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1.  Cardiovascular risk management in patients with coronary heart disease in primary care: variation across countries and practices. An observational study based on quality indicators 
BMC Family Practice  2012;13:96.
Background
Primary care has an important role in cardiovascular risk management (CVRM) and a minimum size of scale of primary care practices may be needed for efficient delivery of CVRM . We examined CVRM in patients with coronary heart disease (CHD) in primary care and explored the impact of practice size.
Methods
In an observational study in 8 countries we sampled CHD patients in primary care practices and collected data from electronic patient records. Practice samples were stratified according to practice size and urbanisation; patients were selected using coded diagnoses when available. CVRM was measured on the basis of internationally validated quality indicators. In the analyses practice size was defined in terms of number of patients registered of visiting the practice. We performed multilevel regression analyses controlling for patient age and sex.
Results
We included 181 practices (63% of the number targeted). Two countries included a convenience sample of practices. Data from 2960 CHD patients were available. Some countries used methods supplemental to coded diagnoses or other inclusion methods introducing potential inclusion bias. We found substantial variation on all CVRM indicators across practices and countries. We computed aggregated practice scores as percentage of patients with a positive outcome. Rates of risk factor recording varied from 55% for physical activity as the mean practice score across all practices (sd 32%) to 94% (sd 10%) for blood pressure. Rates for reaching treatment targets for systolic blood pressure, diastolic blood pressure and LDL cholesterol were 46% (sd 21%), 86% (sd 12%) and 48% (sd 22%) respectively. Rates for providing recommended cholesterol lowering and antiplatelet drugs were around 80%, and 70% received influenza vaccination. Practice size was not associated to indicator scores with one exception: in Slovenia larger practices performed better. Variation was more related to differences between practices than between countries.
Conclusions
CVRM measured by quality indicators showed wide variation within and between countries and possibly leaves room for improvement in all countries involved. Few associations of performance scores with practice size were found.
doi:10.1186/1471-2296-13-96
PMCID: PMC3515459  PMID: 23035928
2.  Design choices made by target users for a pay-for-performance program in primary care: an action research approach 
BMC Family Practice  2012;13:25.
Background
International interest in pay-for-performance (P4P) initiatives to improve quality of health care is growing. Current programs vary in the methods of performance measurement, appraisal and reimbursement. One may assume that involvement of health care professionals in the goal setting and methods of quality measurement and subsequent payment schemes may enhance their commitment to and motivation for P4P programs and therefore the impact of these programs. We developed a P4P program in which the target users were involved in decisions about the P4P methods.
Methods
For the development of the P4P program a framework was used which distinguished three main components: performance measurement, appraisal and reimbursement. Based on this framework design choices were discussed in two panels of target users using an adapted Delphi procedure. The target users were 65 general practices and two health insurance companies in the South of the Netherlands.
Results
Performance measurement was linked to the Dutch accreditation program based on three domains (clinical care, practice management and patient experience). The general practice was chosen as unit of assessment. Relative standards were set at the 25th percentile of group performance. The incentive for clinical care was set twice as high as the one for practice management and patient experience. Quality scores were to be calculated separately for all three domains, and for both the quality level and the improvement of performance. The incentive for quality level was set thrice as high as the one for the improvement of performance. For reimbursement, quality scores were divided into seven levels. A practice with a quality score in the lowest group was not supposed to receive a bonus. The additional payment grew proportionally for each extra group. The bonus aimed at was on average 5% to 10% of the practice income.
Conclusions
Designing a P4P program for primary care with involvement of the target users gave us an insight into their motives, which can help others who need to discuss similar programs. The resulting program is in line with target users' views and assessments of relevance and applicability. This may enhance their commitment to the program as was indicated by the growing number of voluntary participants after a successfully performed field test during the procedure. The elements of our framework can be very helpful for others who are developing or evaluating a P4P program.
doi:10.1186/1471-2296-13-25
PMCID: PMC3352266  PMID: 22453028
3.  Primary care nurses struggle with lifestyle counseling in diabetes care: a qualitative analysis 
BMC Family Practice  2010;11:41.
Background
Patient outcomes are poorly affected by lifestyle advice in general practice. Promoting lifestyle behavior change require that nurses shift from simple advice giving to a more counseling-based approach. The current study examines which barriers nurses encounter in lifestyle counseling to patients with type 2 diabetes. Based on this information we will develop an implementation strategy to improve lifestyle behavior change in general practice.
Method
In a qualitative semi-structured study, twelve in-depth interviews took place with nurses in Dutch general practices involved in diabetes care. Specific barriers in counseling patients with type 2 diabetes about diet, physical activity, and smoking cessation were addressed. The nurses were invited to reflect on barriers at the patient and practice levels, but mainly on their own roles as counselors. All interviews were audio-recorded and transcribed. The data were analyzed with the aid of a predetermined framework.
Results
Nurses felt most barriers on the level of the patient; patients had limited knowledge of a healthy lifestyle and limited insight into their own behavior, and they lacked the motivation to modify their lifestyles or the discipline to maintain an improved lifestyle. Furthermore, nurses reported lack of counseling skills and insufficient time as barriers in effective lifestyle counseling.
Conclusions
The traditional health education approach is still predominant in primary care of patients with type 2 diabetes. An implementation strategy based on motivational interviewing can help to overcome 'jumping ahead of the patient' and promotes skills in lifestyle behavioral change. We will train our nurses in agenda setting to structure the consultation based on prioritizing the behavior change and will help them to develop social maps that contain information on local exercise programs.
doi:10.1186/1471-2296-11-41
PMCID: PMC2889883  PMID: 20500841
4.  Family practice nurses supporting self-management in older patients with mild osteoarthritis: a randomized trial 
Background
Supporting self-management intends to improve life-style, which is beneficial for patients with mild osteoarthritis (OA). We evaluated a nurse-based intervention on older OA patients' self-management with the aim to assess its effects on mobility and functioning.
Methods
Randomized controlled trial of patients (≥ 65 years) with mild hip or knee OA from nine family practices in the Netherlands. Intervention consisted of supporting patients' self-management of OA symptoms using a practice-based nurse. Outcome measures were patients' mobility, using the Timed Up and Go test (TUG), and patient reported functioning, using an arthritis specific scale (Dutch AIMS2 SF).
Results
Fifty-one patients were randomized to the intervention group and 53 to the control group. Patient-reported functioning improved on four scales in the intervention group compared to one scale in the control group. However, this result was not significant. Mobility improved in both groups, without a significant difference between the two groups. There were no differences between the groups regarding consultations with family physicians or physiotherapists, or medication use.
Conclusion
A nurse-based intervention on older OA patients' self-management did not improve self-reported functioning, mobility or patients' use of health care resources.
doi:10.1186/1471-2296-9-7
PMCID: PMC2235871  PMID: 18226255
5.  A randomised controlled trial of the effects of a web-based PSA decision aid, Prosdex. Protocol 
BMC Family Practice  2007;8:58.
Background
Informed decision making is the theoretical basis in the UK for men's decisions about Prostate Specific Antigen (PSA) testing for prostate cancer testing. The aim of this study is to evaluate the effect of a web-based PSA decision-aid, Prosdex, on informed decision making in men. The objective is to assess the effect of Prosdex on six specific outcomes: (i) knowledge of PSA and prostate cancer-related issues – the principal outcome of the study; (ii) attitudes to testing; (iii) decision conflict; (iv) anxiety; (v) intention to undergo PSA testing; (vi) uptake of PSA testing. In addition, a mathematical simulation model of the effects of Prosdex will be developed.
Methods
A randomised controlled trial with four groups: two intervention groups, one viewing Prosdex and the other receiving a paper version of the site; two control groups, the second controlling for the potential Hawthorn effect of the questionnaire used with the first control group. Men between the ages of 50 and 75, who have not previously had a PSA test, will be recruited from General Practitioners (GPs) in Wales, UK. The principal outcome, knowledge, and four other outcome measures – attitudes to testing, decision conflict, anxiety and intention to undergo testing – will be measured with an online questionnaire, used by men in three of the study groups. Six months later, PSA test uptake will be ascertained from GP records; the online questionnaire will then be repeated. These outcomes, and particularly PSA test uptake, will be used to develop a mathematical simulation model, specifically to consider the impact on health service resources.
Trial registration
Current Controlled Trial: ISRCTN48473735.
doi:10.1186/1471-2296-8-58
PMCID: PMC2075498  PMID: 17916259
6.  Developing a facilitation model to promote organisational development in primary care practices 
BMC Family Practice  2006;7:38.
Background
The relationship between effective organisation of general practices and health improvement is widely accepted. The Maturity Matrix is an instrument designed to assess organisational development in general practice settings and to stimulate quality improvement. It is undertaken by a practice team with the aid of a facilitator. There is a tradition in the primary care systems in many countries of using practice visitors to educate practice teams about how to improve. However the role of practice visitors as facilitators who enable teams to plan practice-led organisational development using quality improvement instruments is less well understood. The objectives of the study were to develop and explore a facilitation model to support practice teams in stimulating organisational development using a quality improvement instrument called the Maturity Matrix. A qualitative study based on transcript analysis was adopted.
Method
A model of facilitation was constructed based on a review of relevant literature. Audio tapes of Maturity Matrix assessment sessions with general practices were transcribed and facilitator skills were compared to the model. The sample consisted of two facilitators working with twelve general practices based in UK primary care.
Results
The facilitation model suggested that four areas describing eighteen skills were important. The four areas are structuring the session, obtaining consensus, handling group dynamics and enabling team learning. Facilitators effectively employed skills associated with the first three areas, but less able to consistently stimulate team learning.
Conclusion
This study suggests that facilitators need careful preparation for their role and practices need protected time in order to make best use of practice-led quality improvement instruments. The role of practice visitor as a facilitator is becoming important as the need to engender ownership of the quality improvement process by practices increases.
doi:10.1186/1471-2296-7-38
PMCID: PMC1526440  PMID: 16784540

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