Background

To improve risk factor management in diabetes, we need to support effective interactions between patients and healthcare providers. Our aim is to develop and evaluate a treatment decision aid that offers personalised information on treatment options and outcomes, and is intended to empower patients in taking a proactive role in their disease management. Important features are: (1) involving patients in setting goals together with their provider; (2) encourage them to prioritise on treatments that maximise relevant outcomes; and (3) integration of the decision aid in the practice setting and workflow. As secondary aim, we want to evaluate the impact of different presentation formats, and learn more from the experiences of the healthcare providers and patients with the decision aid.

Methods and design

We will conduct a randomised trial comparing four formats of the decision aid in a 2×2 factorial design with a control group. Patients with type 2 diabetes managed in 18 to 20 primary care practices in The Netherlands will be recruited. Excluded are patients with a recent myocardial infarction, stroke, heart failure, angina pectoris, terminal illness, cognitive deficits, >65 years at diagnosis, or not able to read Dutch. The decision aid is offered to the patients immediately before their quarterly practice consultation. The same decision information will be available to the healthcare provider for use during consultation. In addition, the providers receive a set of treatment cards, which they can use to discuss the benefits and risks of different options. Patients in the control group will receive care as usual. We will measure the effect of the intervention on patient empowerment, satisfaction with care, beliefs about medication, negative emotions, health status, prescribed medication, and predicted cardiovascular risk. Data will be collected with questionnaires and automated extraction from medical records in 6 months before and after the intervention.

Discussion

This decision aid is innovative in supporting patients and their healthcare providers to make shared decisions about multiple treatments, using the patient’s data from electronic medical records. The results can contribute to the further development and implementation of electronic decision support tools for the management of chronic diseases.

Trial registration

Dutch Trial register NTR1942.

Background

Elderly patients with multimorbidity who are treated according to guidelines use a large number of drugs. This number of drugs increases the risk of adverse drug events (ADEs). Stopping medication may relieve these effects, and thereby improve the patient’s wellbeing. To facilitate management of polypharmacy expert-driven instruments have been developed, sofar with little effect on the patient’s quality of life. Recently, much attention has been paid to shared decision-making in general practice, mainly focusing on patient preferences. This study explores how experienced GPs feel about deprescribing medication in older patients with multimorbidity and to what extent they involve patients in these decisions.

Methods

Focusgroups of GPs were used to develop a conceptual framework for understanding and categorizing the GP’s view on the subject. Audiotapes were transcribed verbatim and studied by the first and second author. They selected independently relevant textfragments. In a next step they labeled these fragments and sorted them. From these labelled and sorted fragments central themes were extracted.

Results

GPs discern symptomatic medication and preventive medication; deprescribing the latter category is seen as more difficult by the GPs due to lack of benefit/risk information for these patients.

Factors influencing GPs’deprescribing were beliefs concerning patients (patients have no problem with polypharmacy; patients may interpret a proposal to stop preventive medication as a sign of having been given up on; and confronting the patient with a discussion of life expectancy vs quality of life is ‘not done’), guidelines for treatment (GPs feel compelled to prescribe by the present guidelines) and organization of healthcare (collaboration with prescribing medical specialists and dispensing pharmacists.

Conclusions

The GPs’ beliefs concerning elderly patients are a barrier to explore patient preferences when reviewing preventive medication. GPs would welcome decision support when dealing with several guidelines for one patient. Explicit rules for collaborating with medical specialists in this field are required. Training in shared decision making could help GPs to elicit patient preferences.

Background

The Dutch government has chosen a policy of strengthening palliative care in order to enable patients to die at home according to their preference. In order to facilitate this care by GPs, we wanted to know how to support them in their training. Therefore we examined the ways in which the death of a patient influences the doctor both at a professional and at a personal level.

Methods

Based on a qualitative study, we developed a model for reflection for GP trainees on the meaning of the death of patients and its influence on the GP.

The qualitative study was done in 2007 and is based on open in-depth interviews and a focus group. We recruited 18 participants who were highly professional GPs and experienced in talking about the death of patients. We invited GPs from a list of experienced GPs, who in addition are also second-opinion GPs for euthanasia (SCEN-physicians) and from a pool of GP trainers, our intention being to include GPs holding a variety of world views. Interviews were audio-taped and transcribed verbatim. A grounded theory approach was used to analyze the results. Themes were first identified independently by three researchers, then after discussion these three sets were rearranged to one list of themes and their mutual relation were determined. A model for the interaction of the GP at professional and at a personal level was formulated.

Results

Forty three themes emerged from the interviews and focus group. These themes fell into three groups: professional values and experiences, personal values and experiences, and the opinions of the GPs as to what constitutes a good death. We constructed a model of the doctor-patient relationship on the basis of these findings. This model enables GP trainees identifying the unique character of the doctor-patient relationship as well as its reciprocity when the two were confronted by the patient's impending death.

Conclusions

In dealing with the approaching death of a patient the unique interaction between patient and doctor and the cumulative experiences of doctors with their patients brings about a shift in the GP's own values. The professional development of GP trainees may be facilitated by reflection on the interaction of their own values and beliefs.

Background

Patients suffering from psychotic disorders have an increased risk of comorbid somatic diseases such as cardiovascular disorders and diabetes mellitus. Doctor-related factors, such as unfamiliarity with these patients, as well as patient-related factors, such as cognitive disturbance and negative symptoms, contribute to suboptimal health care for these patients.

General practitioners (GPs) could play a key role in diagnosing and treating this somatic comorbidity as in the Netherlands, almost all residents are registered at a general practice. This study aims to find out whether there are any differences between the levels of health care provided by GPs to patients with psychotic disorders, compared to other types of patients.

Methods

A cohort of patients with an ICPC code of psychosis and two matched control groups, one consisting of patients with other mental problems and the other one of patients without any mental problems, were followed over a period of 5 years.

Results

Patients with psychotic disorders (N = 734) contacted the GP practice more often than patients in the control groups. These patients, both adults (p = 0.051) and the elderly (p < 0.005), received more home visits from their GPs. In the adult group (16 to 65 years old inclusive), the number of consultations was significantly higher among both psychosis patients and the group of patients with other mental problems (p < 0.0005). The number of telephone consultations was significantly higher in both age categories, adult group (p < 0.0005), and > 65 years old (p = 0.007). With regard to chronic illnesses, elderly psychosis patients had fewer contacts related to cardiovascular diseases or chronic lung diseases.

Conclusion

Patients with psychotic disorders contact the GP practice more frequently than other types of patients. Adult psychosis patients with diabetes mellitus, cardiovascular diseases or chronic lung diseases receive the same amount of health care for these diseases as other primary care patients. The finding that older patients with psychotic disorders are diagnosed with cardiovascular diseases and obstructive lung diseases less frequently than other types of elderly patients requires further study.

Background

Communication between general practitioners (GPs) and specialists is important, if we want patients to receive the right type of care at the right moment. Most communication takes place through telephone contact, letters concerning information on patients more recently also by email, and joint postgraduate training. As much research has been aimed at the content of communication between GPs and specialists, we wished to address the procedural aspects of this communication.

We addressed the following research question.

How do GPs and specialists assess their mutual communication through telephone, letters and postgraduate courses?

Methods

A cross-sectional study was conducted among a random sample of 550 GPs and 533 specialists selected from the Netherlands Medical Address Book. The response rate was 47% GPs (n = 259) and 44% specialists (n = 232).

Results

Specialists qualify the GPs' telephone accessibility as poor; while GPs themselves do not. Specialists think poorly of the GPs' referral letter. Merely half of GPs feels their questions are addressed appropriately by the specialist, whereas specialists think this number is considerably higher. According to specialists, GPs often do not follow the advice given by them. GPs rate their compliance much higher. Less than a quarter of GPs feel the specialist's letter arrives on time. Specialists have a different perception of this.

Both parties wish to receive feedback from one and other, while in practice they do so very little.

Conclusion

GPs and specialists disagree on several aspects of their communication. This impedes improvements. Both GP's accessibility by phone and time span to the specialist's report could be earmarked as performance indicators. GPs and specialists should discuss amongst themselves how best to compose a format for the referral letter and the specialist's report and how to go about exchanging mutual feedback.

Background

Patients with severe mental illness (SMI) experience distress and disabilities in several aspects of life, and they have a higher risk of somatic co-morbidity. Both patients and their family members need the support of an easily accessible primary care system. The willingness of general practitioners and the impeding factors for them to participate in providing care for patients with severe mental illness in the acute and the chronic or residual phase were explored.

Methods

A questionnaire survey of a sample of Dutch general practitioners spread over the Netherlands was carried out. This comprised 20 questions on the GP's 'Opinion and Task Perspective', 19 questions on 'Treatment and Experiences', and 27 questions on 'Characteristics of the General Practitioner and the Practice Organisation'.

Results

186 general practitioners distributed over urban areas (49%), urbanised rural areas (38%) and rural areas (15%) of the Netherlands participated. The findings were as follows: GPs currently considered themselves as the first contact in the acute psychotic phase. In the chronic or residual phase GPs saw their core task as to diagnose and treat somatic co-morbidity. A majority would be willing to monitor the general health of these patients as well. It appeared that GP trainers and GPs with a smaller practice setting made follow-up appointments and were willing to monitor the self-care of patients with SMI more often than GPs with larger practices.

GPs also saw their role as giving support and information to the patient's family.

However, they felt a need for recognition of their competencies when working with mental health care specialists.

Conclusion

GPs were willing to participate in providing care for patients with SMI. They considered themselves responsible for psychotic emergency cases, for monitoring physical health in the chronic phase, and for supporting the relatives of psychotic patients.

Background

Coordination between care providers of different disciplines is essential to improve the quality of care, in particular for patients with chronic diseases. The way in which general practitioners (GP's) and medical specialists interact has important implications for any healthcare system in which the GP plays the role of gatekeeper to specialist care. Patient experiences and preferences have proven to be increasingly important in discussing healthcare policy. The Dutch government initiated the development of a special website with information for patients on performance indicators of hospitals as well as information on illness or treatment.

In the present study we focus on the transition of care at the primary – secondary interface with reference to the impact of patients' ability to make choices about their secondary care providers. The purpose of this study is to (a) explore experiences and preferences of patients regarding the transition between primary and secondary care, (b) study informational resources on illness/treatment desired by patients and (c) determine how information supplied could make it easier for the patient to choose between different options for care (hospital or specialist).

Methods

We conducted a qualitative study using semi-structured focus group interviews among 71 patients referred for various indications in the north and west of The Netherlands.

Results

Patients find it important that they do not have to wait, that they are taken seriously, and receive adequate and individually relevant information. A lack of continuity from secondary to primary care was experienced. The patient's desire for free choice of type of care did not arise in any of the focus groups.

Conclusion

Hospital discharge information needs to be improved. The interval between discharge from specialist care and the report of the specialist to the GP might be a suitable performance indicator in healthcare. Patients want to receive information, tailored to their own situation. The need for information, however, is quite variable. Patients do not feel strongly about self-chosen healthcare, contrary to what administrators presently believe.

Background

In primary care, GPs usually provide care for patients with chronic diseases according to professional guidelines. However, such guidelines are not available in the Netherlands for patients with recurring psychoses. It seems that the specific difficulties that GPs experience in providing care for these patients hinder the development and implementation of such guidelines. This study aims to explore the chances and problems GPs meet when providing care for patients susceptible for recurring psychoses, including schizophrenia and related disorders, bipolar disorder, and psychotic depression.

Methods

A qualitative study of focus group discussions with practising GPs in both town and rural areas. Transcripts from three focus groups with 19 GPs were analysed with the computer program 'Kwalitan'. Theoretical saturation was achieved after these three groups.

Results

Analysis showed that eight categories of factors influenced the GPs' care for psychotic patients: patient presentation (acute vs. chronic phase), emotional impact, expertise, professional attitude, patient related factors, patient's family, practice organization, and collaboration with psychiatric specialists.

Conclusion

Current primary care for psychotic patients depends very much on personal characteristics of the GP and the quality of local collaboration with the Mental Health Service. A quantitative study among GPs using a questionnaire based on the eight categories mentioned above would determine the extent of the problems and limitations experienced with this type of care. From the results of this quantitative study, new realistic guidelines could be developed to improve the quality of care for psychotic patients.

Background

Collaboration between general practitioners (GPs) and specialists has been the focus of many collaborative care projects during the past decade. Unfortunately, quite a number of these projects failed. This raises the question of what motivates GPs to initiate and continue participating with medical specialists in new collaborative care models.

The following two questions are addressed in this study:

What motivates GPs to initiate and sustain new models for collaborating with medical specialists?

What kind of new collaboration models do GPs suggest?

Methods

A qualitative study design was used. Starting in 2003 and finishing in 2005, we conducted semi-structured interviews with a purposive sample of 21 Dutch GPs. The sampling criteria were age, gender, type of practice, and practice site. The interviews were recorded, fully transcribed, and analysed by two researchers working independently. The resulting motivational factors and preferences were grouped into categories.

Results

'Developing personal relationships' and 'gaining mutual respect' appeared to dominate when the motivational factors were considered. Besides developing personal relationships with specialists, the GPs were also interested in familiarizing specialists with the competencies attached to the profession of family medicine. Additionally, they were eager to increase their medical knowledge to the benefit of their patients. The GPs stated a variety of preferences with respect to the design of new models of collaboration.

Conclusion

Developing personal relationships with specialists appeared to be one of the dominant motives for increased collaboration. Once the relationships have been formed, an informal network with occasional professional contact seemed sufficient.

Although GPs are interested in increasing their knowledge, once they have reached a certain level of expertise, they shift their focus to another specialty.

The preferences for new collaboration models are diverse. A possible explanation for the differences in the preferences is that professionals are more knowledge driven than organisation driven as the acquiring of new knowledge is considered more important than the route by which this is achieved. A new collaboration model seems a way to acquire knowledge. Once this is achieved the importance of a model possibly diminishes, whereas the professional relationships last.

Background

Collaboration between general practitioners (GPs) and specialists has been the focus of many collaborative care projects during the past decade. Unfortunately, quite a number of these projects failed. This raises the question of what motivates medical specialists to initiate and continue participating with GPs in new collaborative care models.

The following question is addressed in this study: What motivates medical specialists to initiate and sustain new models for collaborating with GPs?

Methods

We conducted semi-structured interviews with eighteen medical specialists in the province of Groningen, in the North of The Netherlands. The sampling criteria were age, gender, type of hospital in which they were practicing, and specialty. The interviews were recorded, fully transcribed, and analysed by three researchers working independently. The resulting motivational factors were grouped into categories.

Results

'Teaching GPs' and 'regulating patient flow' (referrals) appeared to dominate when the motivational factors were considered. In addition, specialists want to develop relationships with the GPs on a more personal level. Most specialists believe that there is not much they can learn from GPs. 'Lack of time', 'no financial compensation', and 'no support from colleagues' were considered to be the main concerns to establishing collaborative care practices. Additionally, projects were often experienced as too complex and time consuming whereas guidelines were experienced as too restrictive.

Conclusion

Specialists are particularly interested in collaborating because the GP is the gatekeeper for access to secondary health care resources. Specialists feel that they are able to teach the GPs something, but they do not feel that they have anything to learn from the GPs. With respect to professional expertise, therefore, specialists do not consider GPs as equals. Once personal relationships with the GPs have been established, an informal network with incidental professional contact seems to be sufficient to satisfy the collaborative needs of the specialist.

The concerns seem to outweigh any positive motivational forces to developing new models of collaborative practice.