Annelies Jacobs

Factors associated with the impact of quality improvement collaboratives in mental healthcare: an exploratory study.

BackgroundQuality improvement collaboratives (QICs) bring together groups of healthcare professionals to work in a structured manner to improve the quality of healthcare delivery within particular domains. We explored which characteristics of the composition, participation, functioning, and organization of these collaboratives related to changes in the healthcare for patients with anxiety disorders, dual diagnosis, or schizophrenia.MethodsWe studied three QICs involving 29 quality improvement (QI) teams representing a number of mental healthcare organizations in the Netherlands. The aims of the three QICs were the implementation of multidisciplinary practice guidelines in the domains of anxiety disorders, dual diagnosis, and schizophrenia, respectively. We used eight performance indicators to assess the impact of the QI teams on self-reported patient outcomes and process of care outcomes for 1,346 patients. The QI team members completed a questionnaire on the characteristics of the composition, participation in a national program, functioning, and organizational context for their teams. It was expected that an association would be found between these team characteristics and the quality of care for patients with anxiety disorders, dual diagnosis, and schizophrenia.ResultsNo consistent patterns of association emerged. Theory-based factors did not perform better than practice-based factors. However, QI teams that received support from their management and both active and inspirational team leadership showed better results. Rather surprisingly, a lower average level of education among the team members was associated with better results, although less consistently than the management and leadership characteristics. Team views with regard to the QI goals of the team and attitudes towards multidisciplinary practice guidelines did not correlate with team success.ConclusionsNo general conclusions about the impact of the characteristics of QI teams on the quality of healthcare can be drawn, but support of the management and active, inspirational team leadership appear to be important. Not only patient outcomes but also the performance indicators of monitoring and screening/assessment showed improvement in many but not all of the QI teams with such characteristics. More studies are needed to identify factors associated with the impact of multidisciplinary practice guidelines in mental healthcare.

Asthma education tailored to individual patient needs can optimise partnerships in asthma self-management.

This paper studies the effects of patient education, tailored to individual needs of patients as part of an asthma self-management program. A tailored education program was designed which took into account individual information needs of patients by using a feedback instrument. Totally 98 steroid dependent asthmatics entered the tailored education program, 95 patients received usual care. Outcome measures were information exchanged and patient satisfaction. Study duration was 6 months. Patients in the tailored education group showed a significant reduction in information need (P=0.005). Patient satisfaction increased from 87.9 to 93.7 in this group while this did not change in the usual care group (P=0.000). Use of this tailored education program improved the GP-patient interaction within the context of a clinically effective asthma self-management program. Findings from this study may be applicable to other chronic conditions as well.

Variation in spirometry utilization between trained general practitioners in practices equipped with a spirometer.

Objective. To explore spirometry utilization among general practitioners and identify practitioner and practice-related factors associated with spirometry utilization. Design. Multivariate multilevel cross-sectional analysis of a questionnaire survey. Setting. Some 61 general practices involved in a spirometry evaluation programme in the Netherlands. All practices owned a spirometer and were trained to perform spirometry. Subjects. A total of 144 general practitioners and 179 practice assistants. Main outcome measures. Extent of spirometry utilization for five indications from national COPD/asthma guidelines, practitioner and practice-related factors associated with spirometry utilization. Results. The response rate was 97%. General practitioners used spirometry mostly to evaluate treatment with inhaled steroids (58%). Significant practitioner-related factors associated with spirometry utilization were: general practitioners’ job satisfaction, general practitioners’ general interest in research, and prior participation in spirometry training. Practice-related factors associated with spirometry utilization were: presence of a practice nurse, delegation of medical tasks to practice assistants, use of spirometry in different rooms, and use of protocols in practice. Conclusion. Practitioner- as well as practice-related factors were associated with the extent of spirometry utilization. In particular, it is essential to improve practice-related factors (e.g. presence of a practice nurse, more delegation of medical tasks to the practice assistant).

COPD prognosis in relation to diagnostic criteria for airflow obstruction in smokers.

The aim of this study was to establish which cut-off point for the forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio (i.e. fixed 0.70 or lower limit of normal (LLN) cut-off point) best predicts accelerated lung function decline and exacerbations in middle-aged smokers. We performed secondary analyses on the Lung Health Study dataset. 4045 smokers aged 35–60 years with mild-to-moderate obstructive pulmonary disease were subdivided into categories based on presence or absence of obstruction according to both FEV1/FVC cut-off points. Post-bronchodilator FEV1 decline served as the primary outcome to compare subjects between the categories. 583 (14.4%) subjects were nonobstructed and 3230 (79.8%) subjects were obstructed according to both FEV1/FVC cut-off points. 173 (4.3%) subjects were obstructed according to the fixed cut-off point, but not according to the LLN cut-off point (“discordant” subjects). Mean±se post-bronchodilator FEV1 decline was 41.8±2.0 mL·year−1 in nonobstructed subjects, 43.8±3.8 mL·year−1 in discordant subjects and 53.5±0.9 mL·year−1 in obstructed subjects (p<0.001). Our study showed that FEV1 decline in subjects deemed obstructed according to a fixed criterion (FEV1/FVC <0.70), but non-obstructed by a sex- and age-specific criterion (LLN) closely resembles FEV1 decline in subjects designated as non-obstructed by both criteria. Sex and age should be taken into account when assessing airflow obstruction in middle-aged smokers. Lower limit of normal cut-off best predicts accelerated lung function decline and exacerbation in middle-aged smokers http://ow.ly/qaZnz

General practitioners’ needs for ongoing support for the interpretation of spirometry tests

Background: Although one out of three general practitioners (GPs) carries out spirometry, the diagnostic interpretation of spirometric test results appears to be a common barrier for GPs towards its routine application. Methods: Multivariate cross-sectional analysis of a questionnaire survey among 137 GPs who participated in a spirometry evaluation programme in the Netherlands. We identified characteristics of GPs and their practice settings associated with GPs’ need for ongoing support for spirometry interpretation. Results: Response rate on the survey questionnaire was 98%. The need for ongoing support among the participating GPs was 69%. GPs’ recent spirometry training showed a statistically significant association with the need for ongoing support for the interpretation of spirometry (odds ratio 0.43, 95% CI 0.20–0.92). Conclusion: There is a need for ongoing support for spirometry interpretation among GPs. Recent spirometry training partially diminished this need.

Patient safety in midwifery care for low-risk women: instrument development.

INTRODUCTION Few studies have examined the safety of midwife-led care for low-risk childbearing women. While most women have a low-risk profile at the start of pregnancy, validated measures to detect patient safety risks for this population are needed. The increased interest of midwife-led care for childbearing women to substitute for other models of care requires careful evaluation of safety aspects. In this study, we developed and tested an instrument for safety assessment of midwifery care. METHODS A structured approach was followed for instrument development. First, we reviewed the literature on patient safety in general and obstetric and midwifery care in particular. We identified 5 domains of patient risk: organization, communication, patient-related risk factors, clinical management, and outcomes. We then developed a prototype to assess patient records and, in an iterative process, reviewed the prototype with the help of a review team of midwives and safety experts. The instrument was pilot tested for content validity, reliability, and feasibility. RESULTS Trained reviewers with clinical midwifery expertise applied the instrument. We were able to reduce the original 100-item screening instrument to 32 items and applied the instrument to patient records in a reliable manner. With regard to the validity of the instrument, review of the literature and the validation procedure produced good content validity. DISCUSSION A valid and feasible instrument to assess patient safety in low-risk childbearing women is now available and can be used for quantitative analyses of patient records and to identify unsafe situations. Identification and analysis of patient safety incidents required clinical judgment and consultation with the panel of safety experts. The instrument allows us to draw conclusions about safety and to recommend steps for specific, domain-based improvements. Studies on the use of the instrument for improving patient safety are recommended.

Patient safety in midwifery-led care in the Netherlands.

OBJECTIVE to describe the incidence and characteristics of patient safety incidents in midwifery-led care for low-risk pregnant women. DESIGN multi-method study. SETTING 20 midwifery practices in the Netherlands; 1,000 patient records. POPULATION low-risk pregnant women. METHODS prospective incident reporting by midwives during 2 weeks; questionnaire on safety culture and retrospective content analysis of 1,000 patient records in 2009. MAIN OUTCOME MEASURES incidence, type, impact and causes of safety incidents. RESULTS in the 1,000 patient records involving 14,888 contacts, 86 safety incidents were found with 25 of these having a noticeable effect on the patient. Low-risk pregnant women in midwifery care had a probability of 8.6% for a safety incident (95% CI 4.8-14.4). In 9 safety incidents, temporary monitoring of the mother and/or child was necessary. In another 6 safety incidents, reviewers reported psychological distress for the patient. Hospital admission followed from 1 incident. No safety incidents were associated with mortality or permanent harm. The majority of incidents found in the patient records concerned treatment and organisational factors. CONCLUSIONS a low prevalence of patient safety incidents was found in midwifery care for low-risk pregnant women. This first systematic study of patient safety in midwifery adds to the base of evidence regarding the safety of midwifery-led care for low-risk women. Nevertheless, some areas for improvement were found. Improvement of patient safety should address the better adherence to practice guidelines for patient risk assessment, better implementation of interventions for known lifestyle risk factors and better availability of midwives during birthing care.

Predicting an accelerated lung function decline in smokers: is there a proper threshold?

To the Editor: We read, with very much interest, the publication by Akkermans et al. [1] in the European Respiratory Journal . In this study they reanalysed data from the first Lung Health Study by forming four groups, based on the forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) <0.70 or <5th percentile, according to the LMS (lambda, mu, sigma) approach. However, we do have some remarks concerning the validity of their analysis and propose a means of reinterpretation of their outcome. Akkermans et al . [1] concluded that the decline of the post bronchodilator FEV1 in the group fixed+/LMS- (FEV1/FVC 5th percentile) was significantly lower compared to the group fixed+/LMS+ (FEV1/FVC <0.70 and <5th percentile). The mean±sd decline was 43.8±50.0 mL·year−1 versus 53.5±51.5 mL·year−1, respectively, and thus one recommended the …

Van lacunes in evidence naar aanbevelingen voor onderzoek bij astma en COPD.

Samenvatting1. Bij het maken van richtlijnen wordt zichtbaar in welke mate medisch handelen evidence-based is en waar zich kennislacunes bevinden.2. Voor astma en COPD zijn er 21 kennislacunes gesignaleerd in de NHG-lacunebak op basis van de NHG-Standaarden uit 2001.