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author:("steele, Ivo")
1.  Implementation of personalized self-management support using the self-management screening questionnaire SeMaS; a study protocol for a cluster randomized trial 
Trials  2013;14:336.
Background
The number of patients with one or more chronic diseases is rising. In several standards of care there is a focus on enhancing self-management. We applied the concept of personalization on self-management support and developed a self-management screening questionnaire (SeMaS). The main research objective is to assess the effectiveness of the SeMaS questionnaire and subsequent personalized self-management on patients’ self-management behaviors.
Methods/Design
A cluster randomized controlled trial will be set up in 15 general practices in the Netherlands. The practices are all group practices, and member of one care group. The practices will be assigned to the control or intervention arms by stratified randomization. The strata are determined by the participation of the practice nurses in a course for behavioral change, and the nurse’s workload. Patients can be included if they are over 18 years of age, have at least one chronic condition and have a checkup appointment with the practice nurse in the inclusion period. The intervention consists of screening patients with the SeMaS questionnaire, producing a graphic profile with the abilities or barriers for self-management. Patients will receive tailored feedback. Practice nurses are trained in using the profile to enhance self-management of the patient and provide personalized self-management support. The use of individual care plans and self-management interventions is stimulated. In the control arm patients will receive care as usual. Patients of both trial arms will be asked to fill in the SeMaS questionnaire and additional questionnaires at inclusion and after 6 months. The primary outcome is the difference in the level of patient activation (PAM-13) between baseline and 6 months. Secondary outcomes include patient measures for lifestyle factors (exercise, diet, smoking), and process measures from medical record data analysis.
Discussion
This manuscript presents the protocol for a cluster randomized clinical trial of personalized self-management support using the SeMaS questionnaire in chronically ill patients in primary care. By carrying out this study, scientific evidence is built for the effectiveness of personalized self-management support.
Trial registration
The Netherlands National Trial Register: NTR3960.
doi:10.1186/1745-6215-14-336
PMCID: PMC3874773  PMID: 24134956
Self-management; Self-management support; Personalization; Chronic diseases; Primary care; Chronic care; Personalized medicine
2.  Lung function decline in relation to diagnostic criteria for airflow obstruction in respiratory symptomatic subjects 
Background
Current COPD guidelines advocate a fixed < 0.70 FEV1/FVC cutpoint to define airflow obstruction. We compared rate of lung function decline in respiratory symptomatic 40+ subjects who were 'obstructive' or 'non-obstructive' according to the fixed and/or age and gender specific lower limit of normal (LLN) FEV1/FVC cutpoints.
Methods
We studied 3,324 respiratory symptomatic subjects referred to primary care diagnostic centres for spirometry. The cohort was subdivided into four categories based on presence or absence of obstruction according to the fixed and LLN FEV1/FVC cutpoints. Postbronchodilator FEV1 decline served as primary outcome to compare subjects between the respective categories.
Results
918 subjects were obstructive according to the fixed FEV1/FVC cutpoint; 389 (42%) of them were non-obstructive according to the LLN cutpoint. In smokers, postbronchodilator FEV1 decline was 21 (SE 3) ml/year in those non-obstructive according to both cutpoints, 21 (7) ml/year in those obstructive according to the fixed but not according to the LLN cutpoint, and 50 (5) ml/year in those obstructive according to both cutpoints (p = 0.004).
Conclusion
This study showed that respiratory symptomatic 40+ smokers and non-smokers who show FEV1/FVC values below the fixed 0.70 cutpoint but above their age/gender specific LLN value did not show accelerated FEV1 decline, in contrast with those showing FEV1/FVC values below their LLN cutpoint.
doi:10.1186/1471-2466-12-12
PMCID: PMC3355014  PMID: 22439763
Airflow obstruction; Chronic obstructive pulmonary disease; Diagnosis; Lung function decline; Primary care; Spirometry
3.  The validity of diagnostic support of an asthma/COPD service in primary care 
Background
To support GPs in diagnosing and monitoring their patients with asthma/chronic obstructive pulmonary disease (COPD), ‘asthma/COPD services’ have been developed. Within these services, pulmonologists perform structured diagnostic and therapeutic assessments based on the combination of written history data and spirometry.
Aim
This study determines the validity of the diagnosis and advice when assessed using only written information.
Design of study
The results of the diagnostic procedures of an asthma/COPD service were compared with the results of regular office consultations by pulmonologists.
Setting
From January until August 2004, two pulmonologists examined 80 randomly selected patients referred to an asthma/COPD service in Eindhoven, the Netherlands.
Method
Concordance was analysed between diagnosis and advice based on written spirometry and history data, with assessments based on live consultations with the same patients by pulmonologists.
Results
The validity of the assessed diagnosis was high (Cohen's κ = 0.82). When the diagnosis was uncertain, the advice for medical treatment scored low in validity (Cohen's κ = 0.39). The advice for additional diagnostic examinations had a high internal validity: in half of the patients, uncertainty in diagnosis turned into a definite diagnosis of asthma/COPD, or another cause for the complaints of the patient was revealed; in the other half, the diagnosis of asthma/COPD could be rejected.
Conclusions
A structured asthma/COPD service offering diagnosis and diagnostic advice assessed from written spirometry and history data is a new and valid facility that can support the GP who faces the complicated diagnostic procedures in a progressive number of patients with asthma/COPD.
PMCID: PMC2169313  PMID: 17976290
asthma; chronic obstructive pulmonary disease; diagnosis; primary care; spirometry
4.  Effect of an integrated primary care model on the management of middle-aged and old patients with obstructive lung diseases 
Objective
To investigate the effect of a primary care model for COPD on process of care and patient outcome.
Design
Controlled study with delayed intervention in control group.
Setting
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.
Subjects
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.
Results
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).
Conclusion
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.
doi:10.1080/02813430701573943
PMCID: PMC3379779  PMID: 17846938
COPD; family practice; guidelines adherence; integrated healthcare system; practice nurse; primary care

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