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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. [Copyright &y& Elsevier]

Abstract: 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. [ABSTRACT FROM AUTHOR]

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 12months. 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. [Copyright &y& Elsevier]

Objective: To assess determinants of patients' experiences and satisfaction with fertility care.Design: Cross-sectional questionnaire study.Setting: Sixteen fertility clinics in The Netherlands.Patient(s): A total of 1,499 infertile women in The Netherlands who visited a participating clinic in April-June 2005 for diagnostics or treatment.Main Outcome Measures: Patients experiences and satisfaction with several aspects of fertility care, and the patient and clinic characteristics that are determinants of those two concepts.Result(s): In general, patients' satisfaction with care was high (94%). Waiting times, information provision and emotional support were experienced the least positive aspects of care. Determinants of all care aspects were found to be significant at four different domains: three at patient level, i.e., demographic characteristics, type of received treatment and both general and mental health status, and one at clinic level, i.e., organization of care.Conclusion(s): This study provides an increased understanding of the determinants of patients' experiences and satisfaction with fertility care. This enables professionals to tailor their care to specific subgroups of patients and adjust their organization of fertility care where needed. Moreover, the study underlines the need to investigate whether case-mix correction is necessary whenever interpreting patient-surveys on care experiences, because both the patient's and the clinic's characteristics can influence the way that health care delivery is experienced. Demographic background of this regional patient sample was rather homogeneous, which should be taken into account when interpreting results. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To develop content for an educational system for dental professionals to be used for patient-tailored evidence-based decisions regarding routine oral examinations (ROEs) and to test the model as a tool in dental education. Methods: Initially, an electronic database was developed comprising conclusive data of a structured literature search and 27 ROE clinical cases which were selected on predefined criteria. A RAND-modified Delphi procedure was successfully conducted with 31 multidisciplinary dental experts. Twenty-one selected risk factors for oral disease were assessed for feasibility and subsequently modelled into 19 risk based clinical vignettes, each representing a specific group of ROE-patients. Each vignette comprised all relevant clinical and non-clinical data. Expert judgements were collected including ROE-content, risk level, bitewing frequency and recall interval. Feedback regarding evidence was provided for each of the topics. A pilot with 35 experienced General Dental Practitioners (GDPs) was conducted to assess the reliability of the model for continuing professional development (CPD). Decisions made on content screening items, bitewing frequencies and recall interval were compared with expert opinions. Results: A comprehensive set of clinical vignettes was developed. Expert consensus was reached with regard to risk factors to be applied, content of ROE-items, bitewing frequency and recall interval. Differences between GDPs and experts were found especially concerning recall length in low-risk patient groups. Conclusions: Clinical vignettes provide a promising educational instrument for CPD to improve clinical performance. Further research is needed to test the reliability of these set of 19 vignettes. [Copyright &y& Elsevier]

Abstract: Objectives: (1) To investigate the frequency of cascades of further diagnostic investigations and referrals after abnormal laboratory results in situations of low disease probability; (2) to investigate pretest and posttest determinants; and (3) to describe the cascades that occur. Study Design and Setting: Prospective cohort study in primary care in The Netherlands. Numbers of investigations/referrals were recorded during 6 months of follow-up for 256 patients with normal and abnormal laboratory results. The influences of the reason for ordering tests, interpretation of results, and pretest/posttest disease probability were examined. Results: After receiving the laboratory results, the physicians ordered further investigations for 22 (17.3%) patients with abnormal results and for two (1.6%) patients with normal results (P <0.001). They referred 12 (9.4%) patients with abnormal results and eight (6.2%) patients with normal results (P =0.33). Six patients had two investigations and/or referrals, and one patient had three referrals. There were significantly more investigations/referrals for results interpreted as abnormal (P =0.004) and for cases with a high posttest disease probability (P =0.001). Conclusion: This study suggests that cascade processes after laboratory testing in situations of low disease probability are limited in magnitude and frequency. Improving interpretations may help improve the appropriateness of further investigations and referrals. [Copyright &y& Elsevier]

Abstract: Objective: When deciding how many embryos to transfer during in vitro fertilisation (IVF), clinicians and patients have to balance optimizing the chance of pregnancy against preventing multiple pregnancies and the associated complications. This paper describes the development and pilot test of a patient decision aid (DA) for this purpose. Methods: The development of the DA consisted of a literature search, establishment of the format, and a pilot test among IVF patients. The DA development was supervised by a panel of experts in the fields of subfertility, obstetrics and DA-research and it was based on the criteria of the International Patient Decision Aid Standards. Results: One Cochrane review and 34 articles were selected for the DA content. The DA presents information in text, summaries, tables, figures and through an interactive worksheet. The DA was reviewed positively and as acceptable for use in clinical practice by patients and professionals. Conclusion: The DA was thoroughly developed and is likely to be helpful for the decision-making process for the number of embryos transferred after IVF. Practice implications: Physicians and researchers can use the DA without restriction in clinical practice or research related to decision-making. [Copyright &y& Elsevier]

Objective: Assessment of patients’ responsiveness to a decision support tool for primary prevention of cardiovascular diseases (CVDs). The booklet focuses on barriers at patient level. Methods: Process evaluation of an intervention in primary care. Patients at high or potentially high-cardiovascular risk were asked by their GP to prepare themselves for a second consultation in order to participate in decisions on risk management. Outcomes: Patients’ actually having read the booklet and returning for the second consultation; comprehension and perceived relevance of the information; perceived reassurance. Results: 17 GPs, in the intervention arm of a cluster RCT, issued 276 decision support tools during the first consultation and were instructed to ask them to return for a second consultation to discuss their CVD risk. Patients had a mean age of 54 years, 47% were male and 19% actually had a high cardiovascular risk. Data on 239 patients, a mixture of returnees and non-returnees, showed that they all read the booklet; comprehension was fair to good; 85% perceived the information as relevant; 68% of the patients felt reassured by the information. Satisfaction with the first consultation was higher in the non-returnees. Conclusions: Cardiovascular prevention spread over two consultations with use of a decision support tool for patients is not easily applicable for GPs. However, based on the findings of good patients’ responsiveness, we recommend further development and implementation of decision support tools in primary care. Practice implications: Decision support for primary CV-prevention is welcomed by patients but needs further adjustment of both the GP and the organization of CV-prevention in primary care. Sharing information between professional and patient on a personal CV-risk management plan is difficult, more training is needed. [Copyright &y& Elsevier]

Abstract: Objectives: Elements of a routine oral examination (ROE) in dental practice may be determined by patients’ oral status, as recommended by prevailing knowledge, as well as by other factors. Our aim was to identify patient and GDP characteristics associated with aspects of oral health assessment (OHA) and clinical management (CM) in patients with various oral conditions. Methods: A prospective observational study was performed, based on clinical case recording of 1059 ROEs by 128 GDPs. A clinical case recording form was used to record oral health assessment, diagnoses made, and clinical management for each ROE. Multilevel logistic regression analyses (with random coefficients) were performed. Results: Overall, ‘patients’ age’ in domains OHA as well as CM was the most salient predictor, while ‘positive attitude to periodontal screening’ showed to be a prominent GDP-factor. Patient characteristics mostly involved in OHA and CM were ‘disease-free period’ (odds ratios from 0.21 to 0.66), ‘oral health compliance’ (odds ratios from 0.32 to 0.65) and ‘risk for periodontal disease’ (odds ratios from 1.79 to 4.97). ‘Continuing professional development’ (odds ratios from 2.54 to 4.95), ‘mean reading hours’ (odds ratios from 2.25 to 4.48) and ‘cooperation with peers’ (odds ratios from 2.78 to 3.72) showed to be significant GDP-predictors. Conclusions: ROEs are determined by patient oral health status, particularly by aspects of oral health compliance and risk for oral disease, but also by GDP characteristics. The latter may reflect perceptions of a professional role, which need to be considered in efforts to improve the quality of ROE in oral care. [Copyright &y& Elsevier]

Abstract: Objective: To provide insight into parents’ awareness of and knowledge about urinary tract infections (UTIs) in young children. Methods: Twenty interviews with parents who had a child recently diagnosed with a UTI were audiotaped, transcribed verbatim, and qualitatively analysed. Results: Most parents knew the typical symptoms related to UTI. But, according to the parents, neither they nor all general practitioners (GPs) thought of a UTI in case of atypical symptoms. The awareness that UTI can be a serious illness usually came to parents later, partly because health care workers often did not explicitly mention this. According to the parents, health care workers should be more aware of UTIs in children. Parents felt that health education or mass screening might not be desirable because it would increase anxiety or would be perceived as not relevant. Conclusion: Parents could not consistently recognise UTI in their children and were most times unaware of the possible consequences of a UTI. Nevertheless, parents were sceptical about health education and mass screening. Practice implications: There seems little scope for health education addressed at parents or screening for UTI in young children. Instead, physicians and nurses should be alert for the possibility of UTIs in young children, and more information should be given once a UTI is diagnosed. [Copyright &y& Elsevier]

Abstract: Objective: To gain insight into the experiences of a palliative care patient and her husband who were living on borrowed time. Methods: A qualitative single case design was used. Systematic content analysis of the interview data, obtained in an in-depth semi-structured interview, from the husband and wife was conducted to extract themes relating to living on borrowed time. Results: Three themes were identified: shifts in the interpretation of physical signs and symptoms, altered view of the future and altered choices and priorities. Conclusion: The identified themes lead to a better understanding of the phenomenon of living on borrowed time. Yet, refinement of, and variation within the themes still need to be studied in order to get more grips on the themes and to be better able to help patients to integrate the ‘new reality’. Practice implications: Our findings can be used to support professionals in the practical application of care when their patients need to integrate the ‘new reality’ and seek new equilibrium, e.g. converted into a conversational guide, or used for educational purposes. [Copyright &y& Elsevier]

Abstract: This study aims to determine the extent and nature of problems in palliative care that are newly identified in the consultation process and the factors influencing their identification. The consultation process includes clarification of problems mentioned by professionals requesting advice. Data are derived from the standard registration forms of Palliative Care Consultation teams. Multilevel logistic regression analysis was carried out with newly identified problem as dependent variable. Fifty seven percent of problems (n =7854) were newly identified. Most newly identified problems were related to physical and pharmacological problems. If psychosocial/spiritual problems were identified, this occurred in most cases through clarification (70%). Newly identified problems were more likely to be identified in the domain of spiritual and psychosocial problems, in bedside consultations, in requests from clinical physicians, and for patients accommodated in a hospice or hospital. Explicit clarification of problems facilitates the identification and addressing of a more comprehensive and specific scope of problems. [Copyright &y& Elsevier]

Abstract: Objective: To characterize patients with chronic obstructive pulmonary disease (COPD) in different motivational stages related to smoking cessation. Methods: 633 smoking COPD patients from 67 general practices participated in a cross-sectional study. The patients were compared with respect to health indicators, demographics, self-efficacy, nicotine dependence, attitudes, and action plans. Results: In line with previous Dutch results, smokers in precontemplation associated significantly fewer advantages with smoking cessation than smokers contemplating quitting and preparing to quit. Preparers had significantly higher self-efficacy expectations about quitting than the other smokers. Patients preparing to quit suffered from more COPD complaints than precontemplators. Smokers contemplating quitting and preparing to quit developed more plans to turn intentions to quit into action. Conclusion: More than 50% of the smokers with COPD are amenable to smoking cessation support. Preparers and contemplators did not differ as much as previous studies found. It would be advantageous to tailor COPD counseling to two distinct groups (unmotivated smokers and smokers motivated to quit), to discuss the advantages of quitting with unmotivated smokers, and to increase self-efficacy, and action planning for smokers motivated to quit. Practice implications: COPD patients are amenable to counseling to quit smoking. Addressing COPD complaints may contribute to greater motivation. [Copyright &y& Elsevier]

Abstract: No instrument to assess autonomy problems in palliative care is currently available. The purpose of this study was to develop a comprehensive and concise questionnaire to measure autonomy problems in palliative cancer patients and to study its validity and reliability. We systematically developed a questionnaire through: a) a literature review of the concepts and elements of autonomy; b) qualitative analysis of interviews with patients and professional carers; c) the construction of questionnaires; and d) testing validity and reliability. The basic conceptual elements were: dependency, losing control, and limitation of activities. Patients with disseminated cancer in the palliative stage of the disease (n = 64) participated in the study. A 9-item Patient Autonomy Questionnaire (PAQ) was developed (Cronbach''s alpha 0.86), followed by a concise 4-item version (PAQs) (Cronbach''s alpha 0.71). Autonomy problems were more prevalent than pain problems. The development of the PAQ may help draw attention to autonomy problems. [Copyright &y& Elsevier]

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

This study describes a new clinical tool for needs assessment in palliative care: the Problems and Needs in Palliative Care questionnaire (PNPC). It was developed to support the provision of care tailored to the specific demands of patients, which only can be provided when their needs are clearly identified. To test validity and reliability, 64 patients with metastatic cancer living at home completed the PNPC. Of 140 initial items, 2 were deleted because of low response. No important topics were missing. Dimensions were proposed to organize the problems and needs in a logical and practical array for use in individual patients, and to enable statistical analysis of patient-groups. Reliability analysis supported the proposed dimensions, with Cronbach''s alpha coefficient >0.70 for dimensions with ≥5 items, and alpha >0.65 for the 3- and 4-item dimensions. However, the dimensions ‘physical symptoms’ and ‘social issues’ lacked coherency with some low item-total correlations. The PNPC demonstrated convergent validity with the European Organization for Research and Treatment of Cancer (EORTC) and COOP-WONCA quality-of-life measures. These data are a first step in validating the PNPC, although the ‘social issues’ dimension needs reconsideration. Further studies are needed to evaluate clinical use. [Copyright &y& Elsevier]

We aimed to examine risk perceptions among patients at moderate to high cardiovascular risk. A questionnaire about perceived absolute risk of myocardial infarction and stroke was sent to 2424 patients with hypertension or diabetes. Response rate was 86.3% and 1557 patients without atherosclerotic disease were included. Actual cardiovascular risk was calculated by using Framingham risk functions. A total of 363 (23.3%) of the 1557 patients did not provide any risk estimates and these were particularly older patients, patients with a lower educational level, and patients reporting no alcohol consumption. The remaining 1194 patients tended to overestimate their risk. In 42.3% (497/1174) and 46.8% (541/1155) of the cases, patients overestimated their actual 10-year risk for myocardial infarction and stroke, respectively, by more than 20%. Older age, smoking, familial history of cardiovascular disease (CVD), and actual absolute risk predicted higher levels of perceived absolute risk. Male sex, higher scores for an internal health locus of control, lower scores for a physician locus of control, and self-rated excellent or (very) good health were positively related to higher accuracy. In conclusion, patients showed inadequate perceptions of their absolute risk of cardiovascular events and physicians should thus provide greater information about absolute risk when offering preventive therapy. [Copyright &y& Elsevier]

The aim of this study was to assess the provision of information and advice by general practitioners (GPs) with respect to patients with hypertension, hypercholesterolaemia, or cardiovascular disease. The study relied on the prospective recording of patient encounters by GPs. Performance indicators were selected from the Dutch national guidelines for general practice. The GPs (n=195) completed 5330 encounter forms. High levels of performance were found with regard to advice on smoking cessation and the provision of information (e.g. information about alarm symptoms or the aim of treatment). Low levels of performance were found with regard to advice on salt consumption, alcohol consumption, weight reduction and physical exercise for patients with hypertension. Discussion of compliance with the therapy in case of hypercholesterolaemia, advice on physical exercise in case of angina pectoris and advice on foot care in case of peripheral arterial disease also showed a substantial gap between recommended and actual care. Performance rates varied considerably across GPs. The patient and GP characteristics examined in this study contributed very little to the clinical performance. [Copyright &y& Elsevier]

This study presents a comprehensive overview of the problems patients experience in a palliative phase of cancer. A two-step qualitative method was used: in-depth interviews with patients and relatives (N=9 patients+7 relatives), followed by interviews (N=31 patients+15 relatives) using a checklist to confirm and complete the picture. Quality of life and quality of care domains were addressed. Patients experienced problems in all of these palliative care domains, although individual patients may have experienced only a few problems. Fatigue, feelings of futility, reluctance to accept help, fear of suffering and the fear that help would not be available if needed, were common problems. Communication problems arose when a grudge against a GP had remained, or because one family member tried to spare the other a confrontation with his/her feelings of fear or grief. A comprehensive checklist of relevant problems is presented. [Copyright &y& Elsevier]