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Background: A patient decision aid (PtDA) can support shared decision making (SDM) in preference-sensitive care, with more than one clinically applicable treatment option. The development of a PtDA is a complex process, involving several steps, such as designing, developing and testing the draft with all the stakeholders, known as alpha testing. This is followed by testing in 'real life' situations, known as beta testing, and then finalising the definite version. Our aim was developing and alpha testing a PtDA for primary treatment of early stage breast cancer, ensuring that the tool is considered relevant, valid and feasible by patients and professionals.Methods: Our qualitative descriptive study applied various methods including face-to-face think-aloud interviews, a focus group and semi-structured telephone interviews. The study population consisted of breast cancer patients facing the choice between breast-conserving therapy with or without preceding neo-adjuvant chemotherapy and mastectomy, and professionals involved in breast cancer care in dedicated multidisciplinary breast cancer teams.Results: A PtDA was developed in four iterative test rounds, taking nearly 2 years, involving 26 patients and 26 professionals. While the research group initially opted for simplicity for the sake of implementation, the clinicians objected that the complexity of the decision could not be ignored. Other topics of concern were the conflicting views of professionals and patients regarding side effects, the amount of information and how to present it.Conclusion: The development was an extensive process, because the professionals rejected the simplifications proposed by the research group. This resulted in the development of a completely new draft PtDA, which took double the expected time and resources. The final version of the PtDA appeared to be well-appreciated by professionals and patients, although its acceptability will only be proven in actual practice (beta testing).Trial Registration: NTR TC 5721 . [ABSTRACT FROM AUTHOR]

The article discusses the importance of shared decision making in medicine. It says that shared decision making between clinicians and patients is essential in reducing unwarranted practice variation in some medical situations and health care costs. It mentions that shared decision making can be promoted using several patient decision aids such as pamphlets, videos and web based tools. It notes that creating awareness on the probabilities, benefits and harms of medical options is necessary step towards shared decision making. Moreover, it considers the potential of guidelines in manipulating patients' decision making.

The article presents a comparative study to test the feasibility of systemically implementing a care program incorporating short-stay admission. It notes that the study was participated by patients with breast cancer from four hospitals in the Netherlands. Through local multidisciplinary meetings and educational outreach visits, it reveals that the care programme with short stay following breast cancer surgery was feasible and safe.

Abstract: Objective: To evaluate the feasibility and acceptability of a computer reminder system (CRS) to improve prescribing behaviour in general practice and to explore the strengths and weaknesses of a reminder system. One group of GPs received reminders on cholesterol lowering drugs, the other group on antibiotics, asthma and COPD drugs. Methods: Process evaluation of the computer reminder system being used by 53 GPs in 20 practices, by means of an analysis of the research database of the CRS. In addition, a questionnaire and semi-structured face-to-face interview were conducted with all GP practices, two project leaders, and one technical consultant. Results: The strategy was largely carried out as planned, although the development period for the CRS had to be extended. Nine percent of the GPs dropped out. We found a significant learning curve without extinguishing effect (p =0.03) for the antibiotics reminders. The questionnaire showed that, in general, GPs were satisfied with the user-friendliness and the content of the different types of reminders, but less satisfied with certain specific technical performance issues of the system. The GPs reported mixed feelings towards the CRS in the interviews. They were generally positive about the guidelines themselves, but negative regarding to the organisational context and the method of implementing the CRS. GPs stated that they sometimes manipulated the system to bypass reminders. Interviews with the project leaders and technical consultant revealed barriers to cooperation and miscommunication between the different parties, and technical problems with multiple updates of the GP information system and the operating system. Conclusions: This process evaluation demonstrated that the implementation of the CRS was mainly carried out as planned, but the subjective experience of working with the CRS was not only positive. Participating GPs had mixed feelings, and quite a number of barriers need to be addressed to facilitate large-scale implementation of the CRS. Costs cannot be neglected, so it is important to analyse the balance between costs and effects. [Copyright &y& Elsevier]

Abstract: Objective: It is difficult to control drug-prescribing behaviour in general practice, despite the development and distribution of guidelines. The purpose of this study was to assess the effect on drug-prescribing behaviour of implementing prescribing guidelines by means of a reactive computer reminder system (CRS). Design: Cluster-randomised controlled trial with an incomplete block design in the south of the Netherlands: 25 GPs (7 GP practices) received reminders about antibiotics and asthma/COPD prescriptions, 28 GPs (7 GP practices) received reminders about cholesterol prescriptions. Prescription guidelines were integrated into the computerised GP information system. Measurements: Both performance indicators and prescription volumes were calculated as the main outcome measures. Next to individual volume measure, sum scores were constructed on the volume measures per drug group (antibiotics, asthma/COPD and cholesterol). Results: Variation between GPs turned out to be larger and more skewed than expected. No differences between groups were found for indicators and volumes related to recommendations advocating certain drugs. Although there was a tendency towards clinically relevant results for prescription volumes that were supposed to drop, the difference in sum score between the groups was not significant. For antibiotic prescriptions that were supposed to drop, the sum score for the intervention group was 28.2 (95% CI: 20.8–44.5) prescriptions per 1000 patients per GP, while this was 39.7 (95% CI: 29.7–64.1) for the control group (p 0.2). For prescriptions asthma/COPD that were supposed to drop, the sum score for the intervention group was 1.1 (95% CI: 0.6–2.6) prescriptions per 1000 patients per GP, while this was 2.2 (95% CI: 1.4–4.3) for the control group (p 0.1). On three specific recommendations (on quinolones for cystitis, corticosteroids for CPOD, and antibiotics for acute sore throat) significant differences were found. Conclusions: This study turned out to be underpowered due to high inter doctor variation in prescribing behaviour. Nevertheless, computerised reminders sometimes have a favourable effect on restricting certain drugs that are not or no longer indicated in general practice. [Copyright &y& Elsevier]

We aim to provide an updated literature overview on patient-reported barriers and facilitators to participation in SDM across different patient groups and healthcare settings to uncover the 'common ground' and to reach for a more generalizable, uniform and inclusive insight in patients' perspective on participation in SDM. We conducted a qualitative meta-summary, using five databases. Search terms were based on the concepts: 'decision-making', 'patient participation', 'patient perceptions' and 'study design' (of patient reporting). We found 9265 unique references, selected 209 studies for further sampling and finally withheld 90 studies for further analysis in this review. In total, we identified 34 different barriers and facilitators. Based on most frequently reported barriers and facilitators, we defined four broad analytical themes corresponding to patients' shared expectations concerning doctors', patients' and others' facilitative roles in SDM: (1) ' Doctors explaining well ', (2) ' Doctors listening well, and fostering a trusting relationship' , (3) ' Patients being assertive , (4) ' Patients being socially supported'. The majority of barriers and facilitators we found transcended differences in patient characteristics or healthcare setting, suggesting that patients are, overall, facing shared challenges and opportunities in SDM, that are mostly generalizable and irrespective of variabilities in decisional setting or patient group. We uncovered new trends such as patients' growing openness to assertiveness and the involvement of significant others, and highlighted some culture-based nuances, compared to earlier literature. These new insights need to be integrated in SDM strategies so that they may serve the ethical imperative of a greater equality and inclusion of diverse patient groups in different SDM settings. • Patients seem to be facing shared challenges and opportunities in SDM, irrespective of the healthcare setting or patient group. • Patients' information needs remain high, as well as their needs of support to recognize their complementary expertise. • Patients newly mention 'assertiveness' as a facilitator, suggesting they are becoming more open to an active role in SDM. • The facilitative effects of 'social support' were more frequently mentioned compared to earlier reviews. • The growing sociocultural mix of patients will possibly create new dynamics in SDM in the future in more parts of the world. [ABSTRACT FROM AUTHOR]

This study compares and explains differences in perceptions of cardiovascular disease (CVD) risk and preventive behaviors in people with and without a known genetic predisposition to CVD. A cross-sectional study using two samples was performed. The first sample (genetic predisposition; n = 51) consisted of individuals recently diagnosed with familial hypercholesterolemia (FH) through DNA testing. The second sample (no genetic predisposition; n = 49) was recruited among patients with CVD-risk profiles based on family history of CVD, cholesterol levels, and blood pressure, registered at general practices. Participants filled out a postal questionnaire asking about their perceived risk, causal attributions (i.e. genetic and lifestyle), and about perceived efficacy and adoption of preventive behavior (i.e. medication adherence and adoption of a healthy diet and being sufficiently active). Perceived comparative risk, genetic attributions of CVD, and perceived efficacy of medication were higher in the “genetic predisposition” sample than in the “no genetic predisposition” sample. The samples did not differ on lifestyle attributions, efficacy of a healthy lifestyle, or preventive behavior. Individual differences in perceived risk, genetic attributions, perceived efficacy of medication, and adoption of a healthy lifestyle were best explained by family history of CVD. Our findings suggest that in people diagnosed with a single gene disorder characterized by a family disease history such as FH, family disease history may be more important than DNA information in explaining perceptions of and responses to risk. [ABSTRACT FROM PUBLISHER]

OBJECTIVE: To get insights into the decision-making strategy of health-care consumers when confronted with comparative consumer information. METHODS: Qualitative descriptive study among 18 consumers who had a hip or knee replacement no longer than five years ago. To study their decision-making strategies a paper draft for a website was used providing comparative consumer information. Data were collected by cognitive interviews and focus-group meetings and subjected to thematic analysis. RESULTS: Consumers were able to understand the presented information, but had problems to use it as a decision aid. They primarily relied on previous experiences. Four themes were revealed: decision making, perceived benefits, unmet information needs, and trustworthiness. Consumers used different decision strategies and showed unpredictable behavior when choosing a hospital. CONCLUSION: Individual decision strategies, unsatisfied information needs, limited tenability and too coarse aggregation levels of quality scores are barriers for a proper use of comparative consumer information. Personal experience remains a valuable information source for hospital selection. We suggest that a website presenting comparative consumer information should be flexible in various ways and should include functionality to share personal experience. [ABSTRACT FROM AUTHOR]

The degree of adherence with evidence-based guidelines for the use of breast ultrasonography was determined in clinical practice of radiologists in six hospitals. Additional ultrasonography was performed in 2,272 (53%) of all 4,257 patients referred for mammography. High adherence rates (mean: 95%) were observed for guidelines recommending ultrasonography in patients referred for palpable breast masses and abnormal screening and diagnostic mammograms. Lower adherence rates (mean: 81%, Pearson correlation coefficient= -0.57; p=0.001) were found for guidelines advising against additional ultrasonography in patients referred for breast symptoms, a known benign abnormality, a family history or anxiety of breast cancer. The overuse of ultrasonography in 442 patients and underuse in 95 patients led to five additional false-positive results. It was concluded that the guidelines seem workable and feasible in clinical practice and that the current daily routine of diagnostic breast imaging corresponded to a great extent to the guidelines proposed. [ABSTRACT FROM AUTHOR]

Aim To explore the quality of the content of communication skills training programmes, we analysed and assessed guidelines for doctor–patient communication used in communication programmes for general practitioner (GP) trainees. Method Guidelines for doctor–patient communication were extracted from educational materials supplied by the 8 Dutch university centres for vocational training in general practice. Four themes guided the analysis of the guidelines: content, type of contact, format and structure and status. The quality of the guidelines was assessed with the Appraisal of Guidelines Research and Evaluation (AGREE) instrument, a validated measurement instrument for guideline quality. Results We identified 18 guidelines. Guideline content covered 64–100% of the GP qualification requirements. General consultations and specific situations were the subject of 9 guidelines each. Format and structure differed between guidelines. Guideline use seemed not to be obligatory. AGREE scores were low. Conclusions Guidelines for doctor–patient communication are difficult to identify in materials of GP training courses. Guideline quality is low; guidelines are little evidence-based and little attention has been paid to applicability and involvement of users. GP qualification requirements are only partly covered. Guidelines differed substantially without clarity about the reasons behind different choices. Guideline status was low. Recommendations When studying the factors that influence training effect, the quality of training content should be considered as well as teaching methods. Communication skills training programmes should be based on evidence-based guidelines that have been developed according to similar standards as for medical technical guidelines. [ABSTRACT FROM AUTHOR]

BACKGROUND: The quality of doctor-patient communication has a major impact on the quality of medical care. Communication guidelines define best practices for doctor patient communication and are therefore an important tool for improving communication. However, adherence to communication guidelines remains low, despite doctors participating in intensive communication skill training. Implementation research shows that adherence is higher for guidelines in general that are user centred and feasible, which implies that they are consistent with users' opinions, tap into users' existing skills and fit into existing routines. Developers of communication guidelines seem to have been somewhat negligent with regard to user preferences and guideline feasibility. In order to promote the development of user centred and practicable communication guidelines, we elicited user preferences and identified which guideline characteristics facilitate or impede guideline use. METHODS: Seven focus group interviews were conducted with experienced GPs, communication trainers (GPs and behavioural scientists) and communication learners (GP trainees and medical students) and three focus group interviews with groups of GP trainees only. All interviews were transcribed and analysed qualitatively. RESULTS: The participants identified more impeding guideline characteristics than facilitating ones. The most important impeding characteristic was that guidelines do not easily fit into GPs' day-to-day practice. This is due to rigidity and inefficiency of communication guidelines and erroneous assumptions underpinning guideline development. The most important facilitating characteristic was guideline structure. Guidelines that were structured in distinct phases helped users to remain in control of consultations, which was especially useful in complicated consultations. CONCLUSION: Although communication guidelines are generally considered useful, especially for structuring consultations, their usefulness is impaired by lack of flexibility and applicability to practice routines. User centred and feasible guidelines should combine the advantages of helping doctors to structure consultations with flexibility to tailor communication strategies to specific contexts and situations. [ABSTRACT FROM AUTHOR]

BACKGROUND: General practitioners (GPs) frequently order blood tests when they see patients presenting with unexplained complaints. Due to the low prevalence of serious pathology in general practice, the risk of false-positive test results is relatively high. This may result in unnecessary further testing, leading to unfavourable effects such as patient anxiety, high costs, somatisation and morbidity. A policy of watchful waiting is expected to lower both the number of patients to be tested and the risk of false-positive test results, without missing serious pathology. However, many general practitioners experience barriers when trying to postpone blood testing by watchful waiting. The objectives of this study are (1) to determine the accuracy of blood tests in patients presenting with unexplained complaints in terms of detecting pathology, (2) to determine the accuracy of a watchful waiting strategy and (3) to determine the effects of a quality improvement strategy to promote the postponement of blood test ordering by GPs for patients with unexplained complaints. DESIGN: General practices are randomised over three groups. Group 1 is instructed to order blood tests immediately, group 2 to apply a watchful waiting policy and group 3 also to postpone testing, but supported by our quality improvement strategy. The trial consists of two sub-studies: a diagnostic study at patient level (group 1 versus groups 2 and 3) and a quality improvement study at GP level (group 2 versus group 3). The diagnostic strategy to be used involves of both customary and innovative tests. The quality improvement strategy consists of two small-group meetings and a practice outreach visit. Patient follow-up ends at 12 months after the initial consultation. Primary outcome measures are the accuracy and added value of blood tests for detecting pathology, the effect of a 4-week postponement of test ordering on the blood test characteristics and the quantity of tests ordered. Secondary outcome measures are the course of complaints, quality of life, satisfaction with care, anxiety of patients and practitioners, determinants of physicians' behaviour, health care utilisation and costs. DISCUSSION: The innovative aspect of this trial is that it combines a clinical-epidemiological study and a quality of care study. [ABSTRACT FROM AUTHOR]

Background: It is known that the use of a Patient Decision Aid (PtDA), combined with advice for professionals on how and when to use it, can enhance the involvement of patients in the treatment decision. However, we need more knowledge with respect to the intention-behaviour gap. This study aims to analyse patients' experiences with the Shared Decision Making (SDM) process to find clues to close this gap.Methods: This qualitative study was part of a pilot study aiming to implement SDM in early adopter breast cancer teams. Patients were given access to a personalised PtDA. Breast cancer teams were instructed on how and when to deliver the PtDA. We interviewed 20 patients about their experience with the PtDA and SDM in general.Results: Most patients experienced SDM, though to a certain extent. Choice talk and option talk were commonly experienced, however the elicitation of preferences and decision talk was rare. The PtDA was used by the majority of patients (N = 13), all indicating that it was useful, especially to recall all the information given. Patients appreciated the contribution of breast cancer nurses in the SDM process. They considered them as true case managers, easy to approach and supportive.Conclusion: Although patients felt well-informed and satisfied about risk-communication, the elicitation of preferences appeared very limited to non-existent. We recommend that breast cancer teams divide tasks in the SDM process and reallocate the elicitation of preferences to the nurses in a well-defined clinical pathway. [ABSTRACT FROM AUTHOR]

Objectives: Under-diagnosis and suboptimal asthma control in children persists. An innovative care pathway was developed by a hospital department of pediatrics with the aim to detect pulmonary problems in children and provide appropriate treatment possibilities through systematic feedback towards the referring primary care physician. Primary care physicians can use this pathway to refer children with asthma-like symptoms for a one-day assessment. Goals are to measure the usage of the pathway by primary care general practitioners (GPs), the outcomes in terms of new diagnoses of asthma, the reduction in regular referrals, generated recommendations/therapy and the adequacy of asthma follow-up. Methods: We collected all feedback letters sent to the GP concerning children who underwent the Pulmocheck in 2010, 2011 and 2012. Furthermore, all GPs, who had referred a child to the Pulmocheck in this period and that subsequently was diagnosed with asthma and was further managed in primary care, were sent a follow-up questionnaire in 2014. Results: There were 121 referrals from 51 GPs in 3 years to this pathway. In 59.5% of these referrals a new diagnosis of asthma was established. In 90.9% one or more changes in clinical management were advised. The response rate to the follow-up questionnaires was 65.7% of which 4.8% of the children with new established asthma were reviewed four times or more in the follow-up period, 17.4% two times, 65.2% once, and in 8.7% were not followed. Conclusions: The specialty pediatric asthma care pathway revealed a high number of children with newly diagnosed asthma, but was also helpful to exclude this diagnosis. However, the referral rate of GPs to this pathway was low, but in the children, that were referred several changes in the clinical management were advised and the frequency of monitoring of the children with diagnosed asthma was not in accordance with the asthma guidelines. [ABSTRACT FROM AUTHOR]

Background: Much research worldwide is focussed on cost containment and better adherence to guidelines in healthcare. The research focussing on professional behaviour is often performed in a well-controlled research setting. In this study a large-scale implementation of a peer review strategy was tested on both test ordering and prescribing behaviour in primary care in the normal quality improvement setting. Methods: We planned a cluster-RCT in existing local quality improvement collaboratives (LQICs) in primary care. The study ran from January 2008 to January 2011. LQICs were randomly assigned to one of two trial arms, with each arm receiving the same intervention of audit and feedback combined with peer review. Both arms were offered five different clinical topics and acted as blind controls for the other arm. The differences in test ordering rates and prescribing rates between both arms were analysed in an intention-to-treat pre-post analysis and a per-protocol analysis. Results: Twenty-one LQIC groups, including 197 GPs working in 88 practices, entered the trial. The intention- to-treat analysis did not show a difference in the changes in test ordering or prescribing performance between intervention and control groups. The per-protocol analysis showed positive results for half of the clinical topics. The increase in total tests ordered was 3% in the intervention arm and 15% in the control arm. For prescribing the increase in prescriptions was 20% in the intervention arm and 66% in the control group. It was observed that the groups with the highest baseline test ordering and prescription volumes showed the largest improvements. Conclusions: Our study shows that the results from earlier work could not be confirmed by our attempt to implement the strategy in the field. We did not see a decrease in the volumes of tests ordered or of the drugs prescribed but were able to show a lesser increase instead. Implementing the peer review with audit and feedback proved to be not feasible in primary care in the Netherlands. Trial Registration: This trial was registered at the Dutch trial register under number ISRCTN40008171 on August 7th 2007. [ABSTRACT FROM AUTHOR]

Background A monitoring-and-feedback tool was developed to stimulate physical activity by giving feedback on physical activity performance to patients and practice nurses. The tool consists of an activity monitor (accelerometer), wirelessly connected to a Smartphone and a web application. Use of this tool is combined with a behaviour change counselling protocol (the Self-management Support Programme) based on the Five A's model (Assess–Advise–Agree–Assist–Arrange). Objectives To examine the reach, implementation and satisfaction with the counselling protocol and the tool. Design A process evaluation was conducted in two intervention groups of a three-armed cluster randomised controlled trial, in which the counselling protocol was evaluated with (group 1, n = 65) and without (group 2, n = 66) the use of the tool using a mixed methods design. Settings Sixteen family practices in the South of the Netherlands. Participants Practice nurses ( n = 20) and their associated physically inactive patients ( n = 131), diagnosed with Chronic Obstructive Pulmonary Disease or Type 2 Diabetes, aged between 40 and 70 years old, and having access to a computer with an Internet connection. Methods Semi structured interviews about the receipt of the intervention were conducted with the nurses and log files were kept regarding the consultations. After the intervention, questionnaires were presented to patients and nurses regarding compliance to and satisfaction with the interventions. Functioning and use of the tool were also evaluated by system and helpdesk logging. Results Eighty-six percent of patients (group 1: n = 57 and group 2: n = 56) and 90% of nurses (group 1: n = 10 and group 2: n = 9) responded to the questionnaires. The execution of the Self-management Support Programme was adequate; in 83% (group 1: n = 52, group 2: n = 57) of the patients, the number and planning of the consultations were carried out as intended. Eighty-eight percent ( n = 50) of the patients in group 1 used the tool until the end of the intervention period. Technical problems occurred in 58% ( n = 33). Participants from group 1 were significantly more positive: patients: χ 2 (2, N = 113) = 11.17, p = 0.004, and nurses: χ 2 (2, N = 19) = 6.37, p = 0.040. Use of the tool led to greater awareness of the importance of physical activity, more discipline in carrying it out and more enjoyment. Conclusions The interventions were adequately executed and received as planned. Patients from both groups appreciated the focus on physical activity and personal attention given by the nurse. The most appreciated aspect of the combined intervention was the tool, although technical problems frequently occurred. Patients with the tool estimated more improvement of physical activity than patients without the tool. [ABSTRACT FROM AUTHOR]

Background: The future risk of heart disease can be predicted with increasing precision. However, more research is needed into how this risk is conveyed and presented. The aim of this study is to compare the effects of presenting cardiovascular risk in different formats on individuals' intention to change behaviour to reduce risk, understanding of risk information and emotional affect.Methods/design: A randomised controlled trial comprising four arms, with a between subjects design will be performed. There will be two intervention groups and two control groups. The first control comprises a pre-intervention questionnaire and presents risk in a bar graph format. The second control presents risk in a bar graph format without pre-intervention questionnaire. These two control groups are to account for the potential Hawthorne effect of thinking about cardiovascular risk before viewing actual risk. The two intervention groups comprise presenting risk in either a pictogram or metonym format (image depicting seriousness of having a myocardial infarction). 800 individuals' aged between 45 and 64 years, who have not been previously diagnosed with heart disease and have access to a computer with internet, will be given a link to a website comprising a risk calculator and electronic questionnaires. 10-year risk of having a coronary heart disease event will be assessed and presented in one of the three formats. A post-intervention questionnaire will be completed after viewing the risk format. Main outcome measures are (i) intention to change behaviour, (ii) understanding of risk information, (iii) emotional affect and (iv) worry about future heart disease. Secondary outcomes are the sub-components of the theory of planned behaviour: attitudes, perceived behavioural control and subjective norms.Discussion: Having reviewed the literature, we are not aware of any other studies which have used the assessment of actual risk, in a trial to compare different graphical cardiovascular risk presentation formats. This trial will provide data about which graphical cardiovascular risk presentation format is most effective in encouraging behaviour change to reduce cardiovascular risk.Trial Registration: Current Controlled Trials ISRCTN91319318. [ABSTRACT FROM AUTHOR]

Objective: Patients with type 2 diabetes mellitus (T2DM) underestimate their risk of developing severe complications, and they do not always understand the risk communication by their caregivers. The aim of this study was to investigate the effects of an intervention focused on the communication of the absolute 10-year risk of developing cardiovascular disease (CVD) in patients with T2DM.Research Design and Methods: A randomized controlled trial was performed in T2DM patients newly referred to the Diabetes Care System (DCS) West-Friesland, a managed-care system in the Netherlands. The intervention group (n = 131) received a six-step CVD risk communication. Control subjects (n = 130) received standard managed care. The primary outcome measure was appropriateness of risk perception (difference between actual CVD risk calculated by the UK Prospective Diabetes Study risk engine and risk perception). Secondary outcome measures were illness perceptions, attitude and intention to change behavior, satisfaction with the communication, and anxiety and worry about CVD risk. Patients completed questionnaires at baseline, at 2 weeks (immediately after the intervention), and at 12 weeks.Results: Appropriateness of risk perception improved between the intervention and control groups at 2 weeks. This effect disappeared at 12 weeks. No effects were found on illness perceptions, attitude and intention to change behavior, or anxiety and worry about CVD risk. Patients in the intervention group were significantly more satisfied with the communication.Conclusions: This risk communication method improved patients' risk perception at 2 weeks but not at 12 weeks. Negative effects were not found, as patients did not become anxious or worried after the CVD risk communication. [ABSTRACT FROM AUTHOR]

Objective. Newly presented unexplained complaints (UCs) are common in general practice. Factors influencing the transition of newly presented into persistent UCs have been scarcely investigated. We studied the number and the nature of diagnoses made over time, as well as factors associated with UCs becoming persistent. Finally, we longitudinally studied factors associated with quality of life (QoL). [ABSTRACT FROM PUBLISHER]

Quality of care is often described by professionals. However, in this study breast cancer patients participated in developing an instrument that reflects quality of care from the patient's perspective. Through focus groups and concept mapping patients' ideas on determinants of good quality of care were generated and categorised according to similarity and importance. Information from eight focus group interviews with a total of 72 participants yielded 221 quality of care aspects. Following reduction, 81 aspects were used for categorisation during six concept mapping sessions with 67 participants. After analysis, 55 aspects remained grouped into six clusters. This study was conducted with a large number of breast cancer patients, undergoing the full range of treatment modalities, in different hospitals, in different areas in the Netherlands. Therefore, this set of quality of care indicators can be considered valid and suitable for the evaluation of breast cancer care as experienced by patients. [ABSTRACT FROM AUTHOR]

BackgroundGeneral practitioners often take their impression of patients' expectations into account in their decision to have blood tests done. It is commonly recommended to involve patients in decision-making during consultations. The study aimed to obtain detailed information on patients' expectations about blood tests.MethodsQualitative study among patients in waiting rooms of general practices. Each patient was presented with a short questionnaire about their preferences in terms of diagnostics. Patients who would like blood tests to be done were interviewed.ResultsFifty-seven (26%) of the 224 respondents wanted blood tests. Twenty-two were interviewed. Patients overestimated the qualities of blood tests. Favourable test results were regarded as proof of good health. Patients regarded blood tests as a useful instrument to screen for serious disorders, and were confirmed in this belief by people in their social environment and by the media. Many patients expected their GP to take an active test ordering approach, though some indicated that they might be convinced if their GP proposed a wait-and-see policy.ConclusionsGPs' perceptions about patient expectations seem justified: patients appear to have high hopes for testing as a diagnostic tool. They expect diagnostic certainty without mistakes and a proof of good health. The question is whether it would be desirable to remove patients' misconceptions, allowing them to participate in policy decisions on the basis of sound information, or whether it would be better to leave the misconceptions uncontested, in order to retain the 'magic' of additional tests and reassure patients. We expect that clarifying the precise nature of patients' expectations by the GP may be helpful in creating a diagnostic strategy that satisfies both patients and GPs. GPs will have to balance the benefits of reassuring their patients by means of blood tests which may be unnecessary against the benefits of avoiding unnecessary tests. Further research is needed into the effects of different types of patient information and the effects of testing on satisfaction and anxiety. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Twelve tips for teaching expertise in clinical reasoning," by Joseph Rencic in the 2011 issue.

Background: Patients with type 2 diabetes mellitus (T2DM) have an increased risk to develop severe diabetes related complications, especially cardiovascular disease (CVD). The risk to develop CVD can be estimated by means of risk formulas. However, patients have difficulties to understand the outcomes of these formulas. As a result, they may not recognize the importance of changing lifestyle and taking medication in time. Therefore, it is important to develop risk communication methods, that will improve the patients' understanding of risks associated with having diabetes, which enables them to make informed choices about their diabetes care.The aim of this study is to investigate the effects of an intervention focussed on the communication of the absolute 10-year risk to develop CVD on risk perception, attitude and intention to change lifestyle behaviour in patients with T2DM. The conceptual framework of the intervention is based on the Theory of Planned Behaviour and the Self-regulation Theory.Methods: A randomised controlled trial will be performed in the Diabetes Care System West-Friesland (DCS), a managed care system. Newly referred T2DM patients of the DCS, younger than 75 years will be eligible for the study. The intervention group will be exposed to risk communication on CVD, on top of standard managed care of the DCS. This intervention consists of a simple explanation on the causes and consequences of CVD, and possibilities for prevention. The probabilities of CVD in 10 year will be explained in natural frequencies and visualised by a population diagram. The control group will receive standard managed care. The primary outcome is appropriateness of risk perception. Secondary outcomes are attitude and intention to change lifestyle behaviour and illness perception. Differences between baseline and follow-up (2 and 12 weeks) between groups will be analysed according to the intention-to-treat principle. The study was powered on 120 patients in each group.Discussion: This innovative risk communication method based on two behavioural theories might improve patient's appropriateness of risk perception and attitude concerning lifestyle change. With a better understanding of their CVD risk, patients will be able to make informed choices concerning diabetes care.Trial Registration: The trial is registered as NTR1556 in the Dutch Trial Register. [ABSTRACT FROM AUTHOR]

Background: Self-tests are available to consumers for more than 25 conditions, ranging from infectious diseases to cardiovascular risk factors. Self-tests are defined as in-vitro tests on body materials such as blood, urine, faeces, or saliva that are initiated by consumers to diagnose a particular disorder or risk factor without involving a medical professional. In 2006, 16% of a sample of Dutch Internet users had ever used at least one self-test and 17% intended to use a self-test in the future. The objectives of this study are to determine (1) the frequency of self-test use, (2) the consumers' reasons for using or not using a self-test, (3) the information that is used by self-testers in the different self-test stages and the consumers' interpretation of the quality of this information, (4) the consumers' response to self-test results in terms of their confidence in the result, reassurance by the test result, and follow-up behaviour, (5) the information consumers report to need in the decision making process of using or not using a self-test, and in further management on the basis of the self-test result, and (6) the quality of the currently available consumer information on a selected set of self-tests.Methods: Mixed methods study with (1) a cross-sectional study consisting of a two-phase Internet-questionnaire, (2) semi-structured interviews with self-testers and consumers who intend to use a self-test, and (3) the assessment of the quality of consumer information of self-tests. The Health Belief Model and the Theory of Planned Behaviour will serve as the theoretical basis for the questionnaires and the interview topic guides.Conclusions: The self-testing area is still in a state of flux and therefore it is expected that self-test use will increase in the future. To the best of our knowledge, this is the first study which combines quantitative and qualitative research to identify consumers' information needs and use concerning self-testing, and the consumers' actual follow-up behaviour based on the self-test result, and simultaneously investigates the quality of the currently available consumer information. The results of this study will be used as an input in developing consumer information on self-testing. [ABSTRACT FROM AUTHOR]

BACKGROUND: General practitioners sometimes base clinical decisions on gut feelings alone, even though there is little evidence of their diagnostic and prognostic value in daily practice. Research into these aspects and the use of the concept in medical education require a practical and valid description of gut feelings. The goal of our study was therefore to describe the concept of gut feelings in general practice and to identify their main determinants METHODS: Qualitative research including 4 focus group discussions. A heterogeneous sample of 28 GPs. Text analysis of the focus group discussions, using a grounded theory approach. RESULTS: Gut feelings are familiar to most GPs in the Netherlands and play a substantial role in their everyday routine. The participants distinguished two types of gut feelings, a sense of reassurance and a sense of alarm. In the former case, a GP is sure about prognosis and therapy, although they may not always have a clear diagnosis in mind. A sense of alarm means that a GP has the feeling that something is wrong even though objective arguments are lacking. GPs in the focus groups experienced gut feelings as a compass in situations of uncertainty and the majority of GPs trusted this guide. We identified the main determinants of gut feelings: fitting, alerting and interfering factors, sensation, contextual knowledge, medical education, experience and personality. CONCLUSION: The role of gut feelings in general practice has become much clearer, but we need more research into the contributions of individual determinants and into the test properties of gut feelings to make the concept suitable for medical education. [ABSTRACT FROM AUTHOR]

Background: While the evidence suggests that the way physicians provide information to patients is crucial in helping patients decide upon a course of action, the field of knowledge translation and exchange (KTE) is silent about how the physician and the patient influence each other during clinical interactions and decision-making. Consequently, based on a novel relationship-centered model, EXACKTE(2) (EXploiting the clinicAl Consultation as a Knowledge Transfer and Exchange Environment), this study proposes to assess how patients and physicians influence each other in consultations.Methods: We will employ a cross-sectional study design involving 300 pairs of patients and family physicians from two primary care practice-based research networks. The consultation between patient and physician will be audio-taped and transcribed. Following the consultation, patients and physicians will complete a set of questionnaires based on the EXACKTE(2) model. All questionnaires will be similar for patients and physicians. These questionnaires will assess the key concepts of our proposed model based on the essential elements of shared decision-making (SDM): definition and explanation of problem; presentation of options; discussion of pros and cons; clarification of patient values and preferences; discussion of patient ability and self-efficacy; presentation of doctor knowledge and recommendation; and checking and clarifying understanding. Patients will be contacted by phone two weeks later and asked to complete questionnaires on decisional regret and quality of life. The analysis will be conducted to compare the key concepts in the EXACKTE(2) model between patients and physicians. It will also allow the assessment of how patients and physicians influence each other in consultations.Discussion: Our proposed model, EXACKTE(2), is aimed at advancing the science of KTE based on a relationship process when decision-making has to take place. It fosters a new KTE paradigm by putting forward a relationship-centered perspective and has the potential to reveal unknown mechanisms that underline effective KTE in clinical contexts. This will result in better understanding of the mechanisms that may promote a new generation of knowledge transfer strategies. [ABSTRACT FROM AUTHOR]

Background: Redesigning care has been proposed as a lever for improving chronic illness care. Within primary care, diabetes care is the most widespread example of restructured integrated care. Our goal was to assess to what extent important aspects of restructured care such as multidisciplinary teamwork and different types of organizational culture are associated with high quality diabetes care in small office-based general practices.Methods: We conducted cross-sectional analyses of data from 83 health care professionals involved in diabetes care from 30 primary care practices in the Netherlands, with a total of 752 diabetes mellitus type II patients participating in an improvement study. We used self-reported measures of team climate (Team Climate Inventory) and organizational culture (Competing Values Framework), and measures of quality of diabetes care and clinical patient characteristics from medical records and self-report. We conducted multivariate analyses of the relationship between culture, climate and HbA1c, total cholesterol, systolic blood pressure and a sum score on process indicators for the quality of diabetes care, adjusting for potential patient- and practice level confounders and practice-level clustering.Results: A strong group culture was negatively associated to the quality of diabetes care provided to patients (beta = -0.04; p = 0.04), whereas a more 'balanced culture' was positively associated to diabetes care quality (beta = 5.97; p = 0.03). No associations were found between organizational culture, team climate and clinical patient outcomes.Conclusion: Although some significant associations were found between high quality diabetes care in general practice and different organizational cultures, relations were rather marginal. Variation in clinical patient outcomes could not be attributed to organizational culture or teamwork. This study therefore contributes to the discussion about the legitimacy of the widespread idea that aspects of redesigning care such as teamwork and culture can contribute to higher quality of care. Future research should preferably combine quantitative and qualitative methods, focus on possible mediating or moderating factors and explore the use of instruments more sensitive to measure such complex constructs in small office-based practices. [ABSTRACT FROM AUTHOR]

Many patients at high risk of cardiovascular diseases are managed and monitored in general practice. Recommendations for cardiovascular risk management, including lifestyle change, are clearly described in the Dutch national guideline. Although lifestyle interventions, such as advice on diet, physical exercise, smoking and alcohol, have moderate, but potentially relevant effects in these patients, adherence to lifestyle advice in general practice is not optimal. The IMPALA study intends to improve adherence to lifestyle advice by involving patients in decision making on cardiovascular prevention by nurse-led clinics. The aim of this paper is to describe the design and methods of a study to evaluate an intervention aimed at involving patients in cardiovascular risk management.~Background~Background~A cluster-randomised controlled trial in 20 general practices, 10 practices in the intervention arm and 10 in the control arm, starting on October 2005. A total of 720 patients without existing cardiovascular diseases but eligible for cardiovascular risk assessment will be recruited. In both arms, the general practitioners and nurses will be trained to apply the national guideline for cardiovascular risk management. Nurses in the intervention arm will receive an extended training in risk assessment, risk communication, the use of a decision aid and adapted motivational interviewing. This communication technique will be used to support the shared decision-making process about risk reduction. The intervention comprises 2 consultations and 1 follow-up telephone call. The nurses in the control arm will give usual care after the risk estimation, according to the national guideline. Primary outcome measures are self-reported adherence to lifestyle advice and drug treatment. Secondary outcome measures are the patients' perception of risk and their motivation to change their behaviour. The measurements will take place at baseline and after 12 and 52 weeks. Clinical endpoints will not be measured, but the absolute 10-year risk of cardiovascular events will be estimated for each patient from medical records at baseline and after 1 year.~Methods~Methods~The combined use of risk communication, a decision aid and motivational interviewing to enhance patient involvement in decision making is an innovative aspect of the intervention.~Discussion~Conclusions~Current Controlled Trials ISRCTN51556722.~Trial Registration~Background [ABSTRACT FROM AUTHOR]