Supporting care engagement in primary care; the development of a maturity matrix.

BACKGROUND: Care engagement or active patient involvement in healthcare contributes to the quality of primary care, but organisational preconditions in routine practice need to be aligned. A Maturity Matrix for Care Engagement to assess and discuss these preconditions in the general practice team was developed and tested on feasibility and acceptability in general practice. METHODS AND FINDINGS: A systematic user-centred approach was applied, starting with a scoping literature search to describe the domains on the horizontal axis of the maturity matrix. The domains and growing steps (vertical axis) were refined by patients (n = 16) and general practice staff (n = 11) in three focus group discussions and reviewed by six experts (local facilitators and scientists). Seven domains could be distinguished: Personalised Care, Shared Decision Making, Self-Management, Patient as Partner, Supportive Means, Patient Environment, and Teamwork among Healthcare Professionals. The growing steps described three to six activities per domain (n = 32 in total) that contribute to care engagement. Local facilitators implemented the tool in two general practice teams according to a user guide, starting with a two-hour kick-off meeting on care engagement. In the next step, practitioners, nurses and assistants in each practice indicated their score on the domains individually. The scores were discussed in the facilitated practice meeting which was aimed at SMART improvement plans. Feasibility and acceptability were assessed in interviews showing that the tool was well received by the pilot practices, although the practice assistants had difficulties scoring some of the activities as they did not always relate to their daily work. An assessment after three months showed changes in practice organisation towards increased care engagement. CONCLUSIONS: The maturity matrix on care engagement is a tool to identify the organisational practice maturity for care engagement. Suggested adaptations must be implemented before large-scale testing.

Patient characteristics associated with measurement of routine diabetes care: an observational study.

BACKGROUND: Non-modifiable patient characteristics, including age, gender, ethnicity as well as the occurrence of multi-morbidities, are associated with processes and outcomes of diabetes care. Information on these factors can be used in case mix adjustment of performance measures. However, the practical relevance of such adjustment is not clear. The aim of this study was to assess the strength of associations between patient factors and diabetes care processes and outcomes. METHODS: We performed an observational study based on routinely collected data of 12,498 diabetes patients in 59 Dutch primary care practices. Data were collected on patient age, gender, whether the patient lived in a deprived area, body mass index and the co-occurrence of cardiovascular disease, chronic obstructive pulmonary disease, depression or anxiety. Outcomes included 6 dichotomous measures (3 process and 3 outcome related) regarding glycosylated hemoglobin, systolic blood pressure and low density lipoprotein-cholesterol. We performed separate hierarchical logistic mixed model regression models for each of the outcome measures. RESULTS: Each of the process measure models showed moderate effect sizes, with pooled areas under the curve that varied between 0.66 and 0.76. The frequency of diabetes related consultations as a measure of patient compliance to treatment showed the strongest association with all process measures (odds ratios between 5.6 and 14.5). The effect sizes of the outcome measure models were considerably smaller than the process measure models, with pooled areas under the curve varying from 0.57 to 0.61. CONCLUSIONS: Several non-modifiable patient factors could be associated with processes and outcomes of diabetes care. However, associations were small. These results suggest that case-mix correction or stratification in assessing diabetes care has limited practical relevance.

Effect of accreditation on the quality of chronic disease management: a comparative observational study.

BACKGROUND: Practice accreditation is widely used to assess and improve quality of healthcare providers. Little is known about its effectiveness, particularly in primary care. In this study we examined the effect of accreditation on quality of care regarding diabetes, chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD). METHODS: A comparative observational study with two cohorts was performed. We included 138 Dutch family practices that participated in the national accreditation program for primary care. A first cohort of 69 practices was measured at start and completion of a 3-year accreditation program. A second cohort of 69 practices was included and measured simultaneously with the final measurement of the first cohort. In separate multilevel regression analyses, we compared both within-group changes in the first cohort and between-groups differences at follow-up (first cohort) and start (second cohort). Outcome measures consisted of 24 systematically developed indicators of quality of care in targeted chronic diseases. RESULTS: In the within-group comparison, we found improvements on 6 indicators related to diabetes (feet examination, cholesterol measurement, lipid lowering medication prescription) and COPD (spirometry performance, stop smoking advice). In the between-groups comparison we found that first cohort practices performed better on 4 indicators related to diabetes (cholesterol outcome) and CVD (blood pressure outcome, smoke status registration, glucose measurement). CONCLUSIONS: Improvements of the quality of primary care for patients with chronic diseases were found, but few could be attributed to the accreditation program. Further development of accreditation is needed to enhance its effectiveness on chronic disease management.

Organizational determinants of high-quality routine diabetes care.

OBJECTIVE: Randomized trials showed that changes in healthcare organization improved diabetes care. This study aimed to identify which organizational determinants were associated with patient outcomes in routine diabetes care. DESIGN: Observational study, in which multilevel regression analyses were applied to examine the impact of 12 organizational determinants on diabetes care as separate measures and as a composite score. SETTING: Primary care practices in the Netherlands. SUBJECTS: 11,751 patients with diabetes in 354 practices. MAIN OUTCOME MEASURES: Patients' recorded glycated hemoglobin (HbA1c), systolic blood pressure, and serum cholesterol levels. RESULTS: A higher score on the composite measure of organizational determinants was associated with better control of systolic blood pressure (p = 0.017). No effects on HbA1C or cholesterol levels were found. Exploration of specific organizational factors found significant impact of use of an electronic patient registry on HbA1c (OR = 1.80, 95% CI 1.12-2.88), availability of patient leaflets on systolic blood pressure control (OR = 2.59, 95% CI 1.06-6.35), and number of hours' nurse education on cholesterol control (OR = 2.51, 95% CI 1.02-6.15). CONCLUSION: In routine primary care, it was found that favorable healthcare organization was associated with a number of intermediate outcomes in diabetes care. This finding lends support to the findings of trials on organizational changes in diabetes care. Notably, the composite measure of organizational determinants had most impact.

Prevalence and consequences of patient safety incidents in general practice in the Netherlands: a retrospective medical record review study.

BACKGROUND: Patient safety can be at stake in both hospital and general practice settings. While severe patient safety incidents have been described, quantitative studies in large samples of patients in general practice are rare. This study aimed to assess patient safety in general practice, and to show areas where potential improvements could be implemented. METHODS: We conducted a retrospective review of patient records in Dutch general practice. A random sample of 1,000 patients from 20 general practices was obtained. The number of patient safety incidents that occurred in a one-year period, their perceived underlying causes, and impact on patients' health were recorded. RESULTS: We identified 211 patient safety incidents across a period of one year (95% CI: 185 until 241). A variety of types of incidents, perceived causes and consequences were found. A total of 58 patient safety incidents affected patients; seven were associated with hospital admission; none resulted in permanent disability or death. CONCLUSIONS: Although this large audit of medical records in general practices identified many patient safety incidents, only a few had a major impact on patients' health. Improving patient safety in this low-risk environment poses specific challenges, given the high numbers of patients and contacts in general practice.

Patient safety in primary care has many aspects: an interview study in primary care doctors and nurses.

RATIONALE, AIMS AND OBJECTIVES: Scientific definitions of patient safety may be difficult to apply in routine health care delivery. It is unknown what primary care workers consider patient safety. This study aimed to clarify the concept of patient safety in primary care. METHODS: We held 29 semi-structured interviews with a purposeful sample of primary care doctors and nurses regarding their perceptions of patient safety. The answers were analysed in an iterative procedure with respect to common themes. RESULTS: A broad range of specific aspects of primary care were named in relation with patient safety. Medication safety was most frequently mentioned. Most items were categorized as organizational, while the remaining aspects were linked to culture or professionalism. Scientific definitions of patient safety were not mentioned, but some primary care workers gave 'do not harm the patient' as a short definition for patient safety. CONCLUSION: Patient safety programmes have mostly targeted specific issues, such as incident reporting and medication safety. However, doctors and practice nurses had a broad view of what constitutes patient safety in primary care. This has implications for the measurement and improvement of patient safety in primary care.

Harm caused by adverse events in primary care: a clinical observational study.

RATIONALE, AIMS AND OBJECTIVES: Patient safety in primary care is important, but not well studied. The aim of our study was to determine the actual and potential harm caused by adverse events in primary care. METHOD: Observational study in two general practices, including the patients of five doctors. Two methods were used to identify adverse events; (1) a prospective registration of adverse events by the general practitioner and (2) a retrospective audit of medical records. Actual harm was registered and a clinical analysis was made to estimate potential harm. RESULTS: A total of 31 adverse events were collected and analysed. The adverse events were spread over different adverse event categories. About half of the events did not have health consequences, but a third led to worsening of symptoms and a few resulted in unplanned hospital admission. Potential negative health consequences were likely in three-quarters of the events. CONCLUSIONS: The identified adverse events had some impact on health outcomes, but a risk for harm existed in a majority of the events. Patient safety programmes in primary care should focus on adverse events and not just on harm.

How do Dutch general practitioners diagnose children's urinary tract infections?

OBJECTIVE: To study which tests general practitioners used to diagnose a urinary tract infection (UTI) in children and which patient characteristics were associated with test choice. DESIGN: Retrospective chart review on the diagnosis of UTIs in children in Dutch general practices who were diagnosed as having a UTI. A total of 49 general practices participated in the study, and provided information on 148 children aged 0-12 years old. RESULTS: The nitrite test, which is recommended as first step, was performed in 87% of the children during the first contact. Less than 30% of the children had a dipslide and 37% a cultured urine. About half of all children with a UTI diagnosis had a follow-up contact in general practice, and an average of 83% of these children had their urine tested. The recommended test, a dipslide, was performed in 26% of the children with a follow-up contact. Patient age and UTI history were associated with choice of test. CONCLUSIONS: The diagnostic procedures for UTIs in children in general practices could be improved, with focus on the importance of an accurate UTI diagnosis in all children, and explaining which tests should be performed and what the test results mean.

Management of childhood urinary tract infections: an economic modeling study.

UNLABELLED: Childhood urinary tract infections (UTIs) can lead to renal scarring and ultimately to terminal renal failure, which has a high impact on quality of life, survival, and health-care costs. Variation in the treatment of UTIs between practices is high. OBJECTIVE: To assess the cost-effectiveness of a maximum care model for UTIs in children, implying more testing and antibiotic treatment, compared with current practice in primary care in The Netherlands. METHODS: We performed a probabilistic modeling study using Markov models. Figures used in the model were derived from a systematic review of the research literature. Multidimensional Monte Carlo simulation was used for the probabilistic analyses. RESULTS: Maximum care gained 0.00102 (males) and 0.00219 (girls) QALYs (quality-adjusted life-years) and saved 42.70 euro (boys) and 77.81 euro (girls) in 30 years compared with current care, and was thus dominant. Net monetary benefit of maximum care ranged from 20 euro to 200 euro for a willingness to pay for a QALY ranging from 0 euro to 80,000 euro, respectively. Maximum care was also dominant over improved current care, although less dominant than to current care. CONCLUSIONS: This study suggested that maximum care for childhood UTI was dominant in the long run to current care, meaning that it delivered more quality of life at lower costs. Nevertheless, making firm conclusions is not possible, given the limitations of the input data.

Mix of methods is needed to identify adverse events in general practice: a prospective observational study.

BACKGROUND: The validity and usefulness of incident reporting and other methods for identifying adverse events remains unclear. This study aimed to compare five methods in general practice. METHODS: In a prospective observational study, with five general practitioners, five methods were applied and compared. The five methods were physician reported adverse events, pharmacist reported adverse events, patients' experiences of adverse events, assessment of a random sample of medical records, and assessment of all deceased patients. RESULTS: A total of 68 events were identified using these methods. The patient survey accounted for the highest number of events and the pharmacist reports for the lowest number. No overlap between the methods was detected. The patient survey accounted for the highest number of events and the pharmacist reports for the lowest number. CONCLUSION: A mix of methods is needed to identify adverse events in general practice.

Management of children's urinary tract infections in Dutch family practice: a cohort study.

BACKGROUND: Optimal clinical management of childhood urinary tract infections (UTI) potentiates long-term positive health effects. Insight into the quality of care in Dutch family practices for UTIs was limited, particularly regarding observation periods of more than a year. Our aim was to describe the clinical management of young children's UTIs in Dutch primary care and to compare this to the national guideline recommendations. METHODS: In this cohort study, all 0 to 6-year-old children with a diagnosed UTI in 2001 were identified within the Netherlands Information Network of General Practitioners (LINH), which comprises 120 practices. From the Dutch guideline on urinary tract infections, seven indicators were derived, on prescription, follow-up, and referral. RESULTS: Of the 284 children with UTI who could be followed for three years, 183 (64%) were registered to have had one cystitis episode, 52 (18%) had two episodes, and 43 (15%) had three or more episodes. Another six children were registered to have had one or two episodes of acute pyelonephritis. Overall, antibiotics were prescribed for 66% of the children having had < or = 3 cystitis episodes, two-thirds of whom received the antibiotics of first choice. About 30% of all episodes were followed up in general practice. Thirty-eight children were referred (14%), mostly to a paediatrician (76%). Less than one-third of the children who should have been referred was actually referred. CONCLUSION: Treatment of childhood UTIs in Dutch family practice should be improved with respect to prescription, follow-up, and referral. Quality improvement should address the low incidence of urinary tract infections in children in family practice.

Improving initial management of lower urinary tract symptoms in primary care: costs and patient outcomes.

OBJECTIVE: Guidelines for primary care management of lower urinary tract symptoms in older men recommend shared decision making regarding the choice of treatment. In this study we aimed to determine the costs and patient outcomes of an implementation strategy designed to enhance uptake of these guidelines. MATERIAL AND METHODS: The intervention comprised a distance learning programme for general practitioners, comprising evidence-based information, assessment of learning needs, a knowledge test and patient education materials. The control group only received the written guidelines. A cluster randomized trial in 187 older male patients compared costs and outcomes in the two study groups. A healthcare perspective was taken in the economic evaluation, with a 3-month time horizon. The primary health outcome was patient-reported urinary symptoms at 3 months. Costs relating to the distance learning package and the healthcare provided were considered, using undiscounted standardized prices. RESULTS: Patient-reported urinary symptoms at 3 months did not differ between the study groups: 66% and 61% with moderate symptoms and 7% and 11% with severe symptoms in the intervention and control groups, respectively. The mean total costs per patient were euro28.15 lower in the intervention group (euro93.11) compared to the control group (euro121.26), mainly because of a lower number of referrals to the urologist. A bootstrap analysis showed an incremental cost-effectiveness ratio of euro111.98 (95% CI -euro423 to +euro329). CONCLUSIONS: The distance learning programme did not change health outcomes, but it reduced costs in the first 3 months after an initial consultation compared to written guidelines. Studies with a longer follow-up period are needed.

Effects of distance learning on clinical management of LUTS in primary care: a randomised trial.

AIM: To determine the effect of a distance learning programme on general practice management of men with lower urinary tract symptoms (LUTS). METHODS: A cluster randomised controlled trial was performed. General practitioners (GPs) were randomised to a distance learning programme accompanied with educational materials or to a control group only receiving mailed clinical guidelines on LUTS. Clinical management was considered as outcome. RESULTS: Sixty-three GPs registered care management of 187 patients older than 50 years attending the practice because of LUTS. The intervention group showed a lower referral rate to a urologist (OR: 0.08 (95% CI: 0.02-0.40)), but no effect on PSA testing or prescription of medication. PSA testing tended to be requested more frequently by intervention group GPs. Secondary analysis showed patients in the intervention group received more educational materials (OR: 75.6 (95% CI: 13.60-419.90)). CONCLUSIONS: The educational programme had impact on clinical management without changing PSA testing. Distance learning is an promising method for continuing education. PRACTICE IMPLICATIONS: Activating distance learning packages are a potentially effective method for improving professional performance. Emotional matters as PSA testing probably need a more complex approach.

Shared care and the management of lower urinary tract symptoms.

OBJECTIVE: To investigate associations between the level of shared care and the clinical management of patients with uncomplicated lower urinary tract symptoms (LUTS). SUBJECTS AND METHODS: A cross-sectional survey study was conducted comprising all urologists and a random selection of general practitioners (GPs) in the Netherlands. Questionnaire responses were obtained from 182 urologists (70%) and 261 GPs (55%). The first part of the questionnaire established the physicians' characteristics and the second the level of familiarity with the national shared-care guidelines, arrangements between urologists and GPs, and the availability of a shared-care prostate clinic. The third part presented a written case of a 50-year-old man with clinical uncomplicated LUTS, and asked questions about diagnostic and therapeutic care. RESULTS: The clinical management of LUTS by GPs and urologists differed, particularly for diagnostic procedures. Only a minority of GPs (8%) and urologists (18%) had a shared-care clinic at their disposal. Such clinics were associated with an increase in tests ordered by the GP, e.g. creatinine levels (odds ratio, OR 3.83) and PSA levels (OR 5.93), and a decrease in choosing a watchful-waiting strategy for patients with mild symptoms (OR 0.24). Furthermore, urologists more often chose surgical intervention for moderate symptoms (OR 9.80). CONCLUSION: A shared-care clinic may lead to a shift in primary care towards the working style of urologists. This healthcare may not be as cost-effective as expected by policy makers. Prospective studies are needed to provide better insight in the health outcomes and efficiency of shared-care clinics.

The effect of a distance-learning programme on patient self-management of Lower Urinary Tract Symptoms (LUTS) in general practice: a randomised controlled trial.

OBJECTIVE: To determine whether a distance-learning programme on LUTS provided to the general practitioner affected patient self-management. METHODS: A randomised trial was performed to examine the effects of the distance-learning programme (an educational package for the GP and a patient information leaflet) compared with written guidelines on LUTS mailed to the GP. In 63 general practices (32 intervention and 31 control) across the Netherlands all patients older than 50 years presenting LUTS for the first time were invited to participate. Main outcome measures were patient evaluation of quality of care received and perceptions of enablement. RESULTS: A total of 151 patients was included. The intervention increased patient enablement regarding maintenance of independence (OR = 3.14) and coping with illness (OR = 2.21). Overall enablement scores were not changed. Patients in the intervention group had more positive evaluations of general practice care received (OR = 2.28 to 3.95). An explorative analysis suggested that the effects of the intervention were mediated in particular by handing out of patient information leaflets. CONCLUSIONS: A distance-learning programme on LUTS for general practitioners had positive effects on patient self-management. Handing out leaflets appeared to be a crucial mediating factor.