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Radboud University, 09 september 2020, Promotores : Batenburg, R.S., Bakker, D.H. de Co-promotor : Velden, L.F.J. van der, Contains fulltext : 221858.pdf (publisher's version ) (Open Access), The working hours of general practitioners (GPs) play a central role in analysing their workload and to enable health workforce planning. Triggered by signals of Dutch GPs experiencing an irresponsible workload, it has become increasingly important to objectively measure their actual workload in terms of time-use during a working week. In this research of Daniël van Hassel, an innovative time-use measurement tool based on SMS text messaging was applied among more than 1,000 GPs. The assessment shows that this tool has many advantages over other methods of time-use measurement. It implies minimal burdening for GPs, provide nearly real time responses and avoids recall bias. In addition, it was found that the working hours of Dutch GPs differ in particular by gender, regardless their age and employment position. Another result is that the image of a higher workload in rural practices does not completely match the working hours of GPs in these areas.

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Contains fulltext : 184191.pdf (publisher's version ) (Open Access), Background: Measuring the working hours of general practitioners (GPs) is an important but complex task due to the effects of bias related to self-reporting, recall, and stress. In this paper we describe the deployment, feasibility, and implementation of an innovative method for measuring, in real time, GPs' working time, plus the response to the study. Methods: A Short Message Service (SMS) application was developed which sent messages at random to GPs during their working week. Approximately nineteen GPs participated each week during a period of 57 weeks. The text messages asked if GPs were doing activities related to patients, directly, indirectly, or not at all, at the moment of sending. Participants were requested to reply by SMS. Results: Approximately 27,000 messages were sent to 1051 GPs over more than one year. The SMS system was functioning 99.9% of the time. GPs replied to 94% of all the messages sent. Only a few participants dropped out of the study. The data was available in real time enabling the researchers to monitor the response and overall quality of the data each day. Conclusions: The SMS method offers advantages over other instruments of measurement because it allows a better response, ease of use and avoids recall bias. This makes it a feasible method to collect valid data about GPs working time.

Contains fulltext : 192433.pdf (publisher's version ) (Open Access), Background: The need for organisational development in primary care has increased as it is accepted as a means of curbing rising costs and responding to demographic transitions. It is only within such inter-organisational networks that small-scale practices can offer treatment to complex patients and continuity of care. The aim of this paper is to explore, through the experience of professionals and patients, whether, and how, project management and network governance can improve the outcomes of projects which promote inter-organisational collaboration in primary care. Methods: This paper describes a study of projects aimed at improving inter-organisational collaboration in Dutch primary care. The projects' success in project management and network governance was monitored by interviewing project leaders and board members on the one hand, and improvement in the collaboration by surveying professionals and patients on the other. Both qualitative and quantitative methods were applied to assess the projects. These were analysed, finally, using multi-level models in order to account for the variation in the projects, professionals and patients. Results: Successful network governance was associated positively with the professionals’ satisfaction with the collaboration; but not with improvements in the quality of care as experienced by patients. Neither patients nor professionals perceived successful project management as associated with the outcomes of the collaboration projects. Conclusions: This study shows that network governance in particular makes a difference to the outcomes of inter-organisational collaboration in primary care. However, project management is not a predictor for successful inter-organisational collaboration in primary care.

Contains fulltext : 180366.pdf (publisher's version ) (Open Access), Our research is based on a technique for time sampling, an innovative method for measuring the working hours of Dutch general practitioners (GPs), which was deployed in an earlier study. In this study, 1051 GPs were questioned about their activities in real time by sending them one SMS text message every 3 h during 1 week. The required sample size for this study is important for health workforce planners to know if they want to apply this method to target groups who are hard to reach or if fewer resources are available. In this time-sampling method, however, standard power analyses is not sufficient for calculating the required sample size as this accounts only for sample fluctuation and not for the fluctuation of measurements taken from every participant. We investigated the impact of the number of participants and frequency of measurements per participant upon the confidence intervals (CIs) for the hours worked per week.

Contains fulltext : 180947.pdf (publisher's version ) (Open Access), Background: In several countries, the number of hours worked by general practitioners (GPs) has decreased, raising concern about current and impending workforce shortages. This shorter working week has been ascribed both to the feminisation of the workforce and to a younger generation of GPs who prefer more flexible working arrangements. There is, however, limited insight into how the impact of these determinants interact. We investigated the relative importance of differences in GPs' working hours in relation to gender, age, and employment position. Methods: An analysis was performed on real-time monitoring data collected by sending SMS text messages to 1051 Dutch GPs, who participated during a 1-week time use study. We used descriptive statistics, independent sample t-tests, and one-way ANOVA analysis to compare the working time of different GP groups. A path analysis was conducted to examine the difference in working time by gender, age, employment position, and their combinations. Results: Female GPs worked significantly fewer hours than their male peers. GPs in their 50s worked the highest number of hours, followed by GPs age 60 and older. GPs younger than 40 worked the lowest number of hours. This relationship between working hours and age was not significantly different for women and men. As shown by path analysis, female GPs consistently worked fewer hours than their male counterparts, regardless of their age and employment position. The relationship between age and working hours was largely influenced by gender and employment position. Conclusions: The variation in working hours among GPs can be explained by the combination of gender, age, and employment position. Gender appears to be the most important predictor as the largest part of the variation in working hours is explained by a direct effect of this variable. It has previously been reported that the difference in working hours between male and female GPs had decreased over time. However, our findings

Contains fulltext : 118609.pdf (publisher's version ) (Open Access), Background and objective. Changes in the Dutch GP remuneration system provided the opportunity to study the effects of changes in financial incentives on the quality of care. Separate remuneration systems for publicly insured patients (capitation) and privately insured patients (fee-for-service) were replaced by a combined system of capitation and fee-for-service for all in 2006. The effects of these changes on the quality of care in terms of guideline adherence were investigated. Design and setting. A longitudinal study from 2002 to 2009 using data from patient electronic medical records in general practice. A multilevel (patient and practice) approach was applied to study the effect of changes in the remuneration system on guideline adherence. Subjects. 21 421 to 39 828 patients from 32 to 52 general practices (dynamic panel of GPs). Main outcome measures. Sixteen guideline adherence indicators on prescriptions and referrals for acute and chronic conditions. Results. Guideline adherence increased between 2002 and 2008 by 7% for (formerly) publicly insured patients and 10% for (formerly) privately insured patients. In general, no significant differences in the trends for guideline adherence were found between privately and publicly insured patients, indicating the absence of an effect of the remuneration system on guideline adherence. Adherence to guidelines involving more time investment in terms of follow-up contacts was affected by changes in the remuneration system. For publicly insured patients, GPs showed a higher trend for guideline adherence for guidelines involving more time investment in terms of follow-up contacts compared with privately insured patients. Conclusion. The change in the remuneration system had a limited impact on guideline adherence.

Contains fulltext : 96510.pdf (publisher's version ) (Closed access), OBJECTIVE: To study trends and variation in adherence to the main national formulary for the 20 most prevalent health problems in Dutch general practice over a 5-year period (2003-07). METHODS: Routine electronic medical records from a pool of 115 representative general practices were linked to the main national formulary. Analyses included over 2 million prescriptions for 246 391 patients. The outcome variable was whether or not the prescribed medication was congruent with recommendations in the national formulary. Trends and variation were analysed using three-level multilevel logistic regression analyses (general practice, patient, and prescription). Results : The percentage of formulary adherent prescriptions for the 20 most prevalent health problems was 73-76% between 2003 and 2007. The percentage varied considerably between guidelines. Lowest adherence rates were found for acute bronchitis and acute upper respiratory infection. Interpractice variation was constant over time. CONCLUSIONS: General practice information networks are useful for monitoring general patterns of formulary on a year-to-year basis. Formulary adherence is stable over time but varies across diagnoses, patients and general practices. In the past decade, efforts have been made to increase the level of formulary adherent prescribing. These general efforts managed to stabilize (variation in) adherence in a field where many other initiatives (e.g. by pharmaceutical companies) are undertaken to influence prescribing behaviour.

Contains fulltext : 97026.pdf (publisher's version ) (Open Access), BACKGROUND: Innovative approaches are needed to support patients' adherence to drug therapy. The Real Time Medication Monitoring (RTMM) system offers real time monitoring of patients' medication use combined with short message service (SMS) reminders if patients forget to take their medication. This combination of monitoring and tailored reminders provides opportunities to improve adherence. This article describes the design of an intervention study aimed at evaluating the effect of RTMM on adherence to oral antidiabetics. METHODS/DESIGN: Randomised Controlled Trial (RCT) with two intervention arms and one control arm involving diabetes type 2 patients with suboptimal levels of adherence to oral antidiabetics (less than 80% based on pharmacy refill data). Patients in the first intervention arm use RTMM including SMS reminders and a personal webpage where they can monitor their medication use. Patients in the second intervention arm use RTMM without SMS reminders or webpage access. Patients in the control arm are not exposed to any intervention. Patients are randomly assigned to one of the three arms. The intervention lasts for six months. Pharmacy refill data of all patients are available from 11 months before, until 11 months after the start of the intervention. Primary outcome measure is adherence to oral antidiabetics calculated from: 1) data collected with RTMM, as a percentage of medication taken as prescribed, and as percentage of medication taken within the correct time interval, 2) refill data, taking the number of days for which oral antidiabetics are dispensed during the study period divided by the total number of days of the study period. Differences in adherence between the intervention groups and control group are studied using refill data. Differences in adherence between the two intervention groups are studied using RTMM data. DISCUSSION: The intervention described in this article consists of providing RTMM to patients with suboptimal adherence levels

Contains fulltext : 81493.pdf (publisher's version ) (Closed access), BACKGROUND: This study aimed to detect striking trends based on a new strategy for monitoring public health. METHODS: We used data over 4 years from electronic medical records of a large, nationally representative network of general practices. Episodes were either directly recorded by general practitioners (GPs) or were constructed using a new record linkage method (EPICON). The episodes were used to estimate raw morbidity rates for all codes of the International Classification of Primary Care (ICPC). Multilevel Poisson regression models were used to analyse the trend over time for 15 health problems that showed an obvious change over time. Based on these models, we calculated adjusted incidence rates corrected for clustering, sex and age. RESULTS: During 2002-05, both men and women increasingly consulted the GP because of concern about a drug reaction, a change in faeces/bowel movements and urination problems. Men showed an increase in consultations for prostate problems and venereal diseases. The incidence of chronic internal knee derangement decreased for both sexes. Women consulted their GP less frequently about sterilization and fear of being pregnant. CONCLUSION: The strategy developed proved to be useful to detect trends across a short period of time. Changes in the health care market, such as the increasing availability of over-the-counter drugs and various large advertising campaigns for medications may explain some of the findings. The increasing incidence of health problems in the urogenital area deserves attention as it could reflect increases in the incidence of sexually transmitted diseases (STDs) and urinary tract infections.

RU Radboud Universiteit Nijmegen, 8 januari 2009, Promotores : Vries Robbe, P.F. de, Zielhuis, G.A. Co-promotor : Bakker, D.H. de, Contains fulltext : 80774.pdf (publisher's version ) (Open Access)

Contains fulltext : 80015.pdf (publisher's version ) (Open Access), BACKGROUND: Physicians' heavy workload is often thought to jeopardise the quality of care and to be a barrier to improving quality. The relationship between these has, however, rarely been investigated. In this study quality of care is defined as care 'in accordance with professional guidelines'. In this study we investigated whether GPs with a higher workload adhere less to guidelines than those with a lower workload and whether guideline recommendations that require a greater time investment are less adhered to than those that can save time. METHODS: Data were used from the Second Dutch National survey of General Practice (DNSGP-2). This nationwide study was carried out between April 2000 and January 2002.A multilevel logistic-regression analysis was conducted of 170,677 decisions made by GPs, referring to 41 Guideline Adherence Indicators (GAIs), which were derived from 32 different guidelines. Data were used from 130 GPs, working in 83 practices with 98,577 patients. GP-characteristics as well as guideline characteristics were used as independent variables. Measures include workload (number of contacts), hours spent on continuing medical education, satisfaction with available time, practice characteristics and patient characteristics. Outcome measure is an indicator score, which is 1 when a decision is in accordance with professional guidelines or 0 when the decision deviates from guidelines. RESULTS: On average, 66% of the decisions GPs made were in accordance with guidelines. No relationship was found between the objective workload of GPs and their adherence to guidelines. Subjective workload (measured on a five point scale) was negatively related to guideline adherence (OR = 0.95). After controlling for all other variables, the variation between GPs in adherence to guideline recommendations showed a range of less than 10%.84% of the variation in guideline adherence was located at the GAI-level. Which means that the differences in adherence levels between guid

Contains fulltext : 70378.pdf (publisher's version ) (Closed access), OBJECTIVES: In this study, we evaluated the internal validity of EPICON, an application for grouping ICPC-coded diagnoses from electronic medical records into episodes of care. These episodes are used to estimate morbidity rates in general practice. METHODS: Morbidity rates based on EPICON were compared to a gold standard; i.e. the rates from the second Dutch National Survey of General Practice. We calculated the deviation from the gold standard for 677 prevalence and 681 incidence rates, based on the full dataset. Additionally, we examined the effect of case-based reasoning within EPICON using a comparison to a simple, not case-based method (EPI-0). Finally, we used a split sample procedure to evaluate the performance of EPICON. RESULTS: Morbidity rates that are based on EPICON deviate only slightly from the gold standard and show no systematic bias. The effect of case-based reasoning within EPICON is evident. The addition of case-based reasoning to the grouping system reduced both systematic and random error. Although the morbidity rates that are based on the split sample procedure show no systematic bias, they do deviate more from the gold standard than morbidity rates for the full dataset. CONCLUSIONS: Results from this study indicate that the internal validity of EPICON is adequate. Assuming that the standard is gold, EPICON provides valid outcomes for this study population. EPICON seems useful for registries in general practice for the purpose of estimating morbidity rates.

Contains fulltext : 70905.pdf (publisher's version ) (Open Access), BACKGROUND: Many assume that outcomes from physical therapy research in one country can be generalized to other countries. However, no well designed studies comparing outcomes among countries have been conducted. In this exploratory study, our goal was to compare patient demographics and treatment processes in outpatient physical therapy practice in the United States, Israel and the Netherlands. METHODS: Cross-sectional data from three different clinical databases were examined. Data were selected for patients aged 18 years and older and started an episode of outpatient therapy between January 1st 2005 and December 31st 2005. Results are based on data from approximately 63,000 patients from the United States, 100,000 from Israel and 12,000 from the Netherlands. RESULTS: Age, gender and the body part treated were similar in the three countries. Differences existed in episode duration of the health problem, with more patients with chronic complaints treated in the United States and Israel compared to the Netherlands. In the United States and Israel, physical agents and mechanical modalities were applied more often than in the Netherlands. The mean number of visits per treatment episode, adjusted for age, gender, and episode duration, varied from 8 in Israel to 11 in the United States and the Netherlands. CONCLUSION: The current study showed that clinical databases can be used for comparing patient demographic characteristics and for identifying similarities and differences among countries in physical therapy practice. However, terminology used to describe treatment processes and classify patients was different among databases. More standardisation is required to enable more detailed comparisons. Nevertheless the differences found in number of treatment visits per episode imply that one has to be careful to generalize outcomes from physical therapy research from one country to another.

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Contains fulltext : 50582.pdf ( ) (Open Access), PURPOSE: Headaches and abdominal pain are examples of minor ailments that are generally self-limiting. We examined the extent to which patterns of visits to family physicians for minor ailments, such as headaches or abdominal pain, cluster within families. METHODS: Using information from the Second Dutch National Survey of General Practice for 96 family practices, we analyzed the visits of families with at least 1 child aged 12 years or younger during a period of 12 months. RESULTS: Family patterns were clearest in the visits of mothers and children. A large part of the similarity in the frequencies of contact by mothers and daughters could be attributed to shared family factors. This finding was especially true for families with a child who had a headache or abdominal pain as the presenting symptom, rather than physical trauma or chronic disease. Within families, we did not find any specific patterns of diagnoses. Diagnoses were recorded by family physicians. In the case of young children, family similarity may have been overestimated because parents initiated the visits and put their child's health problem into words. CONCLUSIONS: Visits to family physicians for headaches or abdominal pain can be seen as indicators of consultation patterns in families. Family patterns related to minor ailments are likely to be a result of socialization. Family consultation patterns might point toward specific needs of families and consequently at a different approach to treatment.

Item does not contain fulltext, OBJECTIVE: To investigate the six-month recommended follow-up after mass screening of Pap smears because of the absence of endocervical columnar cells (ECC-) or ECC+ smears with atypical squamous or glandular cells of undetermined origin (ASCUS/AGUS) or low-grade squamous or glandular intraepithelial lesions (LSIL/LGIL) in a Dutch mass screening cervical cancer programme. METHODS: Data were extracted from computerised medical records of national representative Dutch general practices. We have studied the attendance at and the outcome of the subsequent Pap smears after a 6-month recommendation. RESULTS: The six-month follow-up was linked to 8.7% of the Pap smears (n = 1,002); 77.6% were without endocervical columnar cells (ECC-). Clear differences were found between the follow-up of ECC+ and ECC- smears; after 36 weeks of follow-up of 43.5% the women had an ECC- smear and 66.9% had other conditions. For initial ECC- Pap smears, 84.1% had no abnormalities in the subsequent Pap smear; for initial ECC+ Pap smears, in about 64% of the cases no abnormalities were found (p < 0.0001). CONCLUSIONS: Repeating ECC- smears has a low follow-up rate but also lacks evidence-based necessity. However, for the other 6-month recommended Pap smears, one in five women had still not responded within one year, so improvement is necessary.

Item does not contain fulltext, BACKGROUND: Influenza vaccination has consistently been shown to prevent all-cause death and hospitalizations during influenza epidemics among seniors. However, such benefits have not yet been demonstrated among younger individuals with high-risk medical conditions. In the present study, we evaluated the effectiveness of influenza vaccine in persons recommended for vaccination of any age during an epidemic. METHODS: We conducted a case-control study during the 1999-2000 influenza A epidemic nested in a cohort of 75,227 primary care patients. End points were all-cause mortality and episodes of hospitalizations or general practitioner (GP) visits for influenza, pneumonia, other acute respiratory disease, acute otitis media, myocardial infarction, heart failure, and stroke. The effectiveness of vaccination was evaluated by means of logistic regression analysis with adjustments for age, sex, prior health care use, medication use, and comorbid conditions. RESULTS: Among high-risk children and adolescents younger than 18 years (n=5933; 8% of the study population), 1 death, 3 hospitalizations for pneumonia, and 160 GP visits occurred. After adjustments, 43% (95% confidence interval [CI], 10%-64%) of visits were prevented. Among high-risk adults aged between 18 and 64 years (n=24 928; 33% of the study population), 47 deaths, 23 hospitalizations, and 363 GP visits occurred. After adjustments, vaccination prevented 78% of deaths (95% CI, 39%-92%), 87% of hospitalizations (95% CI, 39%-97%), and 26% of GP visits (95% CI, 7%-47%). Among elderly persons (n=44 366; 59% of the study population), 272 deaths and 166 hospitalizations occurred, and after adjustments the vaccine prevented these end points by 50% (95% CI, 23%-68%) and 48% (95% CI, 7%-71%), respectively. CONCLUSION: Persons with high-risk medical conditions of any age can substantially benefit from annual influenza vaccination during an epidemic.

Contains fulltext : 48186.pdf (publisher's version ) (Open Access), OBJECTIVE: To examine the extent to which the family influences individual use of general practitioner care. DESIGN: Retrospective cohort study of all consultations in one calendar year. Multilevel modelling was used to analyse contact frequencies of individuals within families within practices. SETTING: General practice in the Netherlands. PARTICIPANTS: 42 262 families with children aged 2-21 years registered in 96 practices. MAIN OUTCOME MEASURES: Family influence on individual frequency of contact with general practice and correlation in frequency of contacts between parents and children. RESULTS: After correction for patients' age and sex, analysis of siblings indicates that 22% of the variance in frequencies of contact can be ascribed to influence of the family. This means that contact frequencies of family members within families resemble each other, whereas differences in contact frequencies exist between families. Almost 6% of the variance refers to differences between practices and 73% of the variance refers to individual differences. The strongest correlations were found between mothers and children and between children. CONCLUSIONS: The extent of shared help seeking behaviour within families has considerable implications in the context of the practice.

RU Radboud Universiteit Nijmegen, 30 november 2005, Promotores : Grol, R.P.T.M., Groenewegen, P.P. Co-promotores : Braspenning, J.C.C., Bakker, D.H. de, Contains fulltext : 49122.pdf (Publisher’s version ) (Open Access)

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Contains fulltext : 59136.pdf (publisher's version ) (Closed access), A general practice (GP) based retrospective cohort study was conducted to assess the effects of influenza vaccination on the primary care contact rate during influenza epidemics. Given the rising workload of family physicians, particularly due to ageing of the population, it is very relevant to know to whether influenza vaccination of high-risk patients reduces the contact rate during epidemics. No effect of vaccination was found on the contact rate of GP during a mild epidemic period. During a 'normal' influenza epidemic, the workload was reduced through fewer contacts by patients with cardiovascular or diabetic diseases. Epidemic periods severe enough to show contact rate reduction occurred approximately every other year.

Item does not contain fulltext, Rationale and design of a study on the cost-effectiveness of the Dutch influenza vaccination campaign are described. During two influenza epidemics, about 75,000 primary care patients recommended for influenza vaccination are included. Cases have fatal or non-fatal influenza, pneumonia, otitis media, acute respiratory disease (ARD), heart failure, myocardial infarction, depression or diabetes dysregulation. Per case four controls are sampled, frequency matched on age and high-risk co-morbidity (<18 years, 18-64, >/=65 healthy, >/=65 with co-morbidity). Baseline and outcome data are retrieved from patient records. During the 1999-2000 influenza A epidemic 5891 (7.9%) high-risk children, 24,848 (33.2%) high-risk adults aged 18-64 years, 18,484 (24.7%) elderly with co-morbidity and 25,527 (34.1%) healthy elderly had been included. The mortality rate was 5.2 per 1000 and 2035 non-fatal outcome events were recorded (incidence rate 27.2/1000).

Item does not contain fulltext, BACKGROUND: World-wide each year 30-55% of the target population is vaccinated against influenza. Determinants of successful vaccination programs are not clear. This study was aimed at identifying practice- and patient-related factors that determine differences in vaccination rates. METHODS: Data on patients of the target population were extracted from the computerized medical record systems of 48 family practices. Information about organizational factors was collected by a questionnaire for GP's. Multilevel logistic regression analyses were used to assess the determinants. RESULTS: Of all patients at risk (42,426), 76% were vaccinated. The vaccination rate for patients above age 65 was 15% higher when a medical indication was present. Patients with cardiac diseases or diabetes mellitus attained a relatively higher vaccination rate than other groups at risk. Special hours for vaccination led to significantly higher vaccination rates for the elderly and cardiac patients. Patients below 65 years of age were particularly influenced by special information pamphlets. CONCLUSION: Explanations of differences in uptake rates were found at the patient level. All practices in this study were well organized; nevertheless, subgroup analyses showed that special vaccination hours for elderly people and information pamphlets for young people could improve results further.

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