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1.  Consultations in general practices with and without mental health nurses: an observational study from 2010 to 2014 
BMJ Open  2016;6(7):e011579.
To investigate care for patients with psychological or social problems provided by mental health nurses (MHNs), and by general practitioners (GPs) with and without MHNs.
An observational study with consultations recorded by GPs and MHNs.
Data were routinely recorded in 161–338 Dutch general practices between 2010 and 2014.
All patients registered at participating general practices were included: 624 477 patients in 2010 to 1 392 187 patients in 2014.
Outcome measures
We used logistic and Poisson multilevel regression models to test whether GPs recorded more patients with at least one consultation for psychological or social problems and to analyse the number of consultations over a 5-year time period. We examined the additional effect of an MHN in a practice, and tested which patient characteristics predicted transferral from GPs to MHNs.
Increasing numbers of patients with psychological or social problems visit general practices. Increasing numbers of GPs collaborate with an MHN. GPs working in practices with an MHN record as many consultations per patient as GPs without an MHN, but they record slightly more patients with psychological or social problems (OR=1.05; 95% CI 1.02 to 1.08). MHNs most often treat adult female patients with common psychological symptoms such as depressive feelings.
MHNs do not seem to replace GP care, but mainly provide additional long consultations. Future research should study to what extent collaboration with an MHN prevents patients from needing specialised mental healthcare.
PMCID: PMC4964169  PMID: 27431902
2.  Compliance with referrals to medical specialist care: patient and general practice determinants: a cross-sectional study 
BMC Family Practice  2016;17:11.
In a gatekeeper system, primary care physicians and patients jointly decide whether or not medical specialist care is needed. However, it is the patient who decides to actually use the referral. Referral non-compliance could delay diagnosis and treatment. The objective of this study was to assess patient compliance with a referral to medical specialist care and identify patient and practice characteristics that are associated with it.
Observational study using data on 48,784 referrals to medical specialist care derived from electronic medical records of 58 general practices for the period 2008–2010. Referral compliance was based on claims data of medical specialist care. Logistic multilevel regression analyses were conducted to determine associations between patient and general practice characteristics and referral compliance.
In 86.6 % of the referrals, patients complied. Patient and not practice characteristics were significantly associated with compliance. Patients from deprived urban areas and patients aged 18–44 years were less likely to comply, whereas patients aged 65 years and older were more likely to comply.
About 1 in 8 patients do not use their referral. These patients may not receive adequate care. Demographic and socio-economic factors appear to affect compliance. The results of this study may be used to make general practitioners more aware that some patients are more likely to be noncompliant with referrals.
PMCID: PMC4736608  PMID: 26831125
Referral and consultation; Primary health care; Patient compliance; Cross-sectional studies; Netherlands
3.  Treatment of hip/knee osteoarthritis in Dutch general practice and physical therapy practice: an observational study 
BMC Family Practice  2015;16:75.
A multidisciplinary, guideline-based Stepped-Care-Strategy (SCS), has recently been developed to improve the management of hip and knee osteoarthritis (OA). To date, it is unknown to what extent current Dutch OA care is consistent with the SCS, both with respect to the content of care as well as the sequence of care. Furthermore, there is a lack of clarity regarding the role of different health care providers in the performance of OA care according to the SCS. Therefore, the main purpose of this study is to describe the content of primary care in patients with hip/knee OA, including the compliance to the SCS and taking into account the introduction of patient self-referral to physical therapy.
Data were used from NIVEL Primary Care Database. In total, 12.118 patients with hip/knee OA who visited their GP or physical therapist were selected. Descriptive statistics were used to compare the content of care in GP-referred and self-referred patients to physical therapy.
Content of care performed by GPs mostly concerned consultations, followed by NSAID prescriptions and referrals to secondary care. Both prescriptions of acetaminophen and referrals to physical therapy respectively dietary therapy were rarely mentioned. Nevertheless, still 65% of the patients in physical therapy practice were referred by their GP. Compared to GP-referred patients, self-referred patients more often presented recurrent complaints and were treated less often by activity-related exercise therapy. Education was rarely registered as singular intervention, neither in GP-referred nor in self-referred patients.
In accordance with the SCS, less advanced interventions are more often applied than more advanced interventions. To optimize the adherence to the SCS, GPs could reconsider the frequent use of NSAIDs instead of analgesics and the low referral rate to allied health care. Self-referral to physical therapy partially distorts both the low referral rate in general practice and the low application rate of education as singular intervention in physical therapy practice. Further research is recommended to evaluate the effects of task-shifting in OA care, taking into account the content of the SCS.
Electronic supplementary material
The online version of this article (doi:10.1186/s12875-015-0295-9) contains supplementary material, which is available to authorized users.
PMCID: PMC4483212  PMID: 26116374
Osteoarthritis; Primary health care; General practice; Physical therapy specialty; Community health services; Referral and consultation
4.  Sporting programs for inactive population groups: factors influencing implementation in the organized sports setting 
The organized sports sector has received increased attention as a setting to promote health-enhancing physical activity (HEPA) to the general population. For significant public health impact, it is important that successful HEPA programs are widely adopted, implemented and continued as ongoing practice. The importance of evaluating the context in which programs are implemented has been identified as critical. However, little research has focused on understanding the organized sports implementation context, including factors facilitating and impeding implementation. In this study, the main factors influencing implementation of HEPA programs in the organized sports setting were studied.
Fourteen sporting programs in the Netherlands aimed at increasing participation in sports by inactive population groups and funded within the National Action Plan for Sport and Exercise (NAPSE) were investigated. The programs were developed by ten Dutch National Sports Federations (NSFs) and implemented by different sports clubs in the Netherlands over a 3-year implementation period (June 2008–June 2011). The qualitative research component involved yearly face-to-face interviews (i.e. fourteen interviews each year, n = 12 program coordinators) and a group meeting with the program coordinators of the NSFs (n = 8). Cross-case comparisons and thematic analyses were performed to identify and categorize important facilitating and impeding factors respectively. The quantitative research component, used to identify the most important facilitating and impeding factors across all sporting programs, consisted of ranking of factors according to importance by the program coordinators (n = 12).
Different factors act during six identified (implementation) phases. When comparing factors across phases, several key learnings were evident. Successful implementation relied, for example, on program design and enthusiastic individuals within sporting organizations. On the other hand, inactive people were hard to reach and participation of sports clubs was not self-evident. The findings were discussed in a broader context.
This study adds to the knowledge base concerning the implementation of sporting programs, aimed at inactive people, in the organized sports setting. The main factors facilitating and impeding implementation were identified. The results of this study can be used by sports practitioners and policy makers when developing and implementing HEPA programs in this setting.
Electronic supplementary material
The online version of this article (doi:10.1186/s13102-015-0007-8) contains supplementary material, which is available to authorized users.
PMCID: PMC4451741  PMID: 26038708
Organized sports setting; Sporting program; Implementation; Health-enhancing physical activity promotion
5.  The common characteristics and outcomes of multidisciplinary collaboration in primary health care: a systematic literature review 
Research on collaboration in primary care focuses on specific diseases or types of collaboration. We investigate the effects of such collaboration by bringing together the results of scientific studies.
Theory and methods
We conducted a systematic literature review of PubMed, CINAHL, Cochrane and EMBASE. The review was restricted to publications that test outcomes of multidisciplinary collaboration in primary care in high-income countries. A conceptual model is used to structure the analysis.
Fifty-one studies comply with the selection criteria about collaboration in primary care. Approximately half of the 139 outcomes in these studies is non-significant. Studies among older patients, in particular, report non-significant outcomes (p < .05). By contrast, a higher proportion of significant results were found in studies that report on clinical outcomes.
Conclusions and discussion
This review shows a large diversity in the types of collaboration in primary care; and also thus a large proportion of outcomes do not seem to be positively affected by collaboration. Both the characteristics of the structure of the collaboration and the collaboration processes themselves affect the outcomes. More research is necessary to understand the mechanism behind the success of collaboration, especially on the exact nature of collaboration and the context in which collaboration takes place.
PMCID: PMC4491327  PMID: 26150765
primary health care; inter-professional relations; multidisciplinary collaboration; integrated care; outcomes
6.  Market competition and price of disease management programmes: an observational study 
Managed competition was introduced into the health care system in several countries including the Netherlands, although effects of competition of both providers and health insurers on the price of health care are inconclusive. We investigated the association between competition of both providers (care groups) and health insurers and the price of disease management programmes (DMPs).
Data from 76 DMP contractual agreements for type II diabetes mellitus in 2008, 2009 and 2010 were used to analyse the association between market competition and the price of DMPs. Market competition was calculated per municipal health services region (GGD). Insurer market competition was measured by the Herfindahl-Hirschman Index (HHI), care group competition by the number of care groups and the care group market share of GPs. The effect of competition was cross-sectionally studied with linear regression analyses.
Insurer market concentration (HHI) and care group market share were not associated with the price of DMPs. The number of care groups in a GGD region was associated with a lower price (−€4.68; 95% CI: −8.36 - -1.00). The mean difference in the price of DMPs between health insurers was €58.
The price of DMPs seems to be more dependent on the particular health insurer than on market conditions. For competition among health insurers and provider groups to develop, preconditions such as selective contracting and option for patient to change provider should be in place.
PMCID: PMC4219132  PMID: 25359224
Managed competition; Disease management programmes; Price; Netherlands; Health insurance
7.  Personnel planning in general practices: development and testing of a skill mix analysis method 
General practitioners (GPs) have to match patients’ demands with the mix of their practice staff’s competencies. However, apart from some general principles, there is little guidance on recruiting new staff. The purpose of this study was to develop and test a method which would allow GPs or practice managers to perform a skill mix analysis which would take into account developments in local demand.
The method was designed with a stepwise method using different research strategies. Literature review took place to detect available methods that map, predict, or measure patients’ demands or needs and to fill the contents of the skill mix analysis. Focus groups and expert interviews were held both during the design process and in the first test stage. Both secondary data analysis as primary data collection took place to fill the contents of the tool. A pilot study in general practices tested the feasibility of the newly-developed method.
The skill mix analysis contains both a quantitative and a qualitative part which includes the following sections: i) an analysis of the current and the expected future demand; ii) an analysis of the need to adjust skill mix; iii) an overview about the functions of different provider disciplines; and iv) a system to assess the input, assumed or otherwise, of each function concerning the ‘catching up demand’, the connection between supply and demand, and the introduction of new opportunities. The skill mix analysis shows an acceptable face and content validity and appears feasible in practice.
The skill mix analysis method can be used as a basis to analyze and match, systematically, the demand for care and the supply of practice staff.
PMCID: PMC4177762  PMID: 25234141
Demand; General practice; Skill mix; Supply; Validity
8.  Effectiveness and cost-effectiveness of a blended exercise intervention for patients with hip and/or knee osteoarthritis: study protocol of a randomized controlled trial 
Exercise therapy in patients with hip and/or knee osteoarthritis is effective in reducing pain, increasing physical activity and physical functioning, but costly and a burden for the health care budget. A web-based intervention is cheap in comparison to face-to-face exercise therapy and has the advantage of supporting in home exercises because of the 24/7 accessibility. However, the lack of face-to-face contact with a professional is a disadvantage of web-based interventions and is probably one of the reasons for low adherence rates. In order to combine the best of two worlds, we have developed the intervention e-Exercise. In this blended intervention face-to-face contacts with a physical therapist are partially replaced by a web-based exercise intervention. The aim of this study is to investigate the short- (3 months) and long-term (12 months) (cost)-effectiveness of e-Exercise compared to usual care physical therapy. Our hypothesis is that e-Exercise is more effective and cost-effective in increasing physical functioning and physical activity compared to usual care.
This paper presents the protocol of a prospective, single-blinded, multicenter cluster randomized controlled trial. In total, 200 patients with OA of the hip and/or knee will be randomly allocated into either e-Exercise or usual care (physical therapy). E-Exercise is a 12-week intervention, consisting of maximum five face-to-face physical therapy contacts supplemented with a web-based program. The web-based program contains assignments to gradually increase patients’ physical activity, strength and stability exercises and information about OA related topics. Primary outcomes are physical activity and physical functioning. Secondary outcomes are health related quality of life, self-perceived effect, pain, tiredness and self-efficacy. All measurements will be performed at baseline, 3 and 12 months after inclusion. Retrospective cost questionnaires will be sent at 3, 6, 9 and 12 months and used for the cost-effectiveness and cost-utility analysis.
This study is the first randomized controlled trial in the (cost)-effectiveness of a blended exercise intervention for patients with osteoarthritis of the hip and/or knee. The findings will help to improve the treatment of patients with osteoarthritis.
Trial registration
PMCID: PMC4243525  PMID: 25103686
Osteoarthritis; Physical activity; Blended care; e-Health
9.  Overweight and obese adults have low intentions of seeking weight-related care: a cross-sectional survey 
BMC Public Health  2014;14:582.
The prevalence of obesity is growing worldwide. Obesity guidelines recommend increasing the level of weight-related care for persons with elevated levels of weight-related health risk (WRHR). However, there seems to be a discrepancy between need for and use of weight-related care. The primary aim of this study is to examine predisposing factors that may influence readiness to lose weight and intention to use weight-related care in an overweight population.
A population-based, cross-sectional survey was conducted. Data were collected using an online self-administered questionnaire sent to a population-representative sample of 1,500 Dutch adults on the Health Care Consumer Panel (n = 861 responded). Data were used from individuals (n = 445) with a mildly, moderately or severely elevated level of WRHR. WRHR status was based on self-reported data on Body Mass Index, risk assessment for diabetes mellitus type 2 (DM2) and cardiovascular disease (CVD), or co-morbidities.
55.1% of persons with increased WRHR were ready to lose weight (n = 245). Depending on level of WRHR; educational level, marital status, individuals with an accurate perception of their weight and better perceptions and expectations of dietitians were significantly related to readiness to lose weight. Most of them preferred individual weight-loss methods (82.0% of n = 245). 11% (n = 26 of n = 245) intended to use weight-related care. Weight-related care seeking was higher for those with moderate or severe WRHR. Expectations and trust in dietitians did not seem to influence care seeking.
Many Dutch adults who are medically in need of weight-related care are ready to lose weight. Most intend to lose weight individually, and only a few intend to use weight-related care. Therefore, obesity prevention initiatives should focus on monitoring weight change and weight-loss plans, and timely referral to obesity management. However, many people are not ready to lose weight. For this group, strategies for behaviour change may depend on WRHR, perceptions of weight and dietitians, educational level and marital status. Obesity prevention initiatives should focus on increasing the awareness of the seriousness of their condition and offering individually appropriate weight management programmes.
PMCID: PMC4085466  PMID: 24916037
Overweight; Obesity; Weight change; Patient’s acceptance of health care; Perception; Dietary services
10.  Effectiveness of a Web-Based Physical Activity Intervention in Patients With Knee and/or Hip Osteoarthritis: Randomized Controlled Trial 
Patients with knee and/or hip osteoarthritis (OA) are less physically active than the general population, while the benefits of physical activity (PA) have been well documented. Based on the behavioral graded activity treatment, we developed a Web-based intervention to improve PA levels in patients with knee and/or hip OA, entitled “Join2move”. The Join2move intervention is a self-paced 9-week PA program in which the patient’s favorite recreational activity is gradually increased in a time-contingent way.
The aim of the study was to investigate whether a fully automated Web-based PA intervention in patients with knee and/or hip OA would result in improved levels of PA, physical function, and self-perceived effect compared with a waiting list control group.
The study design was a two-armed randomized controlled trial which was not blinded. Volunteers were recruited via articles in newspapers and health-related websites. Eligibility criteria for participants were: (1) aged 50-75 years, (2) self-reported knee and/or hip OA, (3) self-reported inactivity (30 minutes of moderate PA, 5 times or less per week), (4) no face-to-face consultation with a health care provider other than general practitioners, for OA in the last 6 months, (5) ability to access the Internet weekly, and (6) no contra-indications to exercise without supervision. Baseline, 3-month, and 12-month follow-up data were collected through online questionnaires. Primary outcomes were PA, physical function, and self-perceived effect. In a subgroup of participants, PA was measured objectively using accelerometers. Secondary outcomes were pain, fatigue, anxiety, depression, symptoms, quality of life, self-efficacy, pain coping, and locus of control.
Of the 581 interested respondents, 199 eligible participants were randomly assigned to the intervention (n=100) or waiting list control group (n=99). Response rates of questionnaires were 84.4% (168/199) after 3 months and 75.4% (150/199) after 12 months. In this study, 94.0% (94/100) of participants actually started the program, and 46.0% (46/100) reached the adherence threshold of 6 out of 9 modules completed. At 3 months, participants in the intervention group reported a significantly improved physical function status (difference=6.5 points, 95% CI 1.8-11.2) and a positive self-perceived effect (OR 10.7, 95% CI 4.3-26.4) compared with the control group. No effect was found for self-reported PA. After 12 months, the intervention group showed higher levels of subjective (difference=21.2 points, 95% CI 3.6-38.9) and objective PA (difference=24 minutes, 95% CI 0.5-46.8) compared with the control group. After 12 months, no effect was found for physical function (difference=5 points, 95% CI −1.0 to 11.0) and self-perceived effect (OR 1.2, 95% CI 0.6-2.4). For several secondary endpoints, the intervention group demonstrated improvements in favor of the intervention group.
Join2move resulted in changes in the desired direction for several primary and secondary outcomes. Given the benefits and its self-help format, Join2move could be a component in the effort to enhance PA in sedentary patients with knee and/or hip OA.
Trial Registration
The Netherlands National Trial Register: NTR2483; (Archived by WebCite at
PMCID: PMC3841352  PMID: 24269911
physical activity; osteoarthritis; Web-based intervention; randomized controlled trial
11.  The construction of a decision tool to analyse local demand and local supply for GP care using a synthetic estimation model 
This study addresses the growing academic and policy interest in the appropriate provision of local healthcare services to the healthcare needs of local populations to increase health status and decrease healthcare costs. However, for most local areas information on the demand for primary care and supply is missing. The research goal is to examine the construction of a decision tool which enables healthcare planners to analyse local supply and demand in order to arrive at a better match.
National sample-based medical record data of general practitioners (GPs) were used to predict the local demand for GP care based on local populations using a synthetic estimation technique. Next, the surplus or deficit in local GP supply were calculated using the national GP registry. Subsequently, a dynamic internet tool was built to present demand, supply and the confrontation between supply and demand regarding GP care for local areas and their surroundings in the Netherlands.
Regression analysis showed a significant relationship between sociodemographic predictors of postcode areas and GP consultation time (F [14, 269,467] = 2,852.24; P <0.001). The statistical model could estimate GP consultation time for every postcode area with >1,000 inhabitants in the Netherlands covering 97% of the total population. Confronting these estimated demand figures with the actual GP supply resulted in the average GP workload and the number of full-time equivalent (FTE) GP too much/too few for local areas to cover the demand for GP care. An estimated shortage of one FTE GP or more was prevalent in about 19% of the postcode areas with >1,000 inhabitants if the surrounding postcode areas were taken into consideration. Underserved areas were mainly found in rural regions.
The constructed decision tool is freely accessible on the Internet and can be used as a starting point in the discussion on primary care service provision in local communities and it can make a considerable contribution to a primary care system which provides care when and where people need it.
PMCID: PMC4231547  PMID: 24161015
Health workforce planning; Local population demand; Synthetic estimation method; General practitioner care; Spatial microsimulation model; Decision tool
12.  The effectiveness of interventions using electronic reminders to improve adherence to chronic medication: a systematic review of the literature 
Many patients experience difficulties in adhering to long-term treatment. Although patients' reasons for not being adherent are diverse, one of the most commonly reported barriers is forgetfulness. Reminding patients to take their medication may provide a solution. Electronic reminders (automatically sent reminders without personal contact between the healthcare provider and patient) are now increasingly being used in the effort to improve adherence.
To examine the effectiveness of interventions using electronic reminders in improving patients' adherence to chronic medication.
A comprehensive literature search was conducted in PubMed, Embase, PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials. Electronic searches were supplemented by manual searching of reference lists and reviews. Two reviewers independently screened all citations. Full text was obtained from selected citations and screened for final inclusion. The methodological quality of studies was assessed.
Thirteen studies met the inclusion criteria. Four studies evaluated short message service (SMS) reminders, seven audiovisual reminders from electronic reminder devices (ERD), and two pager messages. Best evidence synthesis revealed evidence for the effectiveness of electronic reminders, provided by eight (four high, four low quality) studies showing significant effects on patients' adherence, seven of which measured short-term effects (follow-up period <6 months). Improved adherence was found in all but one study using SMS reminders, four studies using ERD and one pager intervention. In addition, one high quality study using an ERD found subgroup effects.
This review provides evidence for the short-term effectiveness of electronic reminders, especially SMS reminders. However, long-term effects remain unclear.
PMCID: PMC3422829  PMID: 22534082
Chronic medication; electronic reminders; interventions; medication adherence; systematic review
13.  Effectiveness of Start to Run, a 6-week training program for novice runners, on increasing health-enhancing physical activity: a controlled study 
BMC Public Health  2013;13:697.
The use of the organized sports sector as a setting for health-promotion is a relatively new strategy. In the past few years, different countries have been investing resources in the organized sports sector for promoting health-enhancing physical activity. In the Netherlands, National Sports Federations were funded to develop and implement “easily accessible” sporting programs, aimed at the least active population groups. Start to Run, a 6-week training program for novice runners, developed by the Dutch Athletics Organization, is one of these programs. In this study, the effects of Start to Run on health-enhancing physical activity were investigated.
Physical activity levels of Start to Run participants were assessed by means of the Short QUestionnaire to ASsess Health-enhancing physical activity (SQUASH) at baseline, immediately after completing the program and six months after baseline. A control group, matched for age and sex, was assessed at baseline and after six months. Compliance with the Dutch physical activity guidelines was the primary outcome measure. Secondary outcome measures were the total time spent in physical activity and the time spent in each physical activity intensity category and domain. Changes in physical activity within groups were tested with paired t-tests and McNemar tests. Changes between groups were examined with multiple linear and logistic regression analyses.
In the Start to Run group, the percentage of people who met the Dutch Norm for Health-enhancing Physical Activity, Fit-norm and Combi-norm increased significantly, both in the short- and longer-term. In the control group, no significant changes in physical activity were observed. When comparing results between groups, significantly more Start to Run participants compared with control group participants were meeting the Fit-norm and Combi-norm after six months. The differences in physical activity between groups in favor of the Start to Run group could be explained by an increase in the time spent in vigorous-intensity activities and sports activities.
Start to Run positively influences levels of health-enhancing physical activity of participants, both in the short- and longer-term. Based on these results, the use of the organized sports sector as a setting to promote health-enhancing physical activity seems promising.
PMCID: PMC3735486  PMID: 23898920
Sports setting; Sporting organizations; Running; Health-enhancing physical activity; Controlled study; Follow-up
14.  Do patient and practice characteristics confound age-group differences in preferences for general practice care? A quantitative study 
BMC Family Practice  2013;14:90.
Previous research showed inconsistent results regarding the relationship between the age of patients and preference statements regarding GP care. This study investigates whether elderly patients have different preference scores and ranking orders concerning 58 preference statements for GP care than younger patients. Moreover, this study examines whether patient characteristics and practice location may confound the relationship between age and the categorisation of a preference score as very important.
Data of the Consumer Quality Index GP Care were used, which were collected in 32 general practices in the Netherlands. The rank order and preference score were calculated for 58 preference statements for four age groups (0–30, 31–50, 51–74, 75 years and older). Using chi-square tests and logistic regression analyses, it was investigated whether a significant relationship between age and preference score was confounded by patient characteristics and practice location.
Elderly patients did not have a significant different ranking order for the preference statements than the other three age groups (r = 0.0193; p = 0.41). However, in 53% of the statements significant differences were found in preference score between the four age groups. Elderly patients categorized significantly less preference statements as ‘very important’. In most cases, the significant relationships were not confounded by gender, education, perceived health, the number of GP contacts and location of the GP practice.
The preferences of elderly patients for GP care concern the same items as younger patients. However, their preferences are less strong, which cannot be ascribed to gender, education, perceived health, the number of GP contacts and practice location.
PMCID: PMC3699367  PMID: 23800156
Preferences; Elderly; GP care
15.  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
16.  Type II diabetes patients in primary care: profiles of healthcare utilization obtained from observational data 
The high burden of diabetes for healthcare costs and their impact on quality of life and management of the disease have triggered the design and introduction of disease management programmes (DMPs) in many countries. The extent to which diabetes patients vary with regard to their healthcare utilisation and costs is largely unknown and could impact on the design of DMPs. The objectives of this study are to develop profiles based on both the diabetes-related healthcare utilisation and total healthcare utilisation in primary care, to investigate which patient and disease characteristics determine ‘membership’ of each profile, and to investigate the association between these profiles.
Data were used from electronic medical records of 6721 known type II diabetes patients listed in 48 Dutch general practices. Latent Class Analyses were conducted to identify profiles of healthcare and regression analyses were used to analyse the characteristics of the profiles.
For both diabetes-related healthcare utilisation and total healthcare utilisation three profiles could be distinguished: for the diabetes-related healthcare utilisation these were characterised as ‘high utilisation and frequent home visits’ (n=393), ‘low utilisation, GP only’ (n=3231) and ‘high utilisation, GP and nurse’ (n=3097). Profiles differed with respect to the patients’ age and type of medication; the oldest patients using insulin were dominant in the ‘high utilisation, GP and nurse’ profile. High total healthcare utilisation was not associated with high diabetes-related healthcare utilisation.
Healthcare utilisation of diabetes patients is heterogeneous. This challenges the development of distinguishable DMPs.
PMCID: PMC3570342  PMID: 23289605
Type II diabetes mellitus; Healthcare utilisation profiles; Primary care; Latent Class Analyses
17.  Factors associated with the number of consultations per dietetic treatment: an observational study 
Greater understanding of the variance in the number of consultations per dietetic treatment will increase the transparency of dietetic healthcare. Substantial inter-practitioner variation may suggest a potential to increase efficiency and improve quality. It is not known whether inter-practitioner variation also exists in the field of dietetics. Therefore, the aims of this study are to examine inter-practitioner variation in the number of consultations per treatment and the case-mix factors that explain this variation.
For this observational study, data were used from the National Information Service for Allied Health Care (LiPZ). LiPZ is a Dutch registration network of allied health care professionals, including dietitians working in primary healthcare. Data were used from 6,496 patients who underwent dietetic treatment between 2006 and 2009, treated by 27 dietitians working in solo practices located throughout the Netherlands. Data collection was based on the long-term computerized registration of healthcare-related information on patients, reimbursement, treatment and health problems, using a regular software program for reimbursement. Poisson multilevel regression analyses were used to model the number of consultations and to account for the clustered structure of the data.
After adjusting for case-mix, seven percent of the total variation in consultation sessions was due to dietitians. The mean number of consultations per treatment was 4.9 and ranged from 2.3–10.1 between dietitians. Demographic characteristics, patients’ initiative and patients’ health problems explained 28% of the inter-practitioner variation. Certain groups of patients used significantly more dietetic healthcare compared to others, i.e. older patients, females, the native Dutch, patients with a history of dietetic healthcare, patients who started the treatment on their own initiative, patients with multiple diagnoses, overweight, or binge eating disorder.
Considerable variation in number of consultations per dietetic treatment is due to dietitians. Some of this inter-practitioner variation was reduced after adjusting for case-mix. Further research is necessary to study the relation between inter-practitioner variation and the effectiveness and quality of dietetic treatment.
PMCID: PMC3502485  PMID: 22978546
18.  Results after one year introduction of disease oriented payments in the Netherlands 
The purpose of our study was to show the first results after introduction of disease oriented payments for diabetes mellitus type II in the Netherlands.
In 2010 disease oriented payment for diabetes mellitus type II was introduced nationwide in the Netherlands. In disease oriented payment, care for disease groups is organised by a care group that organises both general and more specialised care, and that negotiate a lumpsum for each patient with the health insurer. The care groups can either provide care themselves or sub-contract other providers. Included services within the care program are based on national health care standards. Aim of disease oriented payments is to improve care for chronically ill, by stimulating multidisciplinary collaboration between health care providers.
Selection of patients, health care utilization, organisation of care and self management needs were analysed with the aid data from written structured questionnaires from the National Panel of people with Chronic Illness or Disability (n=275) and data from electronic medical records of general practitioners (n=1144). Diabetes patients with and without disease oriented payment were compared.
Results and conclusions
Our first results show no evidence of selection of patients within disease oriented payments. And hardly any differences in the care between diabetes patients with and without disease oriented payments. Diabetes patients within disease oriented payments tended to go less often to a dietician after the introduction of disease oriented payments. It seems that patients within disease oriented payments receive part of their care from less specialist health care providers. Also, care to diabetes patients within disease oriented payment was only to a limited degree provided according to a programmatic approach.
PMCID: PMC3617746
disease oriented payments; chronically ill; diabetes mellitus type II; the Netherlands
19.  What part of the total care consumed by type 2 diabetes patients is directly related to diabetes? Implications for disease management programs 
Disease management programs (DMP) aim at improving coordination and quality of care and reducing healthcare costs for specific chronic diseases. This paper investigates to what extent total healthcare utilization of type 2 diabetes patients is actually related to diabetes and its implications for diabetes management programs.
Research design and methods
Healthcare utilization for diabetes patients was analyzed using 2008 self-reported data (n=316) and data from electronic medical records (EMR) (n=9023), and divided whether or not care was described in the Dutch type 2 diabetes multidisciplinary healthcare standard.
On average 4.3 different disciplines of healthcare providers were involved in the care for diabetes patients. Ninety-six percent contacted a GP-practice and 63% an ophthalmologist, 24% an internist, 32% a physiotherapist and 23% a dietician. Diabetes patients had on average 9.3 contacts with GP-practice of which 53% were included in the healthcare standard. Only a limited part of total healthcare utilization of diabetes patients was included in the healthcare standard and therefore theoretically included in DMPs.
Organizing the care for diabetics in a DMP might harm the coordination and quality of all healthcare for diabetics. DMPs should be integrated in the overall organization of care.
PMCID: PMC3280920  PMID: 22359520
diabetes; disease management program; healthcare standards
20.  Improving medication adherence in diabetes type 2 patients through Real Time Medication Monitoring: a Randomised Controlled Trial to evaluate the effect of monitoring patients' medication use combined with short message service (SMS) reminders 
Innovative approaches are needed to support patients' adherence to drug therapy. The Real Time Medication Monitoring (RTMM) system offers real time monitoring of patients' medication use combined with short message service (SMS) reminders if patients forget to take their medication. This combination of monitoring and tailored reminders provides opportunities to improve adherence. This article describes the design of an intervention study aimed at evaluating the effect of RTMM on adherence to oral antidiabetics.
Randomised Controlled Trial (RCT) with two intervention arms and one control arm involving diabetes type 2 patients with suboptimal levels of adherence to oral antidiabetics (less than 80% based on pharmacy refill data). Patients in the first intervention arm use RTMM including SMS reminders and a personal webpage where they can monitor their medication use. Patients in the second intervention arm use RTMM without SMS reminders or webpage access. Patients in the control arm are not exposed to any intervention. Patients are randomly assigned to one of the three arms. The intervention lasts for six months. Pharmacy refill data of all patients are available from 11 months before, until 11 months after the start of the intervention. Primary outcome measure is adherence to oral antidiabetics calculated from: 1) data collected with RTMM, as a percentage of medication taken as prescribed, and as percentage of medication taken within the correct time interval, 2) refill data, taking the number of days for which oral antidiabetics are dispensed during the study period divided by the total number of days of the study period. Differences in adherence between the intervention groups and control group are studied using refill data. Differences in adherence between the two intervention groups are studied using RTMM data.
The intervention described in this article consists of providing RTMM to patients with suboptimal adherence levels. This system combines real time monitoring of medication use with SMS reminders if medication is forgotten. If RTMM proves to be effective, it can be considered for use in various patient populations to support patients with their medication use and improve their adherence.
Trial registration
Netherlands Trial Register NTR1882
PMCID: PMC3024217  PMID: 21219596
21.  Minor surgery in general practice and effects on referrals to hospital care: Observational study 
Strengthening primary care is the focus of many countries, as national healthcare systems with a strong primary care sector tend to have lower healthcare costs. However, it is unknown to what extent general practitioners (GPs) that perform more services generate fewer hospital referrals. The objective of this study was to examine the association between the number of surgical interventions and hospital referrals.
Data were derived from electronic medical records of 48 practices that participated in the Netherlands Information Network of General Practice (LINH) in 2006-2007. For each care-episode of benign neoplasm skin/nevus, sebaceous cyst or laceration/cut it was determined whether the patient was referred to a medical specialist and/or minor surgery was performed. Multilevel multinomial regression analyses were used to determine the relation between minor surgery and hospital referrals on the level of the GP-practice.
Referral rates differed between diagnoses, with 1.0% of referrals for a laceration/cut, 8.2% for a sebaceous cyst and 10.2% for benign neoplasm skin/nevus. The GP practices performed minor surgery for a laceration/cut in 8.9% (SD:14.6) of the care-episodes, for a benign neoplasm skin/nevus in 27.4% (SD:14.4) of cases and for a sebaceous cyst in 26.4% (SD:13.8). GP practices that performed more minor surgery interventions had a lower referral rate for patients with a laceration/cut (-0.38; 95%CI:-0.60- -0.11) and those with a sebaceous cyst (-0.42; 95%CI:-0.63- -0.16), but not for people with benign neoplasm skin/nevus (-0.26; 95%CI:-0.51-0.03). However, the absolute difference in referral rate appeared to be relevant only for sebaceous cysts.
The effects of minor surgery vary between diagnoses. Minor surgery in general practice appears to be a substitute for specialist medical care only in relation to sebaceous cysts. Measures to stimulate minor surgery for sebaceous cysts may induce substitution.
PMCID: PMC3024924  PMID: 21205305
22.  Primary care nurses: effects on secondary care referrals for diabetes 
Primary care nurses play an important role in diabetes care, and were introduced in GP-practice partly to shift care from hospital to primary care. The aim of this study was to assess whether the referral rate for hospital treatment for diabetes type II (T2DM) patients has changed with the introduction of primary care nurses, and whether these changes were related to the number of diabetes-related contacts in a general practice.
Healthcare utilisation was assessed for a period of 365 days for 301 newly diagnosed and 2124 known T2DM patients in 2004 and 450 and 3226 patients in 2006 from general practices that participated in the Netherlands Information Network of General Practice (LINH). Multilevel logistic and linear regression analyses were used to analyse the effect of the introduction of primary care nurses on referrals to internists, ophthalmologists and cardiologists and diabetes-related contact rate. Separate analyses were conducted for newly diagnosed and known T2DM patients.
Referrals to internists for newly diagnosed T2DM patients decreased between 2004 and 2006 (OR:0.44; 95%CI:0.22-0.87) in all practices. For known T2DM patients no overall decrease in referrals to internists was found, but practices with a primary care nurse had a lower trend (OR:0.59). The number of diabetes-related contacts did not differ between practices with and without primary care nurses. Cardiologists' and ophthalmologists' referral rate did not change.
The introduction of primary care nurses seems to have led to a shift of care from internists to primary care for known diabetes patients, while the diabetes-related contact rate seem to have remained unchanged.
PMCID: PMC2924333  PMID: 20691051
23.  Labour intensity of guidelines may have a greater effect on adherence than GPs' workload 
BMC Family Practice  2009;10:74.
Physicians' heavy workload is often thought to jeopardise the quality of care and to be a barrier to improving quality. The relationship between these has, however, rarely been investigated. In this study quality of care is defined as care 'in accordance with professional guidelines'. In this study we investigated whether GPs with a higher workload adhere less to guidelines than those with a lower workload and whether guideline recommendations that require a greater time investment are less adhered to than those that can save time.
Data were used from the Second Dutch National survey of General Practice (DNSGP-2). This nationwide study was carried out between April 2000 and January 2002.
A multilevel logistic-regression analysis was conducted of 170,677 decisions made by GPs, referring to 41 Guideline Adherence Indicators (GAIs), which were derived from 32 different guidelines. Data were used from 130 GPs, working in 83 practices with 98,577 patients. GP-characteristics as well as guideline characteristics were used as independent variables. Measures include workload (number of contacts), hours spent on continuing medical education, satisfaction with available time, practice characteristics and patient characteristics. Outcome measure is an indicator score, which is 1 when a decision is in accordance with professional guidelines or 0 when the decision deviates from guidelines.
On average, 66% of the decisions GPs made were in accordance with guidelines. No relationship was found between the objective workload of GPs and their adherence to guidelines. Subjective workload (measured on a five point scale) was negatively related to guideline adherence (OR = 0.95). After controlling for all other variables, the variation between GPs in adherence to guideline recommendations showed a range of less than 10%.
84% of the variation in guideline adherence was located at the GAI-level. Which means that the differences in adherence levels between guidelines are much larger than differences between GPs. Guideline recommendations that require an extra time investment during the same consultation are significantly less adhered to: (OR = 0.46), while those that can save time have much higher adherence levels: OR = 1.55). Recommendations that reduce the likelihood of a follow-up consultation for the same problem are also more often adhered to compared to those that have no influence on this (OR = 3.13).
No significant relationship was found between the objective workload of GPs and adherence to guidelines. However, guideline recommendations that require an extra time investment are significantly less well adhered to while those that can save time are significantly more often adhered to.
PMCID: PMC2791751  PMID: 19943953
24.  Does burnout among doctors affect their involvement in patients' mental health problems? A study of videotaped consultations 
BMC Family Practice  2009;10:60.
General practitioners' (GPs') feelings of burnout or dissatisfaction may affect their patient care negatively, but it is unknown if these negative feelings also affect their mental health care. GPs' available time, together with specific communication tools, are important conditions for providing mental health care. We investigated if GPs who feel burnt out or dissatisfied with the time available for their patients, are less inclined to encourage their patients to disclose their distress, and have shorter consultations, in order to gain time and energy. This may result in less psychological evaluations of patients' complaints.
We used 1890 videotaped consultations from a nationally representative sample of 126 Dutch GPs to analyse GPs' communication and the duration of their consultations. Burnout was subdivided into emotional exhaustion, depersonalisation and reduced accomplishment. Multilevel regression analyses were used to investigate which subgroups of GPs differed significantly.
GPs with feelings of exhaustion or dissatisfaction with the available time have longer consultations compared to GPs without these feelings. Exhausted GPs, and GPs with feelings of depersonalisation, talk more about psychological or social topics in their consultations. GPs with feelings of reduced accomplishment are an exception: they communicate less affectively, are less patient-centred and have less eye contact with their patients compared to GPs without reduced accomplishment.
We found no relationship between GPs' feelings of burnout or dissatisfaction with the available time and their psychological evaluations of patients' problems.
GPs' feelings of burnout or dissatisfaction with the time available for their patients do not obstruct their diagnosis and awareness of patients' psychological problems. On the contrary, GPs with high levels of exhaustion or depersonalisation, and GPs who are dissatisfied with the available time, sometimes provide more opportunities to discuss mental health problems. This increases the chance that appropriate care will be found for patients with mental health problems. On the other hand, these GPs are themselves more likely to retire, or risk burnout, because of their dissatisfaction. Therefore these GPs may benefit from training or personal coaching to decrease the chance that the process of burnout will get out of hand.
PMCID: PMC2754435  PMID: 19706200
25.  Do list size and remuneration affect GPs' decisions about how they provide consultations? 
Doctors' professional behaviour is influenced by the way they are paid. When GPs are paid per item, i.e., on a fee-for-service basis (FFS), there is a clear relationship between workload and income: more work means more money. In the case of capitation based payment, workload is not directly linked to income since the fees per patient are fixed. In this study list size was considered as an indicator for workload and we investigated how list size and remuneration affect GP decisions about how they provide consultations. The main objectives of this study were to investigate a) how list size is related to consultation length, waiting time to get an appointment, and the likelihood that GPs conduct home visits and b) to what extent the relationships between list size and these three variables are affected by remuneration.
List size was used because this is an important determinant of objective workload. List size was corrected for number of older patients and patients who lived in deprived areas. We focussed on three dependent variables that we expected to be related to remuneration and list size: consultation length; waiting time to get an appointment; and home visits. Data were derived from the second Dutch National Survey of General Practice (DNSGP-2), carried out between 2000 and 2002. The data were collected using electronic medical records, videotaped consultations and postal surveys. Multilevel regression analyses were performed to assess the hypothesized relationships.
Our results indicate that list size is negatively related to consultation length, especially among GPs with relatively large lists. A correlation between list size and waiting time to get an appointment, and a correlation between list size and the likelihood of a home visit were only found for GPs with small practices. These correlations are modified by the proportion of patients for whom GPs receive capitation fees. Waiting times to get an appointment tend to become shorter with increasing patient lists when there is a larger capitation percentage. The likelihood that GPs will conduct home visit rises with increasing patient lists when the capitation percentage is small.
Remuneration appears to affect GPs' decisions about how they provide consultations, especially among GPs with relatively small patient lists. This role is, however, small compared to other factors such as patient characteristics.
PMCID: PMC2654894  PMID: 19245685

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