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

Rationale, aims and objectives In most countries, different health care providers are involved in emergency care. In the Netherlands, out-of-hours care is provided by general practitioner cooperatives (GPCs) and emergency departments (EDs). Our aim was to describe the flow of patients attending emergency care in these settings. Method A retrospective record review was performed, concerning patients who had visited a GPC or ED. Recorded information included urgency, diagnostic tests, and follow-up contacts. Descriptive figures were determined for patient flows in GPC and ED for urgent contacts and non-urgent contacts. Results We included 319 GPC contacts and 356 ED contacts, of which 78% were non-urgent. The majority of GPC contacts were completed at the GPC without follow-up; 37% of non-urgent patients had a follow-up contact, usually with primary care. Only 5% of non-urgent GPC patients received diagnostic tests compared to 63% of non-urgent ED patients (mostly X-rays). The majority of non-urgent ED patients (88%) had a follow-up contact, usually at an outpatient clinic (67%). Most non-urgent ED patients (83%) who received a diagnostic test also had an outpatient clinic follow-up contact. Of urgent ED patients, the majority had a follow-up contact (85%), mostly with an outpatient clinic (74%). Conclusion Although most out-of-hours care patients present non-urgent health problems, at the ED they are more likely to receive diagnostic tests and follow-up contacts. This may reflect differences in patient populations between the ED and GPC or suggest opportunities for improving efficiency of planning follow-up contacts. [ABSTRACT FROM AUTHOR]

Patient outcomes are poorly affected by lifestyle advice in general practice. Promoting lifestyle behavior change require that nurses shift from simple advice giving to a more counseling-based approach. The current study examines which barriers nurses encounter in lifestyle counseling to patients with type 2 diabetes. Based on this information we will develop an implementation strategy to improve lifestyle behavior change in general practice. Method: In a qualitative semi-structured study, twelve in-depth interviews took place with nurses in Dutch general practices involved in diabetes care. Specific barriers in counseling patients with type 2 diabetes about diet, physical activity, and smoking cessation were addressed. The nurses were invited to reflect on barriers at the patient and practice levels, but mainly on their own roles as counselors. All interviews were audio-recorded and transcribed. The data were analyzed with the aid of a predetermined framework. Results: Nurses felt most barriers on the level of the patient; patients had limited knowledge of a healthy lifestyle and limited insight into their own behavior, and they lacked the motivation to modify their lifestyles or the discipline to maintain an improved lifestyle. Furthermore, nurses reported lack of counseling skills and insufficient time as barriers in effective lifestyle counseling. Conclusions: The traditional health education approach is still predominant in primary care of patients with type 2 diabetes. An implementation strategy based on motivational interviewing can help to overcome 'jumping ahead of the patient' and promotes skills in lifestyle behavioral change. We will train our nurses in agenda setting to structure the consultation based on prioritizing the behavior change and will help them to develop social maps that contain information on local exercise programs. [ABSTRACT FROM AUTHOR]

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

Background: The use of guidelines in general practice is not optimal. Although evidence-based methods to improve guideline adherence are available, variation in physician adherence to general practice guidelines remains relatively high. The objective for this study is to transfer a quality improvement strategy based on audit, feedback, educational materials, and peer group discussion moderated by local opinion leaders to the field. The research questions are: is the multifaceted strategy implemented on a large scale as planned?; what is the effect on general practitioners' (GPs) test ordering and prescribing behaviour?; and what are the costs of implementing the strategy? Methods: In order to evaluate the effects, costs and feasibility of this new strategy we plan a multi-centre cluster randomized controlled trial (RCT) with a balanced incomplete block design. Local GP groups in the south of the Netherlands already taking part in pharmacotherapeutic audit meeting groups, will be recruited by regional health officers. Approximately 50 groups of GPs will be randomly allocated to two arms. These GPs will be offered two different balanced sets of clinical topics. Each GP within a group will receive comparative feedback on test ordering and prescribing performance. The feedback will be discussed in the group and working agreements will be created after discussion of the guidelines and barriers to change. The data for the feedback will be collected from existing and newly formed databases, both at baseline and after one year. Discussion: We are not aware of published studies on successes and failures of attempts to transfer to the stakeholders in the field a multifaceted strategy aimed at GPs' test ordering and prescribing behaviour. This pragmatic study will focus on compatibility with existing infrastructure, while permitting a certain degree of adaptation to local needs and routines. [ABSTRACT FROM AUTHOR]

Objective To determine whether patient evaluations of the accessibility to general practice and co-ordination with other care providers were associated with characteristics of general practice organizations. Background In 1998 patients across Europe perceived that small general practices have better accessibility than large practices. Since then a number of changes in primary care have had impact on accessibility and co-ordination of care. Design, setting and participants The study was based on data from the European Practice Assessment study, an observational study in 284 general practices in 10 countries in 2004. Main outcome measures Patient evaluations of general practice were measured with the 23-item Europep instrument, from which seven items on accessibility and co-ordination were selected in a principal factor analysis. Six practice characteristics were examined: percentage of female general practitioners, mean age of physicians, mean number of physician hours worked per week, number of general practitioners, number of care providers, urbanization level. Mixed regression models were applied, in which patients were clustered within practices, and practices within countries. Results Practices with a higher numbers of care providers received less positive patient evaluations ( b = −0.112, P = 0.004). The other practice characteristics were not related to patient evaluations. Only a small proportion of the total variation in patient evaluations of accessibility and co-ordination (1.8%) was explained by characteristics of the general practice organizations. Conclusions General practices have become larger in most developed countries in recent years, but patients seemed to prefer general practice organizations with fewer health professionals. [ABSTRACT FROM AUTHOR]

Background: Supporting self-management intends to improve life-style, which is beneficial for patients with mild osteoarthritis (OA). We evaluated a nurse-based intervention on older OA patients' self-management with the aim to assess its effects on mobility and functioning. Methods: Randomized controlled trial of patients (≥ 65 years) with mild hip or knee OA from nine family practices in the Netherlands. Intervention consisted of supporting patients' self-management of OA symptoms using a practice-based nurse. Outcome measures were patients' mobility, using the Timed Up and Go test (TUG), and patient reported functioning, using an arthritis specific scale (Dutch AIMS2 SF). Results: Fifty-one patients were randomized to the intervention group and 53 to the control group. Patient-reported functioning improved on four scales in the intervention group compared to one scale in the control group. However, this result was not significant. Mobility improved in both groups, without a significant difference between the two groups. There were no differences between the groups regarding consultations with family physicians or physiotherapists, or medication use. Conclusion: A nurse-based intervention on older OA patients' self-management did not improve self-reported functioning, mobility or patients' use of health care resources. [ABSTRACT FROM AUTHOR]

Objective To describe the implementation of a nationwide programme and to determine the effects of specific quality improvement (QI) interventions within this programme on perceived barriers to collaboration between general practitioner (GPs) and mental health professionals and frequency of structural one-on-one contact regarding individual patients. Methods The implementation of regional QI-interventions, perceived barriers to collaboration, and frequency of structural one-on-one contact, were assessed in a cohort study involving two surveys (2001 and 2003) among a random sample of 2757 GPs. Results 1336 and 1358 GPs returned baseline and follow-up questionnaires respectively. Most of the interventions were only offered to a minority of GPs. Less than 25% of GPs that had been offered interventions actually participated. The frequency of structural one-on-one contact with mental health professionals did not change, but barriers to collaboration decreased between 2001 and 2003. For GPs who actually participated in interactive small group meetings or in intervention in which mental health professionals were integrated in general practice, a reduction of perceived barriers could be observed as well as an increase in the frequency of structural one-on-one contact. Conclusion Interventions that could be characterized as interactive small group meetings as well as interventions that involved the integration of mental health professionals in general practice led to a reduction of perceived barriers as well as an increase in the frequency of structural one-on-one contact. These findings add to the knowledge of which interventions have an effect on the collaboration between different health care providers. [ABSTRACT FROM AUTHOR]

Background: This study aims to examine the impact of women's characteristics (demographics, risk behaviour, and beliefs) on the uptake of cervical cancer screening, taking practice characteristics (demographic and organizational) into account. Methods: Routinely collected data of screening status were sampled from electronic medical records of 32 Dutch general practices. Additionally, a questionnaire was sent to a sample of 2224 listed women--1204 screened, 1020 unscreened. We used a step-by-step, logistic, multilevel approach to examine determinants of the screening uptake. Results: Analyses of data for 1392 women (968 screened and 424 unscreened) showed that women's beliefs about cervical screening and attendance are the best predictors of screening uptake, even when demographic and organizational aspects are taken into account. Women aged 40-50 years who felt high personal moral obligation, who had only one sexual partner ever, and who were invited and reminded by their own general practice had the greatest likelihood of screening uptake. A non-response study was performed; the non-responders to the questionnaire (mainly unscreened) thought they had less risk of cervical cancer, were less motivated, less often intended to get future screening, and were more convinced that cervical cancer cannot be cured. Conclusion: To improve the uptake rate, we should focus on the personal moral obligation of eligible women, beliefs about the risks of cervical cancer, and available cures. Invitations and reminders within general practices enhance the uptake rate. [ABSTRACT FROM AUTHOR]

Background: The introduction of large-scale out-of-hours GP cooperatives has led to questions about increased distances between the GP cooperatives and the homes of patients and the increasing waiting times for home visits in urgent cases. We studied the relationship between the patient's waiting time for a home visit and the distance to the GP cooperative. Further, we investigated if other factors (traffic intensity, home visit intensity, time of day, and degree of urgency) influenced waiting times. Methods: Cross-sectional study at four GP cooperatives. We used variance analysis to calculate waiting times for various categories of traffic intensity, home visit intensity, time of day, and degree of urgency. We used multiple logistic regression analysis to calculate to what degree these factors affected the ability to meet targets in urgent cases. Results: The average waiting time for 5827 consultations was 30.5 min. Traffic intensity, home visit intensity, time of day and urgency of the complaint all seemed to affect waiting times significantly. A total of 88.7% of all patients were seen within 1 hour. In the case of life-threatening complaints (U1), 68.8% of the patients were seen within 15 min, and 95.6% of those with acute complaints (U2) were seen within 1 hour. For patients with life-threatening complaints (U1) the percentage of visits that met the time target of 15 minuts decreased from 86.5% (less than 2.5 km) to 16.7% (equals or more than 20 km). Discussion and conclusion: Although home visits waiting times increase with increasing distance from the GP cooperative, it appears that traffic intensity, home visit intensity, and urgency also influence waiting times. For patients with life-threatening complaints waiting times increase sharply with the distance. [ABSTRACT FROM AUTHOR]

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

Background Doctor-patient communication is an essential component of general practice. Improvement of GPs' communication patterns is an important target of training programmes. Available studies have so far failed to provide conclusive evidence of the effectiveness of educational interventions to improve doctor-patient communication. Aim To examine the effectiveness of a learner-centred approach that focuses on actual needs, to improve GPs' communication with patients. Design of study Randomised controlled trial. Setting One hundred volunteer GPs in the Netherlands. Method The intervention identified individual GPs' deficiencies in communication skills by observing authentic consultations in their own surgery. This performance assessment was followed by structured activities in small group meetings, aimed at remedying the identified shortcomings. Outcomes were measured using videotaped consultations in the GPs' own surgery before and after the intervention. Communication skills were rated using the MAAS-Global, a validated checklist. Results The scores in the intervention group demonstrated a significant improvement compared with those of the control group (95% confidence interval = 0.04 to 0.75). The effect size was moderate to large (d-value = 0.66). The level of participation significantly contributed to the effectiveness. Largest improvement was found on patient-centred communication skills. Conclusion The approach of structured individual improvement activities based on performance assessment is more effective in improving communication skills than current educational activities. [ABSTRACT FROM AUTHOR]

Introduction The aim of this study is to develop a new tool to assess professional behaviour in general practitioner (GP) trainees: the evaluation of professional behaviour in general practice (EPRO-GP) instrument. Methods Our study consisted of 4 phases: (1) development of a model of professionalism in general practice based on a literature review on professionalism, competency models of general practice and the overall educational objectives of postgraduate training for general practice; (2) development of the EPRO-GP instrument in collaboration with a sounding board; (3) establishing the content validity of the EPRO-GP instrument using a nominal group technique; and (4) establishing the feasibility of the EPRO-GP instrument in 12 general practice trainees and their general practice trainers. Results The model of professionalism in general practice encompassed 4 themes within professionalism: (a) professionalism towards the patient; (b) professionalism towards other professionals; (c) professionalism towards the public; and (d) professionalism towards oneself. These 4 themes covered 26 elements of professionalism. This model provided the framework of the EPRO-GP instrument, which we developed further by operationalising the 26 elements in 127 behavioural items. The expert ratings confirmed the content validity of the instrument with one exception: the element ‘altruism’ was removed as a stand-alone category but it remained throughout the tool in items giving primacy to patient welfare. The results on the feasibility of the EPRO-GP instrument were very encouraging. All tutorials yielded professional behaviour learning points. Discussion Our results support the content validity of the EPRO-GP instrument as well as its feasibility as a tool to educate for professionalism in general practice . [ABSTRACT FROM AUTHOR]

Background: The relationship between effective organisation of general practices and health improvement is widely accepted. The Maturity Matrix is an instrument designed to assess organisational development in general practice settings and to stimulate quality improvement. It is undertaken by a practice team with the aid of a facilitator. There is a tradition in the primary care systems in many countries of using practice visitors to educate practice teams about how to improve. However the role of practice visitors as facilitators who enable teams to plan practiceled organisational development using quality improvement instruments is less well understood. The objectives of the study were to develop and explore a facilitation model to support practice teams in stimulating organisational development using a quality improvement instrument called the Maturity Matrix. A qualitative study based on transcript analysis was adopted. Method: A model of facilitation was constructed based on a review of relevant literature. Audio tapes of Maturity Matrix assessment sessions with general practices were transcribed and facilitator skills were compared to the model. The sample consisted of two facilitators working with twelve general practices based in UK primary care. Results: The facilitation model suggested that four areas describing eighteen skills were important. The four areas are structuring the session, obtaining consensus, handling group dynamics and enabling team learning. Facilitators effectively employed skills associated with the first three areas, but less able to consistently stimulate team learning. Conclusion: This study suggests that facilitators need careful preparation for their role and practices need protected time in order to make best use of practice-led quality improvement instruments. The role of practice visitor as a facilitator is becoming important as the need to engender ownership of the quality improvement process by practices increases. [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 falsepositive 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]

Objective To evaluate the effects of a programme to enhance the involvement of older patients in their consultations in general practice. Design Cluster randomized trial, in which data was collected from different cohorts. Setting and participants Twenty-five general practices in the south-east part of the Netherlands and their patients aged 70 years and over. Intervention Patients in the intervention group received a leaflet to help them prepare for the consultation. General practitioners (GPs) received an outreach visit to optimize older patients’ involvement when visiting their GP. Patients in the control group received usual care. Main outcome measures Questionnaires measuring involvement (COMRADE), enablement (Patient Enablement Index) and satisfaction with their care (EUROPEP). Results Pre-intervention 315 patients and post-intervention 263 patients were included. Subjects were satisfied with their involvement and the GP's behaviour during the consultation. No differences in effect as a result of the leaflet on involvement, enablement or satisfaction were found between the intervention and the control group. Of 318 patients who received the leaflet and visited their GP in the intervention period, 47 patients used the leaflet. These users were more accustomed to prepare themselves for consultations. Users reported more psychological problems than non-users. Conclusions No relevant effects of the implementation programme on involvement, enablement or satisfaction were found. Other strategies are needed to enhance involvement of older patients in their care. Alternatively, older patients may perceive themselves sufficiently involved. [ABSTRACT FROM AUTHOR]

Background Anxiety disorders are common in general practice and are associated with several problems regarding recognition and management Aim To systematically evaluate the effectiveness of interventions aimed at improving recognition, diagnosis, and management of patients with anxiety disorders. Design of study Systematic review. Method MEDLINE, EMBASE, PsychINFO, and the Cochrane Clinical Trials' Register were searched up until 2003. Randomised controlled trials, controlled before/after trials, and interrupted time series for professional, organisational, financial, and regulatory interventions were eligible. Primary effect measures consisted of anxiety outcomes, diagnosis, prescription, and referral. Two reviewers independently made eligibility judgments: eight out of 563 articles were found to be eligible. Two reviewers participated independently in the quality assessment and data extraction process using a standardised form based on the Effective Practice and Organisation of Care checklist. Relative risks or standardised mean differences were calculated when possible. Results Four professional interventions and three organisational interventions were examined. In general, the professional interventions seemed to increase recognition, referral, and prescription as well as improving anxiety outcomes. Two out of three organisational interventions showed a positive effect on anxiety outcomes. The one study that took prescription into account showed no effect. Conclusions The quality of care for patients with anxiety can be improved. A combination of professional and organisational interventions in which an external expert is introduced seems to be most promising. Additional research is nevertheless necessary to determine the exact effects of such interventions using patient effect measures, economic evaluations, and feasibility studies. [ABSTRACT FROM AUTHOR]

Quality improvement of organizational aspects in general practice is receiving increasing attention. In particular, the impact of effective organization on preventative care has been recognized. Organizational assessments are typically used as part of professionally led accreditation schemes where there is a tension between externally led quality assurance and internally led quality improvement. The aim of this article is to inform the debate by reviewing the international-peer-reviewed literature on organizational assessments used in general practice settings. Systematic literature review. The literature was searched for articles relating to organizational assessment. Titles and abstracts were examined by two independent reviewers and relevant articles obtained. Bibliographies were examined for follow-up references. Data were extracted on the development and use of assessment methods. Thirteen papers describing five organizational assessment instruments were included for detailed appraisal. This review discovered a developing field containing different approaches to the measurement of organizational aspects of general practice. Whilst professionally led accreditation is well-developed and dependent on externally led quality assurance, approaches to internally led quality improvement are less well-developed. There is a need for organizational assessment tools designed for the purpose of stimulating internal development. [ABSTRACT FROM AUTHOR]

Background: General practitioners (GPs) play a crucial part in palliative care. The quality of care can be improved by investigating and addressing barriers perceived by GPs in daily practice. The aim of this study was to investigate GPs' task perception and barriers involved in palliative care. Methods: Qualitative focus group study. We gathered together a group of GPs representing a broad range of experience in palliative care. Content analysis was performed to derive a comprehensive view of tasks and barriers in daily palliative care. Results: GPs described their palliative care tasks as satisfactory and varied, but burdensome. Palliative care tasks included somatic and psychosocial care. Opinions differed with respect to whether the coordination of care belonged to the primary GP tasks. Barriers were classified according to three levels: (1) personal: barriers related to knowledge, skills, emotions; (2) relational: barriers concerning communication and collaboration; (3) organizational: barriers related to the organization of care and compartmentalization in healthcare. Conclusions: This study revealed a complex web of tasks and barriers. It may be possible to trace back a problem (lack of knowledge, for example) on the personal level to an isolated knowledge gap, but the problem may well have originated from communication or compartmentalization problems. To maintain GPs' feeling of being at ease with palliative care requires helping them acquire the appropriate balance between technical and organizational interventions and a compassionate orientation to their terminally ill patients. [ABSTRACT FROM AUTHOR]

Purpose: Our goal was to explore patients' anticipated needs for contact with their general practitioner (GP) at the time of hospital admissions and other life events.Methods: We undertook a questionnaire survey of 875 patients from 35 general practices spread throughout The Netherlands and a qualitative interview study with 30 patients.Results: Most patients expected to need contact with their GP if admitted to a hospital for a serious condition, such as a malignancy (98%) or a heart attack (97%). For minor conditions, such as a minor foot operation, contact was considered less important (33%). At the time of major life events, many patients anticipated needing contact as well: 81% in the case of a birth within the family, 90% in the case of a death in the family. In the quantitative analysis patients' wants were related only to a minor extent to patient characteristics. The qualitative analysis, however, distinguished categories of patients with different needs. Some patients were more technical in their needs, others focussed primarily on the relationship.Conclusion: Patients appear to have considerable need for contact with their physician at the time of hospital admission and other life events. The profession should reflect on this underexplored field and attempt to take a policy-making position toward initiating patient contact. [ABSTRACT FROM AUTHOR]

Patients with dyspepsia do not always use their medication according to instructions. It is important to understand patterns of medication use, because of clinical effectiveness as well as cost. A quarter of all patients used their prescribed medication on demand; when using PPIs the probability of on-demand use decreased. Consultation with the GP in the past 12 months was associated with on-demand use and with use of over-the-counter medication. Objective - To explore patient factors related to the use of prescribed and non-prescribed drugs for dyspepsia in The Netherlands. Design - Patient survey study. Setting and subjects - Questionnaires sent to patients who had a prescription for dyspepsia medication from their general practitioner. Main outcome measures - Patient factors related to the on-demand use of prescribed medication and the use of non-prescribed medication for dyspepsia. Results - 74% of the (n=518) patients had been receiving prescribed medication for dyspepsia for more than one year. A quarter of the patients were using the prescribed medication "on demand" instead of adhering to the instructions on the prescription. PPI prescriptions reduced the probability of using the medication on demand, compared with other prescribed drugs (OR 0.39). Some 19% of the patients were using non-prescribed drugs for dyspepsia. More of the patients who had visited their general practitioner in the previous 12 months were using their drugs on demand (OR 2.27) and were using non-prescribed drugs (OR 2.40) than the patients who had not visited their GP. Conclusion - Clear information for patients on how to use their medication for dyspepsia may contribute to decreasing unnecessary drug use. Communication about (in)appropriate use of drugs "on demand", non-prescribed drugs, and health education should be addressed to all patient groups. Further studies on these topics should aim to improve medical care based on shared decision-making for patients with dyspepsia. [ABSTRACT FROM AUTHOR]

Objective To examine the impact on general practitioners' workload of adding nurse practitioners to the general practice team. Design Randomised controlled trial with measurements before and after the introduction of nurse practitioners. Setting 34 general practices in a southern region of the Netherlands. Participants 48 general practitioners. Intervention Five nurses were randomly allocated to general practitioners to undertake specific elements of care according to agreed guidelines.The control group received no nurse. Main outcome measures Objective workload,derived from 28 day diaries,included the number of contacts per day for each of three conditions (chronic obstructive pulmonary disease or asthma,dementia, cancer),by type of consultation (in practice, telephone,home visit),and by time of day (surgery hours,out of hours).Subjective workload was measured by using a validated questionnaire. Outcomes were measured six months before and 18 months after the intervention. Results The number of contacts during surgery hours increased in the intervention group compared with the control group (P <0.06),particularly for patients with chronic obstructive pulmonary disease or asthma (P <0.01).The number of consultations out of hours declined slightly in the intervention group compared with the control group,but this difference did not reach significance.No significant changes became apparent in subjective workload. Conclusion Adding nurse practitioners to general practice teams did not reduce the workload of general practitioners,at least in the short term.This implies that nurse practitioners are used as supplements, rather than substitutes,for care given by general practitioners. [ABSTRACT FROM AUTHOR]

GPs are advised to use risk tables for an individualised risk calculation in the primary prevention of cardiovascular diseases. The high-risk approach in primary prevention encounters many barriers. GPs do not regard the risk table as a supportive tool for patient involvement. Training of GPs in risk communication is an important part of the required active implementation strategy for risk tables. Design - Qualitative study. GPs were interviewed after analysing two audiotaped cardiovascular consultations. Setting - Primary health care. Subjects - A sample of 15 GPs who audiotaped 22 consultations. Main outcome measures - Barriers hampering GPs from following the guideline. Results - Data saturation was reached after about 13 interviews. The 25 identified barriers were related to the risk table, the GP or to environmental factors. Lack of knowledge and poor communication skills of the GP, along with pressure of work and demanding patients, cause GPs to deviate from the guideline. GPs regard barriers external to themselves as most important. Conclusion - Using the risk table as a key element of the high-risk approach in primary prevention encounters many barriers. Merely incorporating risk tables in guidelines is not sufficient for implementation of the guidelines. Time-efficient implementation strategies dealing in particular with the communication and presentation of cardiovascular risk are needed. [ABSTRACT FROM AUTHOR]

Objective – Asthma self-management is a generally accepted effective treatment strategy for asthma patients. Acceptance by patients may be a barrier for successful implementation. In this study, the role of inhaled steroids in starting asthma self-management is described. Design – Cross-sectional explorative study. Setting – General practice. Subjects – 283 adult steroid-requiring asthma patients were invited by their GP to participate in a self-management programme. Main outcome measures – In a multivariate logistic regression model, the relation between baseline dosage of inhaled steroids, occupational status, age and sex as independent variables and willingness to participate as dependent variables was explored. Results – Of all invited, 148 (52%) were willing to participate. Subjects not using inhaled steroids were least willing to participate (43/143 =30%). Subjects with low doses of inhaled steroids (< 400 mcg daily) were most willing to participate (44/54 =81%). Unemployed asthmatics had a higher tendency to participate than patients with a regular job. Conclusion – Acceptance of self-management by patients is not a limiting issue in promoting self-management of asthma in general practice. High acceptance in patients taking low or intermediate doses of inhaled steroids makes general practice the most appropriate setting for self-management. A selection procedure is recommended. [ABSTRACT FROM AUTHOR]

This study compares the predictive values of written-knowledge tests and a standardized multiple-station examination for the actual medical performance of general practitioners (GPs) in order to select effective assessment methods to be used in quality-improvement activities. A comprehensive assessment was performed in four phases. First, 100 GPs from the southern part of the Netherlands were assessed by a general medical knowledge test and by a knowledge test on technical skills. Second, in order to check for time-order effects, participants were randomly divided into two groups of 50 each, comparable on scores of both knowledge tests and on professional characteristics. Finally, both groups went through a multiple station examination using standardized patients and a practice video assessment of real surgery, but in opposite orders. Consultations were videotaped and assessed by well-trained peer observers. The drop-out rate was 10%. In both groups the predictive value of medical knowledge tests, ranging from 0·43 to 0·56 (Pearson correlation disattenuated), proved to be comparable with the predictive value of the multiple-station examination for actual performance (0·33–0·59). The overall explained variance of scores of the practice video assessment, measured by multiple regression analysis with performance scores as dependent variables and scores on the knowledge tests and the multiple-station examination as independent variables was moderate (19%). A time-order effect showed in only one direction: from practice video assessment to the multiple-station examination. The GP's professional characteristics did not contribute to the explanation of variation in performance. Medical knowledge tests can predict actual clinical performance to the same extent as a multiple-station examination. Compared with a station examination, a knowledge test may be a good alternative method for assessment the procedures of a large number of practising GPs. [ABSTRACT FROM AUTHOR]

The article outlines a method for national guidance development for family practice in the Netherlands and provides a comparison of this method with that of the Agency for Health Care Policy and Research (AHCPR) in the U.S. The national guidelines for family practice care are developed by the Dutch College of General Practitioners and covers a wide range of problems and conditions seen in family practice, such as type II diabetes, sprained ankle, otitis media, dementia and sleeping disorders. Meanwhile, the AHCPR approach is a government-sponsored initiative aimed at the elimination of inefficient, unnecessary care.

We conducted a study in which we measured GPs' attitudes towards personal continuity directly after consultations, and identified which factors predicted its perceived importance. Moreover, we related these data to attitudes as measured by a postal survey. GPs varied considerably In their attitudes towards personal continuity. Continuity was valued for serious and psychosocial issues and also for routine checks for a chronic illness. There was no relation whatsoever between the importance that individual GPs attached to continuity after consultations, and their scores on the postal survey. [ABSTRACT FROM AUTHOR]

The article offers insights on developing evidence-based clinical guidelines. The importance of ensuring the cost-effectiveness of guidelines is discussed. It is said that clinical guidelines can be valuable in supporting decision making in general practice. It is suggested to focus on the needs of patients and improving care when developing guidelines.

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: Background. : Chronic Obstructive Pulmonary Disease (COPD) forms an increasing health problem. Despite smoking cessation improving the prognosis of the disease, many patients persist smoking. The present study presents the results of a smoking cessation counseling protocol in general practice (Smoking Cessation in patients with COPD in general practice (SMOCC)). Methods. : A randomized controlled trial of patients with COPD compared smoking cessation counseling according to an intensified minimal intervention strategy with usual care. In total 43 general practices with 392 patients participated in Nijmegen, The Netherlands, in 2001-2002. Results. : Significantly more smokers in the experimental group made a quit attempt (44.9% versus 36.5%) and actually quitted smoking than in the control group (16.0% versus 8.8%). The motivation to stop smoking at baseline was not associated with smoking cessation. Conclusion. : The SMOCC strategy doubled the self-reported quit rates and was complied well by the general practitioners. Implementation in general practice is recommended. [Copyright &y& Elsevier]

Involvement of older patients in general practice care is regarded as important, but is not widespread. To determine specific barriers to the involvement of older patients in general practice care and to identify variations between countries, we performed an international comparative study based on qualitative interviews with 233 general practitioners (GPs) in 11 countries. Most GPs thought that involving older patients had positive outcomes. GPs saw patient involvement as a process taking place solely during consultations. The main barrier for GPs was lack of time. Barriers related to older patients were their feelings of respect for doctors, their lack of experience in being involved and possible mental and physical impairments. To conclude, increasing involvement of older patients is not easy and will only be effective when GPs have adopted a more developed concept of patient involvement and are supported with the different methods for achieving this. The range of appropriate interventions may be similar in all countries. [Copyright &y& Elsevier]