Exposure to and experiences with a computerized decision support intervention in primary care: results from a process evaluation.

BACKGROUND: Trials evaluating the effects of interventions usually provide little insight into the factors responsible for (lack of) changes in desired outcomes. A process evaluation alongside a trial can shed light on the mechanisms responsible for the outcomes of a trial. The aim of this study was to investigate exposure to and experiences with a computerized decision support system (CDSS) intervention, in order to gain insight into the intervention's impact and to provide suggestions for improvement. METHODS: A process evaluation was conducted as part of a large-scale cluster-randomized controlled trial investigating the effects of the CDSS NHGDoc on quality of care. Data on exposure to and experiences with the intervention were collected during the trial period among participants in both the intervention and control group - whenever applicable - by means of the NHGDoc server and an electronic questionnaire. Multiple data were analyzed using descriptive statistics. RESULTS: Ninety-nine percent (n = 229) of the included practices generated data for the NHGDoc server and 50 % (n = 116) responded to the questionnaire: both general practitioners (GPs; n = 112; 49 %) and practice nurses (PNs; n = 52; 37 %) participated. The actual exposure to the NHGDoc system and specific heart failure module was limited with 52 % of the GPs and 42 % of the PNs reporting to either never or rarely use the system. Overall, users had a positive attitude towards CDSSs. The most perceived barriers to using NHGDoc were a lack of learning capacity of the system, the additional time and work it requires to use the CDSS, irrelevant alerts, too high intensity of alerts and insufficient knowledge regarding the system. CONCLUSIONS: Several types of barriers may have negatively affected the impact of the intervention. Although users are generally positive about CDSSs, a large share of them is insufficiently aware of the functions of NHGDoc and, finds the decision support not always useful or relevant and difficult to integrate into daily practice. In designing CDSS interventions we suggest to more intensely involve the end-users and increase the system's flexibility and learning capacity. To improve implementation a proper introduction of a CDSS among its target group including adequate training is advocated. TRIAL REGISTRATION: Clinical trials NCT01773057 .

Evaluating the uptake and effects of the computerized decision support system NHGDoc on quality of primary care: protocol for a large-scale cluster randomized controlled trial.

BACKGROUND: Computerized decision support systems (CDSSs) are increasingly used to improve quality of care. There is evidence for moderate to large effects from randomized controlled trials (RCTs), but evidence on their effectiveness when implemented at a national level is lacking. In the Netherlands, the Dutch College of General Practitioners (NHG) initiated their successful guideline program already 30 years ago. NHGDoc, a CDSS based on these NHG guidelines, covering multiple disease areas for general practice, was developed in 2006 with the aim to improve quality of primary care. In this paper, a protocol is presented to evaluate the uptake and effects of NHGDoc. METHODS: A cluster RCT will be conducted among 120 general practices in the Netherlands. Eligible general practices will be randomized to receive either the regular NHGDoc decision support modules (control arm) or the regular modules plus an additional module on heart failure (intervention arm). The heart failure module consists of patient-specific alerts concerning the treatment of patients with heart failure. The effect evaluation will focus on performance indicators (e.g., prescription behavior) as well as on patient outcomes (e.g., hospital admissions) relevant in the domain of heart failure. Additionally, a process evaluation will be conducted to gain insight into the barriers and facilitators that affect the uptake and impact of NHGDoc. DISCUSSION: Results of this study will provide insight in the uptake and impact of a multiple-domain covering CDSS for primary care implemented by a national guideline organization to improve the quality of primary care. Whereas the trial focuses on a specific domain of care-heart failure-conclusions of this study will shed light on the functioning of CDSSs covering multiple disease areas for primary care, particularly as this study also explores the factors contributing to the system's uptake and effectiveness. TRIAL REGISTRATION: Clinical trials NCT01773057.

Goodness ratings of melodic openings and closures.

The purpose of the present study was to map the suitability of melodic intervals for opening and closing a melody. Listeners (n = 13), belonging to two groups with different levels of expertise, rated the 25 within-octave intervals (unison plus the 12 nonunison intervals in ascending and in descending directions), for their suitability as openings; another, similarly subdivided group of listeners (n = 12) rated the intervals as candidates for closure. Both data sets were modeled by means of multiple regression. For openings, a three-factorial model (intervallic size, direction, and implicit harmony) provided a satisfactory description of the data; for closures, an extra factor (intervallic gravity) had to be added to the model. Differences involving level of expertise were established-notably, the importance of harmony for the experts, which played only a subordinate role in the responses of the nonexperts. The two sets of data were contrasted with those of closely related perceptual studies of openings and closures. In addition, the findings were discussed in relation to their contribution to insight into overlapping, a syntactical construction in which tones serve the double function of closing a musical phrase and opening the next one.