Development of a tailored strategy to improve postpartum hemorrhage guideline adherence.

BACKGROUND: Despite the introduction of evidence based guidelines and practical courses, the incidence of postpartum hemorrhage shows an increasing trend in developed countries. Substandard care is often found, which implies an inadequate implementation in high resource countries. We aimed to reduce the gap between evidence-based guidelines and clinical application, by developing a strategy, tailored to current barriers for implementation. METHODS: The development of the implementation strategy consisted of three phases, supervised by a multidisciplinary expert panel. In the first phase a framework of the strategy was created, based on barriers to optimal adherence identified among professionals and patients together with evidence on effectiveness of strategies found in literature. In the second phase, the tools within the framework were developed, leading to a first draft. In the third phase the strategy was evaluated among professionals and patients. The professionals were asked to give written feedback on tool contents, clinical usability and inconsistencies with current evidence care. Patients evaluated the tools on content and usability. Based on the feedback of both professionals and patients the tools were adjusted. RESULTS: We developed a tailored strategy to improve guideline adherence, covering the trajectory of the third trimester of pregnancy till the end of the delivery. The strategy, directed at professionals, comprehending three stop moments includes a risk assessment checklist, care bundle and time-out procedure. As patient empowerment tools, a patient passport and a website with patient information was developed. The evaluation among the expert panel showed all professionals to be satisfied with the content and usability and no discrepancies or inconsistencies with current evidence was found. Patients' evaluation revealed that the information they received through the tools was incomplete. The tools were adjusted accordingly to the missing information. CONCLUSION: A usable, tailored strategy to implement PPH guidelines and practical courses was developed. The next step is the evaluation of the strategy in a feasibility trial. TRIAL REGISTRATION: Clinical trial registration: The Fluxim study, registration number: NCT00928863 .

From Postpartum Haemorrhage Guideline to Local Protocol: A Study of Protocol Quality.

Objective Postpartum hemorrhage (PPH) has a continuously rising incidence worldwide, suggesting suboptimal care. An important step in optimizing care is the translation of evidence-based guidelines into comprehensive hospital protocols. However, knowledge about the quality of these protocols is lacking. The objective of this study was to evaluate the quality of PPH-protocols on structure and content in the Netherlands. Methods We performed an observational multicenter study. Eighteen PPH-protocols from 3 University Hospitals (UH), 8 Teaching Hospitals (TH) and 7 Non-Teaching hospitals (NTH) throughout the Netherlands were acquired. The structure of the PPH-protocols was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE-II) Instrument. The content was appraised using previously developed quality indicators, based on international guidelines and Advance-Trauma-Life-Support (ATLS)-based course instructions. Results The quality of the protocols for postpartum hemorrhage for both structure and content varied widely between different hospitals, but all of them showed room for improvement. The protocols scored mainly below average on the different items of the AGREE-II instrument (8 of the 10 items scored <4 on a 1-7 scale). Regarding the content, adoption of guideline recommendations in protocols was 46 %. In addition, a timely indication of 'when to perform' a recommendation was lacking in three-fourths of the items. Conclusion This study shows that the quality of the PPH-protocols for both structure and content in the Netherlands is suboptimal. This makes adherence to the guideline and ATLS-based course instructions difficult.

Influencing factors for high quality care on postpartum haemorrhage in the Netherlands: patient and professional perspectives.

BACKGROUND: Postpartum haemorrhage (PPH) remains a major contributor to maternal morbidity even in high resource settings, despite the development and dissemination of evidence-based guidelines and Advance-Trauma-Life-Support (ATLS) based courses for optimal management of PPH. We aimed to assess current influencing factors (obstacles and facilitators) for the delivery of high quality PPH-care from both patient and professional perspective. METHODS: We qualitatively explored influencing factors for delivering high quality PPH-care, by having individual interviews with PPH-patients and focus group interviews with the different types of professionals working in the delivery room. For both perspectives, the theoretical frameworks of Grol and Cabana were used to classify the influencing factors for optimal PPH-care (factors of the guidelines, of professionals, of patients, of the social setting and of the organisation). In order to assess the importance of the influencing factors found among the professionals, we quantified these factors in a web-based questionnaire. RESULTS: A total of 12 patients and 41 professionals participated in the interviews, and 315 complete surveys were analyzed. The main obstacle for high quality PPH-care identified by patients was the lack of information given by the professionals to the patient and partner before, during and after the PPH event. An informative patient website, a patient leaflet and a follow-up consultation were mentioned as facilitators. The main obstacles according to the professionals were: lack of clarity of the guidelines, lack of knowledge and failing team-communication. Team training and checklists/ flowcharts were considered facilitators. CONCLUSIONS: Different obstacles to the delivery of high quality PPH-care were identified by both patients and professionals. These data can be used to develop a focused strategy to improve PPH-care. TRIAL REGISTRATION: NCT 00928863.

Guideline-based development of quality indicators for prevention and management of postpartum hemorrhage.

INTRODUCTION: To systematically develop a set of guideline-based quality indicators for postpartum hemorrhage (PPH) as a tool to measure guideline adherence in actual PPH care. MATERIAL AND METHODS: A Rand-modified Delphi procedure was used to systematically achieve consensus among a panel of 22 experts on PPH care on recommendations extracted from evidence-based guidelines, Managing-Obstetrics-Emergencies-Trauma (MOET) instructions and international literature. The selected recommendations were individually rated on health gain (prevention of maternal mortality and morbidity) and overall efficiency by the expert panel. Subsequently, consensus about the most important recommendations to measure quality of PPH care among the panel members was reached, followed by a final approval. Last, definition of the final set by critical appraisal of the recommendations regarding measurability took place. The main outcome measure was a set of valid quality indicators for prevention and management of PPH. RESULTS: From the 69 extracted recommendations, 50 were selected and translated into 22 quality indicators on professional performance (n = 17) and organization of PPH care (n = 5). The professional performance indicators covered all fields of PPH care, such as prevention (n = 2) and management of PPH, including communication and documentation (n = 4), monitoring and prevention of shock (n = 3), use of blood products (n = 3) and treatment of PPH (n = 5). Organizational indicators (n = 5) were clustered into protocols and agreements, audit, accessibility and documentation. CONCLUSIONS: This study describes a stepwise systematic development of 22 performance and organizational indicators to use for measuring the whole care process of prevention and management of PPH.

Implementing guidelines for depression on antidepressant prescribing in general practice: a quasi-experimental evaluation.

BACKGROUND: Internationally, guidelines for depression recommend a stepped care approach, implying that antidepressant medication should not be offered as a first step treatment to patients with sub-threshold or mild depression. In the Netherlands, antidepressant prescribing rates in general practice as a first treatment step are considered to be high. The aim of this study was to evaluate the implementation of guideline recommendations on antidepressant prescribing. METHODS: A quasi-experimental study with a non-equivalent naturalistic control group and three years follow-up was performed in the general practice setting in the Netherlands. General Practitioners (GPs) participated in a national Quality Improvement Collaborative (QIC), focusing on the implementation of a guideline based model for a stepped care approach to depression. The model consisted of self-help and psychological treatment options for patients with milder symptoms as an alternative to antidepressants in general practice. Changes in antidepressant prescription rates of GPs were documented for a three-year period and compared to those in a control group of GPs, selected from an ongoing national registration network. RESULTS: A decrease of 23.3% (49.4%-26.1%) in antidepressant prescription rates for newly diagnosed patients with depressive symptoms was found within the intervention group, whereas no difference occurred in the reference group (50.3%-52.6%). The decrease over time was significant, compared to the usual care group (OR 0.44, 95% CI: 0.21-0.92). CONCLUSIONS: An implementation program using stepped care principles for the allocation of depression interventions resulted in reduced antidepressant prescription rates in general practice. GPs can change prescribing behaviour within the context of a QIC.

Determinants of success of quality improvement collaboratives: what does the literature show?

CONTEXT: The apparent inconsistency between the widespread use of quality improvement collaboratives and the available evidence heightens the importance of thoroughly understanding the relative strength of the approach. More insight into factors influencing outcome would mean future collaboratives could be tailored in ways designed to increase their chances of success. This review describes potential determinants of team success and how they relate to effectiveness. METHOD: We searched Medline, CINAHL, Embase, Cochrane, and PsycINFO databases from January 1995 to June 2006. The 1995-2006 search was updated in June 2009. Reference lists of included papers were reviewed to identify additional papers. We included papers that were written in English, contained data about the effectiveness of collaboratives, had a healthcare setting, met our definition for collaborative, and quantitatively assessed a relationship between any determinant and any effect parameter. FINDINGS: Of 1367 abstracts identified, 23 papers (reporting on 26 collaboratives) provided information on potential determinants and their relationship with effectiveness. We categorised potential determinants of success using the definition for collaboratives as a template. Numerous potential determinants were tested, but only a few related to empirical effectiveness. Some aspects of teamwork and participation in specific collaborative activities enhanced short-term success. If teams remained intact and continued to gather data, chances of long-term success were higher. There is no empirical evidence of positive effects of leadership support, time and resources. CONCLUSIONS: These outcomes provide guidance to organisers, participants and researchers of collaboratives. To advance knowledge in this area we propose a more systematic exploration of potential determinants by applying theory and practice-based knowledge and by performing methodologically sound studies that clearly set out to test such determinants.

Retrospective evaluation of control measures for contacts of patient with Marburg hemorrhagic fever.

After an imported case of Marburg hemorrhagic fever was reported in 2008 in the Netherlands, control measures to prevent transmission were implemented. To evaluate consequences of these measures, we administered a structured questionnaire to 130 contacts classified as either having high-risk or low-risk exposure to body fluids of the case-patient; 77 (59.2%) of 130 contacts responded. A total of 67 (87.0%) of 77 respondents agreed that temperature monitoring and reporting was necessary, significantly more often among high-risk than low-risk contacts (p<0.001). Strict compliance with daily temperature monitoring decreased from 80.5% (62/77) during week 1 to 66.2% (51/77) during week 3. Contacts expressed concern about development of Marburg hemorrhagic fever (58.4%, 45/77) and infecting a family member (40.2%, 31/77). High-risk contacts had significantly higher scores on psychological impact scales (p<0.001) during and after the monitoring period. Public health authorities should specifically address consequences of control measures on the daily life of contacts.

The effect of watchful waiting compared to immediate test ordering instructions on general practitioners' blood test ordering behaviour for patients with unexplained complaints; a randomized clinical trial (ISRCTN55755886).

BACKGROUND: Immediate blood testing for patients presenting with unexplained complaints in family practice is superfluous from a diagnostic point of view. However, many general pracitioners (GPs) order tests immediately. Watchful waiting reduces the number of patients to be tested and the number of false-positive results. The objectives of this study are: to determine the feasibility of watchful waiting compared to immediate test ordering; to determine if a special quality improvement strategy can improve this feasibility; and to determine if watchful waiting leads to testing at a later time. METHODS: The study is a cluster-randomized clinical trial with three groups, on blood test ordering strategies in patients with unexplained complaints. GPs in group one were instructed to order tests immediately and GPs in group two to apply a watchful waiting approach. GPs in group three received the same instruction as group two, but they were supported by a systematically designed quality improvement strategy. A total of 498 patients with unexplained complaints from 63 practices of Dutch GPs participated. We measured: the percentage of patients for whom tests were ordered and number of tests ordered at the first consultation; performance on the strategy's performance objectives (i.e., ordering fewer tests and specific communication skills); the number of tests ordered after four weeks; and GP and patient characteristics. RESULTS: Immediate test ordering proved feasible in 92% of the patients; watchful waiting in 86% and 84%, respectively, for groups two and three. The two watchful waiting groups did not differ significantly in the achievement of any of the performance objectives. Of the patients who returned after four weeks, none from group one and six from the two watchful waiting groups had tests ordered for them. CONCLUSIONS: Watchful waiting is a feasible approach. It does not lead to testing immediately afterwards. Furthermore, watchful waiting was not improved by the quality improvement strategy. CLINICAL TRIAL REGISTRATION: ISRCTN55755886.

Involvement of general practitioners in managing alcohol problems: a randomized controlled trial of a tailored improvement programme.

AIMS: To assess the effect of a tailored multi-faceted improvement programme on general practitioners' (GPs') behaviour towards prevention of hazardous and harmful alcohol consumption. The improvement programme consisted of activities aimed at the GP, organization and patient. Educational training sessions and visits by a facilitator were tailored to the GPs' needs and attitudes. DESIGN: Cluster randomized controlled trial. SETTING: General practices in the Netherlands. PARTICIPANTS: Seventy-seven general practices; 119 GPs participated. Data from 6318 patients were available, of whom 765 (12.1%) were at risk. A total of 1502 patients' electronic medical records were reviewed. MEASUREMENTS: The primary outcome was the number of eligible patients who received screening and advice. FINDINGS: Difficulties in recruiting GPs and in motivating GPs for participation in the tailored parts of the programme impeded optimal implementation of the programme. Although GPs in both groups became more involved after enrolment, this improvement waned during the trial. The quality improvement programme enhanced the initial improvement in behaviour and it tempered waning (intervention group), compared to our control condition, resulting in average improvement rates of 5% (screening) and 2% (advice-giving) at 12-month follow-up (not significant). CONCLUSIONS: A tailored, multi-faceted programme aimed at improving general practitioner management of alcohol consumption in their patients failed to show an effect and proved difficult to implement. There remains little evidence to support the use of such an intensive implementation programme to improve the management of harmful and hazardous alcohol consumption in primary care.

Evaluation of physicians' professional performance: an iterative development and validation study of multisource feedback instruments.

BACKGROUND: There is a global need to assess physicians' professional performance in actual clinical practice. Valid and reliable instruments are necessary to support these efforts. This study focuses on the reliability and validity, the influences of some sociodemographic biasing factors, associations between self and other evaluations, and the number of evaluations needed for reliable assessment of a physician based on the three instruments used for the multisource assessment of physicians' professional performance in the Netherlands. METHODS: This observational validation study of three instruments underlying multisource feedback (MSF) was set in 26 non-academic hospitals in the Netherlands. In total, 146 hospital-based physicians took part in the study. Each physician's professional performance was assessed by peers (physician colleagues), co-workers (including nurses, secretary assistants and other healthcare professionals) and patients. Physicians also completed a self-evaluation. Ratings of 864 peers, 894 co-workers and 1960 patients on MSF were available. We used principal components analysis and methods of classical test theory to evaluate the factor structure, reliability and validity of instruments. We used Pearson's correlation coefficient and linear mixed models to address other objectives. RESULTS: The peer, co-worker and patient instruments respectively had six factors, three factors and one factor with high internal consistencies (Cronbach's alpha 0.95 - 0.96). It appeared that only 2 percent of variance in the mean ratings could be attributed to biasing factors. Self-ratings were not correlated with peer, co-worker or patient ratings. However, ratings of peers, co-workers and patients were correlated. Five peer evaluations, five co-worker evaluations and 11 patient evaluations are required to achieve reliable results (reliability coefficient ≥ 0.70). CONCLUSIONS: The study demonstrated that the three MSF instruments produced reliable and valid data for evaluating physicians' professional performance in the Netherlands. Scores from peers, co-workers and patients were not correlated with self-evaluations. Future research should examine improvement of performance when using MSF.

Development of generic quality indicators for patient-centered cancer care by using a RAND modified Delphi method.

BACKGROUND: Despite growing attention to patient-centered care, the needs of cancer patients are not always met. OBJECTIVE: Using a RAND modified Delphi method, this study aimed to systematically develop evidence-based indicators, to be used to measure the quality of patient-centered cancer care as a first step toward improvement. METHODS: First, key recommendations were identified from literature and were distributed over 5 domains of patient-centered cancer care: communication, physical support, psychosocial care, after-care, and organization of care. Generic key recommendations, with best available evidence, were selected from guidelines. A multidisciplinary panel of patients and medical professionals (n = 14) rated and prioritized these recommendations in a written procedure. Subsequently, the panel discussed the recommendations at a consensus meeting. RESULTS: Key recommendations were identified for communication (n = 32), physical support (n = 13), psychosocial care (n = 25), after-care (n = 11), and organization of care (n = 11). For all domains, recommendations based on high-level evidence were identified except for after-care and physical support. The panel developed 17 indicators concerning criteria for communication and informed consent, evaluation of communication skills, provision of information, examination of emotional health, appointment of a care coordinator, physical complaints, follow-up, rehabilitation, psychosocial effects of waiting times, and self-management. CONCLUSIONS: A set of 17 indicators for patient-centered cancer care resulted from this study. Evidence support was available for most indicators. IMPLICATIONS FOR PRACTICE: This set provides an opportunity to measure and improve the quality of patient-centered cancer care. It is generic and therefore applies to many patients.

Patient and hospital characteristics associated with variation in guideline adherence in intrauterine insemination care.

OBJECTIVE: To assess the association of patient and hospital characteristics with adherence to guidelines for intrauterine insemination (IUI) care. DESIGN: Retrospective cohort study using multilevel regression analysis. Characteristics studied at the patient level were female age, type and duration of subfertility, diagnosis and number of started IUI cycles. At the hospital level, the characteristics studied were hospital size, teaching hospital, in vitro fertilization (IVF) licence and number of physicians involved in the IUI programme. Data were obtained from medical records and questionnaires for gynaecologists. SETTING AND PARTICIPANTS: Five hundred and fifty-eight subfertile couples who underwent IUI treatment at 10 Dutch hospitals. MAIN OUTCOME MEASURES: Adherence to systematically developed guideline-based performance indicators describing 20 processes of IUI care. RESULTS: A total of 558 couples who started 2,334 IUI cycles participated. Guideline adherence in IUI care was often substandard and varied considerably between hospitals. Variation in guideline adherence in IUI care was associated with the patient characteristics 'diagnosis' and 'female age'. Only adherence to the guideline recommendation regarding 'screening for tubal occlusion' was associated with hospital characteristics ('hospital size' and 'IVF licence'). Large explained variances up to 39% were found for the different models. CONCLUSIONS: A number of patient and hospital characteristics were associated with variation in guideline adherence in IUI care, particularly the patient characteristics 'diagnosis' and 'female age'. The identification of different subgroups in the patient population and different types of hospitals with regard to the extent of guideline adherence in IUI care is important for the tailoring of interventions to improve IUI care.

Development and measurement of guideline-based indicators for patients with non-Hodgkin's lymphoma.

PURPOSE: Patients with cancer are not always treated according to available guidelines. Factors such as age and comorbidities are frequently used as arguments for nonadherence. The aim of this study was to measure guideline adherence with guideline-based indicators for patients with non-Hodgkin's lymphoma (NHL) and to examine the need for improvement, considering relevant arguments. METHODS: A RAND-modified Delphi procedure was used to systematically develop NHL indicators. We evaluated their improvement potential (defined as < 90% score) in a random sample of patients with NHL (N = 431) diagnosed in 2006-2007 in 22 hospitals in the Netherlands with data from medical records. Multilevel logistic regression analyses were used to estimate the relationship between indicator scores and factors: comorbidity index (combined with age), stage, patient's objections, and lymphoma type. Scores were adjusted for significant factors. RESULTS: Of the 20 indicators developed, 16 had improvement potential. Scores were lowest for assessment of International Prognostic Index, 21%; imaging of neck, thorax, and abdomen and bone marrow examination during the diagnostic process, 23%, and after chemotherapy, 37%; adequate pathology reporting, 11%; and multidisciplinary discussion of patients, 21%. Scores for eight indicators were better for patients with a low Charlson index, stage III or IV disease, no objections to care, and aggressive lymphoma. After adjustments, adherence to all but one indicator (administration of the combination of rituximab and cyclophosphamide-doxorubicin-vincristine-prednisone) remained < 90%. CONCLUSION: In the Netherlands, almost all indicators for NHL needed improvement. This should be evaluated in other countries as well. International efforts should be undertaken to improve the quality of care of this often curable malignancy.

A multi-faceted strategy to improve the use of national fertility guidelines; a cluster-randomized controlled trial.

BACKGROUND Proper use of clinical practice guidelines can decrease variation in care between settings. However, actual use of fertility guidelines is suboptimal and in need of improvement. Hence, a cluster-randomized controlled trial was designed to study the effects of two strategies to implement national Dutch guidelines on comprehensive fertility care. METHODS Sixteen fertility clinics participated in the trial. A minimal, professional-oriented implementation strategy of audit and feedback was tested versus a maximal multi-faceted strategy that was both professional and patient oriented. The extent of adherence to guideline recommendations, reflected in quality indicator scores, was the primary outcome measure. To gain an insight into unwanted side effects, patient anxiety and depression scores were gathered as secondary outcomes. Data collection encompassed medical record search, patient and professional questionnaires. RESULTS A total of 1499 couples were included at baseline and 1396 at the after-measurement. No overall significant improvement in indicator scores was found for either strategy [odds ratios ranging from 0.23 (95% confidence interval (CI): 0.06-0.95) to 6.66 (95% CI: 0.33-132.8]. Secondary outcomes did not differ significantly for both groups, although selected anxiety scores appeared lower in the maximal intervention group. Process evaluation of the trial revealed positive patient experiences with the intervention material [e.g. an increased understanding of their doctor's treatment policy (61%), an increased ability to ask questions about the treatment (61%)]. Professionals' appreciation of intervention elements varied, and execution of the multi-faceted strategy appeared incomplete. DISCUSSION Absence of an intervention effect may be due to the nature of the strategies, incomplete execution or flaws in study design. Process evaluation data raise the question of whether professionals should be the only stakeholder responsible for guideline implementation. This study therefore contributes to an increased understanding of fertility guideline implementation in general, and the role of patients in particular.

General practice counseling for patients with chronic obstructive pulmonary disease to quit smoking: impact after 1 year of two complex interventions.

OBJECTIVE: To evaluate two counseling programs in general practice to help smokers with chronic obstructive pulmonary disease (COPD) to quit smoking. METHODS: Cluster randomized controlled trial including 68 general practices (667 patients) using a randomly assigned intervention program with counseling and advice about nicotine replacement therapy (and additional bupropion-SR in one of the programs) or usual care. Usual care consisted of periodic regular check-ups and COPD information. The main outcome measure was biochemically verified point prevalence at 12 months. RESULTS: The two intervention groups were treated as one in the analysis because they were equally effective. The intervention resulted in a significantly self-reported higher success rate (14.5%) compared to usual care (7.4%); odds ratio=2.1, 95% confidence interval=1.1-4.1. Biochemically verified quit rates were 7.5% (intervention) and 3.4% (usual care); odds ratio=2.3, 95% confidence interval=0.9-6.0. CONCLUSION: The program doubled the cessation rates (statistically nonsignificant). Too few participants used the additional bupropion-SR to prove its effectiveness. PRACTICE IMPLICATIONS: The protocols can be used for COPD patients in general practice, but expectations should be modest. If quitting is unsuccessful, a stepped care approach should be considered.

Cost-effectiveness of a quality improvement collaborative focusing on patients with diabetes.

OBJECTIVE: To investigate the lifelong health effects, costs, and cost-effectiveness of a quality improvement collaborative focusing on improving diabetes management in an integrated care setting. STUDY DESIGN AND METHODS: Economic evaluation from a healthcare perspective with lifetime horizon alongside a nonrandomized, controlled, before-after study in the Netherlands. Analyses were based on 1861 diabetes patients in 6 intervention and 9 control regions, representing 37 general practices and 13 out-patient clinics. Change in the United Kingdom Prospective Diabetes Study score, remaining lifetime, and costs per quality-adjusted life year gained were calculated. Probabilistic life tables were constructed using the United Kingdom Prospective Diabetes Study risk engine, a validated diabetes model, and nonparametric bootstrapping of individual patient data. RESULTS: Annual United Kingdom Prospective Diabetes Study risk scores reduced for cardiovascular events (hazard ratio: 0.83 and 0.98) and cardiovascular mortality (hazard ratio: 0.78 and 0.88) for men and women, respectively. Life expectancy improved by 0.97 and 0.76 years for men and women, and quality-adjusted life years by 0.44 and 0.37, respectively. Higher life expectancy in the intervention group increased lifelong costs by &OV0556;860 for men and &OV0556;645 for women. Initial program costs were about &OV0556;22 per patient. The incremental costs per quality-adjusted life year were &OV0556;1937 for men and &OV0556;1751 for women compared with usual care costs. There is a probability >95% that the collaborative is cost-effective, using a threshold of &OV0556;20,000 per quality-adjusted life year. CONCLUSION: Optimizing integrated and patient-centered diabetes care through a quality-improvement collaborative is cost-effective compared with usual care.

DOC questionnaire: measuring how GPs and medical specialists rate collaboration.

PURPOSE: This paper aims to assess the validity of a questionnaire aimed at assessing how general practitioners (GPs) and specialists rate collaboration. DESIGN/METHODOLOGY/APPROACH: Primary data were collected in The Netherlands during March to September 2006. A cross-sectional study was conducted among 259 GPs and 232 specialists. Participants were randomly selected from The Netherlands Medical Address Book. Specialists rarely contacting a GP were not invited to participate. FINDINGS: Exploratory factor analysis indicated that the questionnaire, consisting of 20 items, measured five domains: organisation; communication; professional expertise; image; and knowing each other. Cronbach's alpha coefficients ranged from 0.64 to 0.83 indicating sufficient internal consistency. Correlation coefficients between domains were all < 0.4. All but "communication" clearly produced distinguishing scores for different respondent groups. RESEARCH LIMITATIONS/IMPLICATIONS: This study shows that the doctors' opinions on collaboration (DOC) questionnaire is valid and that it may have the potential to give feedback to both medical professionals and policy makers. Such feedback creates an opportunity to improve collaboration. ORIGINALITY/VALUE: The DOC questionnaire is a useful instrument for assessing collaboration among GPs and specialists. It can provide feedback to both medical professionals and policy makers. Such feedback creates an opportunity to improve collaboration.

Barriers to implementing infection prevention and control guidelines during crises: experiences of health care professionals.

BACKGROUND: Communicable disease crises can endanger the health care system and often require special guidelines. Understanding reasons for nonadherence to crisis guidelines is needed to improve crisis management. We identified and measured barriers and conditions for optimal adherence as perceived by 4 categories of health care professionals. METHODS: In-depth interviews were performed (n = 26) to develop a questionnaire for a cross-sectional survey of microbiologists (100% response), infection preventionists (74% response), public health physicians (96% response), and public health nurses (82% response). The groups were asked to appraise barriers encountered during 4 outbreaks (severe acute respiratory syndrome [SARS], Clostridium difficile ribotype 027, rubella, and avian influenza) according to a 5-point Likert scale. When at least 33% of the participants responded "strongly agree," "agree," or "rather agree than disagree," a barrier was defined as "often experienced." The common ("generic") barriers were included in a univariate and multivariate model. Barriers specific to the various groups were studied as well. RESULTS: Crisis guidelines were found to have 4 generic barriers to adherence: (1) lack of imperative or precise wording, (2) lack of easily identifiable instructions specific to each profession, (3) lack of concrete performance targets, and (4) lack of timely and adequate guidance on personal protective equipment and other safety measures. The cross-sectional study also yielded profession-specific sets of often-experienced barriers. CONCLUSION: To improve adherence to crisis guidelines, the generic barriers should be addressed when developing guidelines, irrespective of the infectious agent. Profession-specific barriers require profession-specific strategies to change attitudes, ensure organizational facilities, and provide an adequate setting for crisis management.

Antibiotic use: how to improve it?

Antibiotics are an extremely important weapon in the fight against infections. However, antimicrobial resistance is a growing problem. That is why the appropriate use of antibiotics is of great importance. A proper analysis of factors influencing appropriate antibiotic use is at the heart of an effective improvement programme, as interventions can only result in improved medical behaviour if they are well attuned to the problems, the target group, and the setting in which the change is to take place. Determinants of appropriate and inappropriate prescribing are not only found in patient knowledge and behaviour, in the way medical professionals think and act, and in the way in which patient care is organised, but also in the wider, socio-cultural environment of doctors and their patients. We present several relevant factors at each of these 4 levels and various possible measures that could be an effective response to them. The reasons why antibiotic use is inappropriate are complex. This means that any programme to rationalise antibiotic use - if it is to be effective - will have to include activities at all 4 levels discussed above. A national programme for 'appropriate antibiotic use' could be considered, including patient, professional and organisational-oriented activities. In addition, close international cooperation is required involving international guidelines, agreements, monitoring and feedback of information, and implementation programmes.

Current treatment of chronic heart failure in primary care; still room for improvement.

UNLABELLED: RATIONAL AND AIMS: In recent years, guidelines for treatment of patients with chronic heart failure (CHF) have been updated. Insight in current pharmacological and non-pharmacological treatment of CHF in primary care, which was non-optimal in earlier studies, is limited. We aim to describe current pharmacological and non-pharmacological treatment of CHF in primary care. METHODS: In this cross-sectional observational study, we included a representative sample of 357 patients diagnosed with CHF from 42 primary care practices in the Netherlands. We combined medical record data with data from patient and doctor questionnaires. RESULTS: Mean age of patients was 75.7 years (SD 10.2), 53% were male, and 73% of patients had mild heart failure (New York Heart Association class I or II). 76.5% of patients received diuretics. Angiotensin-converting enzyme inhibitors were prescribed in 40.6% and angiotensin-II receptor blockers in 20.7%; beta-blockers were prescribed to 54.6%, while 24.9% received spironolactone. Patients with more severe heart failure had a lower probability of being treated according to guideline recommendations. Relevant lifestyle advice was given to 40-60% of the patients, depending on the specific lifestyle advice. CONCLUSIONS: Implementation of evidence-based pharmacotherapy for heart failure in primary care has improved since clinical guidelines have been updated; especially with respect to prescription of beta-blockers. However, there still seems ample room for improvement, as in the case for providing lifestyle advice.