Reflection as a component of formative assessment appears to be instrumental in promoting the use of feedback; an observational study.

BACKGROUND: Although the literature suggests that reflection has a positive impact on learning, there is a paucity of evidence to support this notion. AIM: We investigated feedback and reflection in relation to the likelihood that feedback will be used to inform action plans. We hypothesised that feedback and reflection present a cumulative sequence (i.e. trainers only pay attention to trainees' reflections when they provided specific feedback) and we hypothesised a supplementary effect of reflection. METHOD: We analysed copies of assessment forms containing trainees' reflections and trainers' feedback on observed clinical performance. We determined whether the response patterns revealed cumulative sequences in line with the Guttman scale. We further examined the relationship between reflection, feedback and the mean number of specific comments related to an action plan (ANOVA) and we calculated two effect sizes. RESULTS: Both hypotheses were confirmed by the results. The response pattern found showed an almost perfect fit with the Guttman scale (0.99) and reflection seems to have supplementary effect on the variable action plan. CONCLUSIONS: Reflection only occurs when a trainer has provided specific feedback; trainees who reflect on their performance are more likely to make use of feedback. These results confirm findings and suggestions reported in the literature.

In-training assessment using direct observation of single-patient encounters: a literature review.

We reviewed the literature on instruments for work-based assessment in single clinical encounters, such as the mini-clinical evaluation exercise (mini-CEX), and examined differences between these instruments in characteristics and feasibility, reliability, validity and educational effect. A PubMed search of the literature published before 8 January 2009 yielded 39 articles dealing with 18 different assessment instruments. One researcher extracted data on the characteristics of the instruments and two researchers extracted data on feasibility, reliability, validity and educational effect. Instruments are predominantly formative. Feasibility is generally deemed good and assessor training occurs sparsely but is considered crucial for successful implementation. Acceptable reliability can be achieved with 10 encounters. The validity of many instruments is not investigated, but the validity of the mini-CEX and the 'clinical evaluation exercise' is supported by strong and significant correlations with other valid assessment instruments. The evidence from the few studies on educational effects is not very convincing. The reports on clinical assessment instruments for single work-based encounters are generally positive, but supporting evidence is sparse. Feasibility of instruments seems to be good and reliability requires a minimum of 10 encounters, but no clear conclusions emerge on other aspects. Studies on assessor and learner training and studies examining effects beyond 'happiness data' are badly needed.

Out-of-hours primary care: development of indicators for prescribing and referring.

BACKGROUND: Dutch general practitioners have reorganized their out-of-hours primary health care to general practice cooperatives. Good insight into the quality of delivered medical care is important to make the accountability of health practitioners and managers transparent to society and to identify and minimize medical errors. OBJECTIVE: Development of a set of quality indicators for internal quality improvement in out-of-hours primary clinical care. METHOD: A systematic approach combining the opinion of three different general practitioner expert panels, and an empirical test in daily practice. The indicators were based on clinical, evidence-based, national guidelines. We tested the validity, feasibility, reliability and opportunity for quality improvement. RESULTS: Of the 80 available national clinical guidelines, 29 were approved and selected by the first general practitioner expert panel. Out of these 29 guidelines, 73 indicators concerning prescribing and referring were selected by the second panel. In an empirical test on 36 254 patient contacts, 7344 patient contacts (22.7%) were relevant for the assessment of these 73 indicators. Six indicators were excluded because they scored more than 15% missing values. In total, 38 indicators were excluded because the opportunity for quality improvement was limited (performance score > or =90%). In the final meeting, the third general practitioner expert panel excluded five indicators, leading to a final set of 24 indicators. CONCLUSION: This study shows the importance of subjecting indicators to an empirical test in practice. The national clinical guidelines are only partially applicable in the assessment of out-of-hours primary care. They need to be expanded with topics that are related to general practitioner care in an out-of-hours setting and acute medical problems.

Patients either contacting a general practice cooperative or accident and emergency department out of hours: a comparison.

INTRODUCTION: Lack of collaboration between general practice (GP) cooperatives and accident and emergency (A&E) departments and many self referrals may lead to inefficient out-of-hours care. METHODS: We retrospectively analysed the records of all patients contacting the GP cooperative and all patients self referring to the A&E department out of hours in a region in the Netherlands. RESULTS: 258 patients contacted the GP cooperative and 43 self referred to the A&E department per 1000 patients per year. A wide range of problems were seen in the GP cooperative, mainly related to infections (26.2%). The A&E department had a smaller range of problems, mainly related to trauma (66.1%). Relatively few urgent problems were seen in the GP cooperative (4.6%) or for self referrals in the A&E department (6.1%). Women, children, the elderly, and rural patients chose the GP cooperative significantly more often, as did men and patients with less urgent complaints, infections, and heart and airway problems. DISCUSSION: The contact frequency of self referrals to the A&E department is much lower than that at the GP cooperative. Care is complementary: the A&E department focuses on trauma while the GP cooperative deals with a wide range of problems. The self referrals concern mostly minor, non-urgent problems and can generally be treated by the general practitioner, by a nurse, or by advice over the telephone, particularly in the case of optimal collaboration in an integrated care facility of GP cooperatives and A&E departments with one access point to medical care for all patients.

[Sexual contact between general practitioner and patient in the Netherlands: prevalence and risk factors]. / Seksueel contact tussen huisarts en patiënt: prevalentie en risicofactoren.

OBJECTIVE: To obtain data on sexual contact between general practitioners (GPs) and their patients and to determine the relationship between sexual abuse and GP characteristics. DESIGN: Cross-sectional. METHOD: In February-May 2002, anonymous questionnaires were mailed to a randomized sample of 1250 general practitioners in the Netherlands. RESULTS: A total of 977 general practitioners responded (response: 80%). This number included relatively large numbers of women and GPs aged > or = 50. Out of the 977 GPs, 32 had had sexual contact with a patient at some time: 30/695 (4.3%) of the male GPs and 2/247 (0.8%) of the female GPs Coitus was reported by 24 (75%) of them. Of the 32 perpetrators 11 (34%) had had sexual contact with 2 or more patients. Of the 30 male GPs who engaged in sexual contact with patients, 20 (67%) afterwards felt positive about the sexual encounter for himself and 22 (73%) for the patient. Sexual contact with a patient occurred more often among men who at the time of the survey were aged < or = 50 [corrected]. The incidence was not related to the degree of urbanisation of the practice area or to the size of the practice partnership. CONCLUSION: Sexual contacts between general practitioners and their patients are not just incidents. It is not enough to be conscious of one's own sexual feelings towards patients. Implementation of a clear policy is needed.

Ethnic specific recommendations in clinical practice guidelines: a first exploratory comparison between guidelines from the USA, Canada, the UK, and the Netherlands.

OBJECTIVES: To investigate whether clinical practice guidelines in different countries take ethnic differences between patients into consideration and to assess the scientific foundation of such ethnic specific recommendations. DESIGN: Analysis of the primary care sections of clinical practice guidelines. SETTING: Primary care practice guidelines for type 2 diabetes mellitus, hypertension, and asthma developed in the USA, Canada, the UK, and the Netherlands. MAIN OUTCOME MEASURES: Enumeration of the ethnic specific information and recommendations in the guidelines, and the scientific basis and strength of this evidence. RESULTS: Different guidelines do address ethnic differences between patients, but to a varying extent. The USA guidelines contained the most ethnic specific statements and the Dutch guidelines the least. Most ethnic specific statements were backed by scientific evidence, usually arising from descriptive studies or narrative reviews. CONCLUSION: The attention given to ethnic differences between patients in clinical guidelines varies between countries. Guideline developers should be aware of the potential problems of ignoring differences in ethnicity.

[Less ethnic knowledge in the Dutch College of General Practitioner's practice guidelines on type 2 diabetes mellitus, hypertension and asthma in adults than in the supporting literature]. / Minder etnische kennis in de standaarden van het Nederlands Huisartsen Genootschap over diabetes mellitus type 2, hypertensie en over astma bij volwassenen dan in de onderbouwende literatuur.

OBJECTIVE: To assess whether ethnic differences present in the scientific literature used as the basis for the Dutch College of General Practitioner's (NHG) practice guidelines were reflected in the ethnic-specific information the guidelines contained. DESIGN: Analysis of published information. METHOD: The scientific literature used as the basis for the guidelines about type 2 diabetes mellitus, hypertension and asthma in adults was collected and carefully screened. Relevant ethnic-specific information was compared to the content of the guidelines. RESULTS: Several relevant ethnic differences were stated in the scientific literature used as the basis for the guidelines. Differences in prevalence and clinical progress were stated for type 2 diabetes mellitus, differences in lung-volume were stated for asthma and differences in prevalence, onset, complications, response to pharmacological treatment and dietary salt restriction were stated for hypertension. The type 2 diabetes mellitus guideline stated a higher prevalence of diabetes in Hindustani people and recommended earlier screening in this group. The asthma guideline stated that the lung volume is dependent of ethnicity. The hypertension guideline did not state any ethnic-specific information. CONCLUSION: The guidelines on type 2 diabetes mellitus, hypertension and asthma in adults only adopted a limited number of the ethnic differences contained in the scientific literature on which they were based. Possible explanations are that information was only included if there was a clear scientific basis, and that ethnic distinctions were found to be politically and socially undesirable. However, this lack of information might lead to ineffective or sub-optimal care for ethnic minorities.

[Disinfection of the skin prior to injections does not influence the incidence of infections; a literature study]. / Desinfecteren van de huid vóór injecties niet van invloed op het ontstaan van infecties; een literatuurstudie.

OBJECTIVE: To assess the incidence of infections after subcutaneous, intramuscular or intravenous injections--using sterile needles--with or without prior disinfection of the skin. METHOD: Literature searches were made in the database Medline from 1966-June 2001, in the databases Picarta, Embase and the Cochrane Library, as well as manually in the reference lists of the collected articles. Original papers in English, Dutch or German were selected. RESULTS: Four relevant studies were found, generally of poor quality. In these two infections were reported after disinfecting the skin prior to over 2300 injections in 156 patients, and none were reported after not disinfecting the skin prior to over 7000 injections in more than 700 patients. CONCLUSION: Both disinfection prior to skin injections and omission of disinfection were followed by (almost) no infections.

[Roaming through methodology. XXXVIII. Common misconceptions involving standard deviation and standard error]. / Dwalingen in de methodologie. XXXVIII. Veelvoorkomende misverstanden rond standaarddeviaties en standaardfouten.

Standard deviation and standard error have a clear mutual relationship, but at the same time they differ strongly in the type of information they supply. This can lead to confusion and misunderstandings. Standard deviation describes the variability in a sample of measures of a variable, for instance the variability in ages of the members of a group. It represents the degree to which the values are scattered around their mean: the higher the standard deviation the wider the spread. The value of the standard deviation is not influenced by the number of observations in the sample. The standard error is always used for extrapolation: to estimate the intervals between which the true value of a statistic will occur, based on a sample of observations and with a certain degree of certainty. When interpreting a standard error, it is important to know which statistic (mean, percentage, relative risk, odds ratio) is to be estimated. The value of the standard error is strongly influenced by the number of observations in the sample: the bigger the sample, the smaller the standard error and the more accurate the estimation. To avoid confusion it is recommended to report no longer the standard error of the mean but instead the confidence intervals of the mean to estimate the true value of the mean.

Continuous quality improvement in small general medical practices: the attitudes of general practitioners and other practice staff.

OBJECTIVES: Continuous quality improvement (CQI) offers opportunities to improve care in small-scale office-based practice. Little is yet known about the implementation of CQI in small primary care practices. We studied the attitudes of physicians and staff in small family practices to a model of CQI tailored to office-based practice setting. PRACTICES AND DESIGN: An exploratory study in 20 family practices in The Netherlands. Practices were stimulated to adopt the model for continuous quality improvement. MAIN OUTCOME MEASURES: The use of the model at the end of the study period, the perception of the physicians and staff of their success with adopting the model, their view of its usefulness, their willingness to continue and personal and practical obstacles. Measurements were made using written questionnaires. RESULTS: The rate of implementation of the model varied between practices. Participants rated their success in performing improvement projects, holding regular quality meetings and setting targets and priorities. They were positive about the usefulness of the model and they were generally willing to continue to use it. Barriers included the size of workload and the tendency to postpone actions until external support by an outreach visitor was provided. Physician and staff attitudes were homogeneous at a practice level. CONCLUSION: Our findings stress the importance of starting CQI with small, easy-to-handle projects. Workload reduction might be an important issue to focus on. Personal obstacles should be addressed throughout the introduction. We found attitudes in small-scale practices to be homogeneous, so that it was important to pay explicit attention to commitment to CQI from the start of the introduction.

Health perception of patients after cardiovascular risk detection and after intervention in general practice.

BACKGROUND. To explore unfavorable effects, health perception was assessed in patients enrolled in a cardiovascular program in general practice. METHODS. A prospective questionnaire survey was conducted shortly after risk detection and after 1 year of intervention. Patients (n=413) with an elevated risk were selected from 27 practices in The Netherlands. The outcome measure was patients' perceptions of their general health status. RESULTS. The response rate was 62%. Two thirds of the patients did not show any change in general health status at either point in time. Substantially more patients showed improvement after 1 year of intervention. Compared to reference data, no major differences were found. CONCLUSION. Enrollment in a cardiovascular risk detection and intervention program did not lead to unfavorable perceptions of general health status, either shortly after risk detection or after 1 year of intervention. (c) 2001 by CHF, Inc.

Cardiovascular risk detection and intervention in general practice: the patients' views.

OBJECTIVE: To assess patients' views on the organization of (cardiovascular) preventive care. DESIGN: Prospective questionnaire survey with measurements shortly after risk assessment (T1) and after 1 year of risk intervention (T2). SETTING: Twenty-seven general practices participating in a project to enhance systematic cardiovascular disease prevention in two regions in The Netherlands. STUDY PARTICIPANTS: Two-hundred and ninety-eight successive patients aged 30-60 years identified with an elevated cardiovascular risk. MAIN OUTCOME MEASURES: Organizational aspects such as the acceptability of the care provider, practicality of special clinics, accessibility of the practice for routine care. RESULTS: Most of the respondents (74%) had no preference for a care provider in cardiovascular preventive care and only a few patients (3%) reported having little confidence in the expertise of the practice assistant to provide such care. The vast majority (88%) considered special preventive clinics to be practical, especially at T1. Most of the respondents (76%) did not report a decline in the accessibility of their practice for routine care. These outcome measures were not affected by age, sex, educational level or the number of risk factors measured during 1 year of risk intervention. CONCLUSION: Most patients did not have any major objections against the organization of preventive care through opportunistic case finding and risk monitoring in special preventive clinics managed by the practice assistant.

Setting up improvement projects in small scale primary care practices: feasibility of a model for continuous quality improvement.

OBJECTIVES: To evaluate the feasibility of a model for continuous quality improvement in small scale general practice and the improvement projects that practices ran after the introduction of continuous quality improvement. DESIGN: A descriptive study. SETTING: Twenty general practices in the Netherlands tested the model in an intervention period of 18 months. INTERVENTION: A model for continuous quality improvement adapted for general practice was introduced into the practices using a structured strategy. Practices were supported by trained facilitators. MAIN OUTCOME MEASURES: Acceptance at introduction and continued application of the model; the topics of improvement projects that were set up in the practices; whether the improvement projects had been completed; whether they had met the criteria (the use of the "quality cycle" and the Oxford audit score); and whether the self set objectives had been met. RESULTS: The model was introduced and accepted in all participating practices. Practices started 51 improvement projects. At the end of the study period 33 improvement projects had been completed. Practices chose a wide variety of objectives for these projects; most of them concerned medical or organisational topics. Practices started projects mainly because the topic was felt to be a problem or was causing a bottleneck in the organisation. The quality cycle was used in all projects, but practices did not always collect data and evaluate the outcomes. Fourteen projects could be discerned as "full audit". No differences existed in the quality of improvement projects among the various types of practice or between the topics addressed. At the end of the study period half of the practices continued applying the model. CONCLUSION: This study showed that the model was feasible for small scale general practice. However, application of the model tended to disintegrate after the facilitator had left the practice. Practices succeeded reasonably well in running improvement projects. Introduction of continuous quality improvement should particularly focus on this. It is suggested that intensive support is necessary to implement and maintain continuous quality improvement in small scale practices.

Attributes of clinical guidelines that influence use of guidelines in general practice: observational study.

OBJECTIVE: To determine which attributes of clinical practice guidelines influence the use of guidelines in decision making in clinical practice. DESIGN: Observational study relating the use of 47 different recommendations from 10 national clinical guidelines to 12 different attributes of clinical guidelines-for example, evidence based, controversial, concrete. SETTING: General practice in the Netherlands. SUBJECTS: 61 general practitioners who made 12 880 decisions in their contacts with patients. MAIN OUTCOME MEASURES: Compliance of decisions with clinical guidelines according to the attribute of the guideline. RESULTS: Recommendations were followed in, on average, 61% (7915/12 880) of the decisions. Controversial recommendations were followed in 35% (886/2497) of decisions and non-controversial recommendations in 68% (7029/10 383) of decisions. Vague and non-specific recommendations were followed in 36% (826/2280) of decisions and clear recommendations in 67% (7089/10 600) of decisions. Recommendations that demanded a change in existing practice routines were followed in 44% (1278/2912) of decisions and those that did not in 67% (6637/9968) of decisions. Evidence based recommendations were used more than recommendations for practice that were not based on research evidence (71% (2745/3841) v 57% (5170/9039)). CONCLUSIONS: People and organisations setting evidence based clinical practice guidelines should take into account some of the other important attributes of effective recommendations for clinical practice.

Tailored outreach visits as a method for implementing guidelines and improving preventive care.

OBJECTIVES: Authors of successful outreach visit studies stress the importance of tailoring the intervention to the unique attributes and needs of each practice. For a better understanding of the outreach visit method, the tailoring mechanism is explored in this article. The variation among practices in preventive outreach visits to implement guidelines and characteristics that determine the variation (baseline adherence to organizational guidelines, practice and visitor characteristics) are described. We explored whether and how many visits were paid to practices that showed no increase in adherence to guidelines. SETTING AND STUDY PARTICIPANTS: For 18 months, six trained nurse visitors assisted 33 family practices in implementing a set of guidelines to organize a program for cardiovascular disease prevention. MEASURES: Visit and consultative action parameters (number and duration of visits, duration of training and of conferring) and increase in adherence to organizational guidelines after 18 months of assistance compared to baseline adherence. RESULTS: Practices differed considerably concerning the visit and consultative action parameters. Exploratory multiple regression analysis showed that baseline adherence to guidelines, and practice and visitor characteristics were related to the number of visits. Visitor characteristics were strongly related to the total time spent on visits, training, and conferring. DISCUSSION: Our findings confirm that, concerning the number of visits, assistance is primarily adapted to the unique attributes of each clinic. It may be useful, from the viewpoint of cost-effectiveness, to standardize the performance of visitors somewhat more with regard to the visit length. The tailoring mechanism resulted in time well spent in assisting practices. We hope that our results contribute to the further development of the outreach method.

Dissemination of guidelines: which sources do physicians use in order to be informed?

OBJECTIVE: To gain insight into processes of dissemination of clinical guidelines, sources of information physicians use to become informed about them, and factors influencing these processes. DESIGN: National survey among a random sample of family physicians using a structured questionnaire. SETTING: Family practice in The Netherlands; evaluation of a national programme of (evidence based) practice guidelines. STUDY PARTICIPANTS: A random sample of 1531 family physicians. MAIN MEASURES: Being informed about national guidelines and specific recommendations from these guidelines; being informed about specific educational programmes on the national guidelines; sources of information used in order to be informed; doctor and practice characteristics. RESULTS: The response rate was 67%, the responders being younger than the non-responders. The scientific journal for family physicians proved to be the most important source of information (85%), discussing the guidelines in the local family doctor group was also important (53%). Following continuing medical education courses was less important (33%). On average 80% knew about the different guidelines and recommendations, 63% about the educational programmes. Doctors who use the scientific journal as a source, who are members of the professional organization of family doctors, who are younger and who are actively involved in education on family medicine, proved to be better informed. CONCLUSIONS: Segmentation of the target group is necessary for effective dissemination of guidelines or new research findings. For some doctors it is desirable to make evidence available quickly, for others spreading the guidelines through the local network may be effective, while for another group a more active, personal approach may be necessary.

Relationship between practice organization and cardiovascular risk factor recording in general practice.

BACKGROUND: Research findings suggest that the level of cardiovascular risk factor recording in general practice is not yet optimal. Several studies indicate a relation between the organization of cardiovascular disease prevention at practice level and cardiovascular risk factor recording. AIM: To explore the relation between the organization of cardiovascular disease prevention and risk factor recording in general practice. METHOD: A cross-sectional study was conducted using data on adherence to selected practice guidelines and on cardiovascular risk factor recording from 95 general practices. Practice guidelines were developed beforehand in a consensus procedure. Adherence was assessed by means of a questionnaire and practice observations. Risk factor recording was assessed by an audit of 50 medical records per practice. RESULTS: Factor analysis of risk factor recording revealed three dimensions explaining 76% of the variance: recording of health-related behaviour, recording of clinical parameters, and recording of medical background parameters. Adherence to the guideline 'proactively invite patients to attend for assessment of cardiovascular risk' was related to a higher recording level in all three dimensions. Practice characteristics did not show a consistent relationship to the level of risk factor recording. CONCLUSION: This study indicates that the presence of a system of proactive invitation was related to the recording of cardiovascular risk factors in medical records in general practice.

Persisting improvement in complaint-related cognitions initiated during medical consultations in functional abdominal complaints.

BACKGROUND: Previously it was shown that during a series of out-patient consultations dysfunctional complaint-related cognitions and anxiety diminished significantly in patients with functional abdominal complaints (IBS). The aim of the present study was to assess the maintenance of positive changes initiated during medical consultations in the patients' complaint-related cognitions and anxiety, as well as the influence of these cognitions on the severity of the complaints, 6 months after the first visit to the out-patient clinic. METHODS: One hundred and five consecutive patients with IBS referred by their general practitioners to the out-patient clinic for internal medicine completed questionnaires about their complaints and their complaint-related cognitions and anxiety before the first and after the last out-patient visit and again at follow-up, 6 months after the first out-patient consultation. RESULTS: Positive changes in the patients' complaint-related cognitions during the consulting period were found to persist during the follow-up period. Improvement in abdominal complaints at follow-up was found to be related to the level of the patients' state anxiety, fear of cancer, and catastrophizing cognitions at the last out-patient visit. CONCLUSIONS: Medical consultations can bring about long-lasting positive changes in prognostically unfavourable cognitions and anxiety. These changes appear to be related to a better outcome of IBS.

Changing preventive practice: a controlled trial on the effects of outreach visits to organise prevention of cardiovascular disease.

OBJECTIVES: To assess the effects of outreach visits by trained nurse facilitators on the organisation of services used to prevent cardiovascular disease. To identify the characteristics of general practices that determined success. DESIGN: A non-randomised controlled trial of two methods of implementing guidelines to organise prevention of cardiovascular disease: an innovative outreach visit method compared with a feedback method. The results in both groups were compared with data from a control group. SETTING AND SUBJECTS: 95 general practices in two regions in The Netherlands. INTERVENTIONS: Trained nurse facilitators visited practices, focusing on solving problems in the organisation of prevention. They applied a four step model in each practice. The number of visits depended on the needs of the practice team. The feedback method consisted of the provision of a feedback report with advice specific to each practice and standardised instructions. MAIN OUTCOME MEASURES: The proportion of practices adhering to 10 different guidelines. Guidelines were on the detection of patients at risk, their follow up, the registration of preventive activities, and teamwork within the practice. RESULTS: Outreach visits were more effective than feedback in implementing guidelines to organise prevention. Within the group with outreach visits, the increase in the number of practices adhering to the guidelines was significant for six out of 10 guidelines. Within the feedback group, a comparison of data before and after intervention showed no significant differences. Partnerships and practices with a computer changed more. CONCLUSION: Outreach visits by trained nurse facilitators proved to be effective in implementing guidelines within general practices, probably because their help was practical and designed for the individual practice, guided by the wishes and capabilities of the practice team.