[Summary of the 'Stroke' guideline of the Dutch College of General Practitioners' (NHG)]. / Samenvatting van de NHG-standaard 'Beroerte'.

The Dutch College of General Practitioners (NHG) guideline 'Stroke' covers the diagnosis, management and long-term care of stroke in general practice. Patients with neurological symptoms suspected to be due to cerebral infarction or haemorrhage should be transferred directly to a stroke unit. The specialized care provided by these units, including emergency interventions (e.g. intravenous thrombolysis) and early mobilization help improve outcomes. If neurological symptoms have resolved completely, the patient should be referred to a TIA service as soon as possible, preferably within 1 day. Stroke often leads to permanent disability and neuropsychological impairments. The general practitioner (GP) should provide patients and caregivers with information and support, and should be alert to the psychological consequences of stroke, both in patients and caregivers. Secondary prevention measures are started as soon as the diagnosis of stroke is confirmed. GPs should regularly evaluate and monitor risk factors and compliance.

Improving test ordering in primary care: the added value of a small-group quality improvement strategy compared with classic feedback only.

PURPOSE: We wanted to evaluate the added value of small peer-group quality improvement meetings compared with simple feedback as a strategy to improve test-ordering behavior. Numbers of tests ordered by primary care physicians are increasing, and many of these tests seem to be unnecessary according to established, evidence-based guidelines. METHODS: We enrolled 194 primary care physicians from 27 local primary care practice groups in 5 health care regions (5 diagnostic centers). The study was a cluster randomized trial with randomization at the local physician group level. We evaluated an innovative, multifaceted strategy, combining written comparative feedback, group education on national guidelines, and social influence by peers in quality improvement sessions in small groups. The strategy was aimed at 3 specific clinical topics: cardiovascular issues, upper abdominal complaints, and lower abdominal complaints. The mean number of tests per physician per 6 months at baseline and the physicians' region were used as independent variables, and the mean number of tests per physician per 6 months was the dependent variable. RESULTS: The new strategy was executed in 13 primary care groups, whereas 14 groups received feedback only. For all 3 clinical topics, the decrease in mean total number of tests ordered by physicians in the intervention arm was far more substantial (on average 51 fewer tests per physician per half-year) than the decrease in mean number of tests ordered by physicians in the feedback arm (P = .005). Five tests considered to be inappropriate for the clinical problem of upper abdominal complaints decreased in the intervention arm, with physicians in the feedback arm ordering 13 more tests per 6 months (P = .002). Interdoctor variation in test ordering decreased more in the intervention arm. CONCLUSION: Compared with only disseminating comparative feedback reports to primary care physicians, the new strategy of involving peer interaction and social influence improved the physicians' test-ordering behavior. To be effective, feedback needs to be integrated in an interactive, educational environment.

Block design allowed for control of the Hawthorne effect in a randomized controlled trial of test ordering.

BACKGROUND AND OBJECTIVE: To evaluate the value of balanced incomplete block designs in quality improvement research, and their capacity to control for the Hawthorne effect. METHODS: General practitioners teams were randomized into three arms and received an intervention on test ordering, relating to tests for two groups of clinical problems (A tests and B tests). In the two trials within the block design, we tried to control for the Hawthorne effect by comparing the complete intervention in both arms on either the A (arm I) or B tests (arm II); the arms acted as blind controls for each other. In the classical trial, the complete intervention on B tests (arm II) was compared with a control arm without any intervention on B tests (arm III). RESULTS: The trials with the block design yielded statistically significant changes in the numbers of A tests ordered (P=.013), but not in the numbers of B tests ordered (P=.29). In the classical design, the complete intervention reached a marginally significant change in the B tests (P=.068). The Hawthorne effect was the same for both arms of the block design. In the classical design, the effect could to some extent be attributed to the Hawthorne effect. CONCLUSION: Our block design allowed us to control for the Hawthorne effect. Suitable use of block designs may further our knowledge of nonspecific effects in quality improvement research.

Comparing cost effects of two quality strategies to improve test ordering in primary care: a randomized trial.

OBJECTIVE: To determine the costs and cost reductions of an innovative strategy aimed at improving test ordering routines of primary care physicians, compared with a traditional strategy. DESIGN: Multicenter randomized controlled trial with randomization at the local primary care physicians group level. SETTING: Primary care: local primary care physicians groups in five regions of the Netherlands with diagnostic centers. STUDY PARTICIPANTS: Twenty-seven existing local primary care physicians groups, including 194 primary care physicians. INTERVENTION: The test ordering strategy was developed systematically, and combined feedback, education on guidelines, and quality improvement sessions in small groups. In regular quality meetings in local groups, primary care physicians discussed each others' test ordering behavior, related it to guidelines, and made individual and/or group plans for change. Thirteen groups engaged in the entire strategy (complete intervention arm), while 14 groups received feedback only (feedback arm). MAIN OUTCOME MEASURE: Running costs, development costs, and research costs were calculated for the intervention period per primary care physician per 6 months. The mean costs of tests ordered per primary care physician per 6 months were assessed at baseline and follow-up. RESULTS: The new strategy was found to cost 702.00, while the feedback strategy cost 58.00. When including running costs only, the intervention was found to cost 554.70, compared with 17.10 per primary care physician per 6 months in the feedback arm. When excluding opportunity costs for the physicians' time spent, the intervention was found to cost 92.70 per physician per 6 months in the complete intervention arm. The mean costs reduction that physicians in that arm achieved by reducing unnecessary tests was 144 larger per physician per 6 months than the physicians in the feedback arm (P = 0.048). CONCLUSION: On the basis of our findings, including the expected non-monetary benefits, we recommend further long-term effect and cost-effect studies on the implementation of the quality strategy.

Variation in test ordering behaviour of GPs: professional or context-related factors?

OBJECTIVE: The aim of this study was to describe GPs' test ordering behaviour, and to establish professional and context-related determinants of GPs' inclination to order tests. METHODS: A cross-sectional analysis was carried out of 229 GPs in 40 local GP groups from five regions in The Netherlands of the combined number of 19 laboratory and eight imaging tests ordered by GPs, collected from five regional diagnostic centres. In a multivariable multilevel regression analysis, these data were linked with survey data on professional characteristics such as knowledge about and attitude towards test ordering, and with data on context-related factors such as practice type or experience with feedback on test ordering data. The main outcome measure was the percentage point differences associated with professional and context-related factors. RESULTS: The total median number of tests per GP per year was 998 (interquartile range 663-1500), with significant differences between the regions. The response to the survey was 97%. At the professional level, 'individual involvement in developing guidelines' (yes versus no), and at the context-related level 'group practice' (versus single-handed and two-person practices) and 'more than 1 year of experience working with a problem-oriented laboratory order form' (yes versus no) were associated with 27, 18 and 41% lower numbers of tests ordered, respectively. CONCLUSION: In addition to professional determinants, context-related factors appeared to be strongly associated with the numbers of tests ordered. Further studies on GPs' test ordering behaviour should include local and regional factors.

Effect of a practice-based strategy on test ordering performance of primary care physicians: a randomized trial.

CONTEXT: Numbers of diagnostic tests ordered by primary care physicians are growing and many of these tests seem to be unnecessary according to established, evidence-based guidelines. An innovative strategy that focused on clinical problems and associated tests was developed. OBJECTIVE: To determine the effects of a multifaceted strategy aimed at improving the performance of primary care physicians' test ordering. DESIGN: Multicenter, randomized controlled trial with a balanced, incomplete block design and randomization at group level. Thirteen groups of primary care physicians underwent the strategy for 3 clinical problems (arm A; cardiovascular topics, upper and lower abdominal complaints), while 13 other groups underwent the strategy for 3 other clinical problems (arm B; chronic obstructive pulmonary disease and asthma, general complaints, degenerative joint complaints). Each arm acted as a control for the other. SETTING: Primary care physician groups in 5 regions in the Netherlands with diagnostic centers recruited from May to September 1998. STUDY PARTICIPANTS: Twenty-six primary care physician groups, including 174 primary care physicians. INTERVENTION: During the 6 months of intervention, physicians discussed 3 consecutive, personal feedback reports in 3 small group meetings, related them to 3 evidence-based clinical guidelines, and made plans for change. MAIN OUTCOME MEASURE: According to existing national, evidence-based guidelines, a decrease in the total numbers of tests ordered per clinical problem, and of some defined inappropriate tests, is considered a quality improvement. RESULTS: For clinical problems allocated to arm A, the mean total number of requested tests per 6 months per physician was reduced from baseline to follow-up by 12% among physicians in the arm A intervention, but was unchanged in the arm B control, with a mean reduction of 67 more tests per physician per 6 months in arm A than in arm B (P =.01). For clinical problems allocated to arm B, the mean total number of requested tests per 6 months per physician was reduced from baseline to follow-up by 8% among physicians in the arm B intervention, and by 3% in the arm A control, with a mean reduction of 28 more tests per physician per 6 months in arm B than in arm A (P =.22). Physicians in arm A had a significant reduction in mean total number of inappropriate tests ordered for problems allocated to arm A, whereas the reduction in inappropriate test ordered physicians in arm B for problems allocated to arm B was not statistically significant. CONCLUSION: In this study, a practice-based, multifaceted strategy using guidelines, feedback, and social interaction resulted in modest improvements in test ordering by primary care physicians.