Bas Maiburg

Quality of clinical aspects of call handling at Dutch out of hours centres : cross sectional national study

Objective To assess the quality of telephone triage by following the consecutive phases of its care process and the quality of the clinical questions asked about the patient’s clinical condition, of the triage outcome, of the content of the home management advice, and of the safety net advice given at out of hours centres. Design Cross sectional national study using telephone incognito standardised patients. Setting The Netherlands. Participants 17 out of hours centres. Main outcome measures Percentages of clinical obligatory questions asked and items within home management and safety net advice, both in relation to pre-agreed standards, and of care advice given in relation to the required care advice. Results The telephone incognito standardised patients presented seven clinical cases three times each over a period of 12 months, making a total of 357 calls. The mean percentage of obligatory questions asked compared with the standard was 21%. Answers to questions about the clinical condition were not always correctly evaluated from a clinical viewpoint, either by triagists or by general practitioners. The quality of information on home management and safety net advice varied, but it was consistently poor for all cases and for all out of hours centres. Triagists achieved the appropriate triage outcome in 58% of calls. Conclusion In determining the outcome of the care process, triagists often reached a conclusion after asking a minimal number of questions. By analysing the quality of different phases within the process of telephone triage, evaluation of whether an appropriate triage outcome has been arrived at by means of good clinical reasoning or by an educated guess is possible. In terms of enhancing the overall clinical safety of telephone triage, apart from obtaining an appropriate clinical history, adequate home management and safety net advice must also be given.

Fielding incognito standardised patients as 'known' patients in a controlled trial in general practice.

Background  Incognito standardised patients (SPs) have only been used to represent new patients so far. The few trials with incognito SPs provide little detail on the method used for fielding them.

New methodology for using incognito standardised patients for telephone consultation in primary care

Context  Many countries now use call centres as an integral part of out‐of‐hours primary care. Although some research has been carried out on safety issues pertaining to telephone consultations, there has been no published research on how to train and use standardised patients calling for medical advice or on the accuracy of their role‐play.

Education improves referral of patients suspected of having spondyloarthritis by general practitioners: a study with unannounced standardised patients in daily practice.

Objectives To evaluate the practice performance of general practitioners (GPs) and GP residents in recognising and referring patients suspected for having axial or peripheral spondyloarthritis (SpA), and to investigate the influence of education on this performance. Methods GP (residents) were visited in two rounds by standardised patients (SPs) simulating axial SpA, peripheral SpA or carpal tunnel syndrome (CTS) with in between an educational intervention on SpA for part of the participants. Participants were unaware of the nature of the medical problem and study purpose. CTS was included as diversionary tactic. The primary outcome was ≥40% improvement in (considering) referral of the SPs with SpA to the rheumatologist after education. Secondary outcomes included ordering additional diagnostic tests, correct recognition of SpA and identification of variables contributing to this. Results 68 participants (30 GPs and 38 GP residents) were included, of which 19 received education. The primary outcome was met. A significantly higher proportion of GP (residents) from the intervention group referred patients to the rheumatologist compared with the control group after education (change scores, axial SpA +71% vs +15% (p<0.01); peripheral SpA +48% vs 0% (p<0.001)). Participants who received education, more frequently correctly recognised SpA compared with controls (change scores, axial SpA +50% vs −5% (p<0.001); peripheral SpA +21% vs 0% (p=0.01). Conclusions Recognition and referral of patients suspected for having SpA by GP (residents) is low, but targeted education markedly improved this. This supports the development of educational initiatives to improve recognition of SpA and hence referral to a rheumatologist.

Kwaliteit van telefonische triage op huisartsenposten in Nederland

SamenvattingDerkx HP, Rethans JJ, Maiburg HJS, Winkens RAG, Muijtjens AM, Van Rooij HG, Knottnerus JA. Kwaliteit van telefonische triage op huisartsenposten in Nederland. Communicatieve vaardigheden en verslaglegging. Huisarts Wet 2009;52(9):455-61.Doel De kwaliteit van telefonische triage op huisartsenposten wordt behalve door het niveau van de medische inhoud ook bepaald door de kwaliteit van de communicatie en de verslaglegging van de telefonische consulten. Er is nog weinig onderzoek gedaan naar de kwaliteit van deze aspecten. We hebben de communicatieve vaardigheden van triagisten onderzocht en bepaald in hoeverre de verslagen een feitelijke weergave zijn van de gesprekken.Methode Voor de uitvoering van ons onderzoek belden twaalf telefonische simulatiepatiënten (TSP’s) in de periode april 2006 tot juli 2007 naar zeventien verschillende huisartsenposten voor zeven medische problemen. Iedere huisartsenpost werd voor iedere casus driemaal gebeld. Van alle 357 opgenomen gesprekken maakten we een verbatim. Nadat alle gesprekken waren gevoerd vroegen we de betrokken huisartsenposten een kopie van het verslag te sturen. Voor de beoordeling van de kwaliteit van de communicatie en verslaglegging ontwikkelden en gebruikten we de HAAK-scorelijst. We vergeleken de inhoud van de verslagen met de verbatims.Resultaten De gemiddelde score voor communicatie bedroeg 35% van de maximaal haalbare score. Triagisten stelden vragen over het medische probleem in het algemeen op de juiste wijze, maar vroegen weinig over de persoonlijke situatie en omstandigheden van de patiënt of diens verwachtingen. De triagisten gaven het zorgadvies meestal zonder te controleren of de patiënt het had begrepen of had geaccepteerd. De gesprekken verliepen vaak zonder vaste structuur, samenvatting of aankondiging van de verschillende fasen van het gesprek. Er was een positieve correlatie van 0,86 (p < 0,01) tussen de gespreksduur en de kwaliteit van de communicatie. Van 78% van de 357 gesprekken stuurden de huisartsenposten een verslag. Van de overige 22% was geen verslag gemaakt. De verslagen vermeldden bijna altijd de medische reden van het telefoongesprek, maar bevatten weinig medisch inhoudelijke informatie. Slechts zelden vermeldde men de persoonlijke situatie en verwachtingen van de patiënt. In 12% van de verslagen gaven triagisten een subjectieve weergave van de lichamelijke situatie van de patiënt. Veel verslagen bevatten antwoorden op obligate vragen die niet waren gesteld: dit varieerde van 1% tot 54%.Conclusie Beoordeling van de communicatieve vaardigheden van triagisten toonde aan dat er sprake was van diverse tekortkomingen. Deze bieden leermomenten om de kwaliteit van de communicatie tijdens telefonische triage te verbeteren. Behalve goede communicatieve vaardigheden moeten triagisten ook voldoende tijd hebben om telefonische consulten met een goede communicatieve kwaliteit te leveren. De verslagen bevatten weinig informatie over de persoonlijke en lichamelijke situatie van de patiënt. Daardoor kan de continuïteit van zorg voor de patiënt in het gedrang komen.

De kwaliteit van telefonische triage op huisartsenposten

SamenvattingDerkx HP, Rethans JJ, Maiburg BH, Winkens RAG, Muijtjens AM, Van Rooij HG, Knottnerus JA. De kwaliteit van telefonische triage op huisartsenposten. Huisarts Wet 2009;52(7):326-31.Doel Om de kwaliteit en veiligheid van telefonische triage op een huisartsenpost te bepalen moeten we de kwaliteit van de verschillende fasen van dit zorgproces onderzoeken. Dit betekent dat we niet alleen moeten beoordelen of de triagist het juiste urgentieniveau heeft bepaald, maar ook dat we de kwaliteit van de medisch inhoudelijke vragen en de inhoud van een zelfzorg- en vangnetadvies moeten onderzoeken.Methode Voor de uitvoering van dit onderzoek belden twaalf telefonische simulatiepatiënten (TSP’s) in de periode april 2006 tot juli 2007 naar zeventien verschillende huisartsenposten voor zeven medische problemen. De TSP’s belden iedere huisartsenpost voor iedere casus driemaal.Resultaten De triagisten stelden gemiddeld 21% van de verplichte vragen die in de standaarden waren vermeld. Gemiddeld 54% van alle gestelde vragen behoorde tot de categorie verplichte vragen. Niet altijd schatten de triagisten het belang van een antwoord op een vraag op de juiste wijze in. Triagisten bepaalden voor 58% van alle gesprekken de gewenste urgentie. Voor 41% was het urgentieniveau te laag en voor 1% te hoog ingeschat. De kwaliteit van de zelfzorg- en vangnetadviezen varieerde sterk per casus en was op alle huisartsenposten beperkt.Conclusie De triagisten formuleerden meestal een zorgadvies na het stellen van een zeer beperkt aantal verplichte vragen, waardoor ze een mogelijk gezondheidsrisico voor de patiënt niet tot het minimum beperkten. Als we de kwaliteit tijdens opeenvolgende fasen van het zorgproces van telefonische triage-onderzoeken, kunnen we vaststellen in hoeverre triagisten de juiste urgentie bepalen op basis van voldoende en juist geïnterpreteerde informatie of dat het toeval daarbij een grote rol heeft gespeeld. Om de veiligheid van telefonische triage te bevorderen moeten triagisten niet alleen de juiste vragen stellen en de antwoorden correct inschatten, maar ook een volledig zelfzorg- en vangnetadvies geven.

Should we assess clinical performance in single patient encounters or consistent behaviors of clinical performance over a series of encounters? A qualitative exploration of narrative trainee profiles

Abstract Background: A variety of tools have been developed to assess performance which typically use a single clinical encounter as a source for making competency inferences. This strategy may miss consistent behaviors. We therefore explored experienced clinical supervisors’ perceptions of behavioral patterns that potentially exist in postgraduate general practice trainees expressed as narrative profiles to aid the grading of clinical performance. Methods: We conducted semistructured interviews with clinical supervisors who had frequently observed clinical performance in trainees. Supervisors were asked to describe which behavioral patterns they had discerned in excellent and underperforming trainees, during different stages of training, in their careers as clinical supervisor. We analyzed the interviews using a grounded theory approach. Results: The analysis resulted in a conceptual framework that distinguishes between desirable and undesirable narrative profiles. The framework consists of two dimensions: doctor–patient interaction and medical expertise. Personal values appear to be a moderating factor. Conclusions: According to experienced clinical supervisors, consistent behaviors do exist in GP trainees when observing clinical performance over time. The conceptual framework has to be validated by further observational studies to assess its potential for making robust and fair assessments of clinical performance and monitor the development of consultation performance over time.

GPs’ patterns of clinical assessment when faced with a patient suspected for spondyloarthritis: a prospective educational intervention study

Background Timely recognition and referral of patients with spondyloarthritis (SpA) is challenging due to the frequent unawareness of the clinical picture. Aim To identify clinical assessment patterns of GPs and GP-residents when facing a patient suspected of having SpA, and to determine which components of clinical assessment were most prevalent prior to referral to the rheumatologist and whether targeted education could positively influence pattern recognition. Design & setting Prospective multicentre educational intervention study in primary care practices in the Netherlands. Method GPs and GP-residents were visited in two rounds by standardised patients (SPs) simulating axial or peripheral SpA (dactylitis). Between these rounds, an educational intervention regarding SpA took place for part of the participants. SPs completed a case-specific checklist inquiring about disease-related items and items on physical examination. Results Sixty-eight participants (30 GPs and 38 GP-residents) were included and 19 (28%) received the educational intervention. In round 1, about half of the participants asked at least one question to differentiate between an inflammatory or mechanical origin of the back pain or peripheral complaint; on average, <15% asked for extra-articular manifestations. After education, GP-residents inquired more about the presence of extra-articular manifestations and family history of axial SpA; this pattern was also observed in the GPs and GP-residents who correctly referred the SP. In the peripheral SpA case, the observed gain was less evident when compared to the axial SpA case. Conclusion Pattern recognition of patients suspected for SpA by GP(-residents) is essential for referral to a rheumatologist and can be improved by education.

OP0146 Patterns of Clinical Assessment of General Practitioners When Facing A Patient Suspected for Spondyloarthritis; A Study with Unannounced Standardized Patients in Daily Practice

Background Timely recognition and referral of patients with spondyloarthritis (SpA) is challenging due to the insidious disease onset and frequent unawareness of the clinical picture by general practitioners (GPs). In a previous intervention study, we demonstrated that an educational programme targeted at recognition of SpA clearly improves referral of patients suspected for SpA.[1] Objectives To evaluate (1) the clinical assessment patterns of GPs and GP-residents when facing a patient suspected of having spondyloarthritis (SpA) and (2) the influence of an educational intervention on these clinical assessment patterns. Methods Alongside the intervention study, data were collected for this present qualitative study. GP (residents) were visited in 2 rounds by standardised patients (SPs) simulating either axial or peripheral SpA. In between, an educational intervention on SpA for half of the GP residents was organized. The other half and all GPs served as controls. Participants were visited by the SPs during their regular outpatient clinic and were unaware of the nature of the medical problem and study purpose. After the visit, SPs completed a case-specific checklist inquiring about disease-related items. These items were categorized into four subgroups: questions regarding (1) differentiation between a mechanical or inflammatory origin of the complaint, (2) presence of swollen joints, back pain or entheseal complaints (3) presence of extra-articular manifestations and (4) family history. Differences in patterns of clinical assessment were explored for the education versus the control group. Descriptive analyses were used to analyse demographic data. Results Sixty-eight (38 GP-residents (mean age 27.9 yrs, 32% male) and 30 GPs (mean age 52.5 yrs, 80% male) participated. Both rounds of SP-encounters were completed by 61 (90%) and 59 (87%) participants for the axial and peripheral SpA case, respectively. Axial SpA case (Figure): participants who received education were in round 2, as compared to round 1, somewhat more likely to ask questions about the specific inflammatory character of the complaint. However, the most noticeable gain was seen in questions regarding the presence of extra-articular manifestations and family history of SpA. Despite that controls also tended to ask more questions regarding the inflammatory character of the complaint and family history of SpA in round 2, an evident increase in questions belonging to other subgroups (e.g. extra-articular manifestations) was not observed. Peripheral SpA case (data not shown): in round 2, GP residents who received the educational intervention asked more questions regarding extra-articular complaints and family history of SpA. However, the observed gain was less evident as compared to the axial SpA case. In the control group, no difference was observed between both rounds. Conclusions Targeted education can help GPs to improve their history taking and hence pattern recognition of patients suspected for SpA. Focusing on history taking alone already increases the chance of referral to the rheumatologist and targeted education should therefore be offered to all GPs to maximize a successful implementation of a referral strategy in primary care. References van Onna M, et al. RMD Open 2015;1:e000152. Disclosure of Interest M. Van Onna Consultant for: Janssen-Cilag and UCB, S. Gorter Speakers bureau: UCB, B. Maiburg: None declared, G. Waagenaar: None declared, A. van Tubergen Grant/research support from: Roche, Pfizer, Consultant for: Janssen-Cilag, UCB, Abbvie, MSD, Novartis, Speakers bureau: Abbvie, MSD, UCB, Pfizer

FRI0223 Education Enhances Referral and Recognition of Spondyloarthritis by General Practitioners in Daily Practice; A Study with Unannounced Standardized Patients

Background Timely recognition and referral of patients with spondyloarthritis (SpA) is challenging due to the insidious disease onset and frequently unawareness of the clinical picture by primary care physicians. Objectives The aims of this study were to assess the current practice performance of general practitioners (GPs) and GP-residents in recognizing SpA, and to investigate the influence of education on this performance. Methods GP-residents and their supervising GPs were visited in two rounds by standardized patients (SPs) during their regular outpatient clinic, simulating axial SpA (axSpA), peripheral SpA (perSpA) (i.e. dactylitis) or carpal tunnel syndrome (CTS), respectively. Participants were unaware of the nature of the medical problem and purpose of the study. CTS was included as a diversionary tactic. Each case was simulated by a male and a female, in random order, according to a predefined schedule. After the 1st round, half of the GP-residents were educated about SpA, as part of the GP specialty training without referring to the actual study. The other half of the GP-residents and all GPs served as controls. Next, all participants were visited by SPs again in the 2nd round. Participants ranked their differential diagnosis based on their probabilities (rank order: 1=most likely to 3=less likely) and indicated whether referral to a hospital physician would be appropriate. The primary outcome was at least 40% improvement in referral of the SPs with SpA by GP residents to the rheumatologist. Descriptive statistics, chi-square and McNemar tests were used to analyse the data. In addition, the difference in change scores between the educational and control group with regard to referral of the SP and correct recognition of SpA was compared. Results Sixty-eight (38 GP-residents (mean age 27.9 yrs, 32% male) and 30 GPs (mean age 52.5 yrs, 80% male) participated. Both rounds of SP-encounters were completed by 61 (90%) and 59 (87%) participants for the axSpA and perSpA case, respectively. Participants who received education were more likely to refer the patient or considered referral to the rheumatologist optional (change scores, axSpA 71% vs. 15% (P<0.001); perSpA 48% vs. 0% (P<0.001)); Figure 1). AxSpA was ranked as the no. 1 diagnosis by 12/61 (20%) participants, whereas perSpA was correctly diagnosed by none of participants in the 1st round. Participants who received the educational intervention, were more likely to rank axSpA and perSpA as the no. 1 diagnosis in the 2nd round when compared to the control group (change scores, axSpA 50% educational group vs. -5% control group, (P<0.001); perSpA change scores: 21% vs. 0% (P=0.01)). All 18 participants, who received the educational intervention, listed axSpA in their differential diagnosis in the 2nd round. Conclusions Patients with SpA are not adequately recognized by general practitioners. Providing an educational programme to GP-residents markedly improved the referral of patients with SpA to the rheumatologist and recognition of SpA. Disclosure of Interest M. Van Onna Consultant for: Janssen-Cilag and UCB, S. Gorter: None declared, B. Maiburg: None declared, G. Waagenaar: None declared, A. van Tubergen Grant/research support from: Pfizer, Roche, Consultant for: AbbVie, MSD, Pfizer, UCB, Janssen-Cilag, Speakers bureau: AbbVie, MSD, UCB, Pfizer