proportion of abnormal test results increased with increasing pretest probability (from 13.9% to 34.7%) and was 13.4% for tests ordered to reassure the patient and 13.3% for psychosocial diagnoses. The proportion of patients with at least one abnormal test result was high: 53.1% for tests ordered to reassure and 57.7% in patients with low pretest probability. Corresponding values for a marked abnormality were 11.1% and 12.4%, respectively.
Abnormal laboratory test results were frequent, even when pretest probability was low. Physicians should therefore carefully consider when tests are necessary. Future research could explore physicians' interpretation of test results and its impact on diagnosis and management.
PMCID: PMC3440609  PMID: 20121652
Clinical chemistry tests; diagnostic tests; family practice; interpretation of laboratory tests; laboratory utilization; primary healthcare
3.  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
4.  Effect of an integrated primary care model on the management of middle-aged and old patients with obstructive lung diseases 
To investigate the effect of a primary care model for COPD on process of care and patient outcome.
Controlled study with delayed intervention in control group.
The GP delegates tasks to a COPD support service (CSS) and a practice nurse. The CSS offers logistic support to the practice through a patient register and recall system for annual history-taking and lung function measurement. It also forms the link with the chest physician for diagnostic and therapeutic advice. The practice nurse's most important tasks are education and counselling.
A total of 44 practices (n =22 for intervention and n =22 for control group) and 260 of their patients ≥40 years with obstructive lung diseases.
Within the intervention group planned visits increased from 16% to 44% and from 19% to 25% in the control condition (difference between groups p =0.014). Annual lung function measurement rose from 17% to 67% in the intervention and from 11% to 18% in the control group (difference between groups p =0.001). Compared with control, more but not statistically significant smokers received periodic advice to quit smoking (p =0.16). At baseline 41% of the intervention group were using their inhalers correctly and this increased to 54% after two years; it decreased in the control group from 47 to 29% (difference between groups p =0.002). The percentage of patients without exacerbation did not change significantly compared with the control condition. The percentage of the intervention group not needing emergency medication rose from 79% to 84% but decreased in the controls from 81 to 76% (difference between groups p =0.08).
Combining different disciplines in one model has a positive effect on compliance with recommendations for monitoring patients, and improves the care process and some patient outcomes.
PMCID: PMC3379779  PMID: 17846938
COPD; family practice; guidelines adherence; integrated healthcare system; practice nurse; primary care
5.  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
6.  Impact of nurse practitioners on workload of general practitioners: randomised controlled trial 
BMJ : British Medical Journal  2004;328(7445):927.
Objective To examine the impact on general practitioners' workload of adding nurse practitioners to the general practice team.
Design Randomised controlled trial with measurements before and after the introduction of nurse practitioners.
Setting 34 general practices in a southern region of the Netherlands.
Participants 48 general practitioners.
Intervention Five nurses were randomly allocated to general practitioners to undertake specific elements of care according to agreed guidelines. The control group received no nurse.
Main outcome measures Objective workload, derived from 28 day diaries, included the number of contacts per day for each of three conditions (chronic obstructive pulmonary disease or asthma, dementia, cancer), by type of consultation (in practice, telephone, home visit), and by time of day (surgery hours, out of hours). Subjective workload was measured by using a validated questionnaire. Outcomes were measured six months before and 18 months after the intervention.
Results The number of contacts during surgery hours increased in the intervention group compared with the control group (P < 0.06), particularly for patients with chronic obstructive pulmonary disease or asthma (P < 0.01). The number of consultations out of hours declined slightly in the intervention group compared with the control group, but this difference did not reach significance. No significant changes became apparent in subjective workload.
Conclusion Adding nurse practitioners to general practice teams did not reduce the workload of general practitioners, at least in the short term. This implies that nurse practitioners are used as supplements, rather than substitutes, for care given by general practitioners.
PMCID: PMC390208  PMID: 15069024
7.  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
8.  Understanding laboratory testing in diagnostic uncertainty: a qualitative study in general practice. 
BACKGROUND: Better knowledge of the professional's motives for ordering laboratory tests in the case of diagnostic uncertainty may lead to interventions directed at reducing unnecessary testing. AIM: To gain insight into the general practitioner's (GP's) motives for ordering laboratory tests for patients presenting with unexplained complaints. DESIGN OF STUDY: Semi-structured interviews based on surgery observations. SETTING: Twenty-one general practices in rural and urban areas of The Netherlands. METHOD: Investigation of the GP's perception of determinants of test-ordering behaviour in the situation of diagnostic uncertainty. The interviews were structured by evaluating the consultations and test-ordering performance of that day. RESULTS: Dutch GPs vary considerably in their motives for ordering tests. Numerous motives emerged from the data. Some examples of important themes include: personal routines; tolerance of diagnostic uncertainty; time pressure; and tactical motives for test ordering. Complying with the perceived needs of the patient for reassurance through testing is seen as an easy, cost- and time-effective strategy. A clear hierarchy in the determinants was not found. CONCLUSION: The decision to request laboratory testing is the result of a complex interaction of considerations that are often conflicting. Designers of interventions meant to improve the ordering of tests should be aware of the numerous determinants, and take contextual variables into account.
PMCID: PMC1314466  PMID: 12528582
9.  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
10.  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
11.  Diversity in diabetes care programmes and views on high quality diabetes care: are we in need of a standardized framework? 
To explore views on high quality diabetes care based on an analysis of existing diversity in diabetes care programmes and related quality indicators.
A review of systematic reviews was performed. Four databases (MEDLINE database of the National Library of Medicine, COCHRANE database of Systematic Reviews, the Cumulative Index to Nursing and Allied Health Database-CINAHL and Pre-Cinahl) were searched for English review articles published between November 1989 and December 2006. Methodological quality of the articles was assessed. A standardized extraction form was used to assess features of diabetes care programmes and diabetes quality indicators with special reference to those aspects that hinder the conceptualization of high quality diabetes care. Based on these findings the relationship between diversity in diabetes care programmes and the conceptualization of high quality diabetes care was further explored.
Twenty-one systematic reviews met the inclusion criteria representing a total of 185 diabetes care programmes. Six elements were identified to produce a picture of diversity in diabetes care programmes and hinder their standardization: 1) the variety and relative absence of conceptual backgrounds in diabetes care programmes, 2) confusion over what is considered a constituent of a diabetes care program and components of the implementation strategy, 3) large variety in type of diabetes care programmes, settings and related goals, 4) a large number and variety in interventions and quality indicators used, 5) no conclusive evidence on effectiveness, 6) no systematic results on costs.
There is large diversity in diabetes care programmes and related quality indicators. From this review and our analysis on the mutual relationship between diversity in diabetes care programmes and the conceptualization of high quality diabetes care, we conclude that no single conceptual framework used to date provides a comprehensive overview of attributes of high quality diabetes care linked to quality indicators at the structure, process and outcome level. There is a need for a concerted action to develop a standardized framework on high quality diabetes care that is complemented by a practical tool to provide guidance to the design, implementation and evaluation of diabetes care programmes.
PMCID: PMC2387191  PMID: 18493592
diabetes; quality of care; systematic review

Results 1-11 (11)